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Difficulty: MediumPediatric Infectious Diseases

A 55-month-old boy is brought to the pediatric emergency department in January due to a 33-day history of nasal congestion, clear rhinorrhea, and a mild cough. Over the past 2424 hours, his mother noticed that his breathing has become faster than usual and he has been feeding poorly. His mother has a history of seasonal allergies and asthma. His temperature is 37.8∘C37.8^\circ\text{C} (100.0∘F100.0^\circ\text{F}), pulse is 160/min160/\text{min}, respirations are 66/min66/\text{min}, and oxygen saturation is 93%93\% on room air. Physical examination reveals a fussy but consolable infant with moderate suprasternal and intercostal retractions, nasal flaring, and diffuse polyphonic wheezing with bilateral scattered crackles. Which of the following is the most appropriate next step in the management of this patient?

  1. Supportive care with nasal suctioning and fluid managementAnswer
  2. B
    Trial of nebulized albuterol
  3. C
    Administration of oral dexamethasone
  4. D
    Prescription of oral azithromycin
  5. E
    Administration of intravenous ceftriaxone

Answer

Supportive care with nasal suctioning and fluid management is the correct management strategy.
This patient's presentation—an infant under 22 years of age during the winter months with a viral prodrome (rhinorrhea, congestion) that progresses to lower respiratory tract distress (tachypnea, retractions, wheezing, and crackles)—is the classic clinical picture of acute viral bronchiolitis. Respiratory syncytial virus (RSV) is the most common etiology. According to the American Academy of Pediatrics (AAP) guidelines, the diagnosis of bronchiolitis is clinical, and routine management is strictly supportive. Supportive care includes maintaining adequate hydration (orally or intravenously if respiratory distress precludes safe feeding) and relieving upper airway obstruction with nasal suctioning. Oxygen supplementation is provided if saturations fall below 90%90\% persistently, though this patient's saturation is adequate at 93%93\%.

Step-by-Step Solution

1
Analyze the patient's demographic and seasonal presentation.
A 55-month-old infant presenting in the winter months with upper respiratory symptoms progressing to lower respiratory distress.
Age under 22 years and winter seasonality are classic epidemiologic clues for Respiratory Syncytial Virus (RSV) bronchiolitis.
2
Evaluate the physical examination findings.
Tachypnea, retractions, nasal flaring, diffuse polyphonic wheezing, and bilateral crackles without high fever.
These findings indicate diffuse small airway inflammation and obstruction typical of bronchiolitis, distinguishing it from focal bacterial pneumonia.
3
Determine the appropriate management based on established clinical guidelines.
Select supportive care, avoiding bronchodilators, corticosteroids, and antibiotics.
Current pediatric guidelines emphasize that bronchiolitis is a self-limiting viral disease. Pharmacologic interventions like albuterol or dexamethasone do not alter the disease course.

Key Concept

The diagnosis of acute viral bronchiolitis is clinical, and management is primarily supportive (hydration and airway clearance). Bronchodilators, corticosteroids, and antibiotics are explicitly not recommended.
Estimated Time:1m 15s
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Pediatric Infectious Diseases

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