Examkin

Question

Difficulty: MediumPediatric Infectious Diseases

A 9-month-old boy is brought to the pediatric emergency department during the winter due to a 3-day history of low-grade fever, rhinorrhea, and worsening cough. Today, his mother noted that he is breathing faster than usual and has been fussy, feeding slightly less than normal. His temperature is 37.9°C (100.2°F), pulse is 145/min, respirations are 56/min, and blood pressure is 90/55 mm Hg. Pulse oximetry shows 94% on room air. On examination, the patient has clear nasal discharge. There are mild subcostal retractions. Lung auscultation reveals diffuse bilateral polyphonic wheezes and scattered coarse crackles. Cardiovascular and abdominal examinations are unremarkable. Which of the following is the most appropriate next step in management?

  1. Nasal suctioning and oral hydrationAnswer
  2. B
    Administration of inhaled albuterol
  3. C
    Administration of oral dexamethasone
  4. D
    Prescription of oral amoxicillin
  5. E
    Prescription of oral azithromycin

Answer

Nasal suctioning and oral hydration
The clinical presentation of a viral prodrome followed by tachypnea, retractions, and polyphonic wheezing in an infant during the winter is classic for acute bronchiolitis, most commonly caused by Respiratory Syncytial Virus (RSV). For infants with bronchiolitis who are well-oxygenated (SpO2 > 90%) and do not have severe respiratory distress (e.g., severe retractions, grunting, lethargy), the cornerstone of therapy is supportive care. Infants are obligate nose breathers, so nasal suctioning is critical to relieve upper airway congestion and reduce work of breathing. Ensuring adequate oral hydration is also essential, as tachypnea and poor feeding can lead to dehydration. Pharmacological interventions have not been shown to change the disease course or improve outcomes in typical cases.

Step-by-Step Solution

1
Identify the clinical syndrome based on the patient's age, symptoms, and physical exam findings.
The patient is an infant presenting in winter with a viral prodrome (rhinorrhea, fever) followed by lower respiratory tract signs (tachypnea, retractions, wheezing, and crackles). This is the classic presentation of acute bronchiolitis, typically caused by Respiratory Syncytial Virus (RSV).
Accurate diagnosis prevents the inappropriate use of medications targeted at other respiratory diseases like asthma or bacterial pneumonia.
2
Assess the severity of the patient's respiratory distress and oxygenation status.
The patient has mild subcostal retractions (mild work of breathing) and a normal oxygen saturation of 94% on room air (no hypoxemia).
Severity dictates the level of intervention required, specifically whether the patient needs supplemental oxygen, intravenous fluids, or hospitalization.
3
Determine the appropriate management strategy for mild-to-moderate acute bronchiolitis.
The appropriate management is purely supportive, prioritizing airway clearance via nasal suctioning and ensuring the infant remains well-hydrated.
Pharmacological interventions (bronchodilators, steroids, antibiotics) do not alter the disease course of viral bronchiolitis and expose the child to unnecessary adverse effects.

Key Concept

The management of mild-to-moderate acute viral bronchiolitis in well-oxygenated infants is supportive, focusing on nasal suctioning and adequate hydration, without the use of bronchodilators, corticosteroids, or antibiotics.
Rate this question

Topics

Pediatric Infectious Diseases

More questions from this topic