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Difficulty: MediumPediatric Respiratory Disorders

A 33-month-old boy is brought to the emergency department in mid-February due to a 33-day history of worsening cough and nasal congestion. Today, his parents noted that he is breathing much faster than usual and has had a significant decrease in oral intake, producing only two wet diapers over the past 1212 hours. The infant was born at term and has no significant past medical history. His temperature is 37.6∘C37.6^\circ\text{C} (99.7∘F99.7^\circ\text{F}), heart rate is 162/min162/\text{min}, respiratory rate is 68/min68/\text{min}, and oxygen saturation is 91%91\% on room air. On examination, the infant is irritable but consolable. He has prominent nasal flaring, head bobbing, and marked subcostal and intercostal retractions. Auscultation reveals diffuse expiratory wheezes and scattered crackles bilaterally. Which of the following is the most appropriate next step in management?

  1. Admission to the hospital for supplemental oxygen and intravenous fluidsAnswer
  2. B
    Trial of nebulized albuterol in the emergency department
  3. C
    Administration of a single dose of oral dexamethasone
  4. D
    Administration of nebulized racemic epinephrine
  5. E
    Initiation of intravenous ceftriaxone therapy

Answer

The most appropriate next step is admission to the hospital for supplemental oxygen and intravenous fluids.
The correct intervention is admission for supportive care. This infant presents with classic signs of severe viral bronchiolitis, including hypoxemia (oxygen saturation of 91%), severe tachypnea, marked retractions, and poor oral intake leading to dehydration. Because of his severe respiratory distress and hypoxia, he requires immediate hospitalization for supplemental oxygen and intravenous fluid therapy. Current guidelines from the American Academy of Pediatrics emphasize that the treatment for bronchiolitis is strictly supportive.

Step-by-Step Solution

1
Assess the patient's age and clinical severity based on vital signs and physical examination.
The patient is a 3-month-old infant with hypoxia (SpO2 91%), severe tachypnea (RR 68/min), significant work of breathing, and clinical signs of dehydration (decreased wet diapers).
Identifying the severity of respiratory distress dictates whether the patient can be managed safely as an outpatient or requires inpatient admission.
2
Determine the most likely diagnosis based on the clinical presentation.
The combination of a viral prodrome followed by wheezing, crackles, and increased work of breathing in a winter month is classic for viral bronchiolitis, typically caused by Respiratory Syncytial Virus (RSV).
Establishing the correct diagnosis prevents the inappropriate use of therapies meant for other pediatric respiratory conditions like asthma or croup.
3
Select the appropriate evidence-based interventions for severe viral bronchiolitis.
Management includes admission for supportive care with supplemental oxygen to correct hypoxia and intravenous fluids to correct dehydration.
Current pediatric guidelines emphasize supportive care and strongly recommend against the use of bronchodilators, systemic steroids, and antibiotics, as they do not improve clinical outcomes.

Key Concept

The management of severe viral bronchiolitis is strictly supportive (supplemental oxygen and hydration); bronchodilators, corticosteroids, and antibiotics are not indicated.
Estimated Time:1m 0s
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Topics

Pediatric Respiratory Disorders

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