During a busy winter clinic session, a pediatrician evaluates an infant aged 5 months who … — USMLE Step 2 CK

During a busy winter clinic session, a pediatrician evaluates an infant aged $5$ months who has been exhibiting noisy breathing and nasal congestion for the past $3$ days. The caregiver notes that the child's formula intake remains at baseline, but his breathing appears more rapid than usual. He was born at $39$ weeks of gestation without perinatal complications. Current vital signs include a temperature of $37.6^{\circ}\text{C}$ ( $99.7^{\circ}\text{F}$ ), pulse of $138$ /min, respiratory rate of $56$ /min, and an oxygen saturation of $94\%$ on ambient air. On examination, the infant is alert with mild subcostal retractions. Auscultation of the lungs reveals widespread expiratory wheezes and fine crackles bilaterally. Which of the following are appropriate components of the initial management for this patient? (Select all that apply)

Provide education on nasal saline drops and bulb suctioningAnswer
Discharge home with instructions on signs of respiratory distressAnswer
C
Administer an aerosolized trial of albuterol
D
Administer a single dose of oral dexamethasone
E
Obtain a chest radiograph to evaluate for consolidation

Answer

The correct interventions are providing education on nasal saline drops with bulb suctioning and discharging the patient home with instructions on signs of respiratory distress.

The patient's presentation is highly characteristic of acute viral bronchiolitis, an infection typically caused by Respiratory Syncytial Virus (RSV). The illness typically begins with upper respiratory tract symptoms and progresses to lower respiratory tract involvement, characterized by wheezing, crackles, and increased work of breathing. Because this infant has adequate oral intake, lacks signs of severe respiratory distress (e.g., severe retractions, grunting, lethargy), and has an oxygen saturation above

90\%

on room air, he can be safely managed in the outpatient setting. Supportive care, specifically nasal suctioning with saline drops, is the most effective intervention to maintain airway patency in infants, who are obligate nose breathers. Providing caregivers with clear instructions on when to return to the emergency department (e.g., decreased urine output, worsening work of breathing) is essential for safe discharge.

Step-by-Step Solution

Analyze the patient's age, presentation, and seasonal timing.

A 5-month-old infant in winter with upper respiratory symptoms progressing to wheezing, crackles, and mild retractions.

This classic constellation of findings points to a clinical diagnosis of acute viral bronchiolitis, most commonly caused by Respiratory Syncytial Virus (RSV).

Assess the severity of the respiratory distress and hydration status.

The infant is feeding well, has only mild subcostal retractions, and maintains an oxygen saturation of 94% on room air.

Determining severity dictates whether the infant requires inpatient admission (e.g., for hypoxia below 90%, dehydration, or severe distress) or can be managed safely as an outpatient.

Select the appropriate evidence-based interventions for mild to moderate bronchiolitis.

Supportive care (nasal suctioning) and discharge with anticipatory guidance are chosen. Pharmacologic therapies and imaging are omitted.

Current guidelines recommend against the routine use of bronchodilators, corticosteroids, and chest radiography in typical bronchiolitis.

Key Concept

Diagnosis and management of mild acute viral bronchiolitis

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