Bronchiolitis (RSV)

Patient < 2 y/o with h/o eczema and no h/o intubation presents in January with increased respiratory effort. Parents report 3 days of increasing cough and decreased oral intake. Sick contacts include siblings and other children at daycare. Initial SPO2 94%. Low grade fever, tachycardia, rhinorrhea, nasal flaring, dry mucous membranes, grunting, mild retractions, and wheezing/crackles on exam.

  • Obtain daily weights to assess hydration status

  • Do not obtain virus panel

  • CXR shows non-specific peribronchiolar cuffing, hyperinflation, and atelectasis

  • Treatment

    • Start supplemental (blow-by) oxygen to maintain SPO2 > 90%

    • Nasal suction bulb PRN; avoid over-suctioning and/or deep suction

    • Respiratory rate > 60 breath/min or unable to maintain sufficient PO intake: Administer fluids via IV and/or nasogastric tube

    • Antipyretics

      • Weight > 2.7 kg (6 lbs): Acetaminophen q6h PRN fever

      • Age > 6 months, weight > 5.4 kg (12 lbs): Ibuprofen q6h PRN fever

  • Counseling

    • Parents counseled that symptoms typically peak at 2-3 days and last 7-10 days

    • Parents reassured that it is unlikely a child will be hospitalized during the full illness course

    • Parents educated about the importance of hand washing and avoidance of second hand smoke to reduce risk for future respiratory infection

Notes

  • Lower respiratory tract infection most commonly caused by respiratory syncytial virus (RSV)

  • Peak season: December through March

  • Prophylaxis

    • Palivizumab: RSV monoclonal antibody administered monthly during peak RSV season (maximum 5 doses)

    • Administer to infants

      • Born before 29 WGA

      • Born before 32 WGA with chronic lung disease of prematurity

      • With hemodynamically significant heart disease

  • Diagnosis and treatment

    • Respiratory virus panels (PCR) cost between $1,000 and $3,500 and do not change management

    • Routine CXR is not recommended

    • Continuous pulse oximetry is not required

    • Treatment such as albuterol, epinephrine, corticosteroids, and/or antibiotics are ineffective and should be avoided

    • Infants with respiratory rates > 60 breaths/min may demonstrate poor feeding and benefit from NG tube or IV hydration

  • Predictors of severity

    • Safe discharge predicted by age > 2 months, no h/o intubation, h/o eczema, initial SPO2 of 94%, and adequate oral intake

    • More concerning s/sx include tachycardia, evidence of dehydration (decreased weight, dry mucous membranes), and increased respiratory effort