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Patient Story

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A 5-month-old full-term female infant presents to your office with 3 days of fever and cough. On examination, you note a frequent wet cough and appreciate bilateral wheezes. Pulse oximetry reveals a normal oxygen saturation. You reassure the mom that her daughter has bronchiolitis and needs supportive care only (Figure 48-1). She agrees to follow up with you in 1 to 2 days.

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FIGURE 48-1

Bronchiolitis illustration with captions embedded. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2012. All Rights Reserved.)

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Introduction

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Bronchiolitis is inflammation of the bronchioles typically caused by a viral illness that frequently affects young children.1

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Synonyms

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Respiratory Syncytial Virus (RSV) or lower respiratory tract infection (LRTI).

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Epidemiology

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  • Most common lower respiratory tract infection in children less than 1 year of age.1

  • Annual hospitalizations for bronchiolitis account for greater than half a billion dollars in health care expenditures.2

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Etiology and Pathophysiology

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  • Viral etiology, most frequently RSV.

  • Other viruses implicated include influenza, parainfluenza, adenovirus, and human metapneumovirus.

  • Inflammation, edema, and necrosis of epithelial cells lining bronchioles (Figure 48-1).

  • Leads to increased mucus production and bronchospasm.

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Risk Factors

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  • Up to 90 percent of infants will have had an RSV infection by the age of 2 years.1

  • Infants with exposure to child care center populations, school-aged siblings, and smoke are at higher risk for developing bronchiolitis.3

  • Risk factors for severe disease include:

    • Prematurity of less than 35 weeks gestation.

    • Chronic lung disease or congenital airway malformations.

    • Cyanotic congenital heart disease.

    • Severe neuromuscular disease.

    • Immunocompromised state.4

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Diagnosis

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Clinical Features
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  • Bronchiolitis is a clinical diagnosis.

  • Signs and symptoms include rhinorrhea, cough, tachypnea, bilateral wheezing, and signs of increased work of breathing such as use of accessory muscles and/or nasal flaring.

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Laboratory Testing
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  • Laboratory testing is not routinely indicated.

  • Respiratory viral testing can be obtained if necessary for epidemiologic surveillance and research but the results do not change the management of the disease.

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Imaging
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  • As most chest x-rays obtained in patients with bronchiolitis are found to be normal, routine chest radiography is not recommended for patients with bronchiolitis (Figure 48-2).

  • Nonspecific findings such as hyperinflation, perihilar markings, or central bronchial thickening can be seen in some patients (Figure 48-3 to 48-5).

  • Chest radiography may be necessary if the patient experiences a severe course or does not improve as expected based on the natural history of disease.

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FIGURE 48-2

Normal chest x-ray of an 8-month old ...

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