A 6-month-old girl is brought to the emergency department due to cough, congestion, and increased work of breathing over the past 2 days. The patient has been very fussy and has a decreased appetite. For the last week, her parents and 5-year-old brother have had congestion and rhinorrhea without high fevers or myalgias. Her brother's school has reported many sick children over the past winter. Temperature is 37.6 C (99.7 F) and respirations are 65/min. On examination, the patient is fussy and tachypneic with nasal flaring and subcostal retractions. Lung examination reveals a prolonged expiratory phase with diffuse crackles and end-expiratory wheezing. Which of the following is the best next step in management of this patient's condition?

Question

A 6-month-old girl is brought to the emergency department due to cough, congestion, and increased work of breathing over the past 2 days.  The patient has been very fussy and has a decreased appetite.  For the last week, her parents and 5-year-old brother have had congestion and rhinorrhea without high fevers or myalgias.  Her brother's school has reported many sick children over the past winter.  Temperature is 37.6 C (99.7 F) and respirations are 65/min.  On examination, the patient is fussy and tachypneic with nasal flaring and subcostal retractions.  Lung examination reveals a prolonged expiratory phase with diffuse crackles and end-expiratory wheezing.  Which of the following is the best next step in management of this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d6b4_e9c2_bc81_d359647c6a47_MD0003_00 This patient has cough, congestion, and increased work of breathing due to bronchiolitis, a lower respiratory tract infection that occurs in children age <2. Respiratory syncytial virus (RSV) is the most common cause and is prevalent in the fall and winter. Other common viral pathogens that cause bronchiolitis include rhinovirus, influenza virus, and parainfluenza virus. Initial symptoms include cough, congestion, and rhinorrhea. Fever may or may not be present. After 2-3 days, inflammation affects the bronchioles, causing diffuse wheezing and/or crackles. Patients may develop hypoxemia and signs of respiratory distress (eg, tachypnea, retractions, nasal flaring), which typically peak on day 3-5 of illness before gradually resolving. Bronchiolitis is a clinical diagnosis. Treatment is supportive and includes nasal saline and suctioning. Hospitalization is indicated for patients requiring intravenous fluids or supplemental oxygen. (Choice A) Antibiotics are used to treat bacterial pneumonia, which presents with fever, cough, and focal crackles. This patient is afebrile with diffuse wheezing and crackles, making viral bronchiolitis more likely. (Choices B and D) Glucocorticoids and racemic epinephrine are used in the treatment of croup, an upper airway infection. Presentation includes fever, barky cough, and inspiratory stridor, none of which are seen in this patient. Glucocorticoids are also indicated for asthma exacerbations, which present with wheezing and respiratory distress. However, they are not beneficial in children age <2 with a first episode of viral-induced wheezing, such as this patient. (Choice C) Loop diuretics are indicated for congestive heart failure, which can cause respiratory distress and crackles. However, this previously healthy patient's congestion, rhinorrhea, and sick contacts are more indicative of an infectious etiology. Educational objective: Bronchiolitis is a viral lower respiratory tract infection that presents in children age <2 with cough, congestion, diffuse wheezes/crackles, and respiratory distress. Diagnosis is clinical, and treatment is supportive (eg, nasal saline and suctioning). References: Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. (http://www.ncbi.nlm.nih.gov/pubmed/25349312)

A 6-Month-Old Girl Is Brought to the Emergency Department Due