A 6-month-old boy is brought to the emergency department by his mother during the winter due to 3 days of nasal discharge and cough. His mother states, "He hasn't been breastfeeding well today because he's so congested." The infant has been voiding adequately and has had no vomiting, diarrhea, or skin rash. His older brother attends preschool and is recovering from an upper respiratory illness. The patient has no prior illnesses and no known allergies, and all vaccinations are up to date. He was born at term via an uncomplicated delivery and has met all developmental milestones appropriately. Temperature is 37.5 C (99.5 F) , blood pressure is 90/60 mm Hg, pulse is 150/min, and respirations are 50/min. Pulse oximetry shows an oxygen saturation of 93% on room air. Examination reveals moderate respiratory distress with subcostal retractions, coarse breath sounds, and expiratory wheezing bilaterally. Oral mucous membranes are dry, but capillary refill is <2 seconds. The patient is admitted to the hospital and placed on appropriate infection-control precautions.
Which of the following is the best next step in management of this patient?

Question

A 6-month-old boy is brought to the emergency department by his mother during the winter due to 3 days of nasal discharge and cough.  His mother states, "He hasn't been breastfeeding well today because he's so congested."  The infant has been voiding adequately and has had no vomiting, diarrhea, or skin rash.  His older brother attends preschool and is recovering from an upper respiratory illness.  The patient has no prior illnesses and no known allergies, and all vaccinations are up to date.  He was born at term via an uncomplicated delivery and has met all developmental milestones appropriately.  Temperature is 37.5 C (99.5 F), blood pressure is 90/60 mm Hg, pulse is 150/min, and respirations are 50/min.  Pulse oximetry shows an oxygen saturation of 93% on room air.  Examination reveals moderate respiratory distress with subcostal retractions, coarse breath sounds, and expiratory wheezing bilaterally.  Oral mucous membranes are dry, but capillary refill is <2 seconds.  The patient is admitted to the hospital and placed on appropriate infection-control precautions. 
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient's clinical presentation is most consistent with bronchiolitis, an infection that occurs in the winter and is most commonly caused by respiratory syncytial virus (RSV). Patients typically have nasal congestion, rhinorrhea, coarse breath sounds, and wheezing with or without crackles. Other common features include a low-grade fever, increased work of breathing with accessory muscle use (eg, retractions), nasal flaring, and grunting. Respiratory symptoms may interfere with feeding and increase the risk of dehydration. Patients with respiratory distress, apnea, hypoxia, and/or dehydration should be hospitalized on contact and droplet precautions to prevent nosocomial spread of this extremely contagious virus. Therapy generally consists of supportive measures, such as intravenous fluids, nasal bulb suctioning, and/or humidified oxygen. Inhaled bronchodilators used to be recommended, but this is no longer the case as current evidence shows that they do not reduce illness duration, admission rates, or length of hospital stay. (Choice A) Antibiotics have no role in the treatment of bronchiolitis unless there is concern for coexisting bacterial pneumonia (eg, high fever, focal crackles on auscultation, consolidation on chest x-ray). (Choice B) Nebulized hypertonic saline has not been shown to improve clinical outcomes or to reduce length of hospital stay. Hypertonic saline can also induce bronchospasm, and it is not recommended in the routine care of patients with bronchiolitis. (Choice C) Although ribavirin has in vitro activity against RSV, it is extremely expensive and has no proven benefit in most children. It is usually reserved for immunocompromised patients with severe disease. In addition, the absence of fever in this patient makes RSV bronchiolitis more likely than influenza; therefore, treatment with oseltamivir is unwarranted. (Choice D) Systemic corticosteroids are not recommended for first-time bronchiolitis due to the lack of evidence of clinical effect. Corticosteroids can be considered in patients with recurrent wheezing or asthma exacerbation. Educational objective: Bronchiolitis is a lower respiratory tract infection occurring during the winter and is caused primarily by respiratory syncytial virus. Infants with moderate to severe respiratory distress or dehydration may require hospitalization. Supportive care is the mainstay of treatment. References: Prospective multicenter study of viral etiology and hospital length of stay in children with severe bronchiolitis. (http://www.ncbi.nlm.nih.gov/pubmed/22473882) Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. (http://www.ncbi.nlm.nih.gov/pubmed/25349312)

A 6-Month-Old Boy Is Brought to the Emergency Department by His