A 6-month-old boy presents with a 2-day history of worsening cough, congestion, and increased work of breathing. On physical examination, the patient is noted to have nasal flaring, intercostal retractions, diffuse rales, and expiratory wheezes. The patient is diagnosed with acute bronchiolitis. What finding would have you seriously consider hospitalization?

A. Respiratory rate of 60 bpm

B. Appropriate oral intake to maintain hydration status

C. Oxygen saturation of 97% on room air

D. Accessory muscle use

E. Identified sick contacts in the home

The correct answer is D.

Explanation: Bronchiolitis is a viral lower respiratory tract infection characterized by an upper respiratory prodrome (rhinorrhea, congestion), increased work of breathing, wheezing, and rales in children less than 2 years of age. It is a common cause for emergency department visits and hospitalizations. Severe bronchiolitis is characterized by significant respiratory distress (accessory muscle use, nasal flaring, tachypnea, grunting), hypoxemia, apnea, or acute respiratory failure.

Several variables have been identified as risk factors for severe bronchiolitis including: prematurity, infants less than 3 months of age, chronic lung disease, anatomic airway abnormalities, congenital heart disease, immunodeficiency, and neurologic disease. Other contributing factors to severe disease include daycare attendance and passive tobacco exposure.

Children with acute bronchiolitis can be managed as outpatients if they are in mild respiratory distress and hemodynamically stable without concerns for dehydration. These patients should be followed closely by their primary care physicians. Hospitalization of patients with the following clinical features should be considered: poor feeding and dehydration; moderate to severe respiratory distress manifested by nasal flaring, retractions, respiratory rate <70 breaths per minute, or dyspnea; cyanosis; apnea; or hypoxemia.

Go to AccessPediatrics for more information on bronchiolitis

Source: Symptom-Based Diagnosis in Pediatrics, Second Edition Copyright © 2014 by McGraw-Hill Education. 

Photo credit: The Color Atlas of Pediatrics 

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