Bronchiolitis breadth - Passmed

Question 1

What is bronchiolitis?

Answer 1

Bronchiolitis is a condition characterized by acute inflammation of the bronchioles, commonly caused by respiratory syncytial virus (RSV).

Question 2

What percentage of bronchiolitis cases is caused by RSV?

Answer 2

75-80% of bronchiolitis cases are caused by the respiratory syncytial virus (RSV).

Question 3

What are the peak age and incidence period for bronchiolitis?

Answer 3

Bronchiolitis most commonly affects infants aged 1-9 months, with a peak incidence around 3-6 months.

Question 4

What factors provide newborns protection against RSV?

Answer 4

Maternal IgG provides newborns with protection against the respiratory syncytial virus (RSV).

Question 5

What is the typical season for higher incidence of bronchiolitis?

Answer 5

The incidence of bronchiolitis is higher in the winter.

Question 6

What are other pathogens that can cause bronchiolitis besides RSV?

Answer 6

Other causes of bronchiolitis include mycoplasma and adenoviruses, and it may be complicated by secondary bacterial infections.

Question 7

What underlying conditions can make bronchiolitis more serious?

Answer 7

Conditions such as bronchopulmonary dysplasia (often in premature infants), congenital heart disease, or cystic fibrosis can make bronchiolitis more serious.

Question 8

What symptoms typically precede the onset of bronchiolitis?

Answer 8

Coryzal symptoms, including mild fever, typically precede the onset of bronchiolitis.

Question 9

What are common symptoms of bronchiolitis?

Answer 9

Symptoms of bronchiolitis include dry cough, increasing breathlessness, wheezing, fine inspiratory crackles, and feeding difficulties associated with increasing dyspnea.

Question 10

Under what conditions does NICE recommend immediate hospital referral for bronchiolitis?

Answer 10

Immediate referral is recommended for apnoea, a child looking seriously unwell, severe respiratory distress, central cyanosis, or persistent oxygen saturation < 92%.

Question 11

What conditions might warrant consideration for hospital referral according to NICE guidelines on bronchiolitis?

Answer 11

Hospital referral should be considered if the respiratory rate is over 60 breaths/minute, there is difficulty with breastfeeding or inadequate oral fluid intake, or signs of clinical dehydration are present.

Question 12

How is RSV detected in patients with bronchiolitis?

Answer 12

Immunofluorescence of nasopharyngeal secretions may show RSV in patients with bronchiolitis.

Question 13

What are the key management strategies for bronchiolitis?

Answer 13

Management of bronchiolitis is largely supportive and includes humidified oxygen if oxygen saturations are persistently < 92%, nasogastric feeding if necessary, and suction for excessive upper airway secretions.

Question 14

summarise

Answer 14

Bronchiolitis

Bronchiolitis is a condition characterised by acute bronchiolar inflammation. Respiratory syncytial virus (RSV) is the pathogen in 75-80% of cases. NICE released guidelines on bronchiolitis in 2015. Please see the link for more details.

Epidemiology
most common cause of a serious lower respiratory tract infection in < 1yr olds (90% are 1-9 months, with a peak incidence of 3-6 months). Maternal IgG provides protection to newborns against RSV
higher incidence in winter

Basics
respiratory syncytial virus (RSV) is the pathogen in 75-80% of cases
other causes: mycoplasma, adenoviruses
may be secondary bacterial infection
more serious if bronchopulmonary dysplasia (e.g. Premature), congenital heart disease or cystic fibrosis

Features
coryzal symptoms (including mild fever) precede:
dry cough
increasing breathlessness
wheezing, fine inspiratory crackles (not always present)
feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission

NICE recommend immediate referral (usually by 999 ambulance) if they have any of the following:
apnoea (observed or reported)
child looks seriously unwell to a healthcare professional
severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
central cyanosis
persistent oxygen saturation of less than 92% when breathing air.

NICE recommend that clinicians ‘consider’ referring to hospital if any of the following apply:
a respiratory rate of over 60 breaths/minute
difficulty with breastfeeding or inadequate oral fluid intake (50-75% of usual volume ‘taking account of risk factors and using clinical judgement’)
clinical dehydration.

Investigation
immunofluorescence of nasopharyngeal secretions may show RSV

Management is largely supportive
humidified oxygen is given via a head box and is typically recommended if the oxygen saturations are persistently < 92%
nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth
suction is sometimes used for excessive upper airway secretions

Question 15

A 5-month-old girl presents to the emergency department with a 24-hour history of cough and wheeze, on a background history of one week of mild fever and coryzal symptoms. She is otherwise well and has no past medical history of note. Respiratory examination identifies generalised wheeze. Observations show:

Respiratory rate 50/min
Blood pressure 90/50mmHg
Temperature 38.1ºC
Heart rate 122 bpm
Oxygen saturation 97% on room air

What is the most appropriate management for this infant?

Amoxicillin
Dexamethasone
Inhaled racemic adrenaline
Nebulised salbutamol
Supportive management only

Answer 15

Bronchiolitis does not require antibiotics, children requires supportive management only
Important for meLess important
The correct answer is supportive management only. This child is presenting with cough and wheeze on a background history suggestive of a viral illness; this should raise suspicion of bronchiolitis. Bronchiolitis is a condition characterised by bronchiole inflammation in response to a recent viral illness, most commonly respiratory syncytial virus (RSV). As this patient’s observations show only a mild fever, the most appropriate management is supportive. Alternatively, if her oxygen saturation was persistently below 92% or her feeding was affected, admission would be considered.

Amoxicillin is incorrect as antibiotics provide no benefit in cases of bronchiolitis. This antibiotic may however be used in cases of uncomplicated community-acquired pneumonia and acute otitis media.

Dexamethasone is incorrect; this is commonly used in the management of croup. This diagnosis is unlikely as it is more likely to present with a barking cough, hoarse voice and inspiratory stridor.

Inhaled racemic adrenaline is incorrect; this is commonly used in the management of croup.

Nebulised salbutamol is incorrect as this patient is haemodynamically stable and requires supportive management only.

Question 16

A 4-month-old boy is brought to the emergency department by his concerned mother. She says that she first noticed he had a mild fever and runny nose around 5 days ago, and over the last few days, he appears to have become more breathless and is grunting when he breathes. She is particularly concerned because she struggles to get him to feed and reports that his nappies are not as wet as normal. On examination, you notice chest recessions, wheeze and bilateral inspiratory crackles.

Given the likely diagnosis, what is the most appropriate treatment?

Admit for intravenous (IV) antibiotics
Admit for salbutamol nebulisers
Admit for supportive treatment
Discharge home with advice
Discharge home with oral antibiotics

Answer 16

Bronchiolitis does not require antibiotics, children requires supportive management only

The correct answer is ‘Admit for supportive treatment’.

This child is likely to have bronchiolitis. They have a typical history of increasing breathlessness, wheezing and reduced feeding, preceded by mild coryzal symptoms. Bronchiolitis is typically caused by a respiratory syncytial virus (RSV) and only requires supportive management. However, the presence of severe respiratory distress (chest recessions and grunting) and a significant reduction in feeding (as evidenced by the change in how wet his nappies are) mean that this patient should be admitted to the hospital for supportive care.

Admit for IV antibiotics is incorrect as the pathogen responsible for bronchiolitis is RSV. This might be appropriate if pneumonia or other bacterial infection was suspected.

Admit for salbutamol nebulisers is incorrect. Bronchodilators such as salbutamol do not typically help those who have bronchiolitis. The typical patient age group has not yet developed the receptors that they act on in the airways.

Discharging home with advice and discharging home with oral antibiotics are incorrect. This child shows signs of potentially serious illness - grunting, chest recessions, and a significant reduction in feeds. As such, they need to be admitted to the hospital for their treatment.

Question 17

You see the mother of a 6-month-old baby who was born premature (at 32 weeks) and has recently been discharged from hospital following an admission with ‘breathing problems’. Whilst he was in the hospital he was given an injection called palivizumab, however, the mother cannot recall what this medication is for.

Which one of the following best describes this medication and its indication?

Synthetic steroid used to treat childhood wheeze
Macrolide antibiotic used to treat respiratory syncytial virus (RSV)
Monoclonal antibody used to prevent respiratory syncytial virus (RSV)
Macrolide antibiotic used to prevent hospital acquired pneumonia
Monoclonal antibody used to treat hospital acquired pneumonia

Answer 17

Palivizumab is a monoclonal antibody which is used to prevent respiratory syncytial virus (RSV) in children who are at increased risk of severe disease.

Those at risk of developing RSV include
Premature infants
Infants with lung or heart abnormalities
Immunocompromised infants

Question 18

A 6-month-old baby presents with feeding difficulties associated with a cough and wheeze and is diagnosed with bronchiolitis.

Which of the following is a precipitating factor for a more severe episode of bronchiolitis and not just an increased risk of developing bronchiolitis?

Underlying congenital heart disease
Fragile X syndrome
Being fed on formula milk instead of breast milk
Aged between 3-6 months
Being born at 37 weeks gestation

Answer 18

Congenital heart disease can cause bronchiolitis to be more severe
Important for meLess important
A ventricular septal defect is the most common type of congenital heart disease and this would be a risk factor for a more severe episode of bronchiolitis occurring. It’s also a risk factor for an increased complication rate.

Fragile X is not associated with worse episodes of bronchiolitis, however, Down’s syndrome has been.

Being fed on formula milk is a risk factor for bronchiolitis, however, does not increase the severity of the disease once it has already been caught

While the ages of 3-6 months are the most common for bronchiolitis, being aged between 3 and 6 months is not an indicator of a more severe episode. But being younger than 3 months (12 weeks) is a risk factor

Being born at term (37 weeks) is normal and not a risk factor. Being premature is however a risk factor for more severe episodes

Question 19

You are reviewing a 9-month-old child with suspected bronchiolitis. Which one of the following features should make you consider other possible diagnoses?

Fine inspiratory crackles
Rhinitis
Feeding difficulties
Temperature of 39.7ºC
Expiratory wheeze

Answer 19

A low-grade fever is typical in bronchiolitis. NICE state the following:

Consider a diagnosis of pneumonia if the child has:
high fever (over 39°C) and/or
persistently focal crackles.

Question 20

A 9-month-old boy presents to the paediatric emergency department with a fever and dry cough for 2 days. He was born 2 weeks premature and has no other significant past medical history. His temperature is 38.6ºC, heart rate is 110 beats per minute and respiratory rate is 45 breaths per minute. On examination, you find tachypnoea, a wheeze on auscultation and nasal flaring. No rash is noted and no abnormalities have been noted upon ear and throat examination.

Normal values of vital signs for children under 1 year are below:
Heart rate 110-160 beats per minute
Respiratory rate 30-40 breaths per minute
Systolic blood pressure 70-90 mmHg
Rectal temperature 36.6°C-37.5°C

What treatment would be recommended for this patient?

IV amoxicillin
IV co-amoxiclav
Oral amoxicillin
Palivizumab
Supportive measures such as maintaining oxygenation and hydration

Answer 20

Bronchiolitis does not require antibiotics, children requires supportive management only
Important for meLess important
This is most likely bronchiolitis as the child was born prematurely, has a low-grade fever and a wheeze on auscultation. Bacterial infections may produce greater systemic upset and worse readings on recording vitals signs. The fact that there is no rash means it is unlikely to be impetigo. A normal ear and throat examination mean it is unlikely to be an ear or throat infection.

There is little evidence to support the use of antibiotics as there is a low prevalence of bacterial infections in patients with bronchiolitis. Amoxicillin and co-amoxiclav are antibiotics and would have minimal effect on most cases as these target bacterial infections.

Palivizumab is a monoclonal antibody that is used as a prophylaxis treatment to prevent lower respiratory tract infections and would not be given in an acute setting.

Management is largely supportive to maintain adequate hydration and oxygenation as the majority of cases are viral. Respiratory syncytial virus is the most common causative organism in bronchiolitis.

Question 21

You are a GP trainee and a woman brings her 4-month-old baby to see you. She thinks he has picked up a virus. She says for the last 3 days he has had a runny nose, a dry cough and he feels hot.

On examination, the baby wakes on stimulation. He looks mildly dehydrated. His colour is normal and there is no cyanosis. He has a temperature of 38ºC and has a respiratory rate of 49 breaths per minute. There is a wheeze on chest auscultation and he is grunting at times.

What is your next course of action?

Reassure mum that this virus tends to get worse on days 3-5 but will get better within 3 weeks with supportive management
Salbutamol via a spacer
Prescribe antibiotics and advise her to bring him straight back or call 111 if he gets worse
Admit immediately via ambulance
Watch and wait

Answer 21

In bronchiolitis, the presence of grunting necessitates immediate referral to hospital

This baby has symptoms suggestive of bronchiolitis. He is grunting which is a sign of respiratory distress and flags as red on the NICE ill child traffic light system. He needs immediate referral to a paediatric assessment unit and in the community often the quickest way of securing appropriate treatment is by telephoning for an emergency ambulance.

Bronchiolitis does tend to worsen on days 3-5 then improve, and if there were no worrying signs then this would be appropriate advice, but given the grunting this is not correct in this case.

Salbutamol via a spacer is not recommended by NICE in bronchiolitis.

Similarly, bronchiolitis is caused by the respiratory syncytial virus (RSV) therefore antibiotics would not be effective.

Watching and waiting would put the child at risk of deterioration and could lead to worsening respiratory difficulties so is incorrect.

Question 22

A 5-month-old boy is brought to the hospital for review after developing coryzal symptoms four days ago which have progressed to a cough with increased work of breathing. He is formula-fed and only managing 50% of his normal feeds. The baby has no medical history, was born at term, and has received his vaccinations.

Pertinent examination findings are a temperature of 37.9ºC, oxygen saturation of 93% on air, a raised respiratory rate of 65 breaths per minute, and scattered expiratory wheeze and crackles on chest auscultation.

What is the appropriate management?

Intramuscular palivizumab
Intravenous amoxicillin
Oral azithromycin
Oral dexamethasone
Supportive care only

Answer 22

Supportive care only

Bronchiolitis does not require antibiotics, children requires supportive management only
Important for meLess important
Supportive care only represents the appropriate management for infants diagnosed with bronchiolitis, as is the case for this infant presenting with a new cough, wheeze, and laboured breathing after a coryzal illness. Given the poor oral intake, hospitalisation is warranted at least initially. Supportive measures will possibly include humidified oxygen and assistance with feeding. Antibiotics are not indicated in the treatment of bronchiolitis because it is typically caused by a viral infection (respiratory syncytial virus), and there is a low incidence of secondary bacterial infection. Furthermore, there is no evidence to support the effectiveness of antibiotics on clinical outcomes in these cases. Similarly, corticosteroids are not advised due to insufficient evidence supporting their benefit.

Intramuscular palivizumab is a monoclonal antibody directed against the respiratory syncytial virus, which is the predominant aetiological agent for bronchiolitis. It is utilised as prophylaxis in high-risk infants but not as a therapeutic intervention once bronchiolitis has developed.

Intravenous amoxicillin would not be appropriate for this patient. As previously mentioned, routine administration of antibiotics is not recommended for bronchiolitis management. Amoxicillin might be considered if pneumonia were suspected based on clinical features such as higher temperature at presentation and focal chest signs rather than diffuse crackles and wheezes.

Oral azithromycin, another antibiotic, would likewise be unsuitable for managing bronchiolitis. Azithromycin would be an appropriate choice for treating an alternative cause of cough, whooping cough. However, this scenario does not describe whooping cough, which typically presents with an initial 1-2 week period of coryzal symptoms followed by several weeks of severe coughing episodes.

Oral dexamethasone also does not have a role in the treatment of bronchiolitis. Corticosteroids like dexamethasone would be prescribed in cases suggestive of croup rather than bronchiolitis. Croup is characterised by inspiratory stridor and a distinctive barking cough.

Question 23

buzz words

Answer 23

Less than 1 years old

emergency department

dry cough

OE:
- increased work of breathing - chest recessions, +/- grunting, nasal flaring
- generalised/scattered expiratory wheeze
- bilateral inspiratory crackles.

breathless - tachypnoea

recent history of mild fever and coryzal symptoms (runny nose).

reduced feeds
less wet nappies

otherwise well and no past medical history of note. - The baby has no medical history, was born at term, and has received his vaccinations.

Observations show:
​
Respiratory rate: normal to high
Blood pressure: normal
Temperature: fever
Heart rate: normal to high
Oxygen saturation - low to normal

Question 24

Normal values of vital signs for children under 1 year

Answer 24

Normal values of vital signs for children under 1 year are below:
Heart rate 110-160 beats per minute
Respiratory rate 30-40 breaths per minute
Systolic blood pressure 70-90 mmHg
Rectal temperature 36.6°C-37.5°C

Question 25

An 8-month-old baby boy is brought to his GP with 3 days of coryzal symptoms, intermittent fever and coughing. He has been taking smaller feeds for the past 2 days and was unsettled last night. He has adequate oral intake. His mother has given him Calpol.

On examination, he is alert, there is no rash. His temperature is 38.2ºC, capillary refill is 1 second, pulse rate 152 bpm (80- 160), respiratory rate 58 breaths per minute (30-60) and oxygen saturation 97% in air. He has a widespread wheeze and fine crackles, his ears and throat are normal.

What is the most appropriate next step in management?

Admission to paediatric ward
Give nebulised salbutamol and review
Prescribe oral co-amoxiclav
Prescribe oral doxycycline
Reassure and give safety netting advice

Answer 25

Reassure and give safety netting advice

Bronchiolitis does not require antibiotics, children requires supportive management only

This young patient has presented with several days of coryza, fever accompanied by cough and wheeze, which are classic symptoms of bronchiolitis. Bronchiolitis is an acute inflammatory condition of the bronchioles that predominantly affects infants under one year old and is most commonly caused by the respiratory syncytial virus (RSV). This condition frequently presents in paediatric general practice, particularly during the winter months. While it can be distressing for parents to witness their child unwell in this manner, it is crucial to recognise red flags indicating a need for hospital admission. It is noteworthy that days three and four typically represent the peak of the severity of bronchiolitis, which should be considered when assessing patients.

Reassure and give safety netting advice is the correct approach. The management of bronchiolitis is primarily supportive, and NICE has issued explicit guidelines regarding hospital admission criteria for these patients. This child does not exhibit any red flags suggestive of respiratory distress such as grunting noises, cyanosis, use of accessory muscles for respiration, a respiratory rate exceeding 70 breaths per minute, oxygen saturations below 92% on room air or episodes of apnoea. These are signs of severe illness requiring immediate referral to secondary care. The child is maintaining an adequate fluid intake and their observations are within normal ranges. Consequently, the best course of action would be to provide safety-netting advice and monitor the child at home.

Admission to paediatric ward is incorrect. Although bronchiolitis is a common ailment that can cause significant parental concern, healthcare professionals must determine whether hospitalisation is necessary based on the presence of red flags. According to NICE guidelines, any child displaying signs of respiratory distress or abnormal observations—particularly a respiratory rate over 70 breaths per minute or oxygen saturations below 92%—should be promptly admitted to hospital care. This patient does not meet these criteria. NICE also recommends considering admission if there are feeding difficulties, insufficient fluid intake or a respiratory rate exceeding 60 breaths per minute; none apply in this instance. Therefore, monitoring from home remains appropriate.

Give nebulised salbutamol and review is incorrect. Although bronchiolitis may sometimes be mistaken for asthmatic exacerbations or virally-induced wheezing conditions in children presenting with coryza symptoms along with widespread wheezing and fine crackles (due to narrowing of the bronchioles), this case exhibits typical features of bronchiolitis warranting supportive care at home since no red flags are present.

Prescribe oral co-amoxiclav and prescribe oral doxycycline are incorrect options as well. Auscultation findings in bronchiolitis can occasionally mimic those seen in pneumonia due to crackles; however, fine widespread crackles concurrent with wheezing point away from focal pathologies such as pneumonia. With a mild fever at 38.2°C present here but without focal crackles or fever over 40°C—as suggested by NICE for considering chest radiography—the most likely diagnosis remains bronchiolitis without any alarming signs; thus supporting management at home should continue.