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You are seeing a 4 month old infant with fever, nasal congestion, and cough for 2 days. The baby is a previously well ex-full term infant with no past medical history, up to date on immunizations. He has been slightly less than usual but still having several wet diapers per day, and is still playful and interactive. On exam, his temperature is 38.4C, HR 135, RR 48, BP 80/40, and O2 sat 93% on room air. He has diffuse mild wheezes and minimal subcostal retractions, but no grunting, nasal flaring, stridor, cardiac murmur, hepatomegaly, or evidence of dehydration. There is no personal or family history of prior wheezing. His parents are able to return to the ED if necessary and can arrange follow-up with their pediatrician.
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April 2, 2021 at 10:04 pm
E) Perform nasal suction, educate parents, discharge with return precautions and pediatrician follow-up
This infant has classic findings of viral bronchiolitis, most commonly caused by RSV, but also caused by other viruses e.g. human metapneumovirus, coronaviruses, influenza. The AAP guidelines state that clinicians can forgo pulse oximetry monitoring and supplemental oxygen as long as the O2 sat is > 90% on room air, although clinical judgement and individualized management is, of course, always important. This patient, being non-toxic, feeding well, and having good follow-up, is a good candidate for following this guideline. The scenario is not worrisome for a cardiac etiology, and routine testing is not necessary with clinically-diagnosed bronchiolitis. The main therapy recommended for ED clinicians based on the evidence is nasal suctioning. Nebulized albuterol, salbutamol, and epinephrine, corticosteroids, antibiotics, and chest physiotherapy are all not recommended. Nebulized hypertonic saline may be useful for inpatients, but is not recommended for ED management. Admitting patients solely due to the risk of apnea is controversial, but the highest risk patients to consider for admission are those < 1 month old (or post-conceptual age of 48 weeks), particularly if born premature.