Treatment for Infants with Rhonchi Lung Sounds
The treatment of an infant with rhonchi lung sounds should focus on identifying and treating the underlying cause, typically a lower respiratory tract infection requiring antibiotics, bronchodilators, and supportive care.
Understanding Rhonchi in Infants
Rhonchi are low-pitched continuous lung sounds with a dominant frequency of about 200 Hz or less 1. They are often described as coarse rattling sounds that can indicate the presence of secretions or mucus in the larger airways. In infants, rhonchi commonly occur with:
- Lower respiratory tract infections
- Bronchiolitis
- Pneumonia
- Bronchopulmonary dysplasia
- Airway obstruction from secretions
Diagnostic Approach
Before initiating treatment, it's important to determine the underlying cause:
Assess severity: Evaluate for signs of respiratory distress including:
- Tachypnea (respiratory rate >50 breaths/min in infants)
- Retractions
- Nasal flaring
- Cyanosis
- Oxygen saturation <92% (indicates severe disease) 2
Chest examination: Look for decreased chest expansion, dullness to percussion, and reduced breath sounds 2
Chest imaging:
Consider bronchoscopy: For infants with persistent wheezing/rhonchi despite standard treatment with bronchodilators or corticosteroids, flexible fiberoptic bronchoscopy with bronchoalveolar lavage may be indicated 2
Treatment Algorithm
1. Infectious Causes (Most Common)
If signs of infection are present (fever, elevated WBC):
Antibiotics: Amoxicillin is first-line for upper and lower respiratory tract infections in infants 3
- Dosing should be adjusted for infants under 12 weeks due to incompletely developed renal function
- Typical dosing: 20-40 mg/kg/day divided every 8-12 hours
Supportive care:
- Maintain hydration
- Nasal suctioning to clear secretions
- Humidified air
- Fever control with acetaminophen if needed
2. Bronchospasm Component
If wheezing accompanies rhonchi:
Bronchodilators: Consider trial of inhaled beta-agonists via nebulizer or metered-dose inhaler with infant spacer
- Note: Response should be monitored as bronchodilators can sometimes worsen airway collapse in certain conditions 2
Corticosteroids: Consider for persistent symptoms, especially with history of recurrent wheezing
3. For Chronic Lung Disease (BPD)
If the infant has established bronchopulmonary dysplasia:
Oxygen therapy: Maintain O₂ saturations between 92-95% 4
Diuretics: May be considered for short-term use only if evidence of pulmonary edema exists
- Not recommended for routine long-term use due to side effects including electrolyte imbalances, nephrolithiasis, and hearing deficits 4
- Monitor electrolytes if used
Inhaled corticosteroids: For inflammatory component
4. For Severe Cases
Hospital admission: All infants with parapneumonic effusion or empyema should be admitted 2
Respiratory support: Supplemental oxygen or mechanical ventilation if needed
Inhaled nitric oxide: Can be effective for infants with established BPD and symptomatic pulmonary hypertension 4
Follow-up and Monitoring
- Reassess within 24-48 hours for improvement
- If fever persists beyond 48 hours of appropriate treatment, re-evaluation is necessary 2
- For chronic cases, serial assessments including pulmonary function tests may be needed
Important Considerations
Avoid empiric food avoidance: For infants without eczema but with persistent wheezing/rhonchi, empiric food avoidance or dietary changes are not recommended 2
Consider swallowing dysfunction: Video-fluoroscopic swallowing studies may be indicated for infants with persistent symptoms to rule out aspiration 2
Beware of terminology confusion: The terms "rhonchi" and "crackles" are sometimes used inconsistently in clinical practice 5, 6, so clarify the exact nature of the lung sounds when communicating with colleagues
Monitor for complications: Severe cases can lead to respiratory failure or, rarely, complications like pneumomediastinum 7