Diagnosis: Viral Bronchiolitis
This 11-month-old infant has viral bronchiolitis, most likely caused by respiratory syncytial virus (RSV), and should receive supportive care only—bronchodilators, corticosteroids, and antibiotics are not indicated. 1, 2
Clinical Reasoning
The clinical presentation is classic for bronchiolitis in this age group:
- Fever, cough, and wheezing following an upper respiratory prodrome are typical initial symptoms 1, 3
- Hyperinflation on chest x-ray without infiltrates is the hallmark radiographic finding that distinguishes bronchiolitis from pneumonia 3
- Age 11 months places this infant in the peak demographic for bronchiolitis (most common in children under 2 years) 4, 2
- Wheezing as the predominant finding suggests viral bronchiolitis rather than bacterial pneumonia, where crackles and decreased breath sounds would be more prominent 5, 6
The absence of infiltrates on chest x-ray effectively rules out bacterial pneumonia, which would show consolidation or infiltrates 7, 3. The hyperinflation pattern reflects air trapping from small airway inflammation and obstruction characteristic of bronchiolitis 3.
Management: Supportive Care Only
Provide only supportive measures—oxygen if saturations <90-92%, hydration, and minimal handling. 1, 2
What NOT to Do (Critical)
- Do not give albuterol or other bronchodilators—these are not recommended for infants ages 1-23 months with bronchiolitis 2
- Do not give systemic corticosteroids—no benefit has been demonstrated 1, 8
- Do not prescribe antibiotics—bronchiolitis is viral and antibiotics provide no benefit 1, 8
- Do not give nebulized epinephrine in the outpatient setting 1
- Do not perform chest physiotherapy—this is not recommended 1
The FDA label for albuterol demonstrates efficacy in asthma and obstructive airway disease 9, but bronchiolitis pathophysiology differs fundamentally—the obstruction is from inflammation and mucus plugging of small airways, not bronchospasm responsive to beta-agonists 1, 8.
Supportive Care Specifics
- Monitor oxygen saturation: Maintain SpO2 >90% (at altitude) or >92% (at sea level) 3
- Provide supplemental oxygen if saturations fall below these thresholds 1, 3
- Ensure adequate hydration: Use nasogastric or intravenous routes if oral intake is insufficient 1
- Nasal suctioning to clear secretions 2
- Minimal handling to reduce oxygen demand 1
Admission Criteria
Consider hospitalization if:
- Oxygen saturation <90-92% 3
- Severe respiratory distress (grunting, nasal flaring, significant retractions) 3
- Inability to maintain hydration 1
- Age <3 months, prematurity, or comorbidities (congenital heart disease, chronic lung disease) 8, 3
Common Pitfalls
Do not confuse bronchiolitis with pneumonia or asthma. The key distinguishing features are:
- Hyperinflation without infiltrates = bronchiolitis 3
- Infiltrates or consolidation = pneumonia 7
- Wheezing in bronchiolitis does not respond to bronchodilators like it does in asthma 1, 8
Do not obtain routine chest x-rays—the diagnosis is clinical, and imaging is only needed if pneumonia is suspected or the diagnosis is unclear 1, 2, 3. In this case, the x-ray was already done and confirms bronchiolitis by showing hyperinflation without infiltrates 3.
Do not order viral testing or blood work routinely—these do not change management 1, 3. Complete blood counts and C-reactive protein are not useful in bronchiolitis 3.
Expected Course
Most cases are self-limited, with symptoms worsening for several days before gradually resolving over 1-3 weeks 2. However, some infants may have increased risk of asthma later in childhood 1, 8.