History Collection for Bronchiolitis
When evaluating a patient for bronchiolitis, collect a focused history that includes the viral prodrome pattern, current respiratory symptoms, feeding/hydration status, and specific risk factors for severe disease—this clinical history alone, without routine laboratory or radiographic studies, is sufficient for diagnosis. 1
Essential Historical Elements
Current Illness Pattern
- Viral upper respiratory prodrome: Document presence of rhinorrhea and cough that preceded lower respiratory symptoms 1
- Progression to lower respiratory tract involvement: Ask about onset of increased respiratory effort, wheezing, and worsening cough 1, 2
- Timing and seasonality: Bronchiolitis typically occurs during winter months, which supports the diagnosis 1
Functional Impact Assessment
- Mental status changes: Assess for lethargy, irritability, or decreased responsiveness 1
- Feeding difficulties: Document decreased oral intake, tiring during feeds, or complete refusal to eat/drink 1, 3
- Hydration status: Ask about urine output, number of wet diapers, and signs of dehydration 1
- Sleep disturbance: Inquire about ability to sleep and positioning that helps breathing 3
Critical Risk Factors for Severe Disease
Age and Prematurity
- Age less than 12 weeks: This is the single most important age-related risk factor 1, 2
- History of prematurity: Document gestational age at birth and corrected age 1
- Postconceptional age: For preterm infants, calculate current postconceptional age 1
Underlying Medical Conditions
- Cardiopulmonary disease: Specifically ask about hemodynamically significant congenital heart disease and chronic lung disease/bronchopulmonary dysplasia 1, 2
- Immunodeficiency: Document any known immunocompromising conditions 1
- Genetic abnormalities: Ask about diagnosed genetic conditions associated with severe presentations 1
- Congenital anomalies: Document any structural abnormalities 1
Environmental and Social History
- In utero smoke exposure: Ask about maternal smoking during pregnancy 1
- Current smoke exposure: Document household smoking and secondhand smoke exposure 3, 4
- Crowded living conditions: Assess exposure risk during RSV season 3
- Sick contacts: Document exposure to individuals with respiratory infections 3
Previous Respiratory History
- Prior wheezing episodes: Children with recurrent wheezing after the first year likely have asthma rather than first-time bronchiolitis 2
- Previous apneic events: Document any history of apnea, particularly in preterm infants 1
- Previous hospitalizations: Ask about prior respiratory illnesses requiring admission 1
Family and Caregiver Assessment
- Ability to provide home care: Assess family's capacity to monitor the child and provide supportive care 1
- Access to follow-up: Determine ability to return for reevaluation if condition worsens 1
- Understanding of warning signs: Ensure caregivers can recognize red flags for deterioration 3
Apnea Risk Stratification
- Age and gestational history: One large study found no apnea in infants >1 month (full-term) or >48 weeks postconceptional age (preterm) without previous apneic events 1
- Previous apnea: Any prior apneic episode significantly increases risk 1
- Neuromuscular disease: Document any conditions affecting respiratory drive 1
What NOT to Routinely Obtain
The American Academy of Pediatrics explicitly states that when bronchiolitis is diagnosed based on history and physical examination, radiographic or laboratory studies should NOT be obtained routinely. 1, 2 This includes:
- Chest radiographs 1, 2, 4
- RSV testing 4
- Viral cultures 4
- Complete blood counts 4
- Blood cultures (unless sepsis is suspected) 4
These tests do not alter management and may lead to inappropriate antibiotic prescribing 4.