What are the diagnostic criteria and treatment options for bronchitis in pediatric patients?

Diagnosing Bronchitis in Pediatric Patients

Bronchiolitis in infants and young children (under 2 years) should be diagnosed based solely on history and physical examination—do not routinely order chest radiographs, viral testing, or laboratory studies. 1, 2

Clinical Presentation and Diagnostic Criteria

The diagnosis requires identifying a constellation of findings in children under 2 years of age: 2

• Viral upper respiratory prodrome (rhinorrhea, congestion) followed by lower respiratory signs 1, 2
• Lower respiratory tract signs: tachypnea, wheezing, rales, and cough 2
• Increased respiratory effort: grunting, nasal flaring, intercostal/subcostal retractions 2

Key History Elements to Assess

When evaluating a child with suspected bronchiolitis, focus on: 2

• Feeding and hydration status: Is the child able to maintain oral intake? 2
• Mental status changes: Look for lethargy or irritability 2
• Duration of symptoms: Viral prodrome typically precedes lower respiratory symptoms 1

Physical Examination Specifics

Count the respiratory rate for a full 60 seconds—this is critical for accuracy. 2 Tachypnea ≥70 breaths/minute suggests increased risk of severe disease. 2

Serial observations over time are necessary rather than relying on a single examination, as bronchiolitis has substantial temporal variability in physical findings. 1, 2

Risk Stratification for Severe Disease

Identify high-risk patients who require closer monitoring: 1, 2

• Age <12 weeks 1, 2
• History of prematurity 1, 2
• Hemodynamically significant congenital heart disease 1, 2
• Chronic lung disease 1, 2
• Immunodeficiency 1, 2
• In utero smoke exposure 2

What NOT to Order

Do not routinely obtain chest radiographs, laboratory studies, or RSV testing in children with typical bronchiolitis. 2 These tests do not alter management and increase costs without improving outcomes. 2

When Radiography May Be Considered

Chest radiography may be useful only when: 1

• The hospitalized child does not improve at the expected rate 1
• The severity of disease requires further evaluation 1
• Another diagnosis (such as pneumonia) is suspected 1

Important caveat: In prospective studies, children with suspected lower respiratory tract infections who received radiographs were more likely to receive antibiotics without any difference in time to recovery. 1

Laboratory Testing

Complete blood counts are not useful in either diagnosing bronchiolitis or guiding therapy. 1 The occurrence of serious bacterial infections (urinary tract infections, sepsis, meningitis) is very low (<1%). 1, 3

Virologic testing for RSV demonstrates high predictive value during peak season but rarely alters management decisions or outcomes. 1 Virologic testing may be useful only when cohorting of patients is feasible. 1

Distinguishing Bronchiolitis from Other Conditions

Pneumonia

Suspect pneumonia in patients with: 4

• Tachypnea, tachycardia, dyspnea 4
• Lung findings suggestive of pneumonia 4
• Radiography is warranted in these cases 4

Pertussis

Consider pertussis when: 4

• Cough persisting for more than two weeks 4
• Paroxysmal cough, whooping cough, post-tussive emesis 4
• Recent pertussis exposure 4

Common Pitfalls to Avoid

Do not treat based solely on pulse oximetry readings without clinical correlation. 3 Pulse oximetry can reliably detect hypoxemia not suspected on physical examination, but among outpatients, evidence differs on whether mild reductions in pulse oximetry (<95% on room air) predict disease progression. 1

Fever alone does not justify antibiotics—the risk of serious bacterial infection in febrile infants with bronchiolitis is <1%. 3

Routine diagnostic testing increases costs without improving outcomes and may lead to inappropriate antibiotic prescribing. 2

Note on Terminology

The term "bronchitis" in pediatric patients typically refers to bronchiolitis in infants and young children under 2 years of age. 1 In older children, acute bronchitis is characterized by cough due to acute inflammation of the trachea and large airways without evidence of pneumonia, and is usually viral. 4 The diagnosis of chronic or recurrent bronchitis in children is poorly defined and may overlap considerably with asthma. 5