What to assess and do when a patient presents to a primary care clinic with symptoms of bronchiolitis?

Primary Care Assessment of Bronchiolitis

Diagnose bronchiolitis based on history and physical examination alone—do not routinely order chest X-rays, viral testing, or laboratory studies. 1

Clinical Diagnosis

Bronchiolitis presents as a constellation of specific findings in children under 2 years of age:

History to Obtain

• Viral upper respiratory prodrome (rhinorrhea, cough) followed by increased respiratory effort and wheezing 1
• Impact on feeding, hydration, and mental status—these are critical markers of severity 1
• Duration of symptoms—typically 2-3 weeks is normal and does not indicate treatment failure 2
• Apnea episodes—particularly important in young infants 1

Physical Examination Findings

• Count respiratory rate over a full minute (not shorter intervals)—tachypnea ≥70 breaths/minute indicates increased severity risk 1, 2
• Assess work of breathing: nasal flaring, grunting, intercostal/subcostal retractions 1
• Auscultation: wheezing, rales/crackles 1
• Upper airway assessment: nasal congestion contributing to work of breathing 1

Clinical pitfall: The physical examination varies with disease state—serial observations over time may be needed to fully assess the child's status, and suctioning/positioning can improve exam quality. 1

Risk Stratification for Severe Disease

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

• Age <12 weeks (especially <1 month)
• History of prematurity (<37 weeks gestation)
• Hemodynamically significant congenital heart disease (on CHF medications, moderate-severe pulmonary hypertension, cyanotic lesions)
• Chronic lung disease/bronchopulmonary dysplasia
• Immunodeficiency or immunocompromised state
• In utero smoke exposure

These patients may have abnormal baseline oxygenation and are at higher risk for progression to severe disease, ICU admission, or mechanical ventilation. 1, 2

Severity Assessment

Indicators of Severe Disease

• Respiratory rate ≥70 breaths/minute 1, 2
• Significant retractions (intercostal, subcostal) 1
• SpO2 persistently <90% 2
• Poor feeding—particularly when respiratory rate exceeds 60-70 breaths/minute (aspiration risk increases significantly) 2
• Signs of dehydration 2
• Apnea episodes 1

What NOT to Do

Avoid routine testing—bronchiolitis is a clinical diagnosis: 1, 2

• No chest X-rays routinely—approximately 25% of hospitalized infants have radiographic atelectasis or infiltrates often misinterpreted as bacterial infection 2
• No viral testing routinely 1
• No laboratory studies routinely (CBC, CRP, blood cultures) 1

The absence of fever, tachycardia >100 bpm, respiratory rate >24 breaths/min, temperature >38°C, and focal consolidation on exam reduces pneumonia likelihood and eliminates need for chest radiography. 3

Immediate Management Decisions

Disposition Algorithm

Can discharge home if: 2

• SpO2 ≥90% on room air
• Feeding well without respiratory compromise
• Minimal respiratory distress
• Family able to care for child and return if needed 1

Consider admission or closer observation if: 2

• SpO2 persistently <90%
• Respiratory rate >60-70 breaths/minute with feeding difficulties
• Significant work of breathing
• Dehydration or inability to maintain oral intake
• High-risk patient (see risk factors above)
• Family unable to provide adequate care or return for follow-up 1

Supportive Care Instructions

For patients managed at home: 2

• Continue breastfeeding if possible—72% reduction in hospitalization risk for respiratory diseases 2
• Gentle nasal suctioning as needed for symptomatic relief only 2
• Maintain hydration—encourage frequent small feeds 2
• Avoid tobacco smoke exposure 2
• Expect symptoms to last 2-3 weeks—this is normal 2

What NOT to Prescribe

Do not routinely prescribe: 2

• Bronchodilators (albuterol)—lack evidence of benefit in bronchiolitis
• Corticosteroids—no significant benefit in length of stay or clinical scores
• Antibiotics—risk of serious bacterial infection is <1% in febrile infants with bronchiolitis; only use with specific indications like acute otitis media or documented bacterial pneumonia

Clinical pitfall: Fever alone does not justify antibiotics in bronchiolitis. 2

Follow-Up Planning

Instruct families to return immediately if: 1, 2

• Worsening work of breathing
• Inability to feed
• Signs of dehydration (decreased urine output, dry mucous membranes)
• Apnea episodes or color changes
• Lethargy or altered mental status

Assess family's ability to recognize these warning signs and access care before discharge. 1