Clinical presentation and management of RSV bronchiolitis in a 54-day-old infant

B.R. is a 54-day-old male child who was taken to Palmdale Emergency Department after two days of increasing respiratory distress and congestion. He was prescribed an Albuterol inhaler and sent home, where he did well for one day, then began to worsen. His mother reported that he looked as if he was choking and began to turn blue. His palms turned pale and felt cold to the touch. He was diagnosed with RSV bronchiolitis and admitted to the pediatric floor for supportive care. B.R. required deep suctioning to keep his airway clear. Since admission, B.R. has experienced difficulty breathing. His lungs have course breath sounds bilaterally with crackles, but no wheezing. His chest movement has retractions and he has nasal flaring. Since admission he has not had a high fever; instead, his temperature has been in the normal range. However, his plus oximetry range has been between 94% to 100%. B.R. is a breast fed infant and has had an adequate appetite, with intake at about 80% of what he normally eats. His bowel patterns have been consistent, with stool and urine consistent with expectations for a breast fed baby (4 to 5 diapers with stool a day), and wet diaper changes approximately every two hours. B.R.'s lab results revealed some abnormalities. His creatine level of .3 was low, which is to be expected in an infant because the kidney is not fully developed. His potassium level of 6 is high, which can be caused by use of albuterol, a bronchodilator. His anion gap of 4 was low, which was due to his potassium being elevated. His past medical history was without trauma or prior illness. His birth was a normal full-term birth. B.R. is up-to-date on recommended immunizations.

Incidence of Medical Diagnosis

Diagnosis was based on B.R.'s symptoms, as reported by his parents and observed in the emergency room. According to Bowden (2009), bronchiolitis- is an acute inflammation and obstruction of the bronchioles, the smallest, most distal sections of the respiratory airway network. Parent reports sneezing and nasal discharge initially, and then the development of a harsh, dry cough and low grade fever. Wheezing on ausculation. The infant may develop increasingly distressed breathing and tachypnea. Feeding difficulties or loss of appetite may be caused by nasal congestion and the increased work required to breath. RSV Brochioles the symptoms of mild infection include rhinorrhea, mild cough, irritability, and low-grade fever for 1-3 days. Moderate infections and infections in infants and young children often present with more pronounced cough, wheezing, moderate fevers to 102°F, and decreased feeding. As the condition progresses and the infant has to work harder to breath, nasal flaring, grunting, tachypnea, and retractions develop.

B.R. began to get sick two days prior to his admission, with respiratory distress and congestion. He was given Albuterol HHN and sent home, but his condition worsened after two days of treatment. His respiratory distress was severe enough to cause choking and for him to turn blue from a lack of oxygen. He had course breath sounds with fine crackles, irregular breathing pattern, labored breathing, and was making an effort to breath. In addition, his chest movement had retractions and nasal flaring.

Genetic Implications

RSV is a virus, and is not related to genetic conditions. Bronchiolitis is also not a genetic disease. However, some genetic conditions can exacerbate a patient's risk of developing a severe form of RSV, such as the fact that male children are at greater risk than female children. "Younger children with several underlying conditions, including chronic lung disease, congenital heart disease or immunodeficiency disorders, are at higher risk for hospital admission for bronchiolitis. In contrast, previously healthy term infants often present with milder symptoms, although some studies report more serious manifestations including respiratory distress, hypoxia, or severe apnoea spells, which may eventually require intensive care" (Papoff et al., 2011). Furthermore, "in both high and low risk infants, several epidemiological, demographic and virological factors have been associated with the severity of bronchiolitis" (Papoff et al., 2011). These include: a family history of atopy, lower birth weight, being male, being younger than six months, maternal smoking, lack of breastfeeding, and crowding in the home (Papoff et al., 2011).

Analysis of Clinical Manifestations

"The diagnosis of bronchiolitis is a clinical one. Most infants present with breathing difficulty in association with a coryzal illness. Neonates may have apnoea, but more typically, babies develop rapid, shallow breathing (often at a rate greater than 60 breaths per min in more severe cases), head bobbing, tracheal tug, chest wall hyperinflation with or without intercostal recession and a characteristic cough. Wheeze is not universal, and the most characteristic auscultatory finding is fine crackles" (Fitzgerald, 2011).

B.R.'s symptoms were in-line with a diagnosis of bronchiolitis. He experienced significant breathing problems and congestion. He not only had crackling sounds and labored breathing, but appeared to be choking when he was trying to breath. On the day of assessment, B.R. had a temperature ranging from 98 to 98.2, blood pressure of 97/57, respiration ranging from 57 to 64, oxygen saturation of 98% to 99% (while being treated with an ae liter nasal cannula oxygen flow). B.R. continued to exhibit labored, irregular breathing with crackle sounds, deep chest movement, and nasal flaring.

Analysis of Laboratory and Diagnostic Tests / Values

B.R. received a chest x-ray to in order to rule out any additional lung or chest problems, because B.R. appeared to be in pain and was too young to communicate what he was feeling. The chest x-ray results were normal. There was no radiographic evidence of acute cardiopulmonary disease. The cardiomediastinal silhouette was normal The lungs were clear and cost costophrenic angles were sharp. The ossous structure was grossy unremarkable.

Treatments: Standards of Care Per Literature

Treatment for bronchiolitis is supportive rather than curative. "In children hospitalized for RSV infection, observation and supportive care are the primary treatments. These treatments include hydration; careful clinical assessment of respiratory status, including oxygen saturation, administration of supplemental oxygen as needed; suctioning of the upper airway; as well as intubation and mechanical ventilation when indicated" (Todd et al., 2010). The optimal level of nasal continuous positive airway pressure is 7 cmH2O (Essouri et al., 2011). B.R.'s treatment aligned with the recommendations of the literature and included: suctioning to maintain a clear aware, humidifying the room, introduction of oxygen to keep B.R.'s oxygen saturation above 94%, monitoring B.R.'s secretions, administration of I.V. fluids to keep B.R. hydrated, and, prior to hospitalization, the administration of albuterol.

B.R.'s breathing was labored and was not significantly improved by the interventions, although suctioning to clear the airways and the introduction of oxygen ensured adequate oxygen intake. Postiaux et al. found that the addition of prolonged slow expirations and provoked coughs could contribute "actively to a direct and immediate drainage of secretions" (2011). This might have helped alleviate "some bronchial obstruction symptoms that are usually associated with an increased load of breathing, due to a positive intrathoracic pressure and an increased respiratory rate" (Postiaux et al., 2011).

Potential Long-Term Effects / Complications

An early and severe infection with RSV bronchiolitis is associated with breathing difficulties such as asthma, wheezing, and atopy later in life (Todd et al., 2010). Whether the RSV causes these problems or whether a common factor makes infants more susceptible to bronchiolitis and later breathing problems is uncertain (Todd et al., 2010). Therefore, B.R. is considered to be at a higher risk of developing these problems.