A wheezin’ we will go: Bronchiolitis/viral pathology

Case presentation

A 6-month-old baby with cough, congestion, and fever for 3 days presents to the emergency department with complaints of respiratory distress. Physical examination is significant for a temperature of 102 degrees Fahrenheit, respiratory rate of 55 breaths per minute, pulse oxygen saturation of 92%, and prominent intercostal, subcostal, and suprasternal retractions. On auscultation, there are diffuse crackles and intermittent wheezing heard in all lung fields. Mucous membranes are moist, and the child is still alert and playful despite increased work of breathing.

Imaging considerations

Several studies have shown that the routine use of radiographs in children with mild bronchiolitis or classic illness may lead to inappropriate antibiotics and is currently not recommended for routine use by pediatric practice guidelines. Secondary bacterial pneumonia is an uncommon complication and should be considered in children not having the expected clinical course or those admitted to the intensive care unit (ICU).

Radiographs are most likely to be useful in children with focal findings, severe disease, or signs of complications such as pneumothorax or when history and physical examination point to other causes in the differential diagnosis that may mimic aspects of the bronchiolitis examination (i.e., undiagnosed heart disease, myocarditis, foreign body, etc.).