 20 month old male who presents to the emergency department with a chief complaint of cough.  Two days ago he developed rhinorrhea, fever, a hoarse cry and a progressively worsening, harsh, "barky," cough.  Today he developed a "whistling" sound when he breathes, so his parents brought him to the emergency department.  His past medical history is unremarkable. His 6 year old brother also has cold symptoms.

 Exam: VS T 37.5, P 140, R 36, BP 90/64, oxygen saturation 96% in room air.  GEN: alert, with good eye contact, in mild respiratory distress. He has a dry barking cough and a hoarse cry.  HEENT: some clear mucus rhinorrhea but no nasal flaring. His pharynx is slightly injected, but there is no enlargement or asymmetry.  CVS: Heart is regular without murmurs.  LUNG: good aeration and slight inspiratory stridor at rest. He has very slight subcostal retractions. No wheeze or rhonchi are noted.  Abdomen: flat, soft, and non-tender.  Extremities: warm and pink with good perfusion.

 He is treated with nebulized racemic epinephrine and his coughing subsides and his stridor resolves. He is also given oral dexamethasone

A lateral neck X-ray reveals no prevertebral soft tissue widening or evidence of epiglottitis. The subglottic region is mildly narrowed.

 He is discharged home after one hour of monitoring and his parents were instructed to treat him with humidified mist therapy.

 < 2yo  URI (rhinorrhea, congestion)  LRT inflammation (crackles/wheezes)  Viral etiology 80%, Mycoplasma Pneumonia  May overlap with Asthma

 Assessing severity:  Persistent increase in respiratory effort (>70 RR), nasal flaring, intercostal retractions, cyanosis, grunting  Hypoxemia (SaPO2 <95%)  Apnea

 Indication for Hospitalization:  Toxic appearing, decreased feeding, lethary, dehydration  SaPO2 <95%  Parents/caregivers cannot manage at home

 *caretakers are comfortable*  Supportive Care  Hydration  Nasal passage clearance  Monitoring progression  Pharmacologic tx NOT recommended b/c lack of proven benefits, increased cost

 EDUCATION**  Course of disease – URI symptoms  LRT symptoms 2-3 days  peak 4-7 days  resolution 2-3 weeks  Suctioning  I/O’s – min 1 wet diaper/12 hours  Feedings/ cyanosis/ increased resp effort/lethargy  F/u 1-2 days for improvement of symptoms (phone call)

 ED  respiratory support (O2)  Fluids  Monitoring  Bronchodilators/nebulized hypertonic saline/glucocorticoids NOT routinely recommended  Contact Precautions  CPAP/HFNC  1 to 23 months of age, emphasizes that testing for specific viruses is unnecessary because bronchiolitis may be caused by multiple viruses.

 Repeated clinical assessment of the respiratory system (eg, respiratory rate; nasal flaring; retractions; grunting)  In children who do not improve at the expected rate, chest radiographs may be helpful in excluding other conditions in the differential diagnosis (eg, foreign body aspiration, heart failure, vascular ring, tuberculosis, cystic fibrosis  older than six months and require hospitalization for management of bronchiolitis, the average length of stay is three to four days  wheezing persists in some infants for a week or longer  Risk factors for worsening after initial clinical improvement included age <2 months, <37 weeks gestational age, and severe retractions, apnea, or dehydration at presentation

 Minimal clinical criteria for discharge from the hospital or emergency department include  ●Respiratory rate <60 breaths per minute for age <6 months, <55 breaths per minute for age 6 to 11 months, and <45 breaths per minute for age ≥12 months  ●Caretaker knows how to clear the infant's airway using bulb suctioning  ●Patient is stable while breathing ambient air and has maintained oxygen saturation >94 percent; discharge from the hospital requires that the patient remain stable for at least 12 hours prior to discharge  ●Patient has adequate oral intake to prevent dehydration  ●Resources at home are adequate to support the use of any necessary home therapies (eg, bronchodilator therapy if the trial was successful and this therapy is to be continued)  ●Caretakers are confident they can provide care at home  ●Education of the family is complete

 overall mortality rate in children hospitalized with respiratory syncytial virus (RSV) bronchiolitis in developed countries is less than 0.1 percent  Mortality is increased in young infants (6 to 12 weeks), those with low birth weight, and those with underlying medical conditions

 Immunoprophylaxis with palivizumab, a humanized monoclonal antibody against the respiratory syncytial virus (RSV) F glycoprotein, decreases the risk of hospitalization due to severe RSV illness among preterm infants and those with chronic lung disease and hemodynamically significant congenital heart disease.palivizumab  AAP guidance for palivizumab immunoprophylaxis has become increasingly restricted, driven in part by the high cost associated with monthly administration.

 DX:  Fever  Tachypnea – important  2 – 12 months (>50), 1-5 years (>40)  Auscultation!!  CXR – useful but not the end all be all  positive findings have not been shown to improve clinical outcomes or significantly change treatment  Lobar infiltrates more suggestive of bacterial, as are pleural effusions  Procalcitonin, CRP, WBC (>15k)

 2 to 24 months - Streptococcus pneumoniae  Chlamydia trachomatis  2 to 5 YO - Strep pneumoniae  Mycoplasma pneumoniae  H. influenzae (B and nontypable)  C. pneumoniae  5 years and up - Mycoplasma pneumoniae  C. pneumoniae  Strep pneumoniae  S. aureus accounts for 3 to 5 percent of CAP infections – MRSA is out there, more severe infections.

 60 days to 5 years – Amoxicillin 80 mg/kg/day divided BID for 7-10 days  5 to 16 years – Azithromycin  Day 1 = 10 mg/kg  Day 2-5 = 5 mg/kg

 60 days to 5 years – Cefuroxime 150 mg/kg/day IV, divided Q8 H for 10 to 14 days  If critically ill or OLDER than 5 years, add Erythromycin 40 mg/kg/day IV or orally, divided Q6 H for 10 to 14 days  Now, my caveat to this is in Waterloo we realistically just do Rocephin mg/kg/day along with Azithromycin 10 mg/kg then 5 mg/kg.

 Trend procalcitonin and CRP  Pay big attention to temps and respiratory rate  The absence of tachypnea is the most useful clinical finding for ruling out CAP in children.  Empiric antibiotic choices in children with CAP should be based on the patient’s age and severity of illness, and local resistance patterns of pathogens.  Chest radiography has not been shown to improve clinical outcomes or change treatment of CAP in children.