Indian J Pediatr (November 2011) 78(11):1396–1400
DOI 10.1007/s12098-011-0492-z
SYMPOSIUM ON PGIMER PROTOCOLS ON RESPIRATORY EMERGENCIES
Approach to a Child with Lower Airway Obstruction
and Bronchiolitis
Sudhanshu Grover & J. Mathew & Arun Bansal &
Sunit C. Singhi
Received: 25 April 2011 / Accepted: 16 May 2011 / Published online: 28 May 2011
# Dr. K C Chaudhuri Foundation 2011
Abstract Lower airway obstruction can occur at the level of
trachea, bronchi or bronchioles. It is characterized clinically
by wheeze and hyperinflated chest, apart from other signs of
respiratory distress. Common causes include bronchiolitis,
asthma, pneumonia, laryngotracheo-bronchitis, congenital
malformations and foreign body inhalation. Bronchiolitis
usually occurs in children aged 2 months to 2 years. It is
most commonly caused by respiratory syncytial virus infec-
tion. The diagnosis is mainly clinical, and investigations have
a very limited role. Humidified oxygen and supportive therapy
are the mainstays of treatment. A trial of inhaled epinephrine
or parenteral steroids may be considered for non-responders. It
is usually associated with good outcome.
Keywords Children . Lower airway obstruction . Wheeze .
Bronchiolitis
Lower Airway Obstruction
Obstruction in the lower airways (i.e. airways within the
thorax) may occur in the trachea, bronchi or bronchioles.
The general symptoms/signs of respiratory tract disease
include cough, tachypnea, and increased respiratory effort.
The most characteristic symptom and sign of lower airway
obstruction is wheezing. Wheeze is a high pitched whistling
sound usually heard during expiration (sometimes heard
with stethoscope only). It is caused by vibrations of airways
during passage of air through narrow lumen. Other relatively
S. Grover : J. Mathew : A. Bansal : S. C. Singhi (*)
Department of Pediatrics, Advanced Pediatrics Centre,
Postgraduate Institute of Medical Education and Research,
Chandigarh 160012, India
e-mail: sunit.singhi@gmail.com
specific clinical pointers are prolonged expiration and
hyperinflated chest. Wheeze is most often expiratory, but it
may also be inspiratory or biphasic. Expiration becomes an
active rather than a passive process in such cases. There are
many causes of wheezing in infancy and childhood. These are
summarized in Table 1. The most common among these,
presenting with an acute illness in authors’ emergency
department are bronchiolitis, acute asthma, pneumonia,
congestive cardiac failure, laryngotracheo-bronchitis, airway
foreign bodies and congenital malformations. In a study
published in 2002 from a teaching hospital in north
India, the common causes of wheezing in children aged
2 months to 1 year were bronchopneumonia(50%),
bronchiolitis(34%), bronchial asthma(16%) after exclud-
ing foreign body inhalation, congestive cardiac failure,
and anatomical malformations [1]. In Singapore, 22.7%
children had at least one episode of wheeze by the second
year of life [2], while in the West one-third children had at
least one lower respiratory tract infection with wheeze in
the first 3 years of life [3].
Older patients with lower airway obstruction tend to
breathe at a slower rate; however infants breathe faster. This
is because of a highly compliant chest wall; wherein slower
breathing would lead to subatmospheric intrapleural pres-
sure and collapse of the chest wall.
Approach to a Wheezing Child
In pediatric emergency, important points in history and
examination are as follows:
History
& Age of onset: Onset in neonatal period/early infancy sug-
gests CCF, anatomic malformation, or immunodeficiency.
Indian J Pediatr (November 2011) 78(11):1396–1400 1397

Table 1 Differential diagnosis of acute wheezing in infants & Signs of allergy or atopy like rhinitis, conjunctivitis,
1. Infection eczema suggest asthma/allergic bronchitis.
• Viral: Respiratory syncytial virus bronchiolitis, Parainfluenza, & Look for the signs of CCF like hepatomegaly, neck
Influenza, Adenovirus, Rhinovirus, Human metapneumovirus veins, dependent edema, and growth pattern.
• Bacterial pneumonia Remember
• Chlamydia pneumonia
2. Asthmaa & In a child with acute onset wheezing, with history of
3. Aspiration syndromesa preceding fever and abdominal pain, and presence of
4. Heart diseasea temperature >38°C at presentation, pneumonia is the
• Congestive cardiac failure
likely diagnosis [4].
• Myocarditis
& All infants/children with bilateral wheezing do not have
• Cardiomyopathy
bronchial asthma [4]
& Foreign body aspiration can present with non-
5. Anatomic abnormalitiesa
lateralization of findings; it should be suspected in non-
• Extrinsic airway compression
responders to inhaled bronchodilators and corticosteroids
- Vascular ring/sling
[4].
- Mediastinal lymph node/mass
& Asthma and congenital heart disease can coexist [4].
• Intrinsic airway anomalies
& In a young infant (2 to 6 months) with mild to moderate
- Airway hemangioma
grade fever and wheeze along with respiratory distress,
- Cystic adenomatoid malformation
bronchiolitis is the most likely diagnosis.
- Bronchial lung cyst
- Congenital lobar emphysema
- Sequestration of lung
Bronchiolitis
- Mediastinal lymph node/tumor/TB lymphadenitis
• Central airway obstruction: laryngotracheo-malacia
“Bronchiolitis” refers to inflammation of peripheral air-
6. Foreign body
ways. It is the most common cause of wheezing in young
7. Anaphylaxis
infants.
8. Inhalational injuries (burns)
9. Mucociliary clearance disordersa
Etiology
• Cystic fibrosis
• Primary ciliary dyskinesia
Respiratory syncytial virus (RSV) is responsible for more
• Bronchiectasis than 50% cases. Other etiologic agents include Para-
10. Gastro-esophageal reflux influenza, Adenovirus, Mycoplasma, and Human Meta-
11. Immunodeficiencies – HIV, IgA deficiency, B-cell deficiency pneumovirus. Human Metapneumovirus is an important
a
These conditions can be associated with recurrent wheezing
primary cause or it can occur as a co-infection. There is no
evidence for a bacterial cause of bronchiolitis.
& Frequency: Recurrent or persistent symptoms point to-
wards asthma, cardiac cause, or anatomical malformation. Clinical Features
& A positive family history or a personal history of atopy
indicates asthma. & Age—Bronchiolitis generally occurs in young infants
& Other specific symptoms like fever, cardiac symptoms, 2 to 6 months of age. It may occur up to 2 years of
GERD may suggest the definitive cause of wheeze. age.
& Previous treatment and response to the treatment is also & History—Fever (mild to moderate grade), refusal to
important in making a diagnosis. feed, breathing difficulty, wheeze, lethargy
& On examination: wheeze, hyperinflation, hyper- reso-
Examination
nant percussion note, obliteration of liver and cardiac
& Clubbing is an indicator of chronic disease (e.g. dullness.
bronchiectasis)
& Chest shape: Barrel shaped chest is seen in asthma/ Differential Diagnoses
chronic lung disease; precordial pulsation/bulge is seen
in congenital heart disease. The differential diagnoses of wheezing in infants/children
& Lateralization of findings suggests foreign body, ana- are presented in Table 1. First episode of asthma,
tomical malformations, mediastinal lymph nodes/mass. pneumonia, and congestive cardiac failure are the most
1398
important diagnoses that should be ruled out. The following
points should be kept in mind.
& First episode of bronchial asthma—often has a family
history and shows good response to bronchodilators
& Pneumonia—usually a sick looking child, with moder-
ate to high grade fever; signs of obstruction are less
pronounced; and crackles are audible on auscultation.
& Cardiac failure due to myocarditis or congenital heart
disease—is associated with tachycardia, tender hepato-
megaly, basal crackles, murmur and cardiomegaly on
chest radiography.
Investigations
Indications for investigations: possible alternate diagnosis,
severe distress, worsening, and absence of clinical improvement.
The following investigations may be required:
& Chest radiograph
& Viral studies (nasopharyngeal swab): Nasopharyngeal
swab may be positive for RSV.
& Blood gas analysis
Chest radiograph provides information about the base-
line lung condition for any infant with respiratory distress
and helps to rule out other differential diagnoses such as
foreign body and pneumonia, and to look at chronic lung
conditions e.g. bronchiectasis. In bronchiolitis, it typically
shows hyperinflation and patchy atelectasis.
Figure 1 shows a typical chest radiograph of bronchio-
litis. This one and a half month infant was brought with
fever and paroxysmal cough for 4 days. Long bouts of
cough were associated with apnea. He had family history of
asthma. On examination: respiratory rate was 65/min with
chest wall retractions, decreased air entry and wheeze and
scattered crepts all over chest. Nasophryngeal swab was
positive for Respiratory Syncitial Virus.
Fig. 1 Chest radiograph of a two and a half month infant, with
bronchiolitis showing bilateral hyperinflation (hyperaerated lungs,
widening of intercostals space, straightening of ribs).
Indian J Pediatr (November 2011) 78(11):1396–1400
Treatment
An outline of treatment plan for suspected cases of
bronchiolitis is given in Fig. 2.
1. Humidified oxygen is the mainstay of treatment in
bronchiolitis.
2. Careful attention to fluid therapy is necessary; liberal
fluid therapy may lead to water intoxication [5].
Bronchiolitis of infancy is characterized by water
retention which is caused by impaired renal water
excretion.
Other modalities of treatment have been studied exten-
sively. These include inhaled epinephrine, parenteral ste-
roids (dexamethasone), inhaled salbutamol, inhaled
hypertonic saline etc. Their role is unproven; none of them
is supported by robust evidence of significant clinical
efficacy.
Nebulized Epinephrine
Epinephrine has been aptly described as the “least
ineffective” intervention [6, 7]. There is no benefit in terms
of admission rate or duration of hospitalization; however
subgroup analysis suggests that epinephrine has some
benefit among outpatients. Similarly, there is no difference
for surrogate outcomes including change in oxygen
saturation, heart rate and respiratory rate, although epi-
nephrine results in more favourable clinical score change
from baseline. A meta-analysis of the treatment effects of
nebulized epinephrine suggested a decrease in clinical
symptoms as compared with either placebo or salbutamol
[8].Nebulized epinephrine has been shown to improve
symptoms better than oral or nebulized salbutamol [9–11].
Some infants may experience worsening of symptoms
with nebulized epinephrine. Therefore, a trial should be
considered but treatment should be stopped if there is no
response.
Nebulized Salbutamol
There is no benefit of inhaled salbutamol on admission rate
or duration of hospitalization [12]. A meta-analysis of the
treatment effects of nebulized selective beta-agonists failed
to show any consistent benefits [13].
Nebulized Hypertonic Saline
It has been suggested that hypertonic saline nebulization
may be useful in making secretions less viscous and
promoting their excretion, thereby resulting in clinical
improvement. However, nebulized hypertonic saline has a
limited role in bronchiolitis [14].
Indian J Pediatr (November 2011) 78(11):1396–1400 1399

Fig. 2 Flowchart showing out- Humidified oxygen

line of management in suspected
case of bronchiolitis IV fluids (70%)/ supportive therapy

Assess response

Adequate response Inadequate response

Continue supportive therapy Trial of inhaled epinephrine

Adequate response Worsening/ no response

Stop epinephrine.
PICU transfer
Give Dexamethasone (0.6 mg/kg) 1 dose

Inadequate response

Steroids (Oral/Inhaled) Use of CPAP (Continuous Positive Airway Pressure)

Steroids are no different from placebo with respect to hard A recent randomized controlled trial (n=31) compared the
outcomes and several surrogate outcomes (clinical scores, use of nasal CPAP with standard treatment. CPAP im-
oxygenation parameters, respiratory rate, readmission rate). proved ventilation and hypercapnea [23].
One trial (n=174) showed that a single dose of intravenous
dexamethasone (0.6 mg/kg) results in (statistically but not Treatment Modalities That Should Be Avoided
clinically significant) shorter duration of hospitalization and
time for resolution of respiratory distress [15, 16]. & Chest physiotherapy should not be used routinely in the
Inhaled dexamethasone does not show any difference in management of bronchiolitis.
clinical score and oxygenation compared to saline [17]. & No antibiotics should be given routinely [19].
A recent randomized controlled trial studied 800 patients
divided in 4 intervention groups: 1) Epinephrine–dexa-
Indications for Hospitalization
methasone group, 2) Epinephrine group 3) Dexamethasone
group 4) Placebo group. The doses used were:- Epineph-
Indications for hospitalization are mentioned in Table 2.
rine: 3 ml of generic epinephrine in a 1:1000 solution;
Dexamethasone: 1.0 mg/kg body weight (maximum dose,
Criteria for Discharge
10 mg) or placebo given after the first nebulized treatment
in the emergency department, followed by five once-daily
The following criteria are recommended for sending home
doses of dexamethasone (0.6 mg/kg; maximum daily dose,
an infant with bronchiolitis [24]:
10 mg). The study concluded that combined therapy with
dexamethasone and epinephrine may significantly reduce & Normal respiratory rate
hospital admissions [18]. & Oxygen concentration of at least 94%
& Adequate oral intake
Ribavirin (Aerosol) & Absence of respiratory distress

Ribavirin should not be used routinely in children with
bronchiolitis [19]. Indications for using ribavirin include
selected patients with life threatening RSV infection [20]:
such as prematurity, infants with congenital heart disease,
chronic lung disease and immunocompromised host.
One systematic review and two subsequent RCTs
found that, in children and infants admitted to hospital
with RSV bronchiolitis, ribavirin did not significantly
reduce mortality, respiratory deterioration, or duration of
hospital stay compared with placebo [21], but it signif-
icantly reduced the duration of ventilation compared with
placebo [22].
Table 2 Indications for hospitalization/markers for severe disease
• Age less than 3 months
• Gestational age at birth < 34 wks
• Cardiopulmonary disease/immunodeficiencies
• Anatomical defects of airways
• Neurological disease associated with hypotonia and pharyngeal
in-coordination
• Respiratory rate > 70/min
• Lethargic appearance
• Wheezing and respiratory distress associated with SpO2 <92%
• Atelectasis or consolidation on chest radiography
1400
Conflict of Interest None.
Role of Funding Source None.
References
1. Kumar N, Singh N, Locham KK, Garg R, Sarwal D. Clinical
evaluation of acute respiratory distress and chest wheezing in
infants. Indian Pediatr. 2002;39:478–83.
2. Tan TN, Lim DLC, Chong YS, Lee BW, Van Bever HP.
Prevalence of eczema symptoms in the second year of life. J
Allergy Clin Immunol. 1078;2004:113.
3. Martinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen M,
Morgan WJ. Asthma and wheezing in the first six years of life.
NEJM. 1995;332:133–8.
4. Singhi SC, Mathew JL, Jindal A. Clinical Pearls in Respiratory
Diseases. Indian J Pediatr. 2010 Dec 14.[Epub ahead of print]
doi:10.1007/s12098-010-0270-3.
5. Poddar U, Singhi S, Ganguli NK, Sialy R. Water electrolyte
homeotasis in acute bronchiolitis. Indian Pediatr. 1995;32:59–65.
6. Bush A, Thomson S. Acute bronchiolitis. BMJ. 2007;335:1037–41.
7. Mathew JL. What works in bronchiolitis? Indian Pediatr.
2009;46:154–8.
8. Hartling L, Wiebe N, Russell K, Patel H, Klassen TP. Arch Pediatr
Adolesc Med. 2003;157:957–64.
9. Ray MS, Singh V. Comparison of nebulised adrenaline versus
salbutamol in wheeze associated respiratory infections in infants.
Indian Pediatr. 2002;39:12–22.
10. Bertrand P, Aranibar H, Castro E, Sanchez I. Efficacy of nebulised
epinephrine versus salbutamol in hospitalized infants with
bronchiolitis. Pediatr Pulmonol. 2001;31:284–8.
11. Menon K, Sutcliffe T, Klassen TP. A randomized trial comparing
the efficacy of adrenaline with salbutamol in the treatment of
acute bronchiolitis. J Pediatr. 1995;126:1004–7.
Indian J Pediatr (November 2011) 78(11):1396–1400
12. Gadomski AM, Bhasale AL. Bronchodilators for bronchiolitis.
Cochrane Database Syst Rev. 2006;3:CD001266.
13. Flores G, Horwitz RI. Efficacy of b2 agonists in bronchiolitis: a
reppraisal and meta-analysis. Pediatrics. 1997;100:233–9.
14. Mathew JL. Hypertonic saline nebulization for bronchiolitis.
Indian Pediatr. 2008;45:987–9.
15. Teeratakulpisarn J, Limwattananon C, Tanupattarachai S, et al.
Efficacy of dexamethasone injection for acute bronchiolitis in
hospitalized children: a randomized, double-blind, placebo-
controlled trial. Pediatr Pulmonol. 2007;42:433–9.
16. Garrison MM, Christakis DA, Harvey E, et al. Systemic cortico-
steroids in infant bronchiolitis: a meta-analysis. Pediatrics.
2000;105:E44.
17. Bentur L, Shoseyov D, Feigenbaum D, et al. Dexamethasone
inhalations in RSV bronchiolitis: a double-blind, placebo-
controlled study. Acta Paediatr. 2005;94:866–71.
18. Plint AC, Johnson DW, Patel H, et al. Epinephrine and
dexamethasone in children with bronchiolitis. N Engl J Med.
2009;360:2079–89.
19. American Academy of Pediatrics. Subcommittee on diagnosis and
management of bronchiolitis. Diagnosis and management of
bronchiolitis. Pediatrics. 2006;118:1774–93.
20. American Academy of Pediatrics. Chapter on respiratory
syncytial virus. In: Pickering LK, editor. Red Book: 2009
Report of the Committee on Infectious Diseases. 28th ed.
Elk Grove Village: American Academy of Pediatrics; 2009.
p. 560–4.
21. Hartling L, Russell KF, Patel H, et al. Epinephrine for bronchio-
litis. Cochrane Database Syst Rev. 2004;1:CD003123.
22. Ventre K, Randolph AG. Ribavirin for respiratory syncytial virus
infection of the lower respiratory tract in infants and young
children. Cochrane Database Syst Rev. 2007;1:CD000181.
23. Thia LP, McKenzie SA, Blyth PB, et al. Randomised controlled
trial of nasal continuous positive airways pressure (CPAP) in
bronchiolitis. Arch Dis Child. 2008;93:45–7.
24. Basco WT. Predicting which pediatric bronchiolitis patients can be
safely discharged from the ED. Pediatrics. 2008;121:680–8.