Expiratory rattle with acute intercostal indrawing in children under two years of age

Specialty: Pediatrics.

• Respiratory difficulty due to acute bronchiolitis
• difficulty breathing in the infant

Why it occurs

• Acute bronchiolitis (viral infection of the lower respiratory tract characterized by inflammation of the terminal bronchioles with edema and accumulation of mucus, caused predominantly by the Respiratory Syncytial Virus or RSV, affecting infants under 2 years of age)
• Bacterial or viral pneumonia (infection of the lung alveolar parenchyma with consolidation that makes gas exchange difficult)
• Recurrent virus-induced bronchospasm (exacerbation of bronchial hyperreactivity in predisposed infants)
• Inadvertent foreign body aspiration (intrabronchial mechanical obstruction that generates unilaterally localized indrawing and wheezing)
• Congestive heart failure due to left-right shunt congenital heart disease (consequence of secondary pulmonary edema).

Initial workup

Continuous pulse oximetry and assessment of respiratory effort using validated scales (such as the Wood-Downes Scale modified by Ferres). Rapid detection of viral antigens or multiple PCR in nasopharyngeal aspirate for RSV, Rhinovirus, Influenza and Adenovirus. Capillary blood gas (indicated if there are signs of respiratory muscle fatigue or suspicion of hypercapnia). Chest x-ray in anteroposterior projection (indicated only in cases of atypical clinical course, marked auscultatory asymmetry, suspicion of pneumothorax or lobar pneumonia, or very high refractory fever).

Standard management

• The mainstay of the treatment of acute bronchiolitis is support — hygiene and gentle aspiration of nasal secretions before each feeding, and maintaining adequate oral or parenteral hydration). Humidified supplemental oxygen therapy through high-flow nasal cannulas (HFNC) if moderate-severe distress is associated with hypoxemia or fatigue. Nebulization with 3% hypertonic saline (can reduce the length of hospital stay in admitted infants by hydrating and facilitating the clearance of thick mucus; dose of 4 ml nebulized every 4-6 hours; its routine use in the emergency department is not recommended
• Nebulized adrenaline — occasionally tested empirically in emergencies; doses of 1.5 to 3 mg diluted in physiological saline; suspend if there is no favorable clinical response
• Avoid the routine use of Salbutamol, systemic corticosteroids, antibiotics or antihistamines in classic acute bronchiolitis without comorbidities.