Bronchiolitis and viral lower respiratory tract infection — formative SAQs

SAQ 1 (10 marks)

A 4-month-old girl is brought to the emergency department in winter. She had a runny nose and mild cough for two days and now has fast, laboured breathing and has fed only half her normal amount today. On the carer's lap she has moderate chest-wall recession and nasal flaring, widespread fine crackles and a soft expiratory wheeze, and her oxygen saturation is 91 percent on air. She is alert and there have been no pauses in breathing. [1] [2]

1. State your assessment of severity and how you graded it. (3) [1]
2. Outline your initial management. (4) [1] [4]
3. Describe how you would decide on disposition and what advice you would give. (3) [2]

Model answer — SAQ 1

(1) Severity (3). This is moderate bronchiolitis: a first viral lower respiratory tract infection in an infant under twelve months, with a coryzal prodrome then diffuse crackles and wheeze, moderate work of breathing with recession and flaring, feeding around half normal, and saturations at 91 percent but with no apnoea and a normal conscious level. I grade severity by integrating work of breathing, oxygenation and feeding rather than a single number, and I would reassess her serially because the trajectory matters more than one snapshot. [1]

(2) Initial management (4). Supportive care is the treatment. I would handle her minimally, clear the nose with gentle suction only if secretions block feeding or breathing, and support feeding with small frequent feeds, moving to nasogastric feeding if she cannot maintain intake. I would give oxygen titrated to a target saturation of around 90 to 92 percent, and if she deteriorates despite standard oxygen I would escalate to high-flow nasal cannula, which reduces treatment escalation. I would not give salbutamol, adrenaline, corticosteroids, antibiotics, physiotherapy or hypertonic saline, and I would avoid a routine chest radiograph and bloods. [1] [4]

(3) Disposition and advice (3). I would observe her after supporting feeding and oxygen. If she feeds adequately, saturates at or above target and works only mildly, and the family can reassess and return, she can go home; if feeding or oxygen remain borderline, or there are social or geographic barriers, I would admit and observe. I would give concrete safety-net advice: return urgently for pauses in breathing or colour change, harder breathing with marked in-drawing, feeding under half or fewer wet nappies, pallor, floppiness or drowsiness, and explain that bronchiolitis often worsens around days three to five before improving. [2] [1]

SAQ 2 (10 marks)

A 5-week-old boy, born at 34 weeks, is brought in with two days of coryza and a reported episode where he went briefly blue and floppy during a feed and then recovered. His breathing looks only mildly increased and his chest has scattered crackles; his saturation is 94 percent on air. [1] [2]

1. What is the significance of the reported episode and how does it change your plan? (4) [1]
2. Describe your immediate management priorities. (3) [1]
3. Explain why this infant is at higher risk and how you would prevent severe RSV disease in future. (3) [2]

Model answer — SAQ 2

(1) Significance and plan (4). The episode is likely apnoea, which in a young or ex-premature infant with a viral illness can be the presenting feature of bronchiolitis before the chest signs are marked, and it may recur. This changes my plan from possible discharge to admission and monitored observation with continuous oximetry and apnoea monitoring, because the mild chest examination is falsely reassuring in this age group. I would not be reassured by the current normal saturation. [1]

(2) Immediate priorities (3). Admit and monitor him, handle him minimally, and support feeding with small frequent or nasogastric feeds while watching hydration. I would give oxygen only if his saturations fall persistently below target, and I would be ready to escalate breathing support to high-flow nasal cannula or CPAP if he has further significant apnoeas or increasing work of breathing. I would avoid bronchodilators, steroids, antibiotics and a routine chest radiograph. [1]

(3) Higher risk and prevention (3). He is at higher risk because he is very young and was born prematurely, so he has a small airway and immature respiratory control with little reserve, which is exactly the group prone to apnoea and severe disease. For future prevention I would ensure he receives RSV monoclonal antibody prophylaxis for the season — nirsevimab as a single intramuscular dose, or palivizumab where nirsevimab is unavailable — alongside advice on hand hygiene, avoiding tobacco smoke exposure and supporting breastfeeding. [2] [1]