Bronchiolitis Workup

  • Author: John Udeani, MD, FAAEM; Chief Editor: Zab Mosenifar, MD   more...
 
Updated: Jun 9, 2011
 

Laboratory Studies

The diagnosis of bronchiolitis is based on clinical presentation, the patient's age, seasonal occurrence, and findings from the physical examination. Tests are typically used to exclude other diagnoses, such as bacterial pneumonia, sepsis, or congestive heart failure, or to confirm a viral etiology and determine required infection control for patients admitted to the hospital. Although the use of diagnostic tests is common, several investigators argue that these should not be routinely performed, citing concerns about costs, inappropriate use of antibiotics, and the lack of proven benefit. In reality, few studies exist that critically evaluate the utility of diagnostic tests for this disease. Some hospitals have developed protocols or guidelines on testing and management, while others have left the decision entirely to the treating physician.

From a survey of hospital-based pediatricians, the most common tests are rapid viral antigen testing of nasopharyngeal secretions for RSV, blood gas analysis, WBC count with differential, C-reactive protein (CRP) level, and chest radiography. Other common tests are pulse oximetry, blood culture, urine analysis and culture, and cerebrospinal fluid analysis and culture.

WBC count and differential

This is commonly performed to look for coexisting bacterial infection, but few studies have evaluated its utility for this purpose. Case reports have described patients with bronchiolitis who had elevated WBC counts that prompted further evaluation and eventual identification of a bacterial pathogen. In one study of 120 infants infected by RSV, Saijo et al[7] demonstrated a correlation between an elevated WBC count and a radiographic pattern of lobar pneumonia when compared with a pattern of bronchopneumonia or bronchiolitis. CRP levels and erythrocyte sedimentation rate followed the same pattern in this study. Veira et al[8] also observed an association between a viral etiology and low WBC count and CRP level during initial and follow-up testing.

The WBC count has been decried for its poor test characteristics. Among infants with a febrile illness, WBC values are highly variable. In a study of febrile neonates who received a septic workup, WBC counts overlapped substantially between the groups with bacterial infection, viral infection, pneumonia, and workup negative for sepsis. No WBC count threshold had good discriminatory value for the presence of bacterial infection.

No strong evidence supports a recommendation for or against WBC testing in patients with bronchiolitis.

Septic workup

In most patients with RSV bronchiolitis, especially those with mild disease, the risk of serious secondary bacterial infection is low. In 2 retrospective studies of children who presented with lower respiratory tract infection with RSV, positive culture results were found in 1.2% and 1.6% of children tested, respectively. However, serious bacterial infections can occasionally occur, so the importance of evaluating patients with fever and bronchiolitis remains controversial.

A study of 90 newborns with bronchiolitis, pneumonia, or both noted that among the few who appeared very sick upon presentation or had a prolonged clinical manifestation, a bacterial infection was frequently associated. Kuppermann et al[9] found no evidence of bacteremia in 156 patients with bronchiolitis aged younger than 24 months; patients with lobar consolidation were excluded. Liebelt et al[10] studied infants aged 90 days or younger with bronchiolitis and noted a low risk of serious bacterial infection and wide variability in the use of diagnostic tests in this population.

Multivariate analysis identifies temperature greater than 38°C, oxygen saturation less than 92% at presentation, and a history of apnea as clinical predictors of the use of laboratory studies.

Antonow et al[11] studied 282 hospitalized infants younger than 60 days with bronchiolitis and reported a low rate (5 of 140 tested) of serious bacterial infections. A multivariate model identified a higher bronchiolitis score and normal chest radiograph findings as positive predictors of a sepsis workup, while an admission diagnosis of bronchiolitis and a chest radiograph with findings typical for bronchiolitis were negative predictors.

Among 1795 children in a wider age range (0-14 y) who were hospitalized for RSV bronchiolitis, Bloomfield et al[12] reported positive blood culture findings in 11 of 61 tested. Risk factors identified for concurrent bacteremia in this study included nosocomial RSV infection, cyanotic congenital heart disease, and admission to the pediatric ICU (PICU). In patients with RSV bronchiolitis who require admission to the PICU, the frequency of secondary bacterial infections is very high. Mechanical ventilation in this population significantly increases the risk for contracting pneumonia.

A prospective multicenter study attempted to determine whether infants younger than 60 days with fever and bronchiolitis are at increased risk of serious bacterial infection. Of the 1248 patients enrolled, 269 (22%) had RSV bronchiolitis. The rate of secondary bacterial infections was 7% in the RSV-positive group and 12.5% in the RSV-negative group. The rate of secondary bacterial infections in the RSV-positive group was smaller but remained appreciable.

Viral testing

Tests to identify the viral etiology of bronchiolitis include immunofluorescent antigen (IFA) testing, enzyme-linked immunosorbent assay (ELISA) antigen testing, and viral culture. The overall sensitivity of testing for rapid antigen detection varies from 80-90%. When viral testing is performed, RSV is the most commonly isolated organism (26-95%). This test is frequently performed in febrile young children who present to the emergency department with bronchiolitis. The rapid identification of a viral cause of a febrile illness has been argued to obviate the need for a septic workup or the empiric use of antibiotics, particularly in children who were previously well or do not appear toxic.

One study of infants younger than 8 weeks who were RSV positive and presented to the emergency department found significantly fewer serious bacterial infections in those infants than in infants who were RSV negative. This finding suggests that RSV testing could help in evaluating the probability of bacterial infection in young febrile patients.

When febrile infants aged 1-90 days were stratified into high- or low-risk groups based on the Rochester criteria, patients who were RSV positive and at high risk had significantly fewer bacterial infections than patients who were RSV negative and at high risk (5.5% vs 16.7%). The rate of bacteremia in the high-risk, RSV-positive group was similar to that in the low-risk, RSV-negative group. In fact, introducing RSV rapid antigen testing in the evaluation of febrile children at a single center decreased the use of antibiotics, the duration of use of antibiotics, and the number of prescriptions of antibiotics upon discharge. Therefore, RSV testing should be universally implemented during the RSV season.

In conclusion, RSV testing is commonly practiced and has good utility. Although an argument is that it has little influence on outcome, RSV testing does influence treatment because physicians appear likely to withhold antibiotics or to stop them sooner in patients who are RSV positive. RSV testing can also be used to isolate patients who are RSV positive and to categorize patients for cohort nursing.

Pulse oximetry

Pulse oximetry is measured in almost every child who presents with acute bronchiolitis. Suggested guidelines for lower limits of acceptable oxygen saturation levels for bronchiolitis include 90%, 92%, and 94%. In some studies, oxygen saturation levels of less than these values predicted subsequent deterioration. Emergency department pediatricians are approximately twice as likely to recommend hospitalization when the oxygen saturation level is 92% as when it is 94%.

In previously healthy infants with bronchiolitis who deteriorated in the hospital and required PICU transfer, the mean oxygen saturation level at presentation was 88% (compared with 93% in matched controls). In addition, an oxygen saturation level of 85% or less and a respiratory rate of greater than 80 respirations per minute at presentation each had a specificity of 97% but a sensitivity of 30% or less in predicting subsequent deterioration.

However, increased reliance on the oxygen saturation level, by lowering its admission threshold, may have contributed to the significantly reported increase (nearly 250%) in the hospitalization rate for children with bronchiolitis since the 1980s. A review of the medical records of previously healthy children admitted with bronchiolitis revealed that hospital discharge was delayed based on pulse oximetry values when the patients were otherwise stable for discharge. This was associated with significant cost implications. The variations in the oxygen saturation levels in healthy infants have been reported.

The implications of a particular oxygen saturation level may vary depending on whether the level is determined upon admission in a child who is sick or upon discharge in a child who is otherwise stable. More research is needed to identify the minimum threshold oxygen saturation level at which patients can be safely discharged.

Nasopharyngeal aspirate

Testing for RSV based on nasopharyngeal aspirate is common but may not change the outcome. The test is performed mainly to make a definitive diagnosis. Viral culture for RSV is considered the criterion standard; however, several immunologic tests are more convenient, faster, and less costly. These tests are performed by either direct IFA staining or by ELISA. IFA requires approximately 2-6 hours and is 90% sensitive and specific, whereas ELISA requires 30 minutes for processing and is 85-90% sensitive.

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Imaging Studies

Chest radiography

Radiologic findings in individuals with bronchiolitis are variable and may include bronchial wall thickening, tiny nodules, linear opacities, atelectasis, patchy alveolar opacities, and lobar consolidation.

Among 153 children with acute bronchiolitis, Dawson et al[13] found no correlation between the degree of change on the chest radiograph and a clinical scoring method. However, in Shaw's 1991 study[14] of 213 infants with bronchiolitis, atelectasis was 2.7 times more likely to be found at presentation in the patients with severe disease than in those with mild disease. One survey showed that chest radiographs were obtained 83% of the time in patients with bronchiolitis, while antibiotics were prescribed only 69% of the time. These results likely indicate that physicians withhold antibiotics if no infiltrate is visible on the radiograph of the patient with bronchiolitis.

Finding an infiltrate, however, does not necessarily imply a bacterial etiology. In a study reported in 1990 of 128 infants and children aged 7 years or younger, Friis et al[15] identified 76 patients with bronchiolitis. Thirty-seven of these patients had pathogenic bacteria in their respiratory tract. The chest radiograph showed no abnormality significantly more often in the virus-positive, bacteria-negative group. However, lobar or segmental consolidation was equally likely in those with or without a bacterial pathogen. Therefore, although a radiograph with negative findings may have some value, children who do not appear ill are unlikely to have a radiograph that shows abnormalities. A practical approach is to obtain a chest radiograph in children who appear ill, experience clinical deterioration, or are at high risk, such as those with an underlying cardiac or pulmonary disease.

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Contributor Information and Disclosures
Author

John Udeani, MD, FAAEM  Assistant Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science, University of California, Los Angeles, David Geffen School of Medicine

John Udeani, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Charles I Ojielo, MD  Assistant Professor of Medicine, Rush Medical College; Consulting Staff, Resident Education Coordinator, Department of Pulmonary and Critical Care Medicine, John H Stroger Hospital of Cook County/Rush University Medical Center

Charles I Ojielo, MD is a member of the following medical societies: American College of Physicians, American Medical Association, and American Thoracic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP  Professor of Genomics and Personalized Medicine Research, Internal Medicine, and Pediatrics, Associate Director, Center for Genomics and Personalized Medicine Research, Director of Research, Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest University School of Medicine

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society, and Sigma Xi

Disclosure: See below for list of all activities None None

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H  Professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Southern California Keck School of Medicine

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Osler Society, American Thoracic Society, New York Academy of Medicine, and Royal Society of Medicine

Disclosure: Nothing to disclose.

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

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