Immediate Management

1. Evaluate airway, breathing, and circulation (ABCs).

2. Evaluate and treat life-threatening conditions (eg, impending respiratory failure, tension pneumothorax). Regardless of cause, consider intubation and mechanical ventilation if patient shows signs of impending respiratory failure.

3. Evaluate for hypoxemia and provide supplemental oxygen as necessary.

4. Evaluate for adequate ventilation. Patient may be tachypneic with good air movement in an attempt to compensate for metabolic acidosis. Alternatively, tachypnea may result from inability to achieve adequate tidal volume, a condition that is more ominous.

5. Alleviate airway obstruction. Perform jaw-thrust or chin-lift maneuver immediately, then consider use of oropharyngeal airway, nasopharyngeal airway, and continuous or bilevel positive airway pressure. Administer racemic epinephrine or steroids for airway edema. Management of Specific Conditions

1. Treat underlying conditions (eg, pleural effusion, pneumothorax, sepsis, pneumonia, anaphylaxis, residual neuromuscular blockade, narcotic overdose).

2. Treat reactive or inflammatory airway disease. Consider inhaled B2-receptor agonist, steroids, magnesium, heliox, anticholinergics.

3. Treat fluid overload. Initiate diuresis appropriately as clinical condition warrants.

4. Correct acidosis and conditions leading to acidotic state.

5. Treat pain or anxiety when other serious conditions have been ruled out.

VI. Problem Case Diagnosis. The 6-month-old patient had a positive result on RSV antigen testing and was diagnosed with bronchiolitis. (For further discussion, see VII and VIII, below.)

VII. Teaching Pearl: Question. What is the treatment for RSV bronchiolitis?

VIII. Teaching Pearl: Answer. Treatment is largely supportive care (supplemental oxygen and hydration). Other therapies to consider that remain controversial include inhaled bronchodilators and racemic epinephrine for select and severe cases in children with underlying disorders. In general, steroids are not considered effective. Passive immunization and interruption of transmission are important. Further studies are needed to confirm efficacy of these therapies.

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