Acute Bronchiolitis

Bronchiolitis is a common LRTI in 2 years age group and it is also one of the the leading cause for hospitalization in infants. The most common bus associated with bronchiolitis is RSV (other possible agents are human metapneumovirus, adenovirus, influenza, rhinovirus, and parainfluenza viruses. Following an episode, cough may persist for up to 3 weeks. 

The viral infection in bronchiolitis causes inflammation of the lower respiratory tract leading to edema, necrosis, increased mucus production and bronchospasm eventually causing  air trapping, atelectasis, and hyperinflation of the lower airways and increased work of breathing. 

The peak of symptoms is often between the third and fifth day after onset
  • Coughing. 
  • Rhinorrhea, tachypnea
  • Wheezing and Crackles 
  • Use of accessory muscles and subcostal and intercostal retractions
  • Nasal flaring
  • Low grade fever 
  • Irritability, cyanosis, and poor feeding
  • Apnea in infants
  • Dehydration due to increased insensible losses

Risk Factors for severe disease
  • Chronic Lung Disease
  • Age < 3moths
  • Premature Birth
  • Congenital Heart Disease
  • Immunodeficiency 
  • Neuromuscular Disorders

  • Bronchiolitis is a clinical diagnosis. 
  • No lab tests are useful 
  • Blood tests and CXR: indicated only if other diagnoses need to be excluded or in cases of severe disease (high O2 requirement)

Differential Diagnosis
  • Asthma
  • Pneumonia
  • Foreign Body
  • Cystic Fibrosis

  • Oxygen Target oxygen saturation of >92%.
  • Instillation of saline into the nares followed by suctioning
  • Frequent and smaller feeds to prevent dehydration
  • Caretakers should use frequent hand washing to minimise spread

Controversial Treatment Options:
  • Bronchodilators do not offer any clear benefits and thus should not be given routinely.
  • Inhaled epinephrine should be considered only in severe disease
  • Steroids do not provide any benefit if used alone. However, current guidelines do advocate consideration for steroid use in combination with epinephrine in the treatment of bronchiolitis.24
  • Nebulized Hypertonic Saline: Mixed evidence and not recommended for routine use. It improve mucociliary clearance by loosening mucous plugs through osmotic draw of fluid from submucosal and adventitial spaces. 
  • Ventilatory Support: Noninvasive ventilation may prevent intubation. 
  • Heliox: Heliox does not affect the rates of intubation or mechanical ventilation or length of intensive care admission

Admit if:
  • Risk Factors for severe disease
  • Premature birth
  • Persistent symptoms despite therapy
  • Dehydration, 
  • Spo<90% on room air)
  • Episodes of apnea 

Take Home: 
  • Bronchiolitis affects <2year age group and RSV is the most common bug.
  • Supportive Care and Hydration is the key
  • Most treatment modalities are controversial and thus are not recommend for routine use. Consider using in rapidly deteriorating

References and Further Reading:
  1. Fernandes R, Bialy L, Vandermeer B, et al: Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev 6: CD004878, 2013. [PMID:23733383]
  2. Ralston SL, Lieberthal AS, Meissner HC, et al: Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics 134: e1474, 2014. [PMID: 25349312]

Posted by:

     Lakshay Chanana
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine



Brown Sound: Firecracker vs Testicle

Ultrasound Case of the MontH

A 20-something year old male with PMH of anxiety, depression, and ADHD presents to the Emergency Department after an accidental firecracker injury. Patient denies LOC and respiratory distress, but has a degloving injury to left anterior thigh and a macerated laceration to left wrist. Additionally, he has first degree burns to the ventral aspect of the penile shaft, partial thickness burn and stellate laceration with associated swelling of the left hemiscrotum, and diffuse tenderness of the left testicle. Denies pain to right testicle.

A scrotal ultrasound was obtained demonstrating left-sided hematocele and testicular rupture. Video with audio discussion below.

Testicular injury ultrasound


The above images demonstrate heterogeneous echotexture within the testis as compared to the normal testicle, which has a relatively homogenous echogenicity. There appears to be an area representing herniation of the left testicular parenchyma through a defect in the tunica albuginea with associated hematocele. There is Doppler flow present in relatively equal amounts to that of the normal testicle.

The patient was taken to the OR with urology for emergency surgical exploration. Intraoperatively, patient had 200cc of hematocele evacuated. Ultimately, patient had preservation of approximately 25% of left testicular parenchyma after resection of non-viable testicular parenchyma. General surgery was able to address his other injuries in the OR as well.

Testicular rupture is most commonly the result of blunt sports-related injuries, with 12-15% involving bicyclists/motorcyclists. (1) Ultrasound for testicular rupture has a sensitivity and specificity ranging from 56 to 95%. (2) Irregular contour of the testicle is the most significant predictor of testicular rupture. A study found that the delay of performing testicular ultrasound does not lead to negative outcomes due to delayed surgical intervention. (2)


Step-wise testicular exam. Using a high-frequency linear probe, a “buddy view” should be first obtained in transverse, showing the medial aspects of both left and right testicles in order to compare relative echogenicity and size. Just as you would when you ultrasound for testicular torsion, it is important to obtain images of the normal testicle before the abnormal one. The normal (in this case, right-sided testicle) was interrogated, paying special attention to homogeneity of the testes and circumscribed contour. Then finally, the testicle of concern was ultrasounded, first in transverse and then sagittal views.


Don’t forget your setup! Optimize your exam to minimize patient discomfort. Patient was pre-medicated for with IV pain medications. Lay one towel across the patient’s thighs and suspend the scrotum over the towel. With a second towel, cover the penile shaft so only the scrotum is exposed. Use liberal amounts of gel in order to minimize contact of the probe with the painful area.


Faculty Reviewer: Kristin Dwyer


Additional Resources



Bauer NJG. Case report: Traumatic unilateral testicular rupture. International Journal of Surgery Case Reports. 2016;25:89-90. doi:10.1016/j.ijscr.2016.05.059.

Wang A, Stormont I, Siddiqui MM. A Review of Imaging Modalities Used in the Diagnosis and Management of Scrotal Trauma. Curr Urol Rep. 2017;28(12):98. doi: 10.1007/s11934-017-0744-1.


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