The podcast cited below is part of the The Cribsiders‘ excellent “#179-186: Intern Bootcamp 2026 June 3, 2026 | By Sam Masur”.
Today, I review, link to, and excerpt from The Cribsiders‘ “#2:Go with the High Flow: Bronchiolitis with Dr. Brian Alverson”.*
*Alverson B, Kelly J, Chui C, Berk J. “Go with the High Flow: Bronchiolitis with Dr. Brian Alverson”. The Cribsiders Pediatric Podcast. https://thecurbisiders.com/thecribsiders/2.
All that follows is from the above resource.
Bronchiolitis
Summary
Dive into one of the most common pediatric problems, bronchiolitis, with our guest Dr. Brian Alverson, director of the Division of Hospital Medicine at Hasbro Children’s Hospital. In this episode, we review the workup of bronchiolitis, including the role of the chest x-ray, RPP, CBC, and more. We also discuss the evidence behind treatments such as albuterol, steroids, and high flow nasal cannula. Listen to hear more about this breathtaking topic.
Time Stamps
- Intro 4:00
- Diagnosis of bronchiolitis 7:40
- Oxygenation in Bronchiolitis 10:55
- Appearance and Work of breathing 15:15
- Work-up of Bronchiolitis 16:40
- Future of testing (procalcitonin) 22:30
- The febrile child with bronchiolitis 24:00
- Medical management of bronchiolitis 26:45
- Discussion of critical care and HFNC 37:10
- Admission Criteria 46:45
- Nasal Suctioning 47:40
- Rapid-fire questions (NGT vs IV, readmissions, asthma correlation, viral causes) 49:25
- Final pearls 53:30
Bronchiolitis Pearls
- Transient hypoxemia is not dangerous and is well tolerated in infants.
- In kids who have viral symptoms, chest x-ray increases use of antibiotics but does not improve outcomes.
- Bronchiolitis is a waxing and weaning disease.
- Less frequent superficial nasal suctioning is associated with longer hospitalizations.
- Readmission rates are associated with living closer to the hospital, young age, and low income zip code.
Approach to Diagnosis
- Bronchiolitis is a viral infection that is present in the nose and causes mucus production and then progresses to the small areas of the lungs, which makes it hard for babies to breathe.
- Expert opinion: Presume infants with a URI prodrome followed by increased respiratory effort have bronchiolitis to avoid over-testing and over-treating which can cause harm to the patient. Think broader and formulate a differential diagnosis as time passes or the child gets sicker.
Respiratory Assessment
Bronchiolitis versus bronchitis
- Bronchiolitis and bronchitis can both be caused by viruses.
- Editor’s note: Acute bronchitis involves the large airways (bronchi) compared to bronchiolitis which involves the small bronchi and bronchioles.
Hypoxemia in Bronchiolitis
- Transient hypoxemia is not dangerous in infants. Children can tolerate hypoxemia, as they do not have comorbidities like adults (e.g., atherosclerosis).
- Healthy children on a trekking trip to 1700m had an average overnight SpO2 of 86% (Scrase et al. Arch Dis Child. 2009).
- Hypoxia does not make people feel short of breath, so giving oxygen will not make children more comfortable.
- Bronchiolitis is an issue of CO2 retention more than oxygenation.
Respiratory Status
- Work of breathing can be assessed with retractions
- Retractions are the result of non-compliant lung due to mucus which prevents the lung from expanding and contracting normally
- Children deteriorate when work of breathing exhausts respiratory muscles.
- Expert Opinion: A patient’s respiratory status is more concerning than mild hypoxemia. Practitioner gestalt of the patient, beyond the work of breathing, often plays a role in noticing when a child is in distress.
Diagnostic Workup
- Recommend no testing in the initial workup as per AAP guidelines. Wait and see how the child does with standard therapy for bronchiolitis.
CBC
- Not sensitive or specific in kids for bacterial versus bacterial illness (Virkki et al. Thorax. 2002).
Chem7 / BMP
- Expert opinion: History is a better way to assess hydration status. If worried about significant hydration, consider getting a sodium.
