ILLUSTRATIVE CASE Opening Pandora’s Box: A Chest Radiograph in a 5-Month-Old With Bronchiolitis Neha Patel Wacks, MD, a Kyle Schoppel, MD, b Peter J. Sell, DO, c,d,e Thomas Guggina, MD c,f CASE A 5-month-old, otherwise healthy, former 35-week male infant, presented to our pediatric emergency department with the chief complaint of cough and “sucking in” at the chest. The patient was in his usual state of health until 1 day prior to presentation when he developed nasal congestion. Before coming into the hospital, the family noted decreased oral intake and only 3 wet diapers in the past 24 hours. No other past medical history was notable except intubation at time of delivery due to respiratory distress requiring surfactant administration. Past surgical history was significant for bilateral inguinal hernia repair and circumcision. He is on no medications currently and immunizations are up to date. He lives at home with his nonsmoking parents. In the emergency department, the patient’s vitals were as follows: heart rate, 137; blood pressure, 94/51; temperature, 36.8; respiratory rate, 56; and pulse oximetry, 97% on room air. Physical examination revealed an infant in mild respiratory distress with tachypnea, subcostal retractions, clear nasal discharge, and coarse breath sounds throughout. The patient was treated with nasal suctioning, and the decision was made to send for chest radiograph. Question What is the current American Academy of Pediatrics’ recommendation regarding the use of imaging when diagnosing bronchiolitis? Discussion The American Academy of Pediatrics Clinical Practice Guidelines for the diagnosis, management, and prevention of bronchiolitis from 2014 recommend that the diagnosis of bronchiolitis be made clinically and that the use of imaging is not warranted in most cases. 1 Current evidence does not support routine chest radiography in children with bronchiolitis as data are insufficient to demonstrate that chest radiography correlates well with disease severity. One randomized trial revealed that children with suspected lower respiratory tract infection who had radiography performed were more likely to receive antibiotics without any difference in clinical outcomes. Initial radiography should be reserved for cases in which the patient clinically worsens unexpectedly, respiratory effort is severe enough to warrant ICU admission, or where signs of airway complication (ie, pneumothorax) are present. 1 e Division of Critical Care Pediatrics, f Hanshaw Pediatric Hospital Medicine Division, c Department of Pediatrics, a Family Medicine Residency Program, b Pediatric Residency Program, and d Child Protection Program, University of Massachusetts, Worcester, Massachusetts www.hospitalpediatrics.org DOI:10.1542/hpeds.2015-0267 Copyright © 2016 by the American Academy of Pediatrics Address correspondence to Thomas Guggina, MD, Pediatrics Residency Program, University of Massachusetts 55 Lake Ave North, Worcester, MA 01655. E-mail: thomas.guggina@umassmemorial.org HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671). FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. All authors listed have contributed to the clinical care of the patient presented in this article, and all authors approved the final manuscript as submitted. 642 WACKS et al by guest on October 25, 2017 http://hosppeds.aappublications.org/ Downloaded from