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Pulmonary Blueprint
PANCE Blueprint
Infectious Disorders
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Acute Bronchitis-
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Acute Bronchitis is generally viewed as a self limiting
condition, due to upper airway infection
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Patients usually present with a productive cough
lasting more than 5 days but less than 3 weeks
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Chronic bronchitis is a productive cough for most the
days for at least 3 months in each of two successive
years
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Acute Bronchitis is generally caused by a virus
Acute Bronchitis
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Usual causes of acute bronchitis are influenza A and B, parainfluenza, coronavirus, rhinovirus,
RSV, and human metapneumovirus.
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It has been suggested that bacterial pathogens that cause pneumonia (Strep Pneumoniae,
Haemophilus Influenza, Staph Aureus, Moraxella Catarrhalis) can cause bronchitis, but there
have been no studies to prove this.
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Other organisms that rarely cause acute bronchitis include: mycoplasma pneumoniae,
Bordetella Pertussis, Chlamydophilia Pneumoniae
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Symptoms are productive cough, wheezing and may have an associated fever.
Acute Bronchitis
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Treatment is directed a symptom control. Albuterol for
wheezing and prednisone as needed for an adjunct.
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Indications for chest x ray include a HR greater than
100, RR greater than 24, temperature greater than 38
degrees C, or oxygen saturation less than 94% on
room air on healthy adults
Acute Bronchiolitis
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Acute Bronchiolitis is defined as a syndrome that
occurs in children less than 2 years of age and
presents as rhinorrhea followed by lower
respiratory infection with inflammation that
results in wheezes and/or crackles
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Acute Bronchiolitis typical is caused by viral
pathogens but on occasion can be caused by
Mycoplasma Pneumoniae
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Risk factors for developing severe disease with
bronchiolitis include: prematurity, age less than
12 weeks, chronic pulmonary disease,
congenital and anatomic defects of the airways,
congenital heart disease, immunodeficiency, and
neurologic disease
Acute Bronchiolitis
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Indications for Hospitalization of Acute Bronchiolitis patients:
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1. Signs of respiratory distress nasal flaring, retractions, grunting, RR>70, dyspnea or cyanosis
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2. Toxic appearance, poor feeding, lethargy
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3. Apnea
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4. Hypoxemia
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5. Parents who are unable to care for the child at home
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Management includes management of hydration and oxygenation. Bronchodilator therapy and
glucocorticoids are indicated if wheezing (studies currently published refute this but most clinicians are
skeptical.) Nasal suctioning is also helpful
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As a rule of thumb, antibiotics generally are not indicated in the treatment of acute bronchiolitis
Acute Epiglottitis
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Epiglottis is inflammation of the epiglottis and
adjacent supraglottic structures
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Infectious epiglottitis is cellulitis of the epiglottis and
its adjacent structures. It can result from direct
invasion or from bacteremia
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Once the infection begins, swelling rapidly
progresses to involve the entire supraglottic larynx
and swelling is halted by the tightly bound epithelium
at the level of the vocal cords
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Airway obstruction can result in cardiopulmonary
arrest.
Acute Epiglottitis
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Epiglottis can be caused by bacteria, viral, or fungal etiologies
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The most common pathogen of epiglottis is Haemophilus Influenza Type B (HIB)
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We have seen a dramatic decreased in the frequency of epiglottis because of the HIB vaccine
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In immunocompromised patients candidia or pseudomonas can cause epiglottitis
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Other non infectious etiologies include: thermal injury, foreign body ingestion, and caustic
ingestion
Acute Epiglottitis
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Clinical symptoms include: respiratory
distress, signs of upper airway
obstruction, stridor, sitting in the tripod
or sniffing position, and drooling.
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Fever, severe sore throat,
odynophagia, and drooling are
common
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Chest x ray or soft tissue neck may
reveal a "thumb print" sign
Acute Epiglottitis
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Labs should be deferred until the airway is
secured. Labs should include CBC and Blood Culture
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Two main parts of management of epiglottis include
securing the airway and instituting
antibiotics. Recommended empiric treatment includes
third generation cephalosporins with clindamycin or
vancomycin.
Croup
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Croup is also known as
laryngotracheobronchitis (LTB)
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Croup presents clinically with inspiratory
stridor, bark cough, and a hoarse voice.
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Most common ages afflicted are between the
ages of 6 months and 3 years of age
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Most common offending organism is the
parainfluenza virus
Croup
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Typically presents acutely rather than slow onset
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The mainstays of treatment of croup are glucocorticoids and racemic
epinephrine
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The Wrestly Croup Score determines treatment and it is based on
physical exam
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Severe croup can progress to respiratory failure where there is fatigue,
listlessness, marked retractions, decreased breath sounds, decreased
LOC, cyanosis, pallor, and tachycardia disproportionate to
fever. Rarely this patients may need mechanical ventilation. Capillary
blood gas should be obtained
Croup
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Mild Croup can be treated at home. Cool mist can provide symptomatic relief
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Children have a tendency to get worse at night. If the child looks bad or may need
admission, consider admission especially if in night or evening hours
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Indications for admission of Croup patients include: need for racemic epinephrine
continuously, need for oxygen, moderate retractions, degree of response to initial therapy,
if they look toxic, poor oral intake, if less than 6 months, return visit in 24 hours, poor
parenteral care at home
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Usually resolves itself within 3-7 days
Influenza
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Influenza is an acute respiratory illness caused by
the Influenza A and B viruses
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Transmission of the virus is by respiratory secretions
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Generally speaking, viral shedding can be detected
24-48 hours before the onset of symptoms, but much
lower during the symptomatic period of the illness
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Uncomplicated influenza presents with fever,
headache, myalgias, nasal congestion, non
productive cough, and sore throat. Physical exam is
usually unremarkable
Influenza
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Pneumonia is the most common complication of influenza
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Myositis and rhabdomyolysis are also complications of influenza
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CNS complications of influenza include: encephalopathy, encephalitis, transverse myelitis, aseptic
meningitis, and Guillain Bare Syndrome
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Two classes of antiviral drugs available for treatment of influenza-
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1. Neuraminidase inhibitors such as zanamivir and oseltamivir are active against influenza A and B
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2. The adamantanes such as amantadine and rimantadine that are active against influenza A
Influenza
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These agents can shorten the duration of the illness 12 hours to
3 days. Most studies have shown benefit when instituted 24-48
hours from the onset of symptoms
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Institution of any antivirals is recommended when: illness
requiring hospitalization, age over 65, pregnant women or post
partum less than 2 weeks, or progressive, severe or
complicated illnesses-High priority age groups for influenza
vaccine: pregnancy, immunocompromised patients, healthcare
workers and household contacts