1. Pulmonary Blueprint
PANCE Blueprint

2. Infectious Disorders Acute Bronchitis-
Acute Bronchitis is generally viewed as a self limiting condition, due to upper airway infection
Patients usually present with a productive cough lasting more than 5 days but less than 3 weeks
Chronic bronchitis is a productive cough for most the days for at least 3 months in each of two successive years
Acute Bronchitis is generally caused by a virus

3. Acute Bronchitis
Usual causes of acute bronchitis are influenza A and B, parainfluenza, coronavirus, rhinovirus, RSV, and human metapneumovirus.
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.
Other organisms that rarely cause acute bronchitis include:  mycoplasma pneumoniae, Bordetella Pertussis, Chlamydophilia Pneumoniae
Symptoms are productive cough, wheezing and may have an associated fever.

4. Acute Bronchitis
Treatment is directed a symptom control.  Albuterol for wheezing and prednisone as needed for an adjunct.
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

5. Acute Bronchiolitis
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
Acute Bronchiolitis typical is caused by viral pathogens but on occasion can be caused by Mycoplasma Pneumoniae
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

6. Acute Bronchiolitis
Indications for Hospitalization of Acute Bronchiolitis patients:
1.  Signs of respiratory distress nasal flaring, retractions, grunting, RR>70, dyspnea or cyanosis
2.  Toxic appearance, poor feeding, lethargy
3.  Apnea
4.  Hypoxemia
5.  Parents who are unable to care for the child at home
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
As a rule of thumb, antibiotics generally are not indicated in the treatment of acute bronchiolitis

7. Acute Epiglottitis
Epiglottis is inflammation of the epiglottis and adjacent supraglottic structures
Infectious epiglottitis is cellulitis of the epiglottis and its adjacent structures.  It can result from direct invasion or from bacteremia
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
Airway obstruction can result in cardiopulmonary arrest.

8. Acute Epiglottitis
Epiglottis can be caused by bacteria, viral, or fungal etiologies
The most common pathogen of epiglottis is Haemophilus Influenza Type B (HIB)
We have seen a dramatic decreased in the frequency of epiglottis because of the HIB vaccine
In immunocompromised patients candidia or pseudomonas can cause epiglottitis
Other non infectious etiologies include:  thermal injury, foreign body ingestion, and caustic ingestion

9. Acute Epiglottitis
Clinical symptoms include:  respiratory distress, signs of upper airway obstruction, stridor, sitting in the tripod or sniffing position, and drooling.
Fever, severe sore throat, odynophagia, and drooling are common
Chest x ray or soft tissue neck may reveal a "thumb print" sign

10. Acute Epiglottitis
Labs should be deferred until the airway is secured.  Labs should include CBC and Blood Culture
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.

11. Croup Croup is also known as laryngotracheobronchitis (LTB)
Croup presents clinically with inspiratory stridor, bark cough, and a hoarse voice.
Most common ages afflicted are between the ages of 6 months and 3 years of age
Most common offending organism is the parainfluenza virus

12. Croup Typically presents acutely rather than slow onset
The mainstays of treatment of croup are glucocorticoids and racemic epinephrine
The Wrestly Croup Score determines treatment and it is based on physical exam
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

13. Croup
Mild Croup can be treated at home.  Cool mist can provide symptomatic relief
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
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
Usually resolves itself within 3-7 days

14. Influenza
Influenza is an acute respiratory illness caused by the Influenza A and B viruses
Transmission of the virus is by respiratory secretions
Generally speaking, viral shedding can be detected hours before the onset of symptoms, but much lower during the symptomatic period of the illness
Uncomplicated influenza presents with fever, headache, myalgias, nasal congestion, non productive cough, and sore throat.  Physical exam is usually unremarkable

15. Influenza Pneumonia is the most common complication of influenza
Myositis and rhabdomyolysis are also complications of influenza
CNS complications of influenza include:  encephalopathy, encephalitis, transverse myelitis, aseptic meningitis, and Guillain Bare Syndrome
Two classes of antiviral drugs available for treatment of influenza-
1.  Neuraminidase inhibitors such as zanamivir and oseltamivir are active against influenza A and B
2.  The adamantanes such as amantadine and rimantadine that are active against influenza A

16. Influenza
These agents can shorten the duration of the illness 12 hours to 3 days.  Most studies have shown benefit when instituted hours from the onset of symptoms
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