PANCE Blueprint Pulmonary (10%)

Respiratory syncytial virus infection (ReelDX)



Patient will present as → a 5-month-old infant with a three-day history of a mild respiratory tract infection with serous nasal discharge, fever of 38.5 C, and decreased appetite. Physical exam reveals a tachypneic infant with audible wheezing and a respiratory rate of 65.  Nasal flaring, use of accessory muscles, and subcostal and intercostal retractions are noted. Expiratory wheezes and a cough are present.

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RSV is the most common cause of lower respiratory tract infections in children worldwide. Virtually all children contract it by the age of three.

  • It's the leading cause of pneumonia and bronchiolitis in infants. It may play a major role in the pathogenesis of asthma bronchiolitis

Distinct symptoms of RSV bronchiolitis include:

  • Rhinorrhea
  • Wheezing and coughing can persist for several months
  • Low-grade fever
  • Nasal flaring and retractions
  • Nail Bed cyanosis

Nasopharyngeal secretions RSV antigen test

  • CXR can show hyperinflation, peribronchial thickening, and/or diffuse interstitial infiltrates
Bronchiolitis chest X-ray

Chest X-ray of an infant with respiratory syncytial virus bronchiolitis demonstrating lung hyperinflation with a flattened diaphragm and bilateral atelectasis in the right apical and left basal regions.

What is the only treatment shown to improve bronchiolitis?
The only treatment demonstrated to improve bronchiolitis is oxygen

Indications for hospitalization include moderate tachypnea with feeding difficulties, visible retractions, and oxygen desaturation

  • Supportive measures include albuterol via nebulizer, antipyretics, and humidified oxygen
    • Variable thresholds are used for starting oxygen therapy in infants with bronchiolitis, most commonly SpO2 <90 to <92 percent
  • Steroids (controversial)
  • Symptoms resolve within five to seven days

Vaccination (view current CDC guidelines)

  • Approved for individuals 60 years and older
  • Under review for use during pregnancy

Infants and young children

  • 1 dose of nirsevimab for all infants younger than 8 months born during or entering their first RSV season
  • 1 dose of nirsevimab for infants and children 8–19 months old who are at increased risk for severe RSV disease and entering their second RSV season

Palivizumab (Synagis) prophylaxis

  • Infants born at ≤ 28 weeks 6 days gestational age and <12 months at the start of RSV season
  • Infants < 12 months of age with chronic lung disease (CLD) of prematurity
  • Infants ≤ 12 months of age with hemodynamically significant CHD
  • Infants and children < 24 months of age with CLD of prematurity necessitating medical therapy (eg, supplemental oxygen, bronchodilator, diuretic, or chronic steroid therapy) within 6 months prior to the beginning of RSV season

AAP also suggests that palivizumab prophylaxis may be considered in the following circumstances:

  • Infants < 12 months of age with congenital airway abnormality or neuromuscular disorder that decreases the ability to manage airway secretions
  • Infants < 12 months of age with cystic fibrosis with clinical evidence of CLD and/or nutritional compromise
  • Children < 24 months with cystic fibrosis with severe lung disease (previous hospitalization for pulmonary exacerbation in the first year of life or abnormalities on chest radiography or chest computed tomography that persist when stable) or weight for length less than the 10th percentile
  • Infants and children < 24 months who are profoundly immunocompromised
  • Infants and children < 24 months undergoing cardiac transplantation during RSV season

osmosis Osmosis
Respiratory Syncytial Virus (RSV) Assessment


RSV, or respiratory syncytial virus, is a viral infection that infects upper airway epithelial cells, leading to copious secretions, coughing, sneezing, and wheezing in patients. It primarily affects infants and young children with a peak incidence between 2 to 7 months of age. It affects more males than female infants; occurs less frequently in breastfed infants; and has a peak incidence during winter and spring. Most cases of bronchiolitis are caused by RSV.

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Respiratory Syncytial Virus (RSV) Interventions

The management of caring for a child with RSV is providing supplemental oxygen, maintaining fluid intake and nutrition, airway maintenance, and administration of medications.

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Question 1
A 3 month-old male presents with a hoarse cough and thick purulent rhinorrhea for the past 2 days. The mother noted that yesterday he appeared to get worse and seemed to have increasing problems breathing and trouble feeding. Examination reveals a temperature of 100.2 degrees F and respiratory rate of 80/minute with nasal flaring and retractions. Lung examination reveals a prolonged expiratory phase with inspiratory rales. He is tachycardic. Pulse oximetry reveals oxygen saturation of 89%. Chest x-ray reveals hyperinflation with diffuse interstitial infiltrates. Which of the following is the most appropriate intervention?
Antibiotics are utilized to treat bacterial, not viral, illnesses.
inhaled corticosteroids
Inhaled glucocorticoids (budesonide, fluticasone, dexamethasone) have not been beneficial in reducing symptom duration or readmission rates
Racemic epinephrine
Racemic epinephrine is not indicated in the treatment of bronchiolitis.
Question 1 Explanation: 
This infant most likely has bronchiolitis. While most cases are mild and can be treated at home, hospitalization is recommended for infants with hypoxia on room air, moderate tachypnea with feeding difficulties and marked respiratory distress with retractions. Additionally hospitalization is recommended for infants less than 2-3 months of age, a history of apnea or an underlying chronic cardiopulmonary disease.
Question 2
Which of the following is an indication for hospitalization in a patient who has acute bronchiolitis?
pulse oximetry of 94% on room air
A pulse oximetry reading of 94% on room air is equivalent to a PaO2 of approximately 80 mm Hg which indicates the child is not in severe respiratory distress.
children between 4-6 months of age
Children less than 2 months of age require hospitalization.
moderate tachypnea with feeding difficulties
hyperinflation and interstitial infiltrates on chest x-ray
Hyperinflation and interstitial infiltrates on chest x-ray are frequently seen with acute bronchiolitis and by themselves are not an indication for hospitalization.
Question 2 Explanation: 
Indications for hospitalization include moderate tachypnea with feeding difficulties.
Question 3
A previously healthy 8-month-old boy is hospitalized for acute bronchiolitis. He has no known significant past medical or family history. On admission, he exhibits nasal flaring and retractions with a respiratory rate of 68, axillary temperature of 102.0 degrees F and O2 saturation of 86%. Which of the following medications is indicated?
Corticosteroids are not indicated for the treatment of previously healthy infants with bronchiolitis.
Ceftriaxone (Rocephin)
Antibiotics are not indicated in the treatment of bronchiolitis unless there is a secondary bacterial infection.
Palivizumab (Synagis)
Palivizumab is used only for prevention of RSV infection.
Question 3 Explanation: 
Oxygen is an important supportive therapy for hypoxemic infants with bronchiolitis. Bronchodilators would also be initiated in this patient.
Question 4
A 6-month-old infant presents with a three-day history of cough, wheezing, and difficulty feeding. On examination, the infant has nasal flaring and intercostal retractions. Which of the following is the most appropriate initial diagnostic test?
Chest X-ray
May be used to rule out pneumonia but is not necessary for the initial diagnosis of bronchiolitis.
Nasopharyngeal swab for viral PCR
Complete blood count (CBC)
Not specific for diagnosing bronchiolitis and typically shows nonspecific findings.
Pulmonary function tests
Not feasible or practical in infants with acute respiratory distress.
Blood culture
Indicated if there is a suspicion of bacterial sepsis, not for uncomplicated bronchiolitis.
Question 4 Explanation: 
A nasopharyngeal swab for viral PCR (polymerase chain reaction) is the most appropriate initial diagnostic test for an infant presenting with symptoms suggestive of acute bronchiolitis. This test can rapidly identify the presence of RSV and other viruses, aiding in the diagnosis and management of the condition.
There are 4 questions to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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