Ch 19 PEDS - Foreign-body aspiration and Croup Syndromes Flashcards
Extrathoracic (Upper Airway) Foreign-body aspiration key findings include:
(A CHIP) Determine findings then partial vs complete obstruction
Abrupt onset
Complete Obstruction:
Cyanosis with marked distress
History of child running with food in mouth or playing with seeds, small coins, toys
Inability to vocalize or cough
Partial Obstruction:
Drooling
Stridor
Ability to vocalizeWhat is specific to each - Foreign-body in esophagus: Foreign-body in supraglottic airway: Foreign-body of small objects that passed the glottis: Foreign-body in lower airway:
Esophagus - respiratory distress
Supraglottic airway - laryngospasm (triggers protective reflexes)
small objects passed through Glottis - obstruct trachea
Lower airway - coughing and variable respiratory distress
What age group is at the highest risk for Foreign-body aspiration in the extrathoracic airway?
What are the most common objects?
6 months - 3 years old
nuts, seeds, berries, corn, popcorn, hot dogs, beans
Gold standard for diagnosis of foreign-body aspiration? What are other diagnostic alternatives?
- *Rigid Bronchoscopy** (usually under anesthesia)
others: virtual bronchoscopy or CT scan
How should a partial obstruction of a Foreign-body in the extrathoracic airway be managed?
allow choking person to use his/her own cough reflex to remove foreign-body
A child that is less than 1 years old and awake with a complete airway obstruction, how should this child be managed?
(Think BLS skills)
Place face down over rescuers arm
deliver 5 rapid back blows
followed by rolling infant over and delivering 5 rapid chest thrusts (repeat until obstruction is relieved)
A child that is awake and older than 1 years old with a completed airway obstruction, how should this child be managed?
Abdominal thrusts (Heimlich maneuver)
A child is found unresponsive and the mother states, “he was choking!!” How should this child be managed?
CPR
T/F Blind finger sweeps are acceptable if the child is awake and coughing from a foreign-body aspiration
FALSE - NEVER perform blind finger sweeps as this can push the foreign-body further into airway
However, a foreign-body that is visualized may be carefully removed with fingers or instrument by using the jaw-thrust technique
A child is presenting with persistent apnea and cannot achieve adequate ventilation, what is the NPs next step?
This child needs emergency intubation, tracheotomy, or need cricothyrotomy!
Intrathoracic (Lower Airway) Foreign-body aspiration key findings include:
Sudden onset of coughing, wheezing, or respiratory distress (may diminish overtime to recur later/chronic cough)
Asymmetrical breath sounds (decreased)
Localized/Monophonic wheezing
Children with a chronic cough, persistent wheezing, or recurrent pneumonia (in the same location) should be evaluated for
Intrathoracic (Lower airway) Foreign-body Aspiration
The NP orders two chest XRAYs of a child with suspected foreign-body, what two XRAYs are being obtained? What should the NP instruct the child to do upon XRAY?
Inspiratoy XRAY - inhale and hold breath
Forced Expiratory XRAY: Breathe out forcefully and tighten stomach
T/F Chest XRAYs will help diagnosis and rule out suspected intrathoracic foreign-body aspiration
FALSE - chest XRAY can be normal
gold standard is rigid bronchoscopy
What will present on XRAY during positive forced expiratory
unilateral hyperinflation and possible mediastinal shift away from affected side
What will present on XRAY of a complete obstruction of the distal airway?
Atelectasis and related volume loss
High clinical suspicion based on 2 of 3 findings is diagnostic to foreign-body aspiration. What are the three findings to make a diagnosis?
Possible aspiration
Focal abnormal lung exam
Abnormal chest XRAY
What are two treatments options of post-removal of foreign-body?
Beta-adrenergic nebulizer treatments
Chest PT
An untreated intrathoracic (lower airway) foreign-body aspiration may lead to:
Bronchiectasis
Lung Abscess
What are essentials in viral croup?
B-PREYS
Barking cough Parainfluenza virus serotypes Recent URI Early winter/FALL onset Young child (6 months - 5 years) Stridor - new onset
What are findings specific to viral croup with stridor in
Mild Croup Stridor
Severe Croup Stridor
What are late signs?
mild stridor: presents when agitated
severe stridor: presents at rest
retractions, air hunger, cyanosis
What is the characteristic presentation of croup?
inspiratory stridor, barking “seal” cough and
retractions at rest - URGENT EVALUATION NEEDED!
What are the causative agents of croup?
Parainfluenza virus** RSV (respiratory syncytial virus) Rhinovirus Adenovirus Influenza A/B M pneumoniae
What physiologic changes does croup cause to the airway?
edema in the subglottic space (accounts
for the predominant signs of upper airway obstruction; inflammation of the entire airway is often
present)
What finding is usually absent in croup?
Fever
A patient with mild croup becomes agitated during physical exam, what do you expect to occur?
stridor
What would be an indication that the patient’s condition with croup has worsened?
Stridor at rest (early sign of worsening obstruction)
retractions, air hunger, cyanosis (late signs)
What signs in a patient would indicate a diagnosis of croup vs. epiglottitis?
Presence of cough and absence of drooling
T/F Suspected viral croup requires a chest XRAY
FALSE - the classical presentation should confirm suspcetion
Should a patient present with an atypical presentation for croup, what would you expect to see on CXR that you wouldn’t find in tracheitis? (specific name of sign)
subglottic narrowing “steeple sign” without irregularities
What are some differential diagnoses of croup?
Angioedema
Laryngeal or Esophageal Foreign-body
Spasmodic croup
Retropharyngeal or Peritonsillar abscess
How should the NP care for a patient with mild-moderate Croup?
Viral Croup should improve within a few days
supportive care
Oral hydration
No tests/procedures (cool mist is not effective!)
Parental reassurance about self-limiting nature of illness
Medication: 1 dose Dexamethasone 0.15mg/kg PO or 0.6mg/kg IM (symptoms improve d/c from ED)
How should the NP care for a patient with moderate-severe Croup? What should the NP do if treatment is needed often/increases in frequency?
Administer humidified O2 (for decreasing O2 sat)
Meds:
Nebulized racemic Epi. (0.5 mL of 2.25% solution diluted in sterile saline - onset 10 - 30 min)
1 dose Dexamethasone 0.6 mg/kg IM
if recurrent Racemic Epi is needed: ADMIT for observation and continued neb tx PRN
Unimmunized children are most susceptible to what pathogen that causes epiglottitis?
What pathogens are present in the immunized child with epiglottitis?
Haemophilus Influenzae
nontypeable H. Influenzae
N. Meningitis
Streptococcus species
What will the “sniffing dog position” look like to the NP?
patients’ neck is hyperextended, with their chin stretched forward (compensatory mechanism to assist patient into position that facilitates best airway possible)
A child with a sudden onset of a high fever, dysphagia, drooling, inspiratory retractions, and a muffled cough is sitting in the waiting room. What condition is suspected?
Epiglottitis
A patient remains in the “sniffing dog position/tripod sign” as you examine them. Without immediate treatment interventions, what does the NP expect to occur?
Progression to total airway obstruction and respiratory arrest
In a patient with epiglottitis, the FNP knows a definitive
diagnosis can be made by?
Direct inspection of the epiglottis during intubation by an airway specialist
With direct visualization of the patient’s epiglottis, the FNP expects what physical findings?
Cherry-red and swollen epiglottis and swollen arytenoids
Should diagnostic imaging be ordered on a patient with
epiglottitis?
Determined by patient presentation (do not delay securing an airway for someone with impending respiratory collapse to obtain CXR)
In a stable patient with epiglottitis, what diagnostic imaging should the FNP order? What classic radiograph sign would you expect?
Lateral neck CXR; “thumbprint” sign caused by swollen epiglottis
The FNP has made the diagnosis of epiglottitis. What is your immediate expected intervention?
Allow child to stay in position of comfort, minimal handling to protect airway, IMMEDIATE CONSULT AND INTUBATION BY EXPERIENCE ANESTHESIOLOGIST IN OR IS REQUIRED!
(blood cultures are obtained + initiate IV abx to cover H
influenzae and Streptococcus species – ceftriaxone or equiv. cephalosporin)
What is the expected duration a patient with epiglottitis can be extubated?
24-48hr when direct inspection shows a significant reduction in size of the epiglottis
How long should antibiotics be continued in patient with
epiglottitis?
2-3 days of IV abx, followed by 10 days of PO abx
What is the expected prognosis for a patient diagnosed with epiglottitis?
Rapid resolution of swelling and inflammation with prompt recognition and appropriate treatment (recurrence if VERY unusual)
What is the classic physiological
representation seen in bacterial tracheitis?
Localized mucosal invasion of bacteria in patients with primary viral croup that developed into inflammatory edema, purulent secretions, and pseudomembranes
A child is unresponsive to stand viral Croup therapy with evidence of high fever, toxic appearance, and progressive, intermittent severe upper airway obstruction, what may the child have?
Bacterial Tracheitis
If bacterial tracheitis is left untreated, then it will progress to ____________
SUDDEN RESPIRATORY ATTREST!
If suspected, REQUIRES IMMEDIATE INTERVENTION!
What are the typical lab findings in a patient
with bacterial tracheitis?
(PILE)
Positive Tracheal secretion culture
Irregularity of contour of proximal tracheal mucosa
Lateral neck XRARY show normal epiglottis with severe subglottic and tracheal narrowing
Elevated WBC with left shift
What diagnostic tool will confirm Bacterial Tracheitits?
Bronchoscopy - copious purulent tracheal secretions and membranes with NORMAL epiglottis
What is the treatment of Tracheitis?
Direct visualization of airway to perform debridement Intubation Humidification Frequent suctioning ICU monitoring IV abx to cover S. aureus, H. Influenzae
What is the prognosis of tracheitis?
Thick secretions that persist for several days and require
longer than normal intubation
Full recovery is expected with prompt recognition and initiation of treatment
