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Unit 2 68 > Ch 19 PEDS - Foreign-body aspiration and Croup Syndromes > Flashcards

Ch 19 PEDS - Foreign-body aspiration and Croup Syndromes Flashcards

1
Q

Extrathoracic (Upper Airway) Foreign-body aspiration key findings include:

(A CHIP) Determine findings then partial vs complete obstruction

A 
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 vocalize
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2
Q 
What 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:
A

Esophagus - respiratory distress
Supraglottic airway - laryngospasm (triggers protective reflexes)
small objects passed through Glottis - obstruct trachea
Lower airway - coughing and variable respiratory distress

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3
Q

What age group is at the highest risk for Foreign-body aspiration in the extrathoracic airway?
What are the most common objects?

A

6 months - 3 years old

nuts, seeds, berries, corn, popcorn, hot dogs, beans

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4
Q

Gold standard for diagnosis of foreign-body aspiration? What are other diagnostic alternatives?

A
  • *Rigid Bronchoscopy** (usually under anesthesia)

others: virtual bronchoscopy or CT scan

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5
Q

How should a partial obstruction of a Foreign-body in the extrathoracic airway be managed?

A

allow choking person to use his/her own cough reflex to remove foreign-body

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6
Q

A child that is less than 1 years old and awake with a complete airway obstruction, how should this child be managed?

A

(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)

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7
Q

A child that is awake and older than 1 years old with a completed airway obstruction, how should this child be managed?

A

Abdominal thrusts (Heimlich maneuver)

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8
Q

A child is found unresponsive and the mother states, “he was choking!!” How should this child be managed?

A

CPR

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9
Q

T/F Blind finger sweeps are acceptable if the child is awake and coughing from a foreign-body aspiration

A

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

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10
Q

A child is presenting with persistent apnea and cannot achieve adequate ventilation, what is the NPs next step?

A

This child needs emergency intubation, tracheotomy, or need cricothyrotomy!

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11
Q

Intrathoracic (Lower Airway) Foreign-body aspiration key findings include:

A

Sudden onset of coughing, wheezing, or respiratory distress (may diminish overtime to recur later/chronic cough)
Asymmetrical breath sounds (decreased)
Localized/Monophonic wheezing

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12
Q

Children with a chronic cough, persistent wheezing, or recurrent pneumonia (in the same location) should be evaluated for

A

Intrathoracic (Lower airway) Foreign-body Aspiration

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13
Q

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?

A

Inspiratoy XRAY - inhale and hold breath

Forced Expiratory XRAY: Breathe out forcefully and tighten stomach

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14
Q

T/F Chest XRAYs will help diagnosis and rule out suspected intrathoracic foreign-body aspiration

A

FALSE - chest XRAY can be normal

gold standard is rigid bronchoscopy

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15
Q

What will present on XRAY during positive forced expiratory

A

unilateral hyperinflation and possible mediastinal shift away from affected side

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16
Q

What will present on XRAY of a complete obstruction of the distal airway?

A

Atelectasis and related volume loss

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17
Q

High clinical suspicion based on 2 of 3 findings is diagnostic to foreign-body aspiration. What are the three findings to make a diagnosis?

A

Possible aspiration
Focal abnormal lung exam
Abnormal chest XRAY

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18
Q

What are two treatments options of post-removal of foreign-body?

A

Beta-adrenergic nebulizer treatments

Chest PT

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19
Q

An untreated intrathoracic (lower airway) foreign-body aspiration may lead to:

A

Bronchiectasis

Lung Abscess

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20
Q

What are essentials in viral croup?

B-PREYS

A 
Barking cough
Parainfluenza virus serotypes
Recent URI
Early winter/FALL onset
Young child (6 months - 5 years) 
Stridor - new onset
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21
Q

What are findings specific to viral croup with stridor in
Mild Croup Stridor
Severe Croup Stridor

What are late signs?

A

mild stridor: presents when agitated
severe stridor: presents at rest

retractions, air hunger, cyanosis

22
Q

What is the characteristic presentation of croup?

A

inspiratory stridor, barking “seal” cough and

retractions at rest - URGENT EVALUATION NEEDED!

23
Q

What are the causative agents of croup?

A 
Parainfluenza virus** 
RSV (respiratory syncytial virus)
Rhinovirus
Adenovirus
Influenza A/B
M pneumoniae
24
Q

What physiologic changes does croup cause to the airway?

A

edema in the subglottic space (accounts
for the predominant signs of upper airway obstruction; inflammation of the entire airway is often
present)

25
Q

What finding is usually absent in croup?

A

Fever

26
Q

A patient with mild croup becomes agitated during physical exam, what do you expect to occur?

A

stridor

27
Q

What would be an indication that the patient’s condition with croup has worsened?

A

Stridor at rest (early sign of worsening obstruction)

retractions, air hunger, cyanosis (late signs)

28
Q

What signs in a patient would indicate a diagnosis of croup vs. epiglottitis?

A

Presence of cough and absence of drooling

29
Q

T/F Suspected viral croup requires a chest XRAY

A

FALSE - the classical presentation should confirm suspcetion

30
Q

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)

A

subglottic narrowing “steeple sign” without irregularities

31
Q

What are some differential diagnoses of croup?

A

Angioedema
Laryngeal or Esophageal Foreign-body
Spasmodic croup
Retropharyngeal or Peritonsillar abscess

32
Q

How should the NP care for a patient with mild-moderate Croup?

A

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)

33
Q

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?

A

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

34
Q

Unimmunized children are most susceptible to what pathogen that causes epiglottitis?

What pathogens are present in the immunized child with epiglottitis?

A

Haemophilus Influenzae

nontypeable H. Influenzae
N. Meningitis
Streptococcus species

35
Q

What will the “sniffing dog position” look like to the NP?

A

patients’ neck is hyperextended, with their chin stretched forward (compensatory mechanism to assist patient into position that facilitates best airway possible)

36
Q

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?

A

Epiglottitis

37
Q

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?

A

Progression to total airway obstruction and respiratory arrest

38
Q

In a patient with epiglottitis, the FNP knows a definitive

diagnosis can be made by?

A

Direct inspection of the epiglottis during intubation by an airway specialist

39
Q

With direct visualization of the patient’s epiglottis, the FNP expects what physical findings?

A

Cherry-red and swollen epiglottis and swollen arytenoids

40
Q

Should diagnostic imaging be ordered on a patient with

epiglottitis?

A

Determined by patient presentation (do not delay securing an airway for someone with impending respiratory collapse to obtain CXR)

41
Q

In a stable patient with epiglottitis, what diagnostic imaging should the FNP order? What classic radiograph sign would you expect?

A

Lateral neck CXR; “thumbprint” sign caused by swollen epiglottis

42
Q

The FNP has made the diagnosis of epiglottitis. What is your immediate expected intervention?

A

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)

43
Q

What is the expected duration a patient with epiglottitis can be extubated?

A

24-48hr when direct inspection shows a significant reduction in size of the epiglottis

44
Q

How long should antibiotics be continued in patient with

epiglottitis?

A

2-3 days of IV abx, followed by 10 days of PO abx

45
Q

What is the expected prognosis for a patient diagnosed with epiglottitis?

A

Rapid resolution of swelling and inflammation with prompt recognition and appropriate treatment (recurrence if VERY unusual)

46
Q

What is the classic physiological

representation seen in bacterial tracheitis?

A

Localized mucosal invasion of bacteria in patients with primary viral croup that developed into inflammatory edema, purulent secretions, and pseudomembranes

47
Q

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?

A

Bacterial Tracheitis

48
Q

If bacterial tracheitis is left untreated, then it will progress to ____________

A

SUDDEN RESPIRATORY ATTREST!

If suspected, REQUIRES IMMEDIATE INTERVENTION!

49
Q

What are the typical lab findings in a patient
with bacterial tracheitis?

(PILE)

A

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

50
Q

What diagnostic tool will confirm Bacterial Tracheitits?

A

Bronchoscopy - copious purulent tracheal secretions and membranes with NORMAL epiglottis

51
Q

What is the treatment of Tracheitis?

A 
Direct visualization of airway to perform debridement
Intubation
Humidification
Frequent suctioning
ICU monitoring
IV abx to cover S. aureus, H. Influenzae
52
Q

What is the prognosis of tracheitis?

A

Thick secretions that persist for several days and require
longer than normal intubation
Full recovery is expected with prompt recognition and initiation of treatment

Unit 2 68 (32 decks)

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