Exam 2: Respiratory Flashcards
Upper Respiratory Tract
Nose, pharynx, trachea (epiglottis and larynx)
Lower Respiratory Tract
Bronchi, bronchioles, alveoli
Anatomical Differences of Children’s Respiratory Tracts (3)
- Diameter of airway is smaller
- Distance between structures within the tract is shorter (so organisms move more rapidly down the respiratory tract)
- Bifurcation of trachea is shorter
Signs of Respiratory Distress in Children (8)
- Nasal flaring/use of accessory muscles
- Retractions
- Tachypnea
- Labored and shallow breathing
- Color changes (lips may turn blue)
- Grunting
- Stridor (high pitched)
- May have breath sounds such as crackles, wheezing, rhonchi, or if very severe, may not even hear breath sounds
Retractions (with upper and lower infections)
Indentation/sucking in of the ribs when the child breaths
Upper respiratory infections: retractions will occur in supra clavicular and supra sternal area
Lower respiratory infections: retractions will occur in intercostal, sub sternal, sub costal
Wheezing
Initially occurs on expiration
*Difficult to hear, need to prolong the expiratory phase by having child blow on cotton ball or blow on a tissue
*Later in the illness they will have it on inhalation
Rhonchi
Sounds like snoring; it is a course breath sound
Eustachian Tube in Children
- Eustachian Tube is shorter and more horizontal
* it is easier for stuff to drain into nasal pharynx or easier for secretions in nasal pharynx to go back into the ear (makes ear infections occur more frequently in children) - Anything that decreases the ability of the Eustachian tube to drain secretions that can build up in the middle of the ear can cause otitis media
When is otitis media most prevalent?
6 months to 2 years, then it gradually decreases with slight increase when entering school
*Most prevalent disease of early childhood
Things that can cause inflammation inside the Eustachian tube (4)
- Sleeping with a bottle (bottle fed babies have higher incidence of otitis media than breast fed)
- Infection (bacteria causing inflammation inside the tube so it doesn’t drain)
- Allergies
- Tobacco smoke (living in a household with tobacco smoke increases incidence; secretions don’t drain and then they get infected)
* these will decrease the ability to drain the Eustachian tube
Things that compress the Eustachian tube (2)
- Swollen tonsils
- Tumor
* causes an impact on draining abilities
Bacteria/Infections that can lead to otitis media (3)
- Streptococcus pneumonia
- Haemophilus Influenza
- Moraxella catarrhalis
* these all call inflammation, reducing draining abilities
Feeding techniques and otitis media
Bottle fed babies are totally flat in supine position, and if they regurgitate then the formula can go into the nasal pharynx and into their middle ear and cause infection
*Also, breastmilk has IgA in it which helps decrease incidence of infection (IgA not in formula)
Clinical Manifestations of Otitis Media (7)
- Irritable
- Fever (can go up to ~104 degrees)
- Lymphadenopathy (enlarged lymph nodes)
- Rhonnorhea (clear nasal discharge; shouldn’t be green!)
- Loss of appetite (hurts to suck and swallow)
- V/D
- May be grabbing their ear or pulling on it (indicates ear infection since some other symptoms are non-specific)
Otoscope view of otitis media
- Intact membrane, bright red and bulging
- No landmarks visible
- No light reflex visible
- Check for mobility of tympanic membrane (chronic otitis media reduces mobility due to scar tissue formation, this will also affect hearing)
Otoscope view of chronic otitis media (3)
- Reduced mobility of tympanic membrane
- Need to do auditory test
- Tympanic membrane could be perforated
* Will cause changes in hearing and then maybe in their speech due to scarring
Perforated tympanic membrane
Fever will go down, there will be discharge on the pillow, they will be less irritable
Diagnosis of Acute Otitis Media
Requires:
- A history of acute onset of signs and symptoms
- Presence of middle ear effusion (MEE)
- Bulging of TM
- Limited or absent mobility of TM
- Air fluid level behind TM
- Otorrhea
- Signs and symptoms of middle-ear inflammation
FOLLOW THESE GUIDELINES SO THAT YOU DON’T OVERPRESCRIBE ANTIBIOTICS
Recommended Treatment for Acute Otitis Media for younger than 6 months old
Administer antibiotics to all children younger than 6 months no matter the degree of the diagnostic criteria
Recommended Treatment for Acute Otitis Media For children 6 months-2 years,
Antibacterial therapy is recommended when the diagnosis of AOM is certain or if the diagnosis is uncertain but illness is severe (fever= 102.2 and severe pain or above in past 24 hours)
Observation is recommended if diagnosis is uncertain and symptoms are not severe
*Antibiotics should be prescribed when no improvement occurs after 48-72 hours observation
Recommended Treatment for Acute Otitis Media For children over 2 years old
Antibacterial therapy is recommended when symptoms are severe
Observation is recommended for non-severe illness and uncertain diagnosis
*Antibiotics should be prescribed when no improvement occurs after 48-72 hours observation
Otitis Media PO Antibiotics
Amoxicillin is first line treatment
*If it doesn’t work, there are guidelines for what else to progress to
Otitis media IM antibiotics
Use if concerned about compliance or if child has poor absorption of drug due to diarrhea or vomiting
*Most commonly prescribed: Rocephin
~Very unpleasant
~Risk of getting sterile abscess
Otitis Media Treatment for Discomfort (2)
- Analgesics/antipyretics –> always take temp. before administering
- Warm soaks
Vaccines for Otitis Media
Hib and Prevnar
Hib: for influenza
Prevnar: for pneumococcal infection
Chronic Otitis Media with Effusion Signs and Symptoms (4)
- Fluid persists in the middle ear for weeks-months but it’s not infected
- the ear looks fine but you may see fluid/bubbles; can see bony prominences and other landmarks
- Mild to moderate hearing loss
- No complaints of severe pain, but complains of fullness or ear popping sensation during swallowing
Chronic Otitis Media with Effusion Treatment
Myringotomy (ventilating tube put in during surgery) if fluid persists for more than 3 months and is associated with hearing loss
BENADRYL AND OTHER ANTIHISTMAINES IS NOT AN ADEQUATE TREATMENT FOR KIDS!
Myringotomy criteria (3)
- Three or more episodes of OM in a 6 month period OR 4 episodes during a 1 year period
- Bilateral OME that has been unresponsive to non-surgical therapy for three months or more
- An associated hearing loss
Myringotomy
Ventilation tube to treat chronic otitis media; tube allows for drainage of fluid to go into the nasal pharynx
- Stays in for ~6 months (could be up to a year) then falls out on its own
- Wax may help bring it out, and if it doesn’t come out it will need to be removed
Myringotomy Parent Teaching (2)
- Don’t go swimming/avoid water in the ear
2. Get wax earplugs for when the child showers or gets wet
Croup Syndromes
Characterized by hoarseness, cough, varying degrees of inspiratory stridor and respiratory distress resulting from swelling or obstruction in region of larynx
- Will sound like a seal
- There is sub-glottic edema which makes it very difficult to breath
Croup Syndrome Types (4)
- Acute epiglotitis [MEDICAL EMERGENCY]
- Acute laryngotracheobronchitis (LTB)
- Acute spasmodic laryngitis
- Acute tracheitis
Viral organisms associated with Croup Syndromes (4)
- Parainfluenza
- RSV
- Influenza A and B
- Mycoplasma pneumonia
Acute Laryngotracheobronchitis (LTB)
Viral infection and the most common type of croup
Occurs mainly with ages 3 months-8 years
*Assocaited with seal-like cough
Characteristics of Croup Syndromes (7)
- Hoarseness
- “Barking” cough
- Inspiratory stridor
- Respiratory distress
- Higher incidence in boys
- Age – 6 months to 3 years with peak at 2
- Occurs mainly during late autumn through early winter
LTB Clinical Manifestations (8)
- Gradual onset
- Begins with URI
- Runny nose
- “Seal-like” cough
- May have inspiratory stridor and suprasternal retractions
- —> Upper respiratory: suprasternal retractions
- —>Stridor may tell you whether or not they need to come into hospital - Increased RR
- –> As they get more tired from increased RR, RR may drop - Distressed and frightened
- May develop symptoms of hypoxia
- —>Not getting enough oxygen because they are trying to breath past a narrow airway
Respiratory Rate With Croup Syndromes
- -If child has increased RR with croup, after a period of time of trying to breath very hard past the obstruction they will become very exhausted
- -May initially see an increase in RR, but as they get more tired you will start to see RR drop
- -They can then experience respiratory suppression
- -Ability to blow off CO2 will go down and they can become ACIDOTIC
- -Need to keep an eye on children with this to ensure that it doesn’t progress to this level
- *Always monitor RR very closely!
- *Number 1 cause of cardiac arrest in children= respiratory arrest
Therapeutic Management of Mild LTB (7)
Mild LTB= No Stridor at rest
- Managed at home
1. Elevate the head of the bed- -If they are really young, take crib mattress and put pillows under crib mattress
- -Roll a towel stick it under their butt to prevent them from sliding down
- Keep comfortable
- Antipyretics
- High humidity with cool mist
- -Cold humidifies air calms down inflammation
- -If no cold air humidifier, then they can be wrapped up nice and warm then stand outside in cold moist air (if it’s in winter) or they can be near freezer
- Encourage fluids
- Rx Medications not given
- Call if there are any SandS of respiratory distress!!
Therapeutic Management of Severe LTB (7)
Severe LTB= Stridor at rest
*Managed in the hospital
- Cool mist
- IV fluid
–No oral fluids because there is a difficult time coordinating breathing and swallowing and will be at risk for aspirations - NPO
- Monitor respiratory status
- Give O2 when necessary
**Never plain nasal canulas or mask
**All O2 should be humidified; helps with dilation - Include parents to reduce stress
- Medications:
A. Corticosteroids, IV of Solumedrol
-May get IM in ER
B. Racemic epinephrine via nebulizer
-Decreases the sub-glotic edema
Medications Administered for Severe LTB (2)
- Corticosteroids IV (Solumedrol)
2. Racemic Epinephrine via nebulizer to decrease the sub-glottic edema
Acute Epiglotitis
- Caused by bacterial infection, most frequently by haemophilus influenza (can also be by staph or strep)
- Occurs more commonly in adults because they do not get the haemophilus vaccine
- Can progress very quickly
- If you suspect acute epiglotitis, do not tell parent to take child to ER, you call the ambulance and have them come get the child; NEVER LOOK INTO THE THROAT UNLESS IN ER WITH INTUBATION STUFF READY
Clinical Manifestations of Acute Epiglotitis (6)
- Abrupt onset of severe sore throat
- Fever
- Muffled voice and pain with swallowing
* DO NOT LOOK IN THEIR THROAT UNLESS YOU’RE IN AN ER AND YOU HAVE EVERYTHING YOU NEED TO INTUBATE* This is because inspecting the throat can cause airway spasm and collapse of the airway - Cough usually NOT present
- Assumes upright position, leaning forward with mouth open, drooling and tongue protruding; If they are laying down it completely obstructs the airway
* *Drooling because they don’t want to swallow - Irritable, restless and frightened expression
They will look very sick!!
Signs and Symptoms of Progressed Acute Epiglotitis
Patient develops signs of respiratory obstruction with froglike croaking sound, suprasternal and supraclavicular retractions and cyanosis may develop
Management of Acute Epiglotitis (3)
- In primary care setting, proper assessment and swift management to transport to ER. Throat should NEVER be inspected because it can cause airway spasm
- Lateral neck films in ER to diagnose it
*If acute epiglotitis is confirmed:
A. Most cases require intubation or tracheotomy
B. Within 3-5 days their WBC, fever, inflammation reduces
C. Within a week or less they can be extubated or have trach removed - Will be in ICU to receive proper respiratory treatments
Prevention of Acute Epiglotitis
HIB vaccine
Bronchialitis (RSV) Respiratory Syncytial Virus (6)
- Occurs primarily in winter and spring
- Greatest occurrence between 2 – 6 mths. with the peak between 2 -3 months.
- *Responsible for at least 50% of children admitted for bronchiolitis and most important respiratory pathogen in infancy and early childhood
- Immunity does not occur, but incidence & severity decreases with age
- By age 3 all children have been infected with RSV at least once.
- Sited as risk factor for developing Asthma up to 13 years of age
- Two strains, Strain A and Strain B. Strain A is more severe and more common
Pathophysiology of RSV
1st: RSV invades the bronchiolar epithelial cells and causes both inflammation and edema in the airway.
2nd: The epithelial cells affected by the virus end up dying and then shedding and obstructing the airway passes
3rd: This shedding of necrotic cells causes air trapping, poor gas exchange, hyperinflation, and atelectasis by obstructing the small airway passeges
Risk Factors for RSV (8)
- These put the patient at higher risk for getting sicker by the virus, not higher risk for getting it
1. Male
2. Prematurity (Due to immature lungs or problems with surfactant)
3. Chronic Lung Disease
4. Bronchopulmonary Dysplasia (BPD) (Can be caused by being intubated or getting O2 for a long period of time)
5. Congenital Heart Disease
6. Cystic Fibrosis
7. Immunodeficiency
8. Tobacco smoke exposure
Clinical Manifestations of RSV (6)
- Begins with symptoms of upper respiratory tract infection (URI) then progresses to a lower respiratory tract infection
- Low grade fever
- Cough may be present
- Can progress to lower respiratory tract infection (increase coughing, wheezing, retractions, crackles, dyspnea, tachypnea, decreased breath sounds & prolonged expiratory phase); Has the similar symptoms of asthma
- Must distinguish between RSV & asthma – use nasal pharyngeal secretions
- Chest X-Ray: There are mild peribronchial infiltrates and the lungs are hyperinflated because of air trapping because of mucous necrotic debris in the airways
* *Much lower on diaphragm
Transmission of RSV (2)
- Direct contact not air born
- -Patient will be on contact isolation in the hospital
- -Hand washing, gloving, gowning is very important
- -Use disposable stethoscope instead of your own
- RSV can live on skin or paper for up to 1 hour and cribs for 6 hours
Incubation of RSV
4-6 days
Duration of RSV Symptoms
7-10 days
Most contagious period of RSV
First 2-4 days, but can be infectious for 1-3 weeks after symptoms subside
At home management of RSV (5)
Most can be managed at home
- cool air humidity,
- fluids,
- antipyretics,
- elevate HOB,
- instruct caretaker on symptoms of respiratory distress
Hospital Management of RSV
Occurs if child is tachypneic, has marked retractions, listless and/or poor PO intake
**Listless: a child not acting as they usually do
- Management begins as if they have asthma; when they realize it’s RSV not asthma, they put them in contact isolation for RSV
1. Albuterol (bronchodilators) and corticosteroids don’t work with RSV; Will make them tachycardic, irritable, jittery !!!!!!
- Magement for RSV is for symptom management
- IV fluids
- Normal saline mist humidifier
- DO NOT DO PERCUSSION OR VIBRATION!!- Elevate head of bed
- Cool humidified oxygen if necessary
- Monitor O2 sat and vital signs (monitor respiratory distress)
Medications for RSV
Antibiotics only if there is a secondary infection, but generally don’t because it’s a viral infection
- Use Riboviran – antiviral agent
- -Used if the patient is immunosuppressed (ex: if they are on oncology unit)
- -Causes flu symptoms in people administering it
- -Causes DNA mutation so pregnant women can’t go near it; It is not used very often, so really is just with immunosuppressed patients
*Never give albuterol or corticosteroids
Prevention of RSV
Synagis (pulvizumab)
- Monoclonal antibody
- Given as IM injection every 4 weeks
- Specific guidelines for who is a candidate for it because it is a very expensive drug
- Prevent RSV in high risk infants
- No need to delay varicella or MMR
- 55% reduction in hospitalizations
- May still get RSV
- Usually only covered during the first year of life and for one season (November-March)
- If child has congenital heart defect or is higher risk then they could get more prevention treatment
Asthma
- Most common chronic disease in children
- 80-90% of children get first symptom before 4-5 years old
- Number of children with asthma has increased over past 10 years due to environmental pollution/air quality
- Lower respiratory tract disease
- Reversible!
Asthma Pathophysiology (5)
A Chronic inflammatory disease that causes narrowing of bronchioles due to
- Mucus in airway
- Swelling of airway lining
- Spasm of muscle in wall of airway
- Inflammation that causes increase bronchiole hyper-responsiveness to various stimuli
* *Stimuli are the triggers such as cold air, cockroach dropping, etc. - Allergic component
* *Not every child has an allergic component but if they do they will receive additional medications- *Know if they have an allergic component because you will see elevated immunoglobulin E (IgE)
Classifications of Asthma
Based on clinical symptoms, lung function and frequency and severity of exacerbations
- Intermittent Asthma
- -Ex: may just be using albuterol before exercise - Mild Persistent Asthma
- Moderate Persistent Asthma
- Severe Persistent Asthma
- –Much more aggressive treatment
*Helps with management of asthma by knowing what the child’s needs are based on their classification
Asthma Triggers (11)
- Outdoor – trees, weeds molds, pollens
- Indoor – dust, mold, cockroach
- Irritants (Cleaning products, perfume, cockroach droppings, etc.)
- Exercise
- Colds & infections
- Animals (their dandruff)
- Medications (Should never be on an aspirin based medication or a beta blocker!!)
- Emotions
- Foods
- Cold air
- Tobacco smoke (or any smoke)
Ways that parents can avoid asthma triggers (6)
- No rugs in the house
- Wet mopping hard wood floors
- Hypoallergenic materials
- May use special vacuum cleaner with filter
- Covering mattresses
- Minimize number of stuffed animals
- *Wash the ones that you do clean and put them in the freezer to kill the dust mites
*Avoiding triggers can be as effective as medications
Asthma Clinical Manifestations (11)
- Coughing at night with no infection
- Irritable,
- headache,
- tires easily,
- increase restlessness,
- chest tightness,
- barking paroxysmal nonproductive cough which worsens at night,
- pale with dark circles around eyes
- Increased respiratory rate with S&S of respiratory distress
- May use muscles of neck & abdomen
- Chronic asthma may develop barrel chest
Chest Sounds Associated with Asthma
- Rhonchi may be present
- Wheezing may be heard only on expiration in mild cases
- Both inspiratory and expiratory as obstruction becomes more severe.
- More severe: breath sounds may not be audible
Diagnosing Asthma
- Disease of delineation (ruling out other things)
- Physical exam, lab tests, X-ray to rule out other diseases
- PFT’s – presence and degree of lung disease and response to therapy (Pulmonary function test)
- PEFR - peak expiratory flow rate
* Do PFT and PEFR then give patient bronchodilator then repeat the test —> If they have asthma, you see an improvement in PEFR and PFT after giving the alubertol
PEFR Instructions
1st: Stand up
2nd: Take a deep breath, put PEFR in mouth and blow out as quickly as you can
3rd: Perform 3 times and get personal best (highest number)
- Need to be at least 4 years old to understand/use it
- Personal best should not be done when sick
Corticosteroids for Asthma (PO, IV, Inhaled)
Anti-inflammatory drugs
- PO: Prednisone, for quick relief
- IV: Solumedrol, for quick relief
- Inhaled: Flovent, for long term relief
- -Need to rinse mouth out after inhaled corticosteroid because it can cause thrush
**If rescue inhaler (a B-adrenergic bronchodilator) is used 2x/week or more then they should be started on corticosteroid management medication
Cromolyn for Asthma
Cromolyn & nedocromil sodium
- Nonsteroidal anti-inflammatory
- Only for long term control
- Inhaled
- Cromolyn (Intal)
Beta Adrenergic Agents for Asthma
- Bronchiodialator
- PO, IV or inhaled
- Quick relief: Albuterol (Proventil) and Levalbuterol (Xopenex)
- Long term (not rescue): Salmeterol (Serevent)
- *Has a BBW on it though so isn’t normally prescribed
**If rescue inhaler (a B-adrenergic bronchodilator) is used 2x/week or more then they should be started on corticosteroid management medication
Side Effects of Bronchodilators
- Awake and alert (sleeplessness)
- Restless/jittery
- Sweating
- Increased HR
~If possible, try to avoid PO bronchodilators in order to avoid systemic side effects
Methylxanthines for Asthma
- Third line agent
- Bronchiolar
- IV, PO, IM, or rectal
Theophylline
- Shouldn’t be used unless nothing else works
- The side effects are very significant and there is a narrow therapeutic range (either toxic or subtherapeutic)
Leukotriene Modifiers for Asthma
- Antiinflammatory
For Long term use only
PO: Montelukast (Singular)
*Also helps with inhaled corticosteroids
Long-acting beta-2 antagonists (LABAs) (3)
- Serevent Diskus
- Advair Diskus (Fluticasone/Solmeterol); combo of bronchodilater and corticosteroid
- Foradil Aerolizer
- FDA public health advisory regarding these medications: may in increase the risk of severe asthma episode.
- Avoid these with kids!!!!!
Anti-IgE monoclonal antibodies
Xolair; Allergy associated asthma
Only for ages over 12 years
*Injection every 2 – 4 weeks during allergy season
Asthma Prevention Plan (8)
- Avoid triggers
- Peak flow and chart
- Recognize symptoms
- Breathing exercises; deep breathing exercises
- *Best sport for asthma: swimming
- Maintain health
- Drug compliance
- Promote normal activities
- All children should have spacers on their inhaler (meter dose inhaler)
- –Much easier to use
- –Take deep breath in and count to 10
- –Dissipates the medication
- —Can also use a nebulizer
