Module 12 The Respiratory System Flashcards
What do you need to have an understanding of in this Respiratory system module?
The Childs respiratory System?
- Assessment
- Bronchitis
Bronchitis is an infection of the main airways of the lungs (bronchi), causing them to become irritated and inflamed. The main symptom is a cough, which may bring up yellow-grey mucus (phlegm). Bronchitis may also cause a sore throat and wheezing. - Bronchiolitis
It happens when tiny airways called bronchioles (BRONG-kee-olz) get infected with a virus. They swell and fill with mucus, which can make breathing hard.
Bronchiolitis is more common during the fall and winter months. Most cases can be managed at home.
- Asthma
- Reactive Airways Disease
- Foreign Bodies
- Cystic fibrosis
- Pneumonia
What are causes of Stridor?
https://www.youtube.com/watch?v=JSdEK79J4dw
- Stridor is a sign of upper airway obstruction. It is a harsh, high-pitched sound, usually inspiratory (but can be expiratory also).
- It is produced by turbulent air flow through the upper airways.
- There are a number of causes of stridor:
- Inflammation involving the vocal cords and structures inferior to the cords – laryngitis, laryngotracheitis, and laryngotracheobronchitis
- Inflammation of structures superior to the cords – supraglottitis
What are things we are looking for on Inspection for th respiratory system?
- General appearance
- respiratory rate (RR)
- depth & rhythm of respiration
- dyspnoea Dyspnea, which some refer to as shortness of breath, is a feeling that you cannot breathe enough air into your lungs.
- chest & abdominal movements
- chest shape
- lesions
- spine & scapulae
- clubbing
- cyanosis
- cough
- sputum
General appearance – look for
1. Toxic appearance
2. Tripod position for breathing
3. Alertness (decreased)
4. Distress, irritability
5. Head position to assist breathing
Respiration rate
a. Normal at rest (per minute) –
a. 1 year – 30
b. 2- 5 year - 20-25
c. 10 year – 20
b. Increased respiratory rate is associated with upper and lower airway obstruction
1. Oxygen needed above 50 breaths/minute
2. 40-50 breaths/minute raises suspicion of respiratory
distress
Depth and rhythm of breathing
1. Tachypnea–rapid,shallowbreathing
2 types of abnormal chest shape
Pectus excavatum
Pigeon breast or pacts carinatum
Respiration rate for a full term new born?
1 year?
2-5 years?
10 year
Full term new born
Average 45 awake 35 asleep
Best to measure when asleep as may rise to 70-80 with little excitation
1 year = 30
2-5 years = 20-25
10 years = 20
- Periodic breathing with brief respiratory pauses of up to 10 seconds without cyanosis is common during sleep in normal infants especially premature infants and in the early weeks of life
- Apnoea monitors are generally set to respond if 20 seconds elapses between breaths
- Breathing during infancy is typically abdominal, a thoracic component in young infants suggests pulmonary disease
- The thoracic type of respiration becomes predominant at 7-8 years
What is Apnoea?
What are the 3 types?
Cesstation of breathing for 20 seconds or more, or for a brief periods if accompanied by bradycardia, cyanosis, pr pallor
3 types
1. Obstructive apnoea eg pharyngeal collapse, or incoordination of tongue
- Centra-l airflow and chest wall motion absent
- Mixed- Has characteristics of both central and obstructive apnoea
- mixed
What is Dysponea?
(Shortness of breath)
What are the 5 signs of Dysponea? Exam question
Respiratory effort has to increase as they have shortness of breath:
- Use of accessory muscles - neck
- Suprasternal retractions
- Intercostal retractions
- Infrasternal retractions
- nasal flaring.
(slight retractions may be normal)
Where is cyanosis best observed?
What is the normal 02 saturation?
Cyanosis is best observed over the 1. nail beds
2. lips
3. tongue
4. mucous membranes
Normal O2 saturation is 96-97%,
90% saturation will be detectable by the trained eye,
85% will be obvious to anyone - the tongue must be examined for central cyanosis
What is this and what does it indicate?
Clubbing of fingers - Associated with chronic cyanosis
Cough
What are some causes of a recurrent cough?
What are causes of a Persistent cough?
Recurrent Cough:
-Bronchial reactivity, including allergic asthma
-drainage from upper airways
-aspiration syndromes
-Frequently recurring RTI in immunosuppressed or immunodeficient patients
-Idiopathic pulmonary hemosiderosis
Idiopathic pulmonary hemosiderosis (IPH) is a rare disease, found primarily in children, that is characterized by recurrent episodes of diffuse alveolar hemorrhage (DAH).
PERISTENT COUGH:
reactive airways disease (asthma)
Chronic sinusitis
Pertussis syndrome (whooping cough)
Habit cough
GERD
Hypersensitivity of cough receptors after an infection
How do Chiros treat a cough
The most common cause of persistent and recurrent cough in children is chronic viral infection
Look for signs of chronic/ recurrent URTI, enlarged liver and possible enlarged spleen as well as enlarged tonsils and adenoids (snoring)
Treat for Th1 deficiency and or Th2 excess
Wheezing
Whats it indicative off?
Most recurrent or persistent wheezing n children is the result of reactive airway disease.
The most common cause of wheezing in infants is caused by inflammation, usually due to a viral infection.
Other causes may be nonspecific environmental factors such as cigarette smoke may be important contributors.
Frequently recurring or persistent wheezing starting at or soon after birth suggests a variety of other diagnoses, including congenital structural abnormalities involving the LRT
Wheezing that attends cystic fibrosis is most common in the 1st year of life.
Sudden onset of sever wheezing in a previously healthy child should suggest foreign body aspiration.
List the Risk factors of the ‘wheezing’ child
- Fetal nutrition
- Maternal smoking
- Prenatal and birth complications
- Prenatal environmental allergens
- High infant adiposity
- Fetal and infant immune system priming
- Respiratory viruses in early infancy
- Exposure to airborne molds
- Food allergy
- Dustmite, pet allergens
Wheeze
How would I as a Chiro manage it?
- The most common cause of persistent and recurrent wheeze in children is chronic viral infection.
- Look for signs of chronic/recurrent URTI, enlarged liver and possible enlarged spleen as well as enlarged tonsils and adenoids (snoring).
- Treat for Th1 deficiency and or Th2 excess.
- Examination
1.Assess if localised or generalised by auscultating all 5 lobes
Viral infections are associated with generalised wheeze
2. Assess if inspiratory or expiratory (most common) or both
Palpation for the respiratory system
- tracheal position
- apex beat
- chest wall movement
- masses & lymph nodes
- areas of tenderness
- subcutaneous emphysema
Subcutaneous emphysema occurs when air gets into tissues under the skin. This most often occurs in the skin covering the chest or neck, but can also occur in other parts of the body. - tactile & vocal fremitis
- friction rubs & thuds
What is going on here?
What are some reasons this may occur?
We always need to check tracheal position - it should be midline
If it is not then the cause must be found - a cervical chest X-ray may be needed.
Tracheal deviation may occur with:
1. Foreign body aspiration
2. Lunge collapse, pneumothorax
3. Cardiomegaly and congenital heart disease
4. Mediastinal mass
5. Neck mass
Elevated left hemidiaphragm with volume loss in the left lung and tracheal deviation to the right (this image)
When we auscultation lung sounds what are we looking for
- Rate
- Rhythm
- Sounds
Rhythm:
Normal: Usually inspiration longer than expiration
Abnormal: Expiration prolonged eg asthma, bronchial sounds
2. Short gap between inspiration & expiration eg bronchial
Crackles:
-coarse eg bronchitis
-finer pneumonia
-may decrease with coughing eg bronchitis
Wheezes: asthma, local (obstruction) usually in expiration.
Stridor: M.c inspiratory
Decreased breath sounds= collapsed lunch, or consolidation ie pneumonia.
What are the different sounds and what do they mean?
https://www.youtube.com/watch?v=DJ0cyDgaRQc
https://www.youtube.com/watch?v=tQSjoybsO4M
- Tracheal breath sounds are normally heard over the trachea and larynx
They are louder with a higher pitch
Expiratory phase is louder and longer - Rhonchi are musical, continuous, wheezes and vibrations
- Rales are crackling or bubbling, discontinuous sounds
- Pleural friction rub causes a grating jerky leathery creaking rubbing sound that seems close to your ear
Crackles:
local or general
coarse eg. bronchitis
finer eg. pneumonia
may decrease with coughing eg. bronchitis During inspiration (usually) or expiration
WHEEZES:
widespread eg. asthma, bronchiolitis local eg. obstruction
usually in expiration
STRIDOR
Most commonly inspiratory, or biphasic
Indicate upper respiratory tract obstruction
Often widespread, but heard closer to the sternum and clavicles
Can listen on anterior neck and cheeks – upper respiratory sounds will be louder than lower respiratory sounds
DECREASED BREATH SOUNDS
Collapse, consolidation – lobar pneumonia
* Decreased vesicular breathing may occur early in
1. Pneumonia (consolidation)
2. Hydrothorax
3. Pneumothorax
Chest pain that may spread to the shoulder and back Shortness of breath
Fast, shallow, breathing
4. Lobar emphysema
5. Bronchitis
6. Muscle paralysis
What are some causes of wheeze?
Bronchoconstriction may be induced by three
principal pathways:
1. A direct effect on airway smooth muscle
2. A neural reflex bronchospasm via vagal pathways
3. Release of chemical mediators by degranulation of mast cells.
- Reactive airway disease
- Aspiration
- Cystic Fibrosis
- Cardiac failure
- Bronchiolitis Obliterans
- Extrinsic Compression of airways
- Gastroesophageal reflux
- Pulmonary hemosiderosis
- Hysterical airway closure
- Environmental insults
Describe what you see?
6 month old infant
* A, Radiographic findings characteristic of respiratory syncytial virus pneumonia in a 6 mo old infant with rapid respirations and fever.
* Anteroposterior radiograph of the chest shows hyperexpansion of the lungs with bilateral fine air space disease and streaks of density, indicating the presence of both pneumonia and atelectasis. An endotracheal tube is in place.
* B, One day later, the AP radiograph of the chest shows increased bilateral pneumonia.
What do you see?
- Radiographic findings characteristic of pneumococcal pneumonia in a 14 yr old boy with cough and fever. Posteroanterior (A) and lateral (B) chest radiographs reveal consolidation in the right lower lobe, strongly suggesting bacterial pneumonia.
What is this?
Pneumonia
Bilateral central pulmonary infiltrates, but most marked in the right middle and left lower lobes. The left lower lobe infiltrate is best seen on the lateral view inferiorly over the spine. The lungs are hyperaerated.
Impression: Right Middle and left lower lob infiltrates
A 10 year old male who came to the E.D. with a history of coughing and fever. Poor breath sounds were noted on the left.
- The left lung is consolidated. This atelectasis results in a mediastinal shift to the left. There are air bronchograms evident over the left lung. On the original film, there is a suggestion of a 1.5cm cylindrical foreign body in the left mainstem bronchus. Further history revealed that he had “swallowed” a plastic bullet several days ago.
- Impression: Consolidation of the entire left lung with the suggestion of a foreign body in the left mainstem bronchus
An 11-month old female with a history of a previous pneumonia who now presents with fever and coughing. Mild wheezing and rales are noted on auscultation.
- There are small interstitial central pulmonary infiltrates.
- Impression: Small interstitial central pulmonary infiltrates most consistent with a viral pneumonia.
A 6-week old male infant. His parents brought him to the E.D. because of coughing and congestion. He had a 20 minute episode of frequent coughing, but now seems to be better. He is feeding well. There is no history of fever or cyanosis. His vital signs are normal. Oxygen saturation is 100% in room air. Auscultation is clear.
- The upper mediastinum shows the usual prominent thymus for this age. The thymic shadow is larger on the infant’s right than on his left. There is a density in the right upper lobe, but it is obscured by the thymus. Part of this density appears to be from the scapula, but on close inspection, there are densities suggesting infiltrates aside from the thymus and the scapula in the right upper lobe.
- Impression: Right upper lobe infiltrate or partial atelectasis.
Atelectasis (at-uh-LEK-tuh-sis) is a complete or partial collapse of the entire lung or area (lobe) of the lung. It occurs when the tiny air sacs (alveoli) within the lung become deflated or possibly filled with alveolar fluid. Atelectasis is one of the most common breathing (respiratory) complications after surgery.
An 18-month old female with a history of prematurity and mild bronchopulmonary dysplasia. She arrives in the emergency department with a history of fever, coughing, and difficulty breathing. Coarse breath sounds and mild wheezing are noted on auscultation.
- There is a small area of atelectasis in the right middle lobe. This is best seen on the lateral view as an oblique flattened wedge shaped density over the heart. Instead of the normal triangular shape of the right middle lobe, it appears to be flat and compressed indicating atelectasis.
- Impression: Right middle lobe atelectasis.
Atelectasis (at-uh-LEK-tuh-sis) is a complete or partial collapse of the entire lung or area (lobe) of the lung. It occurs when the tiny air sacs (alveoli) within the lung become deflated or possibly filled with alveolar fluid. Atelectasis is one of the most common breathing (respiratory) complications after surgery.
A 12-year old female complaining of a headache and productive cough. Onset of fever last night to 39 degrees. Rales are noted in the left base.
A 12-year old female complaining of a headache and productive cough. Onset of fever last night to 39 degrees. Rales are noted in the left base.
- There are infiltrates in the right middle and left lower lobes. The right middle lobe infiltrate is blurring the right heart border. It can also be seen on the lateral view as streakiness over the heart. The left lower lobe infiltrate is best seen on the lateral view posteriorly on the diaphragm. It can also be seen on the PA view as haziness in the lower lung on the left. The infiltrate in the right middle lobe was noted two years ago on a previous radiograph, and the possibility of a chronic infiltrate was raised.
- Impression: Right middle and left lower lobe infiltrates.
The term pulmonary infiltrate is considered a context-dependent, non-specific and imprecise descriptive term when used in radiology reports (plain film or CT).
From a pathophysiological perspective, the term “infiltrate” refers to “an abnormal substance that accumulates gradually within cells or body tissues” or “any substance or type of cell that occurs within or spreads as through the interstices (interstitium and/or alveoli) of the lung, that is foreign to the lung, or that accumulates in greater than normal quantity within it”
This is a 9-year old male with a history of fever, headache, nausea, and coughing.
This is a 9-year old male with a history of fever, headache, nausea, and coughing.
- There is a circular density in the right lung. This is the superior segment of the right lower lobe. Although this has the appearance of a mass, it is most likely an infectious process.
- Impression: Spherical consolidation in the right lower lobe (round pneumonia).
- This is a 6-month old male who presents to the pediatric clinic with difficulty breathing. He has had similar episodes in the past. He has been diagnosed with asthma and has been treated with albuterol with only modest improvement.
- He has some nasal congestion, but no fever, vomiting or diarrhea.
- He feeds well and he has been gaining weight well.
- His past history is remarkable for multiple upper respiratory infections and wheezing during the past several months.
- He was born at term. His family history is significant for asthma in several relatives and his older siblings. He has three siblings who currently have colds.
- Exam: VS T 37, P 114, R 39, BP 100/75, oxygen saturation 99% in room air. He is alert, active, and in no distress. He is not toxic. HEENT significant for clear nasal mucus, normal TM’s and a clear pharynx with normal oral mucosa. Heart regular without murmurs, but his breath sounds are noisy so it is difficult to be sure. He has mild inspiratory and expiratory “wheezing”. His lung fields demonstrate good aeration. He has no retractions. His abdomen is soft, non-tender and without organomegaly. His neurologic exam is unremarkable.
- An albuterol aerosol is administered and following this, his lung exam is unchanged. A chest radiograph is ordered. An airway anomaly is also suspected so a lateral neck is also ordered.
