Pediatric Pathophysiology Flashcards
Who falls into “Pediatric”?
Newborn: up to 4 weeks of age (28 days)
Infant: 30 days to 1 year old
Child: 1 to 8 to 12 years
Teen: 13 to 18 years
Special Considerations of Pediatric Population
- Age and ability to comprehend
- Keep teaching/learning short
- Use fun games approach if applicable
- Enlist family assistance
- Parents present or absent
- Decision maker for the child, depending on age
- Parents to be contacted when treatment discussions are reviewed with the child
- Emotional State
- Frightened, confused, angry, sad.
- Comfort them
- Have toys and friendly objects present
- Physical limitations
- Certain diagnostic tests can be dependant on age (PFTs)
- Presentation
- Inability to properly express themselves
Pediatric Special Consideration
Presentation
Prenatal and birth Hx
Developmental Hx
Social Hx of family
Immunization Record
Parent as historian
What makes a pediatric patient different?
They are NOT little adults!
Most therapies, interventions, and drug regimens are not geared, tested, or approved for their population
Pharmacology
Pediatric signs of increased WOB
Tachypnea
Apnea
Nasal Flaring
Grunting
Head Bobbing
Seesaw Respirations
Intercostal Retractions
Tracheal Tug
Preventable Pediatric Disorders
Abuse
MVA’s
Near Drowning
Fires
Acute epiglottitis Vs Laryngotracheobronchitis(croup)
CXR
Croup- Subglottic narrowing, lower in the airway
Epiglottis-Swollen epiglottis (thumb sign), higher in the airway
Acute epiglottitis Vs Laryngotracheobronchitis(croup)
Symptons
Croup- Stridor, barking cough, fever variable, hoarse voice, no position preferred, retractions, irritable, does not appear acutely ill
Epiglottis-stridor, minimal cough, high feer, muffled voice, prefers sitting upright with chin forward, rertactions, drooling, anxiety, appear acuetly ill
Acute epiglottitis Vs Laryngotracheobronchitis(croup)
History
Croup- Gradual onset (2-3 days), previous cold
Epiglottis-Acute onset (few hours), compliant of sore throat
Acute epiglottitis Vs Laryngotracheobronchitis(croup)
Cause
Croup- Viral (parainfluenza, RSV)
Epiglottis-Bacterial (harmophilius influenze type B)
Acute epiglottitis Vs Laryngotracheobronchitis(croup)
Age
Croup- 3 mon to 3 yr
Epiglottis-2-6 yr
Bronchiectasis
- Irreversible dilation and distortion of the bronchial tree
- Develops as a result of airway obstruction, chronic infection and extensive inflammation
- Dilation due to destruction of bronchial cartilageelastic fibres, blood vessels and smooth muscle
- Foreign body aspiration, measles, pertussis, pneumonia, CF
- Congenital condition in a small number of patients
Bronchiectasis
Pathophysiology
Irregularly shaped and dilated bronchi
leads to insufficient airway secretion clearance
Inadequate ciliary activity
The poor bronchial toilet increases the risk of infection
Bronchiectasis
Clinical Manifestations
Chronic, productive cough
Copious amounts of thick, purulent sputum
Foul smelling breath
Multiple URIs
SOBOE
Hemoptysis on occasion
Bronchiectasis
Management
Supplemental oxygen
Typically diagnosed by clinical manifestations and bronchoscopy or CT scan
Chest physiotherapy and postural drainage
Abx based on sputum culture
Surgical resection of the broncheictaticsection of the lung may be considered
Depends on severity and if the disease if localized
Bronchiolitis
- Inflammatory disease of the bronchioles
- Most common lower respiratory infection in pediatrics
- Viral infection of small airways
- Most common cause: RSV (Respiratory Syncytial Virus)
Bronchiolitis Pathophysiology
- Airway wall inflammation and edema, ++ increased mucous production
- Small airwayobstruction
- Primarily effects pediatrics <2
- Infants prone to Respiratory Failure from Acute Bronchiolitis:
- Immunodeficientinfants, comorbidities of CHD, CF, childhood asthma
Bronchiolitis Causes
RSV (Respiratory Syncytial Virus)
- Approx. 90% children infected in first 2 years of life, mostly presents as cold like symptoms
- RSV diagnosed by Nasopharyngeal swab or aspirate
- Predictable outbreaks from January to April
Bronchiolitis Clinical Manifestation
Productive cough
Resp. distress: wheezing, tachypnea, accessory muscle use, nasal flaring, hypoxemia, ++ secretions
O/A coarse crackles
Hyperinflation on CXR
High PaCO2 (in severe cases)
Usually Clinical Diagnosis (by symptom presentation)
75% of infants after acute bronchiolitis have recurrent episodes of coughing and wheezing (often diagnosed as infant asthma)
Bronchiolitis Treatment
- Supportive in the majority of cases:
- Bronchodilaters
- Racemic epinephrine for severe bronchoconstriction
- RSV-specificimmunoglobintherapy
- Severe Cases:
- CPAP
- HFNC
- May require intubation
Bronchiolitis CXR
Reveal flattening of the diaphragm and widening of the anteroposterior diameter, which is indicative of severe air trapping.
Perihilar markings accentuated.
Cystic Fibrosis (CF)
Recessive exocrine gland disorder characterized by excessive viscid secretion
Cystic Fibrosis (CF)
Pathophysiology
- Most common fatal geneticdisease affecting Canadian children and young adults
- Caused by mutations in the gene that encodes multifunctional protein: CF transmembrane conductaneregulator (CFTR)
- Function of this protein is to serve as an apical (side toward the lumen) chloride channel in:
- Airway cells-causing improper regulation of sodium-chloride ions leading to thick, tenacious secretions
- Intestinal cells
- Exocrine glands
- Function of this protein is to serve as an apical (side toward the lumen) chloride channel in:
- Variability of disease symptoms caused by over 1900 types of CFTR mutations
Cystic Fibrosis (CF)
Clinical Manifestation
- Dry cough progressing to frequent wet coughing spells with large quantities of secretions
- Anorexia, weight loss
- Wheezing
- SOBOE
- Chronic colonization of P. Aerguinosa
Cystic Fibrosis (CF)
Cycle of Infection
- CFTR dysfunction leads to a decrease in airway surface liquid which impairs mucous clearance, which leads to airway inflammation/infection. This results in chronic productive cough and Hyperinflation/Bronchiectasis.
- Endstage CF:
- pulmonary HTN
- CorPulmonale
- Most common pathogens associated with CF:
- Staph Aureous,
- Haemophilus influenza,
- Pseudomonas
- Aeruginosa
Cystic Fibrosis (CF)
Non-Respiratory Manifestations
- Pancreatic Insufficiency
- Malabsorption of fats and proteins
- Failure to thrive in infants
- Meconium ileus (infants)
- Meconium but on a much larger scale to the point where their ability to expel the meconium has been blocked
- Reduced fertility
- Increased risk of Diabetes
Cystic Fibrosis (CF)
Diagnosis
- Sweat Chloride Test (> 60 mmol/L)
- Sodium Chloride concentration in sweat are abnormally high in CF
- A small amount of a colorless odorless sweat producing chemical is applied to the patient’s arm. An electrode is attached to the chemically prepared area, and a mild electric current is applied to stimulate sweat production.
- Sodium Chloride concentration in sweat are abnormally high in CF
- Infant Screening
- Failure to gain weight
- Bronchiectasis
- Recurrent Pancreatitis
Sweat Chloride Test
Infants Six Months or Younger
≤29 mmol/L: Normal (CF very unlikely)
30 to 59 mmol/L: Intermediate (Possible CF)
≥60 mmol/L: Abnormal (CF Diagnosis)
Sweat Chloride Test
Infants Older than Six Months, Children and Adults
≤39 mmol/L: Normal (CF very unlikely)
40 to 59 mmol/L: Intermediate (Possible CF)
≥60 mmol/L: Abnormal (CF Diagnosis)
Monitoring at a CF Clinic
Symptom assessment
Physical examinations
Regular sputum cultures
Spirometry
Nutritional Status
Types of Treatment for CF
Bronchopulmonary Hygiene
Medications
Lung Transplant
CF Treatment
Bronchopulmonary Hygiene
- Percussion
- Postural Drainage
- BIPAP (during physical therapy)
Autogenic Drainage
CF Treatment
Medications
Bronchodilators
Inhaled Recombinant Deoxyribonuclease(DNase)(Pulmozyme)–daily in >6 yrs
Nebulized 7% hypertonic saline (BID in patients >6 yrs) help draw out secretions
N-acetyl-cysteine (Mucomyst) – Help pplcough up secretion s
Ibubrofen
Azithromycin (patients > 6 yrs)
Tobramycin (treat P. Aeruginosa)
Where do RT fit in with CF Treatment
- End stagemanagement –BIPAP
- Post-op Lung Transplant management
- Home Oxygen Therapy
- Spirometry-CF clinics
GOOD NEWS!
Due to improvements in therapy, median age of survival has increased from 31 years to 41 years in past two decades
