Pediatrics #2: Airway & Breathing

Question 1

Tonsils (4)

Answer 1

Masses of lymph tissue in the pharyngeal area

Filter pathogenic organisms, help protect respiratory and GI tract

Contribute to antibody formation

Highly vascular, help to protect against infection and harmful organisms entering through the mouth

Question 2

Tonsillitis (4)

Answer 2

Inflammation of palatine and/or pharyngeal (adenoids) tonsils

Palatine tonsils are those removed during tonsillectomy

Pharyngeal (adenoids) are located above palatine tonsils on the posterior wall of the nasopharynx

Removal of the pharyngeal tonsils is called an adenoidectomy

Question 3

Tonsillitis occurs in ….. (2)

Answer 3

Occurs often in children, rarely in those younger than 2 years of age

Most common in 3-7 year old

Question 4

Tonsillitis common S/S (8)

Answer 4

Fever
Sore throat
Foul-smelling breath d/t infection
Dysphagia
Odynophagia (painful swallowing)
Tender cervical lymph nodes
Lethargy
Malaise

Question 5

Treatment (6)

Answer 5

Antibiotics (if d/t bacterial infection)
Liquid acetaminophen (remember: NO aspirin for kids)
Fluid replacement
Rest
Warm saltwater gargles
Surgery (if recurrent or chronic)

Question 6

Differential: Peritonsillar abscess (if infection spreads behind tonsils) (2)

Answer 6

Severe sore throat, fever, drooling (don’t want to swallow), foul-smelling breath, trismus (lockjaw), muffled voice quality

Tx: drainage of the abscess, antibiotics, hydration, pain management

Question 7

Tonsillectomy: Pre-op (4)

Answer 7

Medications: No ibuprofen-type medications, herbal supplements (ginkgo, Echinacea) for 2 weeks prior to surgery

Diet - NPO after midnight the day before the procedure

Psychological support

Talk to the child in words that are age-appropriate
Offer a tour of hospital if possible

Question 8

Tonsillectomy: Post-op 1/2 (4)

Answer 8

Psychological support: regression to cope with surgery

Monitor for frequent swallowing or throat clearing (could indicate bleeding at operative site)

Snoring or breathing trouble may still be present post-op d/t swelling in the throat - subside after swelling does 7 days after surgery

Hydration: water, diluted juice, electrolyte solutions (triple normal fluid intake) (no substances that coat the throat such as milk - can cause cough which causes bleeding)

Question 9

Tonsillectomy: Post-op 2/2 (5)

Answer 9

Discourage from coughing or blowing nose
Diet: avoid acidic foods (irritating)
Recovery time: 7-10 days (on average)
Activity: return to school when off narcotics, no physical activity/sports for 10 days
Pain medications: acetaminophen, ibuprofen, hydromorphone if warranted

Question 10

Epiglottitis: Etiology (5)

Answer 10

Bacterial infection
Most common bacteria is Haemophlius influenzae type b (Hib)
Infection causes inflammation and swelling of the epiglottis - supraglottic (laryngitis is subglottic)
Affects breathings by obstructing passage of air to lungs (can turn emergent very quickly)
Commonly affects children between 2-8 years of age

Question 11

Epiglottitis S/S (8)

Answer 11

Symptoms appear suddenly

Fever and sore throat are usually first symptoms

Dysphagia, muffled voice

Drooling of saliva

Distinctive, large, cherry red edematous epiglottis

Child will likely insist on sitting upright (like tripod)

Restless, frightened, and apprehensive

Possible suprasternal and substernal retractions

Question 12

Epiglottitis Interventions (4)

Answer 12

NO STRESS! Keep client calm until the airway is stabilized
Allow the child to remain in a position of comfort with a caregiver
Nurse should not attempt epiglottis visualization with tongue depressor, nor should the nurse obtain a throat culture
Maintain droplet precautions until client has received effective antibiotic therapy for 24 hours

Question 13

Bronchiolitis: Etiology (3)

Answer 13

A lower respiratory tract infection - bronchiolar level (most commonly caused by viral infection, RSV)

Symptoms generally worsen for the first 3-5 days and then gradually improve

Leading cause of hospitalization in infants and young children (mainly affects infants due to immature immune system and lack of developed cilia)

Question 14

Bronchiolitis: Patho & gen info (4)

Answer 14

Edema and secretions of the lower respiratory tract cause lower airway obstruction with extensive mucus plugging that could lead to atelectasis

Produces small airway obstruction/air trapping

In >90% of cases, pathogen is respiratory syncytial virus (RSV) (Remember: RSV is contact precautions)

Nasal swab will confirm diagnosis

Question 15

Bronchiolitis: Risk factors (5)

Answer 15

Winter season, male gender, second hand smoke, bottle feeding, daycare

Question 16

Bronchiolitis: S/S 1/2 (4)

Answer 16

May present like a typical upper respiratory infection

Nasal obstruction (causes decreased ability to feed, dehydration)

Breath sounds are variable (fine inspiratory crackles, high pitched prolonged expiratory wheezes)

Fever over 100.4 degrees F (38 degrees C)

Question 17

Bronchiolitis: S/S 2/2 (4)

Answer 17

Rhinorrhea (runny nose)

Irritating cough/sneezing

1 to 3 days after onset: Increasing tachypnea and respiratory distress

Increased work of breathing (wheezing with prolonged expiratory phase) (in worse cases, pt may have retractions, nasal flaring, cyanosis, longer episodes of apnea, respirations over 60-80 → all require immediate attention)

Question 18

Bronchiolitis: Interventions (5)

Answer 18

Oxygen to maintain oxygen saturation 95% during acute phase, preferably humidified

Maintain hydration → IV fluids

Control fever (antipyretics)

Close, frequent assessment to monitor for deterioration
Arterial blood gasses, if necessary

Question 19

Pneumonia: Etiology & patho (7)

Answer 19

Pneumonia is a lower respiratory tract infection
Inflammation of the lung parenchyma (tissue of the lung that does gas exchange)
Extravasation of fluid to alveoli, causing hypoxia
Caused by a virus, bacteria, chemical irritant, fungi, or parasite
Air sacs fill with exudate
Pneumonia occurs more often in boys than girls
Viral pneumonia occurs more frequently than bacterial pneumonia, but bacterial pneumonia is more serious

Question 20

Pneumonia: S/S (8)

Answer 20

Dyspnea
Cough, tachypnea, sputum production
Grunting, wheezing, crackles, intercostal retractions
Fever
Pleuritic chest pain
Fatigue
Vomiting, poor feeding
Tachycardia

Question 21

Pneumonia: Interventions (6)

Answer 21

Monitor breath sounds, oxygen saturation (respiratory status)
Oxygen support
Antibiotic therapy (if bacterial pneumonia is diagnosed)
Rest/conserve energy (don’t increase O2 demand)
Adequate hydration
Family support

Question 22

Asthma (3)

Answer 22

Chronic inflammatory disorder that is characterized by:
Airway obstruction due to inflammation (triggered by exposure to substances causing an allergic reaction)

Bronchial hyperresponsiveness - bronchospasm

(Swelling and inflammation of the airway, tightening of the muscles = difficulty breathing)

Question 23

Asthma S/S (6)

Answer 23

Dyspnea
Wheezing
Coughing
Chest tightness, pain
Fatigue and anxiety
Prodromal itch (localized to front of the neck or over the upper part of the back)

Question 24

Asthma interventions 1/2 (meds) (4)

Answer 24

Corticosteroids (inhaled: long-term asthma med) (IV: rescue med)

Beta-adrenergic agonists (long-acting: long-term asthma med) (short-acting: rescue med [albuterol])

Theophylline (long-term asthma med)

Leukotrienes (long-term asthma med)

Question 25

Asthma interventions 2/2 (meds) (3)

Answer 25

Ipratropium (rescue med)

Racemic epinephrine (rescue med)

Combined inhalers that contain both a corticosteroid and a long-acting beta-agonist (long-term asthma med)

Question 26

Peak flow meter: shows maximum volume that can be exhaled in 1 second (L/min). What does green, yellow, and red mean?

Answer 26

Green = > 79% of personal best (airway is ok)
Yellow = 50-79% of personal best (rescue inhaler should be used - suggests exacerbation)
Red = <50% of personal best (emergency - suggests narrowing of airway)

Question 27

Bronchopulmonary Dysplasia (BPD) (Chronic lung disease) (3)

Answer 27

Chronic lung disease associated with respiratory distress syndrome (long-term respiratory problems)

Usually associated with prematurity (premature infants)

Caused by damage to the lungs from mechanical ventilation and prolonged oxygen treatment that causes scarring in the lung tissue

Question 28

Specific causes of bronchopulmonary dysplasia (BPD) (6)

Answer 28

Underdeveloped alveoli
Insufficient surfactant
Prolonged use of high concentration oxygen
Pressure from the vent
Suctioning
Trauma of intubation

Question 29

BPD patho (3)

Answer 29

Diminished respiratory reserve, hyperactive airway, and increased susceptibility to respiratory infections

Classified as mild, moderate, severe based on degree of ongoing oxygen support

Chest x-ray shows spongy appearance of lungs

Question 30

BPD S/S (8)

Answer 30

Tachypnea
Increased work of breathing
Chest retractions
Nasal flaring
Grunting
Decreased breath sounds, crackles, occasionally expiratory wheezing
Respiratory acidosis on arterial blood gas
Tachycardia

Question 31

BPD diagnosis (1)

Answer 31

Diagnosis is made when mechanical ventilator and/or oxygen is still necessary after a premature infant has reached the equivalent of 36 weeks gestation

Question 32

BPD TX (2)

Answer 32

No specific tx exists for BPD except to maintain adequate arterial blood gasses with the administration of oxygen and to avoid progression of disease

Adequate (not over increase!) hydration is extremely important because they lose a lot of fluid thru lungs - however, they’re very susceptible to interstitial edema → Monitor both fluid volume deficit and excess

Question 33

BPD Interventions 1/2 (4)

Answer 33

Bronchodilators, steroids (maximize airway clearance), diuretics (diminish excess fluid in lungs)

Oxygen therapy

Mechanical ventilation until the lungs mature (several months may be required in most severe cases) (usually weened off by age of 1 year)

Nutrition through nasogastric tube or orally when tolerated

Question 34

BPD Interventions 2/2 (4)

Answer 34

Support from family and friends
Regular check-ups and vaccinations
No smoking in home
Avoid other lung irritants

Question 35

Cystic Fibrosis (3)

Answer 35

Inherited, genetic disease of the exocrine (mucus-producing) glands (mutation in the gene that regulates sweat, digestive enzymes, and mucus)

Thick mucus secretions in pancreas and lungs (excessive sodium absorption in the lungs, turning usually thin secretions into thick. Similarly in GI and reproductive systems) (in pancreas, ducts are plugged, so enzymes to break down fats, proteins, carbs are not made, and these nutrients are not digested)

Electrolyte abnormalities in sweat gland secretions

Question 36

Cystic fibrosis diagnosis

Answer 36

A sweat chloride test of greater than 60 mEq/L demonstrates a positive value for a diagnosis of CF (salty perspiration)

Question 37

Cystic fibrosis S/S (4)

Answer 37

Adventitious breath sounds; wheezing and rhonchi
Chronic cough (dry or productive)
Chest hyper-resonant with percussion
Clubbing of fingers (inadequate peripheral tissue perfusion)

Question 38

Cystic fibrosis Interventions (6)

Answer 38

Avoid exposure to respiratory infections
Chest physiotherapy, postural drainage
Monitor for hemoptysis
Nebulizers, aerosol therapy (meds directly to lungs)
Humidified oxygen
Dental hygiene

Question 39

Cystic fibrosis: Signs and Symptoms - Nutrition (7)

Answer 39

Failure to regain normal birth weight within 7-10 days after birth
Meconium ileus
Skin breakdown
Rectal prolapse due to weak musculature
Bulk of feces increases - large BMs (undigested food excreted)
The stools are frothy and extremely foul-smelling (steatorrhea)
Fatty stools

Question 40

Cystic fibrosis Interventions for nutrition (5)

Answer 40

Need up to twice the amount of daily calories
High-protein, high-calorie diet with fat intake as tolerated
Prescribed enzymes; supplemental fat soluble vitamins A, D, E, K; extra calcium
In very hot months, increase sodium intake and monitor for overheating, which leads to excessive chloride and sodium loss
Monitor weight

Question 41

Tetralogy of fallot (5)

Answer 41

Four defects:
- Ventricular septal defect
- Pulmonary stenosis
- Overriding aorta
- Right ventricular hypertrophy

First 3 are congenital, fourth is acquired

Question 42

Tetralogy of fallot: S/S (5)

Answer 42

Cyanosis - blue spells or tet spells
Murmur
Clubbing of fingers
Delayed physical growth and development
Squatting

Question 43

Tetralogy of fallot interventions (6)

Answer 43

Supportive - decrease oxygen demand
Nutrition:
- Feed when hungry
- Soft nipple
- Supplemental gavage feedings
Manage tet spells
Surgical

Question 44

Foreign body aspiration

Answer 44

Common cause of mortality and morbidity in children 1 - 3 years of age

Question 45

Foreign body aspiration: risk factors (4)

Answer 45

Putting objects in their mouth
Improving fine motor skills allows child to pick up small objects and put in mouth
Ability to run or play while eating
Lack molars for proper grinding of food

Question 46

Partial airway obstruction: good airway exchange 1/2 (2)

Answer 46

good airway exchange

Forceful cough, wheezing, crying

Question 47

Partial airway obstruction: good airway exchange 2/2 (3)

Answer 47

• If coughing effectively, encourage child to continue to cough
• Monitor closely
• Manage child’s anxiety

Question 48

Partial airway obstruction: Poor air exchange 1/2 (2)

Answer 48

Weak, ineffective cough, high-pitched breath sounds, cyanosis

Clutches throat: Universal distress signal

Question 49

Partial airway obstruction: Poor air exchange 2/2 (2)

Answer 49

If cough becomes ineffective, call for help

Assess LOC

Question 50

Choking infant - poor air exchange (3)

Answer 50

If conscious: five back blows, then five chest thrusts

Continue to alternate back blows and chest thrusts

If infant becomes unresponsive, start CPR

Question 51

Choking child (1 yr to puberty) - poor air exchange (6)

Answer 51

Series of 5 abdominal thrusts

Repeat until obstruction is relieved or child becomes unresponsive

If unresponsive, open mouth and look for obstruction

If visible, attempt to remove with one finger sweep

If not visible, do not use finger sweep

If unsuccessful begin CPR

Question 52

Nonorganic failure to thrive (1)

Answer 52

Examples of non-organic FTT include lack of food intake due to an inability to afford an appropriate formula, problems with feeding techniques, improperly prepared formula (over-diluting the formula), or an inadequate supply of breast milk (due to the mother being exhausted, under stress or in a poor nutritional state).

Question 53

Aspirin for a child (3)

Answer 53

Reyes syndrome

Better to never give a kid aspirin

Reye’s syndrome, also known as Reye syndrome, is a rare but serious condition that causes swelling in the liver and brain. Reye’s syndrome can occur at any age but usually affects children and teenagers after a viral infection, most commonly the flu or chickenpox.