Respiratory Flashcards
Resp infections in children
4-5 per year, mild to life threatening. The most common cause of illness in infancy and children. Age > 3 highest risk
Upper resp infection structures
Ear, nose, pharynx, and larynx. More flexible larynx because it is cartilage which hasn’t hardened – seen in Laryngomalasia. Resp tract lumen easily obstructed size of little finger, can be obstructed with mucus. Tonsils are enlarged normally. Cannot breathe through mouth, neonates are nose breathers, if congested interferes with breathing and eating
Lower resp tract infection structures
Rigid trachea, bronchi, lungs (bronchioles), Smooth muscle ability to contract. Fewer alveoli at birth which develop until puberty. Lungs, trachea, cilia not developed until age 8 – concerning for secondhand smoke inhalation as they are trying to develop
Croup syndromes
Infections of the larynx and epliglottis
Peds differences in resp system
– Shorter distance between structures
– More flexible larynx
– Lumen in the respiratory tract is smaller and subsequently more easily
obstructed
• i.e., child’s trachea is approx. the size of a child’s little finger
– Fewer alveoli at birth
• #’s, size, and shape increase until puberty
– Eustachiantubesareshorterandmorehorizontal • Facilitates transfer of pathogens into the middle ear
– Tonsillar tissue enlarged
Lack of surfactant
Need it to make lungs more pliable, found in premies, can be supplemented
Narrow nasal airway increases risk of obstruction from
edema, foreign objects, mucus
Infant airway walls have less cartilage leading to
- More flexible, and more prone to collapse
- Intercostal muscles are immature
- Chest wall is less stable
- Retractions are more common
Newborns have less of this, which functions of a cleansing agent
Respiratory mucus
Newborn breathing
Brief periods of apnea are common
Upper airway characteristics
– Narrow tracheo-bronchial lumen until age 5
– Tonsils, adenoids, epiglottis proportionately larger in children
– Tracheo-bronchial cartilaginous rings collapse easily
• Trachea bifurcates higher in the chest, gets lower as you get older
Lower airway chacacteristics
– Fewer alveoli in the neonate
– Poor quality of alveoli until age 8
– Lack of surfactant that lines the alveoli in the premature infant
• Inhibits alveolar collapse at end of expiration
• Chest wall shape varies, when younger small and can’t get mucus out which is why they get so many respiratory issues
Infant resp exam
• Examination approach is similar to that in adults; percussion is less reliable in infants.
• Inspect the thoracic cage,noting size and shape.
• Measure the chest circumference.
– Usually 2 to 3 cm smaller than the head circumference
• Respiratory rate varies between 40 and 60
respirations per minute.
• Periodic breathing, a sequence of relatively
vigorous respiratory efforts followed by apnea of as long as 10 to 15 seconds, is common.
Chest is x smaller than the head
2-3cm
Infants coughing, sneezing, hiccups
No coughing reflex - will choke, sneeze and hiccups are common. do sneeze with little airways and little nostrils, dust, pollen get stuck – all smells are new, They are diagphragmatic breathers will also gradually use intercostal muscles
Paradoxic breathing
the chest wall collapses as the abdomen distends on inspiration is common, particularly during sleep.
Infant resp exam
- Palpate rib and sternum noting masses or crepitus
- Listen to every aspect of chest, Breath sounds are easily transmitted from one segment of the auscultatory area to another.
Stridor
– High-pitched, piercing sound most often heard during
inspiration
– Result of an obstruction high in the respiratory tree
Respiratory Grunting
– Mechanism by which the infant tries to expel trapped air or fetal lung fluid while trying to retain air and increase oxygen levels
– Cause for concern if persistent
Nasal flaring
sign of resp distress
Funnel chest
- Chest is concave
- No full lung expansion
- Needs surgery once 15,16,17
- PICU post op crack sternum, bilateral pneumothorax double chest tubes
Pigeon chest
- More barrel chested, has a peak
* No impact on respiratory status
Seasonal variations
RSV winter and spring, Mycoplasma more common in fall and winter, Asthmatic bronchitis more frequent in cold weather
Cardinal Signs of Respiratory Distress in Infants & Children
• RESTLESSNESS • Tachypnea • Tachycardia to bradycardia =late sign • Diaphoresis • Mood changes • Altered patterns of RR • Grunting = impending respiratory failure • Diminished or absent breath sounds
More s/s resp distress in children
Cyanosis-late sign • Nasal flaring • Retractions • Expiratory grunt • Wheezing • Apnea or gasping respirations • Poor systemic perfusion / mottling • Decrease oxygen saturations
Chest retractions
Retractions suggest an obstruction to inspiration at any point in the respiratory tract. As intrapleural pressure becomes increasingly negative, the musculature “pulls back” in an effort to overcome the blockage. The degree and level of retraction depend on the extent and level of the obstruction.
Bronchiolitis
VIRAL! lower resp tract infection, common in infancy, 90% have this by age 2. Peak is December - March. Reinfection is common. Pathogen is RSV. • S/s: runny nose, nasal congestion, fever (not always), irritable, vomiting from swallowing mucus, Copious clear secretions, tachypnea
Bronchiolitis findings on exam
Copius clear nasal secretions – Tachypnea – Wheezing – Cough – Crackles – Retractions – Nasal flaring – Decreased O2 sat
Respiratory Syncytial Virus
The most common cause of lower respiratory tract infections in children worldwide. Virtually all children contract it by the age of three. The leading cause of pneumonia and bronchiolitis in infants. May play a major role in the pathogenesis of asthma and chronic
obstructive pulmonary disease from the scarring/damage. Spreads easily, lives for 8 hours on a fomite.
Synagis
the first monoclonal antibody successfully developed to help prevent an infectious disease, proven effective in reducing RSV- related hospitalizations in premature infants and infants with CHD. Administered once monthly through the RSV season, October – April in NJ only for first year of life
Mgmt RSV
Dx is based on H & P routine labs and radiographs are not necessary or recommended, Assess risk factors for severe disease – Age
Synagis education
hand hygiene! Breast feeding, avoid tobacco and second hand smoke
Follow up w RSV
Follow up depends on severity and clinician judgment usually 5-7 days but could be as soon as 3-4 or even 24 hrs depending on initial presentation. Refer to ED if Severe respiratory distress, O2 Sat
Pneumonia
Acute inflammation of the lung caused by bacteria or viral infection, Major cause of death in young children world wide. Etiology may be bacterial or viral. Pathogens: HIB, Pertussis, Flu, RSV
Atypical pneumonia
Gradual onset
– Malaise, headache, sore throat, ear infections
– **Lower fevers (101- 102)
– **Usually nonproductive, persistent cough
– May or may not have crackles
Bacterial pneumonia
– Gradual or acute onset – Fatigue, dyspnea, chest pain
– **Fevers often higher (>103)
– **Productive cough
– Decreased or bronchial
breath sounds, crackles, dullness to percussion, egophony
Mgmt pneumonia
• Antibiotics are not routinely required in preschoolers because etiology is mostly viral
• Amoxil 90 mg/kg/day divided in 2 doses • Macrolide for school age and adolescent
children d/t atypical pathogens
• Chemoprophylaxis (immunizations)
– Hib, pertusis, influenza, pneumococcal
When to follow up for pneumonia
2-3 days. once abx start symptoms improve
Refer to ER Pneumonia
– Moderate to severe resp distress
– O2 Sat
Pertussis
• Caused by Bordetella pertussis
• In U.S. it occurs most often in children who
have not been immunized
• Highest incidence in spring and summer
• Highly contagious, Contagious before showing s/s easily spread
• Risk to young infants
• Vaccines
Tx Pertussis
Erythromycin – may stain teeth, Clarithromycin, Azithromycin
Asthma
- Inflammation and constriction of bronchioles that may resolve spontaneously or with medication
- Most common chronic disorder of childhood
- Characterized by acute exacerbation and remission
Asthma s.s
- Chest tightness – Shortness of breath – Late night or early morning cough – Vomiting (post tussive) – Irritability
Asthma exam findings
-- Wheezing – Rhonchi – Retractions – Increased cough (dry hacking or productive) – Hypoxia
Asthma comorbidity
Eczema, Allergic rhinitis, GERD, atopic dermatitis
Asthma mgmt
- Refer to step wise progression to: – Determine severity – Determine risk
- Treatment is determined by severity and risk. Avoid triggers. Get necessary vaccines. • PRN as needed SABA first
- Persistent asthma needs LT corticosteroids
- Bronchodilators for exacerbation
Drug therapy for asthma
- LT control meds
- Quick relief meds
- MDI
- Corticosteroids
- Cromolyn sodium
- Albuterol, metaproterenol, terbutaline
Status Asthmaticus
- Respiratory distress continues despite vigorous therapeutic measures
- Emergency treatment—epinephrine 0.01 ml/kg subQ (max dose 0.3 ml)
- Concurrent infection in some cases • Therapeutic intervention
Asthma f.u
• Every 2 weeks until controlled • Every 3-6 months once controlled • Pulmonologist for complicated cases that do not respond to treatment • Allergist if needed
Reactive airway disease
• Undetermined cause
• Ss of coughing, wheezing, SOB
• Airways are reacting to something
It may be used to describe a history of coughing, wheezing or shortness of breath due to undetermined cause. These signs and symptoms may or may not be caused by asthma.
Croup
Characterized by hoarseness, “barking” cough, inspiratory stridor, and varying degrees of respiratory distress
Differentials w Croup
Differentials
– Acute spasmodic laryngitis (Spasmodic croup)
– Acute laryngotracheobronchitis (LTB) Will usually have URI then a barking cough, most common. Inspiratory stridor
– Acute epiglottitis
– Acute bacterial tracheitis
laryngotracheobronchitis LTB
Viral infection causing
– Inflammation
– Edema
– Narrowing of larynx, trachea, and bronchi
– Usually preceded by recent URI
– Ages 3 mos – 3 years
– Most common of croup syndrome
– Inspiratory stridor “barking cough”
– Parainfluenzae virus, influenzae A & B, respiratory
syncytial virus (RSV), and mycoplasma pneumoniae
s/s LTB
Signs & symptoms – Gradual onset after URI – Low-grade fever – Barking cough – Acute stridor – Noisy respirations – Retractions • Suprasternal, intercostal, subcostal – Sore throat, rhinorrhea – Restlessness, frightened
Therapeutic mgmt LTB
• Airway management, Maintain hydration—PO or IV, High humidity with cool mist, Nebulizer treatments, Racemic epinephrine, Steroids. Heliox if unresponsive to other treatments
LTB Meds - Bronchodilators
•
LTB Meds - Corticosteroids
Cystic Fibrosis
Multisystem disorder. Exocrine glands causing creation of this mucus in bronchioles, small intestines, pancreatic and bile ducts. Impermeability of epithelial cells to chloride. Autosomal trait, mainly white people. Mechanical obstrictions due to thick sputum blocking. Life expectancy 30 years, Terminal, death from resistant pulmonary organisms and fibrosis and destructive lung tissue
CF Gene
• Autosomal recessive genetic disease
• Abnormal gene is located on the long arm of
chromosome 7
• 95% known cases occur in Caucasians
• Most common lethal genetic illness among
Caucasian children
• Approximately 3% of U.S. Caucasian population are symptom-free carriers
CF Lungs
Pulmonary system
– Pooling of thick, sticky secretions w Patchy, atelectasis w/hyperinflation. Unable to expectorate mucous – Due to > viscosity
• Medium of bacterial growth – Reduces O2 and CO2 exchange • Variable degrees of – Hypoxia– Hypercapnia – Acidosis
CF Dx
- Absence of pancreatic enzymes
- > concentration of Na+ & Cl- in sweat • Chronic pulmonary involvement
- Sweat test
Sweat test
– Analyzes Na+ & Cl-
– Concentrations >60 meq/L diagnostic of CF – Infants taste “salty”
– 72 hour fecal fat
– CXR
Resp s/s CF
– Chronic respiratory infections – Wheezing – Dry nonproductive cough – Dyspnea w/paroxysmal cough – Evidence of obstruction – Emphysema & patchy area of atelectasis – Over inflated barrel-shaped chest – Clubbing & cyanosis of fingers/toes (chronic hypoxemia) – Subnormal PFT’s
CF GI Tract
- Thick secretions block ducts → cystic dilation → degeneration → diffuse fibrosis
- Prevents pancreatic enzymes from reaching duodenum
- Impaired digestion/absorption of fat → steatorrhea
- Impaired digestion/absorption of protein → azotorrhea
CF Presentation
- Wheezing respiration, dry nonproductive cough
- Generalized obstructive emphysema
- Patchy atelectasis
- Cyanosis
- Clubbing of fingers and toes
- Repeated bronchitis and pneumonia
CF GI Presentation
• Meconium ileus • Distal intestinal obstruction syndrome • Excretion of undigested food in stool— increased bulk, frothy, and foul • Tissue wasting • Prolapse of the rectum
CF General s/s
– Meconium ileus • May be 1st sign of CF – Bulky, frothy, foul-smelling stool • Steatorrhea “floaters” • Sign of malabsorption – Abdominal distention w/thin extremities – Vitamin deficiency – Anemia – Voracious appetite – Failure to Thrive (FTT) – Marked tissue wasting – Sallow skin
CF POC Postural Drainage
- Segmented PD w/clapping & vibration
* Schedule compatible w/ family’s schedule
Aerosol therapy CF
- Proper use of nebulizer
- Cleaning&sterilization
- Close supervision
Nutrition CF
- High-caloric,highprotein
- Extrasaltinhotweather
- Fat-solublevitaminsupplement
- Nighttime tube feedings/TPN, prn
Maximize health CF
– Nutrition
– Prevention/early aggressive treatment of infection
– Pulmonary hygiene
New research CF
– Gene therapy
– Bilateral lung transplants
– Improved pharmacologic agents
Meds for CF
- Pancreatic enzymes
- Multivitamins
- Antibiotics
Exercise in CF
- Improves ability to clear lung secretions
* > exercise tolerance
Emotional Support in CF
- Encourage verbalization & independence
- Support group
- Remains chronic disease with no cure
- CF Foundation, American Lung Association
- Parents may need respite, especially if care gets involved
Family Support CF
- Coping with emotional needs of child and family
- Child requires treatments multiple times a day
- Frequent hospitalization
- Implications of genetic transmission of disease
