Respiratory Flashcards
1
Q
Laryngomalacia (2)
A
- Most common cause of noisy breathing in infancy
2. Most common cause of Stridor in neonates (60-70%)
2
Q
Laryngomalacia Pathophysiology (3)
A
- A congenital softening of the tissues of the larynx above the vocal cords. Collapse of the larynx due to lack of strength
- Caused by ‘floppy’ supraglottic structures causing the tissues to fall over the airway and partially block it
- Can be present at birth and may present within the first month of life
3
Q
Laryngomalacia Presentatio (4)
A
- Inspiratory stridor
- Coughing
- Choking
- Regurgitation
- over 50% have GEReflux
- Need to treat the reflux!
- Symptoms are worse when agitated, crying, feeding or lying on back
4
Q
Laryngomalacia Course (6)
A
- Not serious for most – noisy but can eat and grow!
- Some struggle with feeding and growth and require prompt attention (~50%)
- Typical course does not require surgery-
- Worsening at 4-8 months
- Improves at 8-12 months
- Resolves by 12-18 months (outgrow it/resolution within 1st 24 months)
5
Q
Laryngomalacia Treatment (7)
A
- 90% resolve without treatment
- Refer to ENT if distress – bronchoscopy to see floppiness
- Surgery (supraglottoplasty) for those with poor feeding and weight gain
- Tracheostomy is very rare
- Observe most for Gastroesophageal Reflux (GER) & treat!
- Acid can cause swelling above the vocal cords and make it worse
- Nasopharyngolaryngoscopy (NPL) to evaluate – thru nose to larynx
6
Q
PNP’s role with Laryngomalacia (9)
A
- Complete history of symptoms
* “classic symptoms” - inspiratory stridor worsened by feeding,agitation, supine or crying - Birth history
- Family history
- Complete PE
* Include Ht/Wt – growth chart-FTT - Observe feeding if you can
- Discuss GERD and treat (ranitidine neonate:2-4mg/kg/24hr divided Q8-12 hours & > 1year: 5-10 mg/kg/24hr divided every 8-12 hours)
- Reflux precautions
- Follow up for feeding and weight gain
- Refer to ENT
7
Q
Differential Diagnosis for Laryngomalacia (9)
A
- Vocal cord paralysis
- Laryngeal web
- Hemangioma
- Edema secondary to trauma
- Birth trauma or aspiration at birth
- Brachial cleft cyst
- Croup (6 months-3 years of age) (parainfluenza virus)
- Epiglottitis (decreased incidence since Haemophilus Influenze type B vaccine – HIB)
- Foreign body (less common in infancy but can happen)
8
Q
Upper Respiratory Infections (3)
A
- AKA- the common cold
- One of the most common illnesses leading to office visits and school absences
- Mainly Caused by a VIRUS
9
Q
URI Virus Etiology Info (5)
A
- Inflames the membranes in the lining of the nose and throat
- Over 200 different viruses
- Rhinovirus most common cause
- Children will have 6-8 colds a year
* Higher for children in daycare - Adults get cold 2-3 times a year
10
Q
URI Viruses (3)
A
- 50% resulting from infection by rhinovirus
- Parainfluenza viruses, Respiratory Syncytial Virus (RSV), Coronovirus, and Human Metapneumovirus – Common
- Adenovius, Enterovirus, Influenza virus can cause occassionally
11
Q
URI Spread (2)
A
- Direct inhalation of the virus by droplet from sneezing, coughing, nose blowing
- Can spread from touching nasal secretions or contaminated object or surface and touching eyes, nose or mouth- the virus gains entry and produces a new infection!
12
Q
URI Symptoms (9)
A
- Runny nose
- Congestion
- Cough
- Hoarse voice
- Poor feeding
- Fever
- Irritable/cranky
- Symptoms usually start 1-3 days after exposure to the virus
- Symptoms can last up to 14 days but usually 5-7 days
13
Q
URI Infants and Nasal Congestion (4)
A
- Remember infants are obligate nasal breathers up to 3 months of life
- Even moderate nasal congestion can create difficulty breathing
- Nasal congestion → leads to feeding problems –> cannot breathe when suckling à unable to expectorate mucous → often gag, choke and vomit
- Infants small airways can be significantly narrowed by inflammation and mucous causing difficulty breathing even Stridor!
14
Q
URI Course (5)
A
- Can last up to 14 days
- MOST viral URIs last 5-7 days
- Respiratory symptoms peak in severity at days 3 to 6
- Then will improve over time
- Longer if complicated by a bacterial infection and severe respiratory distress in infants
15
Q
URI Cause (5)
A
- VIRAL #1
- Bacterial – can develop with inflammation from viral processes damaging the tissue and making it more susceptible to bacterial invasion
- Leads to complications
- Pneumonia
- Otitis Media
16
Q
URI Treatment (7)
A
- Saline rinses / saline spray
* Buy “little noses” or DIY- ½ tsp of salt mix with 1 cup water - Nasal aspirator / bulb syringe
- Nose Frida
- Humidifer
* Cool mist and clean daily - Baby Vapor rub- no menthol
* Not under 3 months of age
* Can be an irritant, increase mucous and inflammation and make respiratory distress worse - No meds
- No honey (until older than 1 year of age)
17
Q
Bronchiolitis (8)
A
- Inflammation of the bronchioles caused by a viral infection
- Most common lower respiratory tract infection in children less than 2 years of age
- Respiratory Syncytial Virus (RSV) is most common pathogen
- Adenovirus
- Human Metapneumovirus
- Influenza
- Parainfluenza
- Co-infections exist
18
Q
Bronchiolitis Epidemiology (4)
A
- Most common lower respiratory tract infection in infants
- Most common etiology is RSV (Respiratory Syncytial Virus)
- Most cases between December and March (75% of cases under 2yrs)
- RSV season is November to April (Oct-April)
19
Q
Bronchiolitis Risks (4)
A
- More common in crowded living conditions and smoke exposure increases risk, prematurity, cardiopulmonary disease, day care attendance, Older child in home.
- Breastfeeding appears to confer a protective advantage
- High vulnerable population – preterm infants with respiratory distress syndrome (RDS) or Bronchopulmonary dysplasia (BPD)- more likely to be hospitalized
- More preemies= more hospitalizations
20
Q
Bronchiolitis Ages (5)
A
- Most severe symptoms in younger (under 2 years)
- Greater than 50% affected by 1 yr
- 80-90% by 2 years
- Re-infections are common – no permanent RSV immunity
- 1-2 % require hospitalization
* More than 100,000 Hospitalizations annually
21
Q
Bronchiolitis Pathophysiology
A
Acute infection of the epithelial cells lining the small airways leading to…
- Edema
- Increased mucous production
- Necrosis and regeneration of cells
22
Q
Bronchiolitis Clinical Presentation (6)
A
- Rhinitis –COPIOUS THICK NASAL SECRETIONS
- Cough
- Tachypnea
- Retractions
- Hypoxia
- Variable wheezing and crackles on auscultation
23
Q
Bronchiolitis Course of Clinical Features (9)
A
- HAPPY WHEEZER to respiratory failure
- Tachypnea – earliest and most sensitive vital sign change
Peak Symptoms days 3-4 of illness
- Rhinorrhea
- Cough – resolves in 90% within 3 weeks
- Fever? – not always
- Increased work of breathing (retractions)
- Tachypnea
- Wheezing
- Tachycardia
24
Q
When to consider hospitalization with bronchiolitis (6)
A
- Expiratory wheezing
- RR>70
- Grunting, flaring and retracting
- Fever
- NO po intake – cannot eat
- Hypoxemia
25
Bronchiolitis Management (5)
1. Oxygenation
- O2sat if < 92% - oxygen
2. Hydration – if no oral hydration- consider IVF
3. Bronchodilators – NO benefit
4. Steroids – NO benefit
5. Epinephrine – NO benefit
26
Bronchiolitis Tests
Viral isolation, blood serology (do not change the course or care – so not recommended) -AAP, 2014
27
Bronchiolitis Chest X-Ray
Hyperinflation, areas of atelectasis, does not correlate with severity of disease, does not guide management, may prompt use of antibiotics when not needed
28
Bronchiolitis Diagnosis (3)
1. Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination
2. Clinicians should assess risk factors for severe disease, such as age less than 12 weeks, a history of prematurity, underlying cardiopulmonary disease, or immunodeficiency, when making decisions about evaluation and management of children with bronchiolitis
3. When clinicians diagnose bronchiolitis on the basis of history and physical examination, radiographic or laboratory studies should not be obtained routinely
29
Bronchiolitis Treatment (10)
1. Clinicians should not administer albuterol to infants and children with a diagnosis of bronchiolitis
2. Clinicians should not administer epinephrine to infants and children with a diagnosis of bronchiolitis
3. Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the emergency department
4. Clinicians may administer nebulized hypertonic saline to infants and children hospitalized for bronchiolitis
5. Clinicians should not administer systemic corticosteroids to infants with a diagnosis of bronchiolitis in any setting
6. Clinicians may choose not to administer supplemental oxygen if the oxyhemoglobin saturation exceeds 90% in infants and children with a diagnosis of bronchiolitis
7. Clinicians may choose not to use continuous pulse oximetry for infants and children with a diagnosis of bronchiolitis
8. Clinicians should not use chest physiotherapy
9. Clinicians should not administer antibacterial medications to infants and children with a diagnosis of bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one
10. Clinicians should administer nasogastric or intravenous fluids for infants with a diagnosis of bronchiolitis who cannot maintain hydration orally.
30
Bronchiolitis Prevention (7)
1. Clinicians should not administer palivizumab to otherwise healthy infants with a gestational age of 29 weeks, 0 days or greater
2. Clinicians should administer palivizumab during the first year of life to infants with hemodynamically significant heart disease or chronic lung disease of prematurity defined as preterm infants <32 weeks 0 days’ gestation who require >21% oxygen for at least the first 28 days of life
3. Clinicians should administer a maximum 5 monthly doses (15 mg/kg/dose) of palivizumab during the respiratory syncytial virus season to infants who qualify for palivizumab in the first year of life
4. All people should disinfect hands before and after direct contact with patients, after contact with inanimate objects in the direct vicinity of the patient, and after removing gloves
5. All people should use alcohol-based rubs for hand decontamination when caring for children with bronchiolitis. When alcohol-based rubs are not available, individuals should wash their hands with soap and water
6. Clinicians should inquire about the exposure of the infant or child to tobacco smoke
7. Clinicians should encourage exclusive breastfeeding for at least 6 months to decrease the morbidity of respiratory infections.
31
Synagis Palivuzamab Prophylaxis (3)
Palivizumab (brand name Synagis by Medimmune)
1. Monoclonal antibody used to prevent RSV infections given in serial doses during RSV season
2. Recommended for infants at ‘high risk’
3. Season in U.S.- November start (Dec outbreaks)-Peaking in Jan-Feb
32
Palivuzamab Dose (4)
1. DOSE: Palivizumab 15mg/kg per dose
2. 5 monthly doses
3. Begin in November through March will cover through April
4. If started in October the 5th dose is in February and will provide protection through March
33
Updated recommendations for Palivuzamab (7)
1. Palivizumab prophylaxis may be administered to infants born before 29 weeks 0 days gestation who are younger than 12 months at the start of RSV season
2. For infants born during RSV season, fewer than 5 monthly doses will be needed
3. Infants born later than 29 weeks 0 days gestation may qualify for receive prophylaxis on the basis of congenital heart disease (CHD), chronic ling disease (CLD), or another condition
4. Palivizumab is not recommended in the second year of life on the basis of prematurity alone.
5. Prophylaxis may be considered during the RSV season of the first year of life for preterm infants who develop CLD as defined as gestational age <32 weeks 0 days, and a requirement of >21% oxygen for at least the first 28 days of life
6. During the 2nd year of life only the infants that satisfy this definition of CLD and continue medical support (oxygen, corticosteroids, diuretics) during the 6 month period before the start of RSV season should receive Synagis
7. Infants with hemodynamically significant CHD who are 12 months or younger may benefit from prophylaxis.
* This does not include ASD, small VSD, septal defects, pulmonic stenosis, mild coarctation of the aorta and PDA)
* Infants corrected by surgery
* Children in the 2nd year of life not automatic
34
Bronchiolitis Considerations (8)
1. Children with Anatomic Pulmonary Abnormalities or Neuromuscular disorders that impairs ability to clear secretions from the upper airway due to ineffective cough May be considered for prophylaxis during the 1st year of life.
2. Prophylaxis May be considered for children <24 months of life who are profoundly immunocompromised during the RSV season
3. Children with Down Syndrome – not unless fit the prior criteria – insufficient data to justify
4. Children with CF- not recommended unless other indication present
5. Alaska and American Indian – eligibility may differ from the rest of the U.S. – use surveillance
6. Discontinuation in children who experience BREAKTHROUGH hospitalization for RSV – STOP giving it.
7. Second Year of life- only for those born <32 wks gestation and required at least 28 days of oxygen after birth and who continue to require supplemental oxygen, steroids, or bronchodilators within 6 months of RSV season start of the 2nd year of life.
8. Prevention of Health care associated RSV- not routine – those who qualify may receive 48-72 hours before discharge OR promptly AFTER discharge
35
Enterovirus (7)
1. Enterovirus 68 (EV-D68)
2. One of more than 100 non-polio enteroviruses
3. U.S. 2014- we experienced a nationwide outbreak associated with severe respiratory illness
4. 941 cases reported from Mid-August to October 22 in 46 states
5. 2 deaths of young children under 5 years of age
6. Need prompt diagnosis
* Developed a quick swab for this
7. This year EV-68 has been the most common type of enterovirus identified (over enterovirus strains and rhinovirus)
36
Enterovirus Season and 2 Risks
1. SEASON- Summer to Fall
RISKS:
1. Young children
2. History of Asthma or wheezing
37
PNP's role with enterovirus (4)
1. Educate parents about EV-68
Identify clinical symptoms early:
1. Mild – fever, runny nose, cough, sneezing, body aches
2. Severe- wheezing, increased work of breathing or difficulty breathing
3. Severe wheezing and work of breathing and history of asthma separates this from other viruses
38
Prevention of Enterovirus (8)
1. Hand washing education with soap!
2. Avoid touching nose, mouth or eyes
3. Avoid sick contacts
4. Do not share utensils, cups
5. Cover your sneeze with a tissue or sleeve not your hand
6. Stay home when you are sick! No school.
7. Asthma action plan update for those with Asthma
8. Get a Flu Vaccine
