respiratory dysfunction

URI/nasopharyngitis

most frequent acute illness in children

typical causes: RSV, adenovirus, influenza, parainfluenza, enterovirus, Hib, mycoplasma

symptoms typically last 10-14 days

children typically have 6-8 episodes a year

winter and spring months

URI/nasopharyngitis symptoms

fever

decreased intake/output

fussy

cough

nasal congestion/rhinorrhea (tend to be mouth breathers)

possible sore throat and/or headache

younger the child’ the more severe the symptoms; anatomy is smaller

URI/nasopharyngitis: treatment

self limiting

keep hydrated: Pedialyte, diluted gatorade, popsicles, water. small frequent amounts throughout the day

I&Os; diaper counts; diaper weights at hospital

feverL antipyretic, nonpharm treatment

decongestant: >6y.o

saline “nasal washes”, bulb suction

cough suppressants: don’t give <6yo, overall not routinely recommended

prevention is key, educate

no antibiotic bc is a virus

streptococcal pharyngitis

GABHS: group A b hemotlogic strep

contagious

sore throat, HA, fever, GI discomfort, decreased intake

pharynx and tonsils erythematous, possible white exudate

cervical lymphadenopathy

can have complications: rheumatic fever (inflammatory disease of heart, joints and CNS), glomerulonephritis

streptococcal pharyngitis diagnosis/treatment

rapid strep test and throat culture

treatment: first line is a PCN antibiotic; needs to be on antibiotic for 24hr before returning to school

Tylenol or Motrin prn for fever

salt water gargles

stay hydrated; small frequent

discuss hygiene: no sharing food or drink, avoid crunchy foods; hard to swallow, replace toothbrush 24hr after AB

tonsilitis

tonsils are lymphatic tissue

often occurs with pharyngitis

children have larger tonsils than adults

tonsils are inflamed, may have “kissing tonsils”

difficulty with swallowing and breathing

typically viral which is self limiting

tonsillitis treatment

comfort measures; same as strep

pain control

soft/liquid diet

throat lozenges/sprays

saltwater gargles

hygiene

prevention: wash hands, no sharing food or drink

tonsillitis surgical treatment

tonsillectomy: surgical removal of the palatine tonsils

adenoidectomy: surgical removal of the adenoids

take both out at same time

benefits have to outweigh the risks

tonsillectomy post op care

position to facilitate drainage of secretions; elevate HOB

analgesics

antiemetic: tissue is fragile; vomiting will destroy

liquid to soft diet

no saltwater gargles

no coughing, clearing throat, or blowing nose

no straws

distinguish old blood from new blood: brown (old) is okay, red is concerning

otitis media

presence of middle ear fluid; eustachian tube dysfunction

highest incidence is in winter months

typically secondary to a URI

increased risk: daycare attendance, smoke exposure, larger households

breastfed babies at less risk; maternal antibodies

otits media symptoms

fever

otalgia (earache)

pulling at ears

fussy/irritable

ear discharge; yellow green

decreased appetite

increased fussiness when laying supine; increases pressure in ears

otitis media: complications/treatment

potential for hearing loss, which can lead to speech delay

labyrinthitis: inner ear infection

mastoiditis

meningitis

treatment:
antibiotics: amoxicillin, augmentin, cefdinir, rocephin (IM for 3 days, only give if resistant to AB)
pain management
pneumococcal vaccine, flu vaccine
decrease risk factors such as no propping of formula bottles; lays too low

otitis media: surgical treatment

tympanostomy tubes (PE tubes)

ventilation of middle ear: allows fluid to drain out

same day surgery

PE tubes will purge out on own, rare cases need to be removed

criteria: 3 episodes in last 6 months, four episodes in 1 year, with on episode withing 6 months, chronic fluid

no water in ears (swimming, showering)

otitis externa

“swimmer’s ear”; water sits in ears and bacteria grows

pseudomonas aeruginosa or staphylococcus aureus most common

external ear infection

most common 5-14 yo

peaks in the summer

otitis externa: symptoms

very painful

aggravated by jaw motion or ear manipulation

possibly itchy

ear canal edematous, erythematous with drainage

may have fever

exam: TM should be normal. this is way to distinguish between media and externa

otitis externa: treatment

pain management

optic preparations with or without corticosteroids

gauze wick to facilitate administration of med if there is >edema

prevention: keep ears dry, can use 50/50 white vinegar and rubbing alcohol after swimming (unless have PE tubes), no foreign body in ears (qtips)

croup syndromes

common respiratory disease

typically 6 months - 3 years old

boys>girls

late autumn to early winter

inflammation and swelling causing narrowing of airway; common in younger bc their airways are already narrow

may or may not have fever

monitor signs of distress: retractions, agitation, pallor/cyanosis, increased HR, restlessness, hypoxia

epiglottitis

bacterial (HIB); vaccine available

rapid onset

medical emergency

airway is significantly compromised due to inflammatory process

can develop at any age however most often 2-5 years old

epiglottitis symptoms

goes to bed with no symptoms, wakes up with abrupt onset of:

sore throat

fever

drooling

restlessness/apprehensive

no cough; airway so narrow

tripod position

epiglottitis care

neck x-ray to confirm

no tongue blades or throat culture; airway is already compromised

antipyretics

humidified O2

fluids

correct acidosis if present

antibiotics

corticosteroids; helps with swelling

intubation if needed

laryngotracheobronchitis (LTB)

most common croup syndrome

preceded by URI symptoms

inspiratory stridor, retractions, bark or seal like cough

increased CO2; acidotic

may need intubation

LTB treatment

cool fluids

cool mist humidifier

can go outside to breath cool air

antipyretics for fever

hygiene; wash hands, no sharing utensils

may need one time dose of oral steroid and/or racemic epi neb

sit upright and allow for rest

spasmodic laryngitis

paroxysmal attacks of laryngeal obstruction at night

attacks lasting 2-5 days then uneventful recovery

typically 1-3 years old

no fever

can be caused by virus, allergy or psychogenic factors

episodes last a couple hours, appears well the next day other than hoarseness

spasmodic laryngitis treatment

cool mist

steam from a hot shower may be helpful

outside cool air

self limiting

racemic epi in severe cases

respiratory syncytial virus (RSV)

most common resp pathogen in childhood

airborne

2-5 months old are at risk for greater severity

sufficient air intake but is trapped (over inflation)

viral shedding can last 3-4 weeks

retractions, wheezing, crackles, dyspnea, tachypnea, diminished breath sounds

RSV treatment

symptomatic care

rest

keep hydrated: small frequent fluids

saline nebs and nasal suction prn

bronchodilators; only if starts to wheeze

no antibiotics, cough suppressants or steroids

ribavirin; antiviral for serious lung infection

synshis/palivizumab: RSV antibodies. only given to immunocompromised, lung issues

pneumonia

bacterial, mycoplasma, viral or aspiration

enters lung by inhalation or from the bloodstream

can be primary disease or secondary to another illness; usually have RSV then progresses to pneumonia

inflammation of the pulmonary parenchyma

viral pneumonia symptoms

viral > bacterial

often associated with URIs

onset can be acute or insidious

fever, cough, malaise, crackles, possible wheezing

diffuse or patchy infiltration on chest x-ray; back will hurt

viral pneumonia treatment

rest

antipyretics

chest percussion; breaks secretions up

O2 if needed

hygiene

stay hydrated

allergic rhinitis

seasonal (SAR): triggers are trees, grass, weed pollen

perennial (PAR): triggers are housold inhalants, feathers, dust, animal dander, mold; around all the time

s/s: allergic salute, shiners; dark circles under eyes, pale boggy turbinate, clear rhinorrhea, throat clearing, sneezing

diagnosis: skin testing, nasal swab, CBC, IgE

allergic rhinitis treatment

avoid allergen

topical nasal corticosteroids; take several days/weeks to work

antihistamines

oral alpha-adrenergic decongestants

cromolyn sodium

leukotriene modifier montelukast

nasal decongestant sprays

allergen immunotherapy; exposes to allergen

asthma

chronic inflammatory disorder of the airway

characterized by recurring symptoms, airway obstruction, and bronchial hyper responsiveness

80-90% of children have 1st symptoms before 4-5 yo

classified as: intermittent, mild persistent, mod persistent, severe persistent

asthma risk factors

atopy (history of allergies or atopic dermatitis)

hereditary

boys>girls until adolescence and then reverses

smoking/exposure to secondhand smoke

maternal smoking during pregnancy

ethnicity: african Americans greatest risk

LBW

being overweight

asthma triggers

dust mites

pets

molds

exercise

season change (to include cold air)

secondhand smoke

wood smoke

perfumes

URIs

strong emotions

nuts, milk, and dairy

asthma manifestations

chest tightness

chest pain

prodromal itching

irritability

restlessness

coughing

HA

wheezing

speaking in short broken phrases

pulmonary function tests (PFT)

objective tests to help diagnose asthma

can usually start around 5-6 yo

measured prior to treatment then after treatment

measures maximum expiratory and inspiratory flow volume

repeated q1-2 years

peak expiratory flow meters

measures peak expiratory flow rates (PEFR)

max flow of air that can be forcefully exhaled in 1 sec

establish a personal best during a 2-3 week period: asthma must be stable

recorded twice a day

value determines the severity of the symptoms

cannot be used to diagnose asthma severity; use to learn how to treat

exercise induced bronchospasm

bronchospasm during or after physical activity: cough, SOB, wheezing, difficulty with endurance

peaks 5-10 mins after stopping the activity

stops in another 20-30 mins

exercise challenge test for diagnosis

asthma management

allergen control: prevent and reduce exposure to airborne allergens and irritants

breathing exercises and physical training: helps develop more efficient patterns of breathing

hyposensitization: allergen immune therapy; used in mild to mod allergic asthma

asthma med management: long term control meds (preventative)

achieve and maintain control of inflammation

meds: inhaled corticosteroids, cromolyn sodium and nedocromil, long acting beta2-agonists, methylxanthines, and leukotriene modifiers are used as meds

asthma med management: quick relief meds (rescue)

treat symptoms and exacerbations

meds: short acting beta2 agonists, anticholinergics, and systemic corticosteroids are used as meds

asthma support and teaching

teach parents to recognize s/s

neb, MDI, diskus teaching

dangers of the overuse of beta2-agonists

create an asthma action plan

cystic fibrosis

most lethal genetic illness

mucus producing gland dysfunction

autosomal recessive trait; gene from both parents

overall incidence of 1 in 4 births if both parents carry the gene

over 1900 known mutations

cystic fibrosis genetics

carrier: 50%

affected: 25%

unaffected: 25%

cystic fibrosis manifestations

vary widely and change as the disease progresses

common symptoms: chronic obstructive lung disease associated with infection, maldigestion, growth failure, diabetes symptoms

FTT increased weight loss despite increased appetite

some children display symptoms at birth, but some will not develop for weeks, months, or years

symptoms vary from mild to severe

affects the resp, GI, reproductive, and integumentary systems

cystic fibrosis diagnosis

must meet criteria:

at least one of the typical features of CF: chronic sinusitis, GI and nutritional abnormalities, salt loss syndromes, obstuctive azoospermia

a sibling with CF

a positive newborn screening

cystic fibrosis management

antibiotics for infections

bronchodilators to help open airways

chest physiotherapy (CPT) to help with cleaning resp passages of mucus

pancreatic enzymes replacement therapy with meals and snack

high calorie and protein diet

fat soluble vitamins supplements

flutter mucus clearance device: positive pressure helps open lungs and allow for mucus clearance

transplant

family support and illness prevention education