chapter 26: Respiratory function and disorders of system of children

how do changes take place in the lungs with age?

• changes take place in the air passages that increase the respiratory surface

• major changes are in the number and size of alveoli and in the increased branching of terminal bronchioles

when is respiratory fuction first evident during gestation?

approximately 20 weeks of gestation

describe the respiratory rate and volume during growth

• RR: steadily decreases until it levels off at maturity

• volume: air inhaled increases with the growth of the lungs and is closely related to body size

• amount of oxygen: in the expired air gradually decreases and the amount of carbon dioxide increases

mechanical respiratory devices (artificial)

increase the pressure entering the air passages (positive pressure breathing devices) or lowers the pressure around the body (negative pressure ventilator)

vetilation

• exchange of gases in the lung

• results from changes in pressure gradients created by changes in the size of the thoracic cavity

contractions of the diaphram and external intercostal muscles

• increases the size of the thorax and decreases the intrathoracic pressure

• As a result, air moves from the atmosphere, which has a higher pressure, into the lungs, which have a lower pressure

surfactant

a lipoprotein at the air-fluid interface that allows alveolar expansion and prevents alveolar collapse, and elastic recoil, the tendency of the lungs to return to the resting state after inspiration (a passive process that requires no muscular effort)

compliance

• normally high in the newborn and infant because of a more pliant (flexible) rib cage

• primary forces that affect the mechanics of breathing

• measure of chest wall and lung distensibility

• It represents the relative ease with which the chest and lungs expand with increasing volume and then collapse away from the pleural wall with decreasing volume (elastic recoil)

• The two major factors determining: alveolar surface tension, which is lowered by surfactant and elastic recoil, the tendency of the lungs to return to the resting state after inspiration

what is and what are causes of tachypnea?

• rapid respirations

• anxiety, excitement, elevated temperature, severe anemia, metabolic acidosis, respiratory alkalosis

what is and what are causes of hyperpnea

• too deep respirations

• fever, severe anemia, respiratory alkalosis associated with psychosis, central nervous system (CNS) disturbances, and respiratory acidosis that accompanies disorders such as diabetic ketoacidosis or diarrhea

what is and what are causes of hypopnea

• too shallow respirations

• metabolic alkalosis.

• in preterm infants may occur as a result of pulmonary immaturity, absence of adequate substrate to support respiratory muscle activity, neurologic insult, and neurologic immaturity

retractions

• sinking in of soft tissues relative to the cartilaginous and bony thorax

• types:

  • supraclavicular retractions

  • suprasternal notch retractions

  • intercostal retractions

  • substernal retractions

  • Subcostal retraction

observed anteriorly at the lower costal margins, indicates a flattened diaphragm because it not only lowers the floor of the thorax but also pulls on the rib cage in response to a greater than normal decrease in intrathoracic pressure

Subcostal retraction

severe airway obstruction, retractions extend to the

supraclavicular areas and the suprasternal notch

nasal flaring

• sign of respiratory distress

• significant finding of respiratory compromise

• enlargement of the nostrils helps reduce nasal resistance and maintains airway patency

• may be intermittent or continuous and should be described as minimum or marked.

head bobbing

• This is caused by neck flexion resulting from contraction of the scalene and sternocleidomastoid muscles.

• seen in a sleeping or exhausted infant is a sign of dyspnea

• The head, supported on the caregiver’s arm only at the suboccipital area, bobs forward with each inspiration

noisy breathing

“snoring” is frequently associated with hypertrophied adenoidal tissue, choanal obstruction, polyps, or a foreign body (FB) in the nasal passages.

stridor

high-pitched, noisy respiration, is an indication of narrowing of the upper airway

• result of edema and inflammation

• in association with an upper airway obstruction from mucus secretions or a foreign object.

• may be inspiratory or expiratory

what are common cause of stridor in children?

croup, epiglottitis, FB, or tracheitis

grunting

• sign of pain in older children and acute pneumonia or pleural involvement

• observed in pulmonary edema (PE) and is a characteristic of respiratory distress in newborns and infants

• It is the body’s attempt at more efficient respiration

• serves to increase end-respiratory pressure and thus prolong the period of oxygen and carbon dioxide exchange across the alveolocapillary membrane

wheezing

• continuous musical sound originating from vibrations in narrowed airways

• heard on expiration

• Infants may have it as a result of increased airway resistance and a compliant chest wall.

• Older children often have it with a lower respiratory tract infection as a result of inflammation, bronchospasm, and accumulated secretions

Color changes of the skin

• mottling, pallor, and cyanosis

• mottling and cyanosis are significant and usually indicate cardiopulmonary disease

• Except for the peripheral bluish discoloration (acrocyanosis) resulting from circulatory stasis in the newborn

• mottling resulting from a cool environment

chest pain

• complaint of older children

• caused by both pulmonary and nonpulmonary

• It may be caused by disease of any of the chest structures.

• Most pleural pain is related to respiration. Rapid and shallow respiratory movements may be accompanied by grunting, especially in the younger patient

clubbing

• proliferation of tissue about the terminal phalanges, accompanies a variety of conditions, frequently those associated with chronic hypoxia, primarily cardiac defects, and chronic pulmonary disease (cystic fibrosis [CF])

• does not accurately reflect disease progression

• degree depends on the extent to which the nail base is lifted on the dorsal surface of the phalanx by the tissue proliferation

• greater the angle formed above the finger or toe at the skin-nail junction, the more pronounced the it is, especially when there is a decided curvature to the nail

cough

• protective mechanism and an indicator of irritation

• severe cough is associated with measles and CF

• paroxysmal cough accompanied by an inspiratory “whoop” is typical of pertussis in infants and small children.

• A brassy, nonproductive cough is part of the symptomatology of croup and FB aspiration.

• Because there are no cough receptors in the alveoli, a cough may be absent in a child with pneumonia in the early stages of the disease but is a common feature during active pneumonia and recovery.

how is respiratory funtion diagnosed and assessed?

repsiratory funtion test

radiography

blood gas measure

pulse ox

pulmonary fuction Tests

pneumotachography or spirometry

noninvasive

radiography

• frquesntly used

• lead shields to protect correctly placed and consistently applied to areas not needed for diagnostic purposes, are essential.

• Play and modification of methodology effectively reduce the trauma sometimes associated with the procedure and gain the child’s cooperation

blood gas

• information regarding lung function, lung adequacy, and tissue perfusion and are essential for monitoring conditions involving hypoxemia, carbon dioxide retention, and pH

• guides decisions regarding therapeutic interventions, such as adjusting mechanical ventilator settings, modifying chest physical therapy (CPT), administering oxygen/continuous positive airway pressure (CPAP)/bilevel positive airway pressure (BiPAP), or positioning the child for maximum ventilation

• newborns can have slightly lower values and still be considered normal. For example, normal pH values for a newborn range from 7.26 to 7.29, the average PaO2 is 70 mm Hg, the average PaCO2 is 33 mm Hg, and the average bicarbonate is 20 mEq/L. ABG values also depend on the concentration of oxygen the child is breathing

what protects the respiratory tract from infections?

lymphoid tissues, mucous balnket, ciliary action, epiglottis, cough, position change, lymphatics, humoral defenses

what consists of the upper respiratory tract?

upper airway, consists of the oronasopharynx, pharynx, larynx, and upper part of the trachea

what consists of the lower respiratory tract

consists of the lower trachea, bronchi, bronchioles, and alveoli

what are the most common respiratory tract infectious agents?

• viruses, particularly respiratory syncytial virus (RSV), rhinovirus, nonpolio enteroviruses (coxsackievirus A and B), parainfluenza virus, influenza virus, adenoviruses, and human metapneumovirus

• Other agents involved in primary or secondary invasion include group A beta-hemolytic streptococci (GABHS), Bordetella pertussis, staphylococci, Haemophilus influenzae, Chlamydia trachomatis, Mycoplasma organisms, and pneumococc

when are infants at risk for infection? WHY?

• infection rate increases from 3 to 6 months old

• which is the period between the disappearance of maternal antibodies and the infant’s own antibody production

• The viral infection rate continues to remain high during the toddler and preschool years

• lowers around 5 years but the incidence of Mycoplasma pneumoniae and GABHS infections increases.

conditions that decrease resistance

malnutrition, anemia, and fatigue

Conditions that weaken defenses of the respiratory tract and predispose a child to infection

allergies (allergic rhinitis), BPD, asthma, history of RSV infection, cardiac anomalies that cause pulmonary congestion, and CF

Meningismus

• Meningeal signs without infection of the meninges

• Occurs with abrupt onset of fever

• Accompanied by

  • Headache

  • Pain and stiffness in the back and neck

  • Presence of Kernig and Brudzinski signsSubsides as the temperature drops

Fever

• May be absent in neonates (<28 days)Greatest at ages 6 months to 3 years

• Temperature may reach 103° to 105 °F (39.5° to 40.5°C) even with mild infections

• Often appears as first sign of infection

• May leave child listless and irritable or somewhat euphoric and more active than normal, temporarily;

• leads some children to talk with unaccustomed rapidity

• Tendency to develop high temperatures with infection in certain families

• May precipitate febrile seizures

Abdominal Pain

• Common complaint

• Sometimes indistinguishable from pain of appendicitis in older child

• May be caused by mesenteric lymphadenitis

• May represent referred pain (e.g., chest pain associated with pneumonia)

• May be related to muscle spasms from vomiting, especially in nervous, tense children

Respiratory Sounds

• Cough

• Hoarseness

• Grunting

• Stridor

• Wheezing

• Findings on auscultation:

  • Wheezing

  • Crackles

  • Absence of air movement

Sore Throat

• Frequent complaints of older children

• Young children (unable to describe symptoms) may not complain even when highly inflamed

• Increased drooling noted by parents

• Refusal by child to take oral fluids or solids

what is in the assessment of a child with a RTI?

• Respiratory effort (respiratory rate, rhythm and depth; accessory muscle use; retractions; nasal flaring)

• Oxygenation (pulse oximetry, skin color)

• Body temperature

• Child’s activity level

• Child’s level of comfort

how to treat or ease RTIs in children?

• Warm or cool mist is a common therapeutic measure for symptomatic relief of respiratory discomfort

  • mist tents

• steam vaporizers are discouraged

• time-honored method: producing steam in the shower for 10-15 mins

• promoting comfort:

  • Topical vapor rubs could be considered for children older than age 2 years

  • correct administration of nose drops or throat gargles

  • infant nasal aspirator or a rubber ear syringe is helpful in removing nasal secretions before feeding (Saline nose drops can be prepared at home by dissolving {1/2} to 1 tsp of salt in 1 cup of warm water)

satisfactory method of assessing output in nonhospitalized infants and toddlers who are not acutely ill

Counting the number of wet diapers in a 24-hour period

urinary output

should be approximately 0.5 to 1 mL/kg/hr in a child who weighs less than 30 kg (66 lb) and 30 mL/hr for children 30 kg and larger

what are Signs of clinical deterioration?

increasing respiratory distress, increasing respiratory rate, increasing heart rate, worsening hypoxia, poor perfusion, reduced level of consciousness, behavioral changes, and lethargy. Any deterioration is notified to the primary service.

what are causes of acute viral nasopharyngitis?

• rhinoviruses

• RSV

• adenovirus

• influenza virus

• parainfluenza virus

what are manifestations of acute viral nasopharyngitis?

• self-limiting

• lasting 10-14 days (peak on day 2-3 days

• Fever

• decreased appetite

• decreased fluid intake

• decreased activity

• nasal inflammation/open mouth breathing

• vomiting

• diarrhea

• older children

  • dryness and irritation of nasal passages and the pharynx

  • chilling sensations,

  • muscular aches, an

  • irritating nasal discharge

  • occasional coughing or sneezing

what is the therapeutic management of acute viral nasopharyngitis?

• managed at home

• antipyretics (tylenol)

• fluid and rest

• Products containing dextromethorphan or codeine may be prescribed for a dry, hacking cough, especially at night

true or false

A cold is often the parents’ first introduction to an illness in their infants

true

what is the Nursing management of acute viral nasopharyngitis?

• elevating the head of the bed or crib to assist with secretions

• suctioning

• vaporizing

• saline nose drops

• gentle suction with bulb syringe (before feeding)

• maintain fluid intake (popcicles, gelatin, broths, soups)

• avoid contact with affected persons

• handwashing and cough into elbow

• hand sanitizer use

what is the family support for acute viral nasopharyngitis?

• reassure because URIs are so frequent in children younger than 3 years of age

• families may feel they are on an endless roller coaster of illness

• Reassure them that frequent colds are a normal part of childhood, there are hundreds of viruses that cause them, and that by 5 years of age most children will have developed immunity to many viruses

what is Early Evidence of Respiratory Complications that Parents are instructed to notify the health professional if they note any?

• Evidence of earache

• Respirations faster than 50 to 60 beats/min

• Fever over 101 °F (38.3°C)

• Listlessness

• Increasing irritability with or without fever

• Persistent cough for 2 days or more

• Wheezing

• Crying

• Refusal to eat

• Restlessness and poor sleep patterns

what is Acute Streptococcal Pharyngitis and what can it cause?

• GABHS infection of the upper airway (strep throat) is not in itself a serious disease,

• affected children are at risk for serious sequelae: acute rheumatic fever, which is an inflammatory disease of the heart, joints, and CNS, and acute glomerulonephritis

• skin manifestations, including impetigo and pyoderma

scarlet fever

• may also occur because of a strain of group A streptococcus.

• The clinical manifestations of scarlet fever include pharyngitis and a characteristic erythematous sandpaper-like rash

• otherwise scarlet fever shares the same clinical manifestations as those mentioned for GABHS, and treatment and sequelae are the same.

• Severe case is rarely seen in the United State

what are clinical manifestations of Acute Streptococcal Pharyngitis?

• no symptoms

• abrupt

• characterized by pharyngotonsillitis

• headache

• fever

• abdominal pain

• The tonsils and pharynx may be inflamed and covered with exudate

• petechiae on palete

• strawberry tongue

• Anterior cervical lymphadenopathy

Anterior cervical lymphadenopathy

• resolves for 3-5 days

• mild-severe pain

• tender nodes

• difficulty swallowing

what is the therapeutic management of Acute Streptococcal Pharyngitis?

• oral penicillin or other related medications such as ampicillin or amoxicillin is prescribed for 10 days

• Intramuscular (IM) penicillin G benzathine

• oral macrolide (erythromycin, azithromycin, clarithromycin) or a cephalosporin (cephalexin) is indicated for children who are allergic to penicillin

nursing care of Acute Streptococcal Pharyngitis?

• obtain throat swab

• instructs the parents about administering the antibiotic and analgesics as prescribed

• Cold or warm compresses to the neck

• old enough to cooperate, warm saline gargles offer some relief of throat discomfort.

• Pain may interfere with oral intake, and the child should not be forced to eat

• encourage cool liquids or ice chips, which are usually more acceptable than solids

• Never administer penicillin G procaine or penicillin G benzathine suspensions intravenously; they may cause embolism or toxic reaction with ensuing death in minutes. Instead, administer these medications deep into the muscle tissue to decrease localized reactions and pain

how to prevent the spread of Acute Streptococcal Pharyngitis?

• Children with streptococcal infection are noninfectious to others 24 hours after initiation of antibiotic therapy.

• It is generally recommended that children not return to school or daycare until they have been taking antibiotics for a full 24-hour period.

• replace toothbrush

what is tonsillitis?

inflammation of the tonsils

Because of the abundant lymphoid tissue and the frequency of URIs

• sore throat

• temperature greater than 100.9 °F (38.3°C)

• cervical adenopathy (>2 cm or tender nodes)

• exudate on the tonsils

• positive culture for GABHS

what are clincal manifestations of tonsilitis?

• caused by inflammation

• self-limiting

• palatine tonsils enlarge from edema, they may meet in the midline (kissing tonsils), obstructing the passage of air or food

• difficulty swallowing or breathing

• mouth breathing is continuous, the mucous membranes of the oropharynx become dry and irritated

• odor/bad breath

• impaired smell/taste

• voice has a nasal and muffled quality

• persistent cough

• otitis media or difficulty hearing

what is the therapeutic management of tonsilitis?

• treatment of viral is symptomatic

• throat culture positive for GABHS infection requires antibiotic treatment

• tonsillectomy (removal of palatine tonsils) for massive hypertrophy

• adenoidectomy(removal of adenoids)

what is indicated for a tonsillectomy?

• more than one peritonsillar abscess

• PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome)

• airway obstruction

• chronic tonsillitis unresponsive to antimicrobials

• multiple antibiotic allergies

• tonsils requiring tissue pathologic study

consideration:

at least seven episodes of tonsillitis in the previous year, or at least five tonsillitis episodes in each of the previous 2 years, or at least three episodes of tonsillitis in each of the previous 3 years

why would a adenoidectomy be recommended?

treatment of chronic nasal or sinus infections, recurrent OM, nasal obstruction, and sleep disturbance or suspected sleep-disordered breathing.

what is the nursing care of tonsilitis?

• comfort and minimizing activities or

• interventions that precipitate bleeding postoperatively

• soft to liquid diet is generally

• Warm saltwater gargles, warm fluids, throat lozenges

• analgesic-antipyretic (acetaminophen and nonsteroidal antiinflammatory and ibuprofen) are useful to promote comfort

• Ice collar

• NPO until they can swallow it

• Straws should be avoided because they may damage the surgical site and cause subsequent bleeding.

most obvious early sign of bleeding after a tonsilectomy

• child’s continuous swallowing of the trickling blood

• While the child is sleeping, note the frequency of swallowing

• signs of hemorrhage are tachycardia, pallor, frequent clearing of the throat or swallowing by a younger child and vomiting of bright red blood. Restlessness, an indication of hemorrhage, may be difficult to differentiate from general discomfort after surgery. Decreasing blood pressure is a much later sign of shock

what is Infectious mononucleosis?

• self-limiting

• infectious disease that is common among young people under 25 years old

• Epstein-Barr virus is the principal cause

• transmitted through direct contact with oral secretions, blood transfusion, transplantation

• diagnosis: nonspecific heterophil antibody tests (Monospot or Paul-Bunnell) and spot test (Monospot)

what are clinical manifestations of Infectious mononucleosis?

• appears 10 days - 6 weeks after exposure

• malaise

• sore throat

• fever with generalized lymphadenopathy and splenomegaly

• exudative pharyngitis with or without petechiae

• an increase in atypical lymphocytosis

what is the therapeutic management for Infectious mononucleosis?

• symptom treatment

• rest for fatigue

• mild analgesic for headache, fever, malaise

• corticosteroids decreases airway obstruction

• Gargles, warm drinks, analgesic or anesthetic troches, or analgesics, including opioids, can relieve a sore throat

nursing care management of Infectious mononucleosis?

• comfort measures

• airway management

• pain meds

what is influenza?

• the flu

• A, B, C

• droplet spread: talking, sneezing, coughing

• 1- to 4-day incubation period (average of 2 days), and affected persons are most infectious for 24 hours before and 3 to 7 days after the onset of symptoms

what are clinical manifestations of the flu?

• dry cough and a tendency toward hoarseness

• A sudden onset of fever and chills is accompanied by flushed face

• photophobia

• myalgia

• sore throat

• headaches

• malaise

• hyperesthesia

• sometimes prostration

what is the therapeutic treatment and prevention of the flu?

• acetaminophen or ibuprofen for fever and sufficient fluids to maintain hydration.

• Children should not receive aspirin because of its possible link with Reye syndrome

• for patients at high risk of complication:

  • Oral oseltamivir (ages 2 weeks and older),

  • inhaled zanamivir (for ages 7 and older),

  • IV peramivir (for all ages)

  • oral baloxavir (for ages 5 and older)

• prevent: vaccine at 6 months and older annually

what is the nursing care management for the flu?

• same as URI

• educate parents on prevention and antiviral meds

what is Otitis Media(OM)? Acute otitis media (AOM)? otitic media with effusion?

• (OM): An inflammation of the middle ear without reference to etiology or pathogenesis

• (AOM): An inflammation of the middle ear space with a rapid onset of the signs and symptoms of acute infection—namely, fever and otalgia (ear pain) in 24 mo

• (OME): Fluid in the middle ear space without symptoms of acute infection

what is the most prevelent illnesses of ealry childhood?

Otitis media

what causes otitis media?

AOM is frequently caused by S. pneumoniae, H. influenzae, and Moraxella catarrhalis. The two viruses most likely to precipitate OM are RSV and influenza, although the adenoviruses, human metapneumoviruses, and picornaviruses (rhinovirus and enterovirus) also cause a significant number of URIs and OM

what children are at risk for Otitis media?

• Children living in households with many members are more likely to have OM than those living with fewer persons.

• Passive smoking increases the risk of persistent middle ear effusion by enhancing attachment of the pathogens that cause otitis to the respiratory epithelium in the middle ear space, prolonging the inflammatory response and impeding drainage through the eustachian tube

• eustachian tubes are short, wide, and straight and lie in a relatively horizontal plane

• The cartilage lining is undeveloped, making the tubes more distensible and therefore more likely to open inappropriately

• The normally abundant pharyngeal lymphoid tissue readily obstructs the eustachian tube openings in the nasopharynx.

• Immature humoral defense mechanisms increase the risk of infection.• The usual lying-down position of infants favors the pooling of fluid, such as formula or exudate, in the pharyngeal cavity

what are complications of ear infections?

• hearing loss

• tympatic membrane structural retractions

• Tympanosclerosis (eardrum scarring)

• Adhesive OM (glue ear)

• Cholesteatoma

what are clinical manifestations of ear infections?

• fluid accumulates

• pain from pressure

• Infants become irritable and can indicate their discomfort by holding or pulling at their ears and rolling their head from side to side

• fever of 104

• postauricular and cervical lymph glands may be enlarged

• Rhinorrhea

• vomiting

• diarrhea

• signs of concurrent respiratory tract or pharyngeal infection

• loss of appetite

• children with OME: exudate accumulates and pressure increases, with the potential for tympanic membrane rupture

• feeling of “fullness” in the ear, a popping sensation during swallowing, and a feeling of “motion” in the ear if air is present above the level of fluid.

• chronic serous OM is the most frequent cause of conductive hearing loss in young children, audiometry may reveal deficient hearing.

what is the therapeutic management of Acute Otitis Media (AOM)

• Delayed antibiotic prescriptions are recommended by the American Academy of Pediatrics for patients 6 months and older with mild to moderate unilateral OM. The caregiver is provided a prescription to only fill if symptoms do not improve in 2 to 3 day:

  • Children younger than 6 months of age

  • Children 6 months of age and older with ear drainage, fever higher than 39°F, ear pain for at least 48 hours, moderate/severe ear pain

  • Bilateral AOM in a child between 6 and 23 months of age

• When antibiotics are necessary, oral amoxicillin in high doses (80 to 90 mg/kg/day, divided twice daily) is recommended for 5 to 7 days with children 2 years and older, and 10 days with younger children

what is the therapeutic management of: recurrent otitis media?

tympanostomy tube placement

what is the therapeutic management of: otitis media with Effusion?

residual effusion include observation, antibiotics alone, or a combination of antibiotic and corticosteroid therapy.

how to prevent ear infections?

• Routine immunization with the pneumococcal vaccine

• breastfeeding infants for at least the first 6 months of life

• avoiding propping the formula bottle

• decreasing or discontinuing pacifier use after 6 months

• maintaining up to date vaccination

• preventing exposure to tobacco smoke

Acute Otitis Externa (AOE)

• Swimmers ear

• commonly caused by Pseudomonas aeruginosa, Staphylococcus epidermidis, or Staphylococcus aureus but may include other pathogens such as Aspergillus and Candida spp

• Inflammation occurs when this environment is altered by swimming, bathing, or increased environmental humidity; by infection, allergic contact dermatitis, dermatoses, or insufficient cerumen; or by trauma from a FB or device in the ear (e.g., hearing aids, earphones) or a by a finger. The ear canal becomes irritated, and maceration takes place.

• It is most common in 5 to 14 year olds

• peaks in summer

what is the Nursing care management of ear infections (AOM&OME)?

• relieve pain and fever (Ibuprofen, heat, position)

• If the ear is draining, the external canal may be cleaned with sterile cotton swabs coupled with topical antibiotic treatment

• Antibiotics if indicated

• Myringotomy with tubes

• Adenoidectomy

• Hearing screening

• Eliminate tobacco smoke

• Feed infants in upright position

• In an older child (usually older than 3 years of age), to keep the ear dry, pull the auricle up and out to straighten the canal

croup syndromes (what is it, causes, types)

definition

• symptom complex of acute respiratory manifestations: a barking cough, hoarseness, inspiratory stridor, and respiratory distress from edema in the laryngeal area

causes:

• H. influenzae type B, most cases of croup in the United States are attributed to viruses: parainfluenza viruses, and to a lesser degree, influenza types A and B, adenovirus, RSV, and measles, and M. pneumoniae

• more common in boys than girls

• 6 months-3 years old and rare after 6 years

types: LTB and Epiglottitis

why are acute infections of the larnyx of greater importance in infants and smaller children than older children?

increased incidence in children in this age-group and the smaller diameter of the airway which renders it subject to significantly greater narrowing with the same degree of inflammation

treatment of croup

• Airway protection, possible intubation, tracheotomy

• Humidified oxygen

• Fluids

• Antibiotics

• Reassurance

• Corticosteroids

• Fluids

• Nebulized epinephrine (possible short-term improvement)

• Heliox: moderate-to-severe croup

• Cool mist

key differences between LTB and epiglottitis

absence of cough, the presence of dysphagia, and the high degree of toxicity in children with epiglottitis.

Children with epiglottitis usually look worse than they sound, in contrast to children with LTB, who sound worse than they look

acute epiglottitis

• medical emergency

• serious obstructive inflammatory process between 2-5 years

  cause:

• H. influenzae type b.

• noninfectious: ingestion of caustic agents, smoke inhalation, smoking drugs (e.g., crack cocaine), or by FBs

• LTB and epiglottitis do not occur together.

• Males are affected more than females.

• A lack of adequate vaccination against H. influenzae type b increases the risk

what are clinical manifestations of acute epiglottitis

• onset abrupt,

• less old symptoms; more sore throat

• rapidly progress to severe respiratory distress

• goes to bed asymptomatic to awaken later complaining of sore throat and pain on swallowing

• fever

• appears sicker than clinical findings

• The child insists on sitting upright and leaning forward (tripod position), with the chin thrust out, mouth open, and tongue protruding.

• Drooling of saliva is common because of the difficulty or pain on swallowing and excessive secretions

• Suprasternal and substernal retractions

• throat is red and inflamed, and a distinctive, large, cherry red, edematous epiglottis

absence of spontaneous cough, presence of drooling, and agitation

slides from class: High fever; muffled voice, sore throat, difficulty
swallowing; excessive drooling refusal of food & fluids, sitting-up
with neck extended (sniffing position); breathing thru mouth

how can epiglottistis be prevented?

H. influenzae type B conjugate vaccine beginning at 2 months old

Laryngotracheobronchitis (LTB)

• most common croup

• 6 mo - 3years

• causes: parainfluenza virus types 1, followed by parainfluenza virus types 2 and 3, adenoviruses, RSV, and M. pneumoniae. Less common causative organisms include influenza A and B, rhinoviruses, human coronaviruses, measles, metapneumoviruses, enteroviruses, herpes simplex virus, S. aureus, Streptococcus pyogenes, and S. pneumoniae

• manifestations: inspiratory stridor; tachypnea; tachycardia; restlessness; cyanosis; substernal or intercostal retractions; barky cough; low-grade fever; previous URI; Respiratory acidosis,

what are Early signs of impending airway obstruction?

include increased pulse and respiratory rate; substernal, suprasternal, and intercostal retractions; nasal flaring; and increased restlessness.

bronchitis

• Lower airway infection of first 4 years

• inflammation of the trachea and bronchi; usually associated with a URI

causes:

• viral: influenza A and B, parainfluenza, coronavirus (types 1 to 3), rhinovirus, RSV, and human metapneumovirus.

• The bacteria: pertussis, M. pneumoniae, and Chlamydia pneumoniae

• Persistent dry, hacking cough (worse at night), becoming productive in 2-3 days

treat:

• analgesics, antipyretics, and humidity

Brinchiolotis

caused by RSV

spring and winter

Respiratory Syncytial Virus (RSV)

• spread through direct contact

• secretions can survive for several hours on countertops, gloves, paper tissues, and cloth, and for 30 minutes on skin; it remains infectious when transferred from hands or objects

• manifestations:

  • initial: Rhinorrhea, Pharyngitis, Coughing, sneezing, Wheezing, Possible ear or eye infection

  • Intermittent: fever With Progression of Illness, Increased coughing and wheezing, Fever, Tachypnea and retractions, Refusal to nurse or bottle feed, Copious secretions

  • Severe Illness: Tachypnea >70 breaths/min, Listlessness, Apneic spells, Poor air exchange; poor breath sounds, Cyanosis

• peaks 3 - 5days

• management:

  • Immunize with Palivizumabid (synagis) for high risk infants q 30 days ( November to March)

  • symptomatically with oxygen, fluids, rest

most frequent cause of hospitalization in children younger than 2 years old

RSV infection