Peds Respiratory DO

• Smaller nares and oral cavity

• LARGER TONGUE and TONSILS

• NEONATES are OBLIGATORY NOSE BREATHER, have an irregular breathing pattern, and the DIAPHRAGM is the major muscle of breathing

• LONG FLOPPY epiglottis

• Flexible larynx, higher in the neck

• Small trachea with BIFURCATION higher in adults and tracheal cartilage is immature

• Narrow bronchi and bronchioles (less air)

• Fever alveoli (gas exchange)

• Chest wall more pliable, “COMPLIANT” (muscles a little weaker)

• Children have GREATER METABOLIC RATE and O2 CONSUMPTION to adults (increased risk of hypoxemia due to O2 use)

What are the differences in the a child’s upper airway?

Risk for aspiration and spasm

What is the risk for a flexible larynx, higher in the neck?

Shorter and more horizontal, fluids goes from nasopharynx to ears easier in young children (from URI)

What does the eustchian tube look like in a child?

Airway collapses easily when neck is flexed (place something underneath shoulders)

What is the risk for a small trachea with bifurcation (split right and left) higher than in adults and immature tracheal cartilage?

• Does not support keeping the lungs well expanded

• Lung volume is dependent on the DIAPHRAGM in infants; intercostal muscles are not fully developed until school age

  • see “RETRACTIONS” more readily in infants and young children

What does it mean if the chest wall being more pliable or compliant in children?

1mm edema only reduces the diameter and radius of an adult bronchus by 20% but 1mm edema reduces the diameter and radius of an infant bronchus by 50%

How does lower airway edema affect young children vs. adults?

• PMH: prematurity, respiratory problems at birth, atopy, frequent colds/respiratory illness

• FAMILY HX: asthma, CF, atopy (genetic predisposition to allergies)

• HPI: onset and progression, fever, congestion, cough, tachypnea, increased WOB

  • Allergies

  • Medications/tx at home

  • Pets/second-hand smoke

• AGE of child

What is the respiratory assessment in children?

Airway

• Cough, congestion, nasal drainage

• Stridor? ability to vocalize?

• Excessive drooling, difficult swallowing

Breathing

• Increased WOB/ tripod position

• Nasal flaring, grunting, head bobbing

• RETRACTIONS; locations and severity (always look at the chest)

Circulation

• Color of skin and lips; central cyanosis

• Weak/thready pulses, delayed cap refill, cap extremities

Disability of neurologic status

• Awake, alert, responsive to sound and verbal command (LOC)

Euthermic

• Do they have fever?

Fluid status

• Assess for dehydration

  • Mucus membranes, fontanels, tears, diapers

  • Signs of poor perfusion

What are the ABCDEF of respiratory assessment?

• Evaluate anterior, posterior, and axillary areas

  • Equal bilaterally, longer inspiratory phase

  • Listen for full inspiration and expiration before moving stethoscope

• Listen for abnormal findings

What is the auscultation of lungs in children?

• PROLONG EXPIRATION → LOWER airway OBSTRUCTION

• REFERRED UPPER airway congestion (same sounds heard over mouth and in lungs)

• WHEEZING; ASTHMA (DOES NOT CLEAR WITH COUGH), CF or CHRONIC lung disease

• CRACKLES/RALES; FLUID in lungs; PNEUMONIA

What are the abnormal findings for ausculation of lungs and what do they mean?

• Blood gases

• PFTs

• Pulse Ox

• CXR

• Bronchoscopy

• Laryngoscopy

• Sweat test (CF)

• Cultures

• Allergy testing (IgE)

What are the LABS/DX for respiratory in children?

• Sinusitis

• Ear infections

  • Acute otitis media (AOM)

  • Otitis media w/ effusion (OME)

• Sore throats

  • Pharyngitis

  • Tonsilitis

• Laryngomalacia

• Laryngotracheobronchitis (Croup)

• Epiglottis

What are the acute upper respiratory infections?

Sinusitis

Bacterial infection of the paranasal sinuses

• Can be acute and chronic

• Similar to COLD except:

  • BAD BREATH

  • FACIAL PAIN

  • EYELID EDEMA

• Sx >10 DAYS

• Nasal CONGESTION continues

What are the SX of sinusitis?

• 14 DAY course AB

• NS wash or spray

What is the TX for sinusitis?

VIRAL OR BACTERIAL (can’t culture ear)

1. URI WITH congestion

2. Fluid and pathogens from nasopharynx

3. Middle ear

What is the PATHO for AOM?

• Ear pain; TUGGING on ear is a classic sign at all ages

• Fever, poor feeding, fussiness, night awakening

• Tympanic PERFORATION (due to a lot of fluid) → drainage, decreased pain

• RED, INFLAMED, BULGING of tympanic membrane

• MILD AND SEVERE

What are the SX for AOM?

OTOSCOPIC EXAMINATION

• C/o of ear pain or intense erythema of the tympanic membrane

• Signs of fluid in the middle ear with moderate to severe bulging of the tympanic membrane

What is the DX for AOM?

• Mild: Mild pain and T <102.2 for <48 HOURS

• Severe: T >102.2 OR severe pain for > 48 HOURS

What is a mild and severe sign of illness in AOM?

• AB

• Analgesics/antipyretics

• Comfort measures

  • NUMBING ear drops

  • HEAT pad or ICE pack to affected ear

• If BILATERAL, generally will require AB

What is the management of AOM?

• FLUID is present WITHOUT signs of infection or pain

• May take SEVERAL MONTHS to resolve

• Primary concern is the effect on HEARING and LANGUAGE development

What is OME?

Pressure-equalizing tubes (PE tubes)

What is the management of OME in severe cases?

Small tubes that allow for fluid behind the ear to drain, allowing for tympanic membrane movement and adequate hearing

• Outpatient surgery

• AB EAR DROPS might be prescribed (couple days, treats lingering infection)

What are PE tubes?

PE tubes stay in for several months, fall out on their own

How long do PE tubes stay in the ear?

EARPLUGS when SWIMMING; FLUID may drain from ear with FUTURE infections

What is the EDUCATION for PE tubes?

Bacterial and viral

What are the two causes of pharyngitis/tonsillitis AKA sore throats?

Group A beta hemolytic streptococcus (GABHS)

What is 20-30% of bacterial pharyngitis/tonsillitis caused by?

• Sore throat W/O nasal congestion

• TONSILLAR EXUDATE; NOT DX for bacterial infection but good indicator

• WHITE or GRAY FURRY tongue

• Includes streptococcal pharyngitis or “Strep Throat”

What are the SX BACTERIAL pharyngitis/tonsillitis?

Supportive care and AB

• Typically PENICILLIN (take full amount)

What is the TX for BACTERIAL pharyngitis/tonsillitis?

Sore throat WITH nasal congestion

What is the SX for VIRAL pharyngitis/tonsillitis?

• SUPPORTIVE care ONLY

  • SALINE GARGLES

  • PAIN relief

  • HARD CANDY

  • Cool MIST humidity

  • Cool LIQUID/POPSICLES

What is the TX for pharyngitis/tonsillitis?

RAPID TEST and/or THROAT CULTURE required (definitive dx for viral or bacterial)

What is the DX for strep throat?

• Fever, headache, N/V, ab pain

• SORE throat (sudden onset)

• TENDER, ENLARGED LYMPH nodes

• RED, SWOLLEN THROAT and TONSILS

• EXUDATES, WHITE or YELLOW (patches) on TONSILS

• PAIN with SWALLOWING (odynophagia)

• NO COUGH, RUNNY NOSE (rhinorrhea), HOARSENESS, CONJUNCTIVITIS,

F STREP

What are the SX strep throat?

• Child not contagious after 24 HOURS on AB

• New toothbrush after on AB for 24 HOURS to prevent reinfection

What is the EDUCATION for strep throat?

• Rheumatic fever (heart)

  • JONES criteria

  • Valvular damage

• Post-streptococcal glomerulonephritis (kidney) (APSGN)

  • Gross hematuria with proteinuria

  • Facial and peripheral swelling

  • Decreased UOP w/ dark brown urine

What are the COMPLICATIONS of streptococcal pharyngitis (strep throat)?

Tonsillectomy

What is the TX for tonsillitis?

Check labs and fam hx for BLEEDING DO

What is the PRE OP for tonsillitis?

• SIDE-LYING/HOB up immediately after surgery (look for swelling)

• Assess for EXCESS SWALLOWING (bleeding)

• Blood-tinged mucous EXPECTED

• FRANK BLOOD = bleeding from surgical site, not expected; may hemorrhage up to 10 DAYS after surgery (MEDICAL EMERGENCY)

• No RED drinks, red foods, SPICY foods, no STRAW (sutures)

• Avoid COUGHING or BLOWING nose

• PAIN management, maintain FLUID VOLUME (drink right away)

What is the POST OP for tonsillitis?

Laryngotrachealmalacia

Congenital FLACCIDITY of the epiglottis and weakness of the airway walls

INSPIRATORY STRIDOR IN NEONATES

What does laryngotrachealmalacia most COMMONLY CAUSE?

• NOISY, CROWING (STRIDOR) INSPIRATORY sounds with or w/o RETRACTIONS (common in neonates)

• SX INCREASE when SUPINE or CRYING (hyperextension helps)

• May have FEEDING issues

What are the SX of laryngotrachealmalacia?

• Hx

• Direct langyngoscopy

What is the DX laryngotrachealmalacia?

• HYPEREXTENSION of NECK improves STRIDOR

• Sx typically resolve by 18-24 MONTHS (usually grow out of it)

• Educate families on signs of RESPIRATORY DISTRESS, address FEEDING issues

What is the EDUCATION for laryngotrachealmalacia?

VIRAL infection of the LARYNX, TRACHEA, and BRONCHI

What is laryngotracheobronchitis or “CROUP”?

3-5 DAYS and WORSE AT NIGHT

How long do SX last in croup?

3 MONTHS-3 YEARS (Younger kids)

What age does croup affect?

• Barky or seal-like cough

• Noisy breathing

• Hoarse voice

Noisy zoo

What are the SX for croup?

• CORTICOSTEROIDS; DEXAMETHASONE

  • Reduces INFLAMMATION

  • Single dose as a shot or oral syrup

• RACEMIC epinephrine via nebulizer

  • Reduces EDEMA (for serious cases)

• Home remedies

  • COOL (open FREEZER door)

  • HUMIDIFIED (HOT SHOWER)

  • Air helps treat sx

What is the TX for croup?

Epiglottitis

Inflammation of the epiglottis leads to upper airway obstruction

• MEDICAL EMERGENCY (QUICK ONSET WITHIN 24 HOURS)

• Most commonly caused by Haemophilus Influenza Type B (bacterial)

Haemophilus Influenza Type B (HIB vaccine)

What is epiglottis most commonly caused by?

Lateral neck x-ray

What is the DX for epiglottis?

• Quick onset within 24 HOURS; HIGH FEVER

• EDEMA of the epiglottis

• TRIPOD position (chin thrust out, mouth open)

• DROOLING

What are the SX epiglottis?

• Keep child CALM and comfortable

• Support TRIPOD positioning (not flat)

• Keep NPO

• IV fluids (dehydration)

• Humidified O2

• DO NOT INSERT ANYTHING INTO MOUTH

• HAVE INTUBATION TRAY AND TRACH EQUIPMENT AT BEDSIDE

• Meds

  • ANTIBIOTICS

  • Antipyretics

  • Corticosteroids (inflammation)

  • PREVENT WITH HIB VACCINE

What is the nursing INTERVENTIONS for epiglottis?

• No throat cultures

• No tongue blades

• No oral temperatures

What is not to be inserted into the mouth for epiglottis?

• Bronchiolitis/RSV bronchiolitis

• Foreign body aspiration

• Apnea

What are the acute lower respiratory DO?

• URI from RSV (virus)

• LOWER TRACHEA and BRONCHIOLES become INFLAMMED/NECROTIC with MUCUS buildup → ALVEOLAR COLLAPSE, HYPERINFLATION, and POOR GAS EXCHANGE

What is the PATHO for RSV bronchiolitis?

Infant or younger children

Which age group does RSV bronchiolitis have a severe effect on?

Upper

• Clear runny nose

• Pharyngitis

• Low grade fever

Breathing

• Cough and wheezing

• Tachypnea

• Retractions

• Increased WOB

What are the SX RSV bronchiolitis?

• Enzyme-linked immunosorbent assay (ELISA) test from nasal pharyngeal washings

• CXR; areas of hyperinflation and atelectasis

• BLOOD GAS

What is the DX for RSV bronchiolitis?

• Supportive care

  • HUMIDIFIED O2 to maintain adequate secretions

  • UPRIGHT positioning

  • HYDRATE

  • Frequent NASAL SUCTIONING

• Severe cases are typically seen in young infants

  • RIBAVIRIN (antiviral) given by AEROSOL

  • BRONCHODILATORS (ALBUTEROL/RACEMIC EPI)

What is the TX for RSV bronchiolitis?

• Handwashing

• RSV vaccine (nirsevimab) for high risk infants

What is the PREVENTION for RSV bronchiolitis?

Foreign body aspiration

Solid or liquid inhaled into respiratory tract

• Common in children 6 months to 3 years of age

• Sometimes can cough it out, but if in lower airway, will need surgical intervention

• SUDDEN onset of COUGH, WHEEZING, STRIDOR

• Lung sounds

  • Decreased breath sounds UNILATERALLY (left side)

  • DECREASED O2 SAT

• X-ray: HYPERINFLATION from air trapping r/t foreign body aspiration

What are the SX of foreign body aspiration?

• Keep small toys, coins, other objects out of reach starting before 6 months

• Popcorn, nuts, grapes, hotdogs and other small foods should be avoided

What is the PREVENTION/ANTICIPATORY GUIDANCE on foreign body aspiration?

Apnea

Absence of breathing for longer than 20 SECONDS

• Prematurity and BRUE

• Prematurity; immature respiratory system

• BRUE (brief resolved unexplained event)

What are the two causes of apnea?

• Stimulation/meds

• Bag-valve-mask ventilation

• NTE

• Prescribed meds

What is the TX for premature apnea?

• Gagging/coughing

• Color changes

• Bradycardia

What are the SX BRUE?

Directed toward CAUSE

• Respiratory illness

• GERD

• Seizures

• Metabolic DO

What is the TX for BRUE?

• Apnea monitor; look at baby first

• Parent CPR

What is the TX for apnea?

• Allergic rhinitis

• Asthma

• Cystic fibrosis

What are the chronic respiratory DO?

• Atopic dermatitis

• Asthma

• AOM

• Recurrent sinusitis

AAAR

What are the RISK FACTORS of allergic rhinitis?

IgE mediated response to allergen

1. ALLERGEN binds to IgE on surface of MAST CELL

2. HISTAMINE and LEUKOTRIENES released

3. SWELLING, MUCOUS production

What is the PATHO for allergic rhinitis?

• Rhinorrhea (runny nose)

• “Allergic shiners” (dark circles under eyes)/”Allergic salute” (habitual gesture of repeated wiping/rubbing nose upward with palm)

• Swollen, blue/grey turbinates (body structures inside nose), clear nasal drainage

• Itching/sneezing

RASI

What are the SX allergic rhinitis?

• NASAL SALINE washes

• CORTICOSTEROID nasal SPRAY

• Oral ANTIHISTAMINES (first line of defense, nondrowsy)

• Oral LEUKOTRIENE modifiers

NCAL

What is the TX for allergic rhinits?

Control exposure to allergens

What is the PREVENTION of allergic rhinitis?

Asthma

What is the most common chronic childhood illness?

Chronic inflammatory DO

• Structural changes, “remodeling” from each exacerbation can cause permanent damage

• Acute and chronic (caused by trigger)

How can asthma get worse over time?

• One or both PARENTS have asthma

• SX of ALLERGIES, including reactions to POLLEN or other AIRBORNE allergens for FOODS

• Area of HIGH POLLUTION

• Exposure to TOBACCO SMOKE

What are the RISK FACTORS of asthma?

• Health hx

  • Cough, particularly at night

  • Chest tightness with play

  • Frequent respiratory infections/HX OF BRONCHIOLITIS

• Inspection

  • Color

  • WOB

  • LOC

• Auscultation

  • WHEEZING (EXPIRATORY)

  • Diminished breath sounds (ominous sign)

What is the ASSESSMENT of asthma?

1. Trigger

2. Inflammatory mediators released

3. INFLAMMATION

4. BRONCHOCONSTRICTION

What is the PATHO for asthma?

Active signs of attack: “EXCITED”

• EXPIRATORY WHEEZING

• Chest tightness/ Coughing

• Increased WOB

• Tachypnea

• Exhale difficulty

• Dyspnea (especially exhaling)

NEEDS MEDICAL TX FAST: “CRC”

• CAN’T SPEAK

• CYANOSIS

• RESCUE INHALER NOT WORKING

What are the SX of asthma attack?

• VS/ respiratory ASSESSMENT

• HIGH FOWLER’S position

• O2 to maintain SATS 95-100%

• Frequent respiratory tx/ work with RT

  • SHORT ACTING BRONCHODILATORS (SABA)

  • ORAL CORTICOSTEROIDS or IV corticosteroids if severe (reduce inflammation)

What is the TX for acute asthma?

• BETA AGONIST

  • AlbuteROL, levalbuteROL (Xopenex); given by MDI or NEBULIZER → RELAX airway SMOOTH MUSCLE

“ALarm”

What are the SABA for acute asthma?

• Shakiness

• Tachycardia

• Palpitations

• Vomiting

• Headache

What are the side effects of SABA?

• Prevention; take as directed, even if ASYMPTOMATIC; NOT FOR ACUTE ATTACKS

  • LONG-ACTING BRONCHODILATORS (LABA) → for prevention of bronchospasm + inhaled steroid

  • INHALED CORTICOSTEROIDS (USE AFTER BRONCHODILATORS)

• ADJUNCTS to therapy with LABAs and Corticosteroids (not for acute)

  • LEUKOTRIENE RECEPTOR ANTAGONIST

  • MAST CELL STABILIZERS

What is the TX for chronic asthma?

• FormoteROL, salmeteROL; use NEBULIZER → MAINTENANCE tx of bronchoconstriction

  • PREVENT INFLAMMATION and RELAX AIRWAY

“For Smooth LONG breathing”

What are the LABA for chronic asthma?

Give WITH STEROIDS to decreased risk of asthma-related death

What should LABA be given with?

Use AFTER bronchodilators

• FluticaSONE, beclomethaSONE; BUDESONIDE INHALER

• REDUCE frequency/severity of EXACERBATIONS by decreasing inflammation

What are the inhaled corticosteroids for chronic asthma?

Risk for ORAL THRUSH infection

• Use SPACER (not in mouth, goes to back of throat), GARGLE and RINSE mouth afterwards

• MDI or NEBULIZER; clean after use

What is the adverse effect for inhaled corticosteroids and prevention?

• MONTELUKAST (oral); GUMMIES, CHEWABLE tablets, GRANULES

• DECREASE INFLAMMATION caused by leukotrienes, RELAX SMOOTH MUSCLE

What are the leukotriene receptor antagonists for chronic asthma?

CROMolyn, nedoCROMil (oral or intranasal) → PREVENT RELEASE of HISTAMINE from sensitized MAST CELLS to DECREASE allergic reactions

What are the mast cell stabilizers for chronic asthma?

• PFT

• Peak expiratory flow rate (PEFR)

What is the testing and monitoring for asthma?

• Help determine severity

• LOWER = asthma attack might be happening

• Most effective if at least 5 YEARS OLD

What is PFT for asthma?

• Objective measurement of lung function

  • SPEED at which air moves out of lungs at the beginning of EXPIRATION

• Can provide EARLY ID of subtle sx changes; SIGNALS WHEN AN EXACERBATION IS IMMINENT (lower score)

• Early tx can help DECREASE RISK of permanent lung changes (REMODELLING)

What is PEFR for asthma?

• Intermittent

• Mild persistent

• Moderate persistant

• Severe persistant

What are the levels of asthma severity?

• Sx under 2x/week

• Nocturnal sx under 2x/month

• Pulmonary function >80% normal

• Rare activity restrictions

What is intermittent asthma severity?

• Sx more than 2x/week but not daily

• Nocturnal sx more than 2x/month

• Pulmonary function >80% normal

• May affect activity

What is mild persistant asthma severity?

• Sx and bronchodilator use daily

• Nocturnal sx more than 1x/week

• Pulmonary function 60-80% normal

• Some activity limitations

What is moderate persistant asthma severity?

• Sx continuous throughout the day

• Frequently nocturnal sx

• Pulmonary function <60% normal

• Severely limited activities

What is severe persistant asthma severity?