Pediatric Respiratory ACUTE PDF

Anatomic Differences  Size of infant’s trachea and lower airway- trachea/lower airway is half the size of an adults  Infants are nose breathers (nose, trachea and pharynx and more susceptible to obstruction)  Limited alveolar surface for gas exchange  Newborns: Poor chest expans...

Anatomic Differences  Size of infant’s trachea and lower airway- trachea/lower airway is half the size of an adults  Infants are nose breathers (nose, trachea and pharynx and more susceptible to obstruction)  Limited alveolar surface for gas exchange  Newborns: Poor chest expansion and decreased lung volume with expiration  Immature immune system increases susceptibility to respiratory infection (lack surfactant)  Greater metabolic and oxygen demands Bifurcation in infant is much larger and trachea is much smaller  Respiratory Assessment of the Infant and Child  Normal Respiratory Rates: Infant 30-35/min. Toddler/Preschooler 20-30/min. School-ager 18-20/min. Adolescent 16-20/min.  Assess rate, depth and rhythm on CHEST  Think…..Is the child TACHYPNEIC (breathing too fast)? Respiratory infection: 40- 100/min. Can go into respiratory arrest after a while  Note the ease of respirations  Think……Is the child DYSPNEIC (difficulty breathing)?  Retractions  RETRACTIONS are inward movement of soft tissues of the chest wall during inspiration. They are associated with increase respiratory effort! The child is using accessory muscles and it is a sign of impending RESPIRATORY FAILURE !  Respiratory infection: Will have dyspnea and retractions  Intercostal retractions surround the ribs  Substernal retractions are at the sides of the sternum  Severe respiratory distress: Suprasternal retractions are near the trachea  Caring for the child with a respiratory infection  Watch for elevation of temperature (can spike at night).  Discharge from nose  Look…………… is it clear, yellow, green in color? Clear with allergy/no infection, yellow (bacterial/viral)  Presence of cough  Listen………….. Is it moist, dry, productive or non productive? (infants cannot blow nose or cough out mucus, will swallow secretions)  Pain: location (chest, use of muscles from coughing? Anterior or posterior?)  Sputum  What color is it? IS the child swallowing frequently? Remove any mucus if attempting to eat or eat from bottle  Audible breath sounds  Wheezes upon inspiration (croup) or expiration (asthma)? Stridor (croup)?  Note odor of breath (tonsillitis)  Early Manifestations of Respiratory Complications  Dysphagia  Use of accessory muscles  Listlessness (no energy)  Persistent cough  Earache  Headache  Fever >101.5F Common Laboratory Tests for Respiratory Disorders  Chest X-ray- rule out infections like pneumonia  Fluorescent antibody testing  Gastric Washings for AFB  Pulmonary Function Tests  Peak expiratory flow rate  Rapid flu and rapid strep  Sweat chloride test- cystic fibrosis  Acute Infectious Disorders  Common Cold or “Acute Nasopharyngitis”  Acute Pharyngitis or “strep throat”  Tonsillitis  Otitis Media  Acute Laryngitis  Croup Syndromes  Acute Epiglottitis  Bronchiolitis and RSV  Pneumonia  Bronchitis  Common Pediatric Respiratory Disorders  Nasopharyngitis : “Common cold” p. 510 Causative agent- viruses such as rhinovirus, adenovirus, influenza virus, RSV, parainfluenza virus Recently, the human meta-pneumovirus identified Bacterial agent- streptococcus (children are susceptible to) Clinical Manifestations: Nasal stuffiness, sneezing, nasal discharge coughing, sore throat, low grade fever, irritability (stop eating), malaise, poor feeding, vomiting, diarrhea Nasopharyngitis- most common is rhinovirus  Diagnosis Usually afebrile with normal WBC count, RADT if sore throat is main symptom rather than rhinitis. A throat culture is not recommended if there are nasal symptoms with a sore throat.  Treatment Antipyretics and non-aspirin analgesics Saline nose drops/bulb syringe suctioning before feeds to clear nares Encourage fluids and treat symptomatically to prevent dehydration Cough suppressants and decongestant nose drops, cool mist humidifier for older child for older children…not infants! Typically lasts 1-10 days, if > 10-14 days, consider other diagnosis (rhinosinisitus)  Patient education Assess how well child has been eating & drinking, record how much Note amt and color of nasal secretions Assess for presence of respiratory distress Teach good handwashing  Acute Pharyngitis  Often referred to as a “sore throat”  Occurs as Group A strep 15-30%  Assess for exudate, white patches, secretions, palpable cervical nodes, scarlatiniform rash with redness (small macular rash aka strep rash)  Viral: Hoarseness, cough, coryza, conjunctivitis, diarrhea  Nursing care includes education on gargles, and completing antibiotic therapy (Penicillin 250 mg, Cephalexin 20 mg/kg/dose BID if allergic to PCN)  Hydrate and relieve pain.  STREP RASH  Tonsillitis  Tonsils are lymphoid tissues located in the oropharynx that protect from invading organisms  Inflammation, infection of the palatine tonsils; may cause peritonsillar abscess that needs to be drained (swollen, enlarged, purulent matter)  Causative agent: Group A beta-hemolytic streptococci (GABHS). Get RADT  If untreated: may lead to otitis media, scarlet fever, suppurative (pus forming) infection of tissues  Major complications of GABHS: glomerulonephritis (kidneys), meningitis (brain), rheumatic fever (heart)  Clinical Manifestations of Tonsillitis  Sore throat and difficulty swallowing  Fever  Nasal congestion  Pain and Headache  Nausea & Vomiting  Diarrhea  Enlarged tonsils and adenoids  Kissing tonsils 3+ or 4+  Halotosis  Purulent drainage Prescence of purulent matter on lymphoid tissue and posterior pharynx  Diagnosis of Tonsillitis  If viral: use warm saline gargles, analgesics, and antipyretics  If bacterial: antibiotics, tonsillectomy, may need adenoidectomy  Diagnosis:  Use an otoscope to examine the child's throat, ears and nose which also may be sites of infection  Check for a rash known as scarlatina, which is associated with some cases of strep throat  Palpate the child's neck to check for enlarged lymph nodes  Auscultate breath sounds bilaterally  Check for enlargement of the spleen (for consideration of mononucleosis)  Labs & Diagnostics:  CBC, Throat culture  Differential Diagnosis  Acute tonsillitis *  Infectious Mononucleosis  Epiglottitis  Peritonsillar Abscess  Retropharyngeal Abscess  Diphtheria  HIV Infection  Treatment Antibiotic therapy  Treatment options for patients with Group A beta-hemolytic streptococcus infections confirmed on antigen testing and/or throat culture (RADT)  Primary Options:  Penicillin V potassium  Children 27 kg and adults: 500 mg orally 2-3 times daily for 10 days  Penicillin G benzathine: 600,000 units IM  Amoxicillin/clavulanate  Amoxicillin 50 mg/kg daily  Secondary Options:  Azithromycin 12 mg/kg/day on day 1 then 6 mg/kg daily for 4 days  Clarithromycin 7.5 mg/kg/dose BID 10 days  Erythromycin  Epocrates, 2021  Treatment  Surgery- usually out patient  Used to treat frequently recurring tonsillitis, chronic tonsillitis or bacterial tonsillitis that doesn't respond to antibiotic treatment.  Frequent tonsillitis is generally defined as:  At least seven episodes in the preceding year  At least five episodes a year in the past two years  At least three episodes a year in the past three years  A tonsillectomy may also be performed if tonsillitis results in difficult-to- manage complications, such as:  Obstructive sleep apnea (most common)  Breathing difficulty  Swallowing difficulty, especially meats and other chunky foods  An abscess that doesn't improve with antibiotic treatment  Patient Education  Post-op  Assess for frequent swallowing (an early manifestation of bleeding from the operative site)!  Monitor for bleeding and infection from nose/throat  Remind child not to cough or blow nose (cause surgical area trauma)  Crushed ice and sips of water are offered first to control bleeding and decrease facial edema  Cool liquids; non-carbonated, non-acidic  No red popsicles, red jello, red fluids (differentiate between bleeding and red dye). Green tylenol recommended  Cool humidification  Pain management: Acetaminophen for mild pain; Ice collar  Otitis Media  An inflammation of the middle ear  Can be acute, chronic, infectious or noninfectious  Can occur with or without effusion (fluid builds up, can be clear and trapped within TM or purulent and pus like)  Peak Incidence: 6-12 months in winter months  Eustachian tubes are wider, shorter and straighter for children 3 months of age: 80-100 mg/kg/day orally given in divided doses every 12 hours for 10 days  Secondary options if allergy to PCN:  Cefdinir: children > 6 months of age 14 mg/kg/day for 10 days  Cefuroxime axetil: children 30 mg/kg/day orally given in divided doses every 12 hours for 10 days Surgical Procedures- myringotomy with tympanostomy tube insertion (facilitate drainage and ventilation of the middle ear)  Patient Education  Teach Parent/Guardian:  Administration of full course of antibiotic therapy for full 10 days  How to monitor for fever and signs of OM  Secondary smoke causes recurrent OM  The benefits of breastfeeding (no bottles in bed so drainage can be facilitated)  Temporary or permanent hearing loss may occur  Croup (Laryngotracheobronchitis) p. 515  Viral infection of the larynx, trachea and large bronchi  Swelling of the mucosa, secretions, muscle spasms in the upper airway.  Incidence  Children 3mo-3years of age  Etiologic agents: parainfluenza and influenza agents, RSV, adenovirus  Occurs in winter months  Rare cases require hospitalization (if severe)  Clinical Manifestations  Hoarseness caused by edema of the larynx  Barking cough caused by inflammation in larynx (sounds like a seal)  Inspiratory stridor caused by narrowing of glottic area  Suprasternal retractions  Anxiety and air hunger  Nasal drainage  Sore throat and rhinorrhea  Low-grade fever  Tachycardia and tachypnea  Wheezing  Fatigue  Pallor or cyanosis  Lateral neck x-ray may reveal narrowing from inflammation  Diagnosis and Treatment  Diagnosis: CXR, neck x-ray, WBC with differential  Treatment  Nebulized Racemic Epinephrine (Vasonephrine)  One dose corticosteroids (dexamethasone)  Fluids, Rest, Cool mist (NO steamy shower!)  Patient Care Ensure patent airway by:  Humidity and supplemental oxygen  Upright position to promote ventilation  Emergency intubation equipment at bedside  Administration of medication  Inform parents symptoms worsen at night  Teach signs of respiratory distress  Acute Epiglottitis p. 517  A type of croup considered a Medical Emergency  Inflammation and swelling of the epiglottitis primarily affecting children 2-7 yrs.  Life threatening - edema obstructs the airway and occludes the trachea within minutes;  Examination of the throat is CONTRAINDICATED can cayuse airway to become compromised and closed off  Etiology  Bacterial Infection  Caused by Haemophiles influenzae type B (HIB vaccine)  Clinical Manifestations of Epiglottitis  Sudden onset that was completely healthy with overall toxic appearance  Awakens with high fever (>102º)  Anxious, fearful, with mouth open and neck extended  TRIPOD position and Drooling (cannot swallow secretions due to inflamed epiglottis)  Absence of cough  Extreme sore throat with cherry red, swollen epiglottis***  Decompensates rapidly, need to go to ED/OR to provide patent airway  Treatment  Hospitalization Call 911  Keep child in upright position  Child will be taken to OR / ER for intubation; expert personnel for all transport  IV’s, blood cultures, gases performed in OR  Keep child NPO  IV Antibiotics for 3 days; po for 7-10 days, corticosteroids  Antipyretics for fever and sore throat  Provide emotional support  Discuss HIB vaccine to prevent recurrence  ***Comparison between Croup & Epiglottitis Croup Epiglottitis Peak age 3 mos – 3 yrs (younger 2-7 yrs (older child) child) Causative agent Viral Bacterial (HIB) Appearance No drooling Shocky; pale, muffled voice, severe Less ill (mild URI sore throat, sits forward with mouth symptoms) open (tripod/drooling); retractions, respiratory distress Signs & Barky seal cough, Usually no cough, symptoms Fever 70 breaths/min to attempt to get air out  Nasal flaring  Retractions  Crackles/rales  Intermittent cyanosis  Apneic episodes  Marked diminished breath sounds  Uncomplicated bronchiolitis resolves in 7-10 days  Diagnosis and Treatment  CXR reveals air trapping and infiltrates  Most managed at home with  rest  fluid intake  management of fever  If dehydrated with respiratory distress  Hospitalization with possible mechanical ventilation if in respiratory failure  Possible use of Ribavirin (Virazole): aerosol antiviral medication  High risk children for RSV: Prematurity, BPD (stiff lungs, inadequate lung exchange), Heart defects  Drugs Used for Prevention of RSV  Synagis or Palivizumab (antibody injection)  Bronchiolitis/RSV  Frequent respiratory assessment for respiratory distress  Monitor O2 saturation and fluid intake  Elevate HOB to breathe easier  Administer antipyretics and nebulized medications  Chest physiotherapy (BPD infant esp.)  Remove secretion via bulb syringe or suctioning (watch use of sterile saline)  Teach proper handwashing to prevent spread, increased fluid intake to prevent respiratory distress from dehydration  Pneumonia p. 525  Inflammation of the lung where bronchioles and alveoli spaces are affected  Causative agents:  Virus (RSV, parainfluenza, influenza). Gradual onset, low grade fever, cough, crackles, wheezing, transient lobal infiltrates on CXR, treatment includes supportive care  Typical bacteria (S. pneumoniae, can follow viral). Acute/abrupt onset, cough, tachypnea, crackles, decreased breath sounds, retractions, chest pain, high grade fever, lobar consolidation on CXR, treatment includes Amoxicillin as first line  Atypical bacteria(mycoplasma pneumoniae). Abrupt onset, malaise, worsening nonproductive cough, diffuse crackles, wheezing, interstitial infiltrates on CXR, treatment includes macrolides (Azithromycin as first line, erythromycin, clarithromycin)  Complications include pleural effusion  May reveal wheezes, rales or diminished breath sounds over an infiltrate  Promote oral fluids; administer IV if necessary  Encourage pneumococcal immunization to prevent otitis media and pneumonia  Pneumonia  Inflammation of the lungs  Bronchioles and alveolar spaces affected  Impairs gas exchange  RSV common causative agent in upper respiratory tract  Bacterial pneumonia often follows viral infection  Locations  Lobar pneumonia: one or more lobes  Bronchopneumonia: terminal bronchioles and nearby lobules  Interstitial pneumonia: confined to alveolar walls, peribronchial and interlobular tissue Right lung has infiltrate in middle lobe, identified as pneumonia Mycoplasma Pneumonia (atypical)  Similar to viral pneumonia  More common in children older than 5 yrs  CXR often reveals patchy infiltrates  Elevated WBC  Symptoms include  Sudden fever, Chills  Diffuse crackles/wheezes  Hacking, nonproductive cough  Sore throat  Clinical Manifestations  Viral Pneumonia  Bacterial Pneumonia  Mild, low-grade fever  High fever  No productive cough  Productive cough  Rhinitis  Ill appearance  5-7 days  Retractions  Wheezing  Grunting respirations  Tachypnea  Chills  respiratory distress  Chest pain  Respiratory distress  Restless  Anxiety  May occur after viral infection  Diagnosis and Treatment  Diagnosis  Sputum culture  CXR: patchy infiltrates, consolidation, fluid (not routine)  Arterial blood gases  WBC count  Viral: normal WBC count  Bacterial: elevated neutrophils  Treatment  Supportive for viral pneumonia (fluids, rest)  Antibiotics (macrolides) for bacterial pneumonia  Acetaminophen or ibuprofen to reduce fever and pain  Prevent dehydration, IV fluids  Oxygen therapy, Chest physiotherapy  COVID-19 and children Multisystem Inflammatory Syndrome (MIS-C)  Is a condition where different body parts can become inflamed, including the heart, lungs, kidneys, brain, skin, eyes, or gastrointestinal organs.  We know that many children with MIS-C had the virus that causes COVID-19, or had been around someone with COVID-19.  MIS-C can be serious, even deadly, but most children who were diagnosed with this condition have gotten better with medical care.  Symptoms  Fever  Abdominal pain  Vomiting  Diarrhea  Neck pain  Rash  Bloodshot eyes  Feeling extra tired  Be aware that not all children will have all the same symptoms. Diffuse, red, patchy rash on torso You are seeing a infant for a follow-up appointment after being hospitalized with a RSV Bronchiolitis. What assessment finding is the highest priority?  A. Increased temperature  B. Increased heart rate  C. Decrease pulse oximeter saturation  D. Decreased bowel sounds The correct answer is:  C. Decrease pulse oximeter saturation  Rationale:  Signs of respiratory distress including decreased pulse oximeter saturations  Increased temp, heart rate and decreased bowel sounds are significant but do not warrant immediate attention. Recommended YouTube video on blackboard “ Identifying Respiratory Distress in the Child