Respiratory (Peds)

• Increased resistance to flow
• Increased work in the act of breathing
• Decreased ability to compensate for swelling, trauma, or spasms

• Larynx if funnel shaped and positioned higher
• Narrowest part of the airway is below the vocal chords (adults the glottic inlet)
• Effects angle if child needs intubation
• Position of head while in respiratory distress much more important
• Increase risk of aspiration

• Newbors/infants have little mucus which acts as a cleaning agent
• Infants are obligatory nose breathers (up to 4 months)
• Infants are diaphragmatic breathers (switch from abdominal breathing to thoracic at 2 years; fully develop at 7)
• Wall of airway have less cartilage than older children/adults and are more likely to collapse after expiration or when neck is flexed
• double the metabolic rate of an adult, therefore a greater need for O2
• Respiratory distress, fever and anxiety add to O2 demand

• MOST frequent cause of illness and hospitalization (Airway and Respiratory Disorders)
• Usually children get sicker or worse before they get better
• Infants and children can panic

• Rate
• Rhythm
• Retractions
• Flaring
• Depth
• Stridor
• Ease
• Wheeze
• Drooling
• Color Changes (pale, blue)
• Does crying improve/worsen color
• Change in voice

• High: muffled or hoarse
• Tonsil: sounds like a hot potatoe stuck
• Level or below glottis: bark

• Wet: productive
• Dry: non-productive
• Brassy: noisy
• Croupy: barking like a seal

Airway obstructed by thick secretions, muscular spasms, tumor or external pressure (rumbling sound is more pronounced during expiration and usually clears with coughing)

• CRACKLES (like rales but coarse due to lower in bronchi or trachea)
• Bubbling noise during inspiration
• Fine popping sound
• Crackles are coarser and originate in large bronchi or trachea, usually lower pitch
• Not cleared with coughing

• Obstruction of posterior nares by membranes or bone growth
• Unilateral or bilateral
• Food intolerance

• Abnormalities involving, mandible, tongue and possibly the palate
• Most have trachs or screws that are turned to move jaw forward

• "Common cold"
• More common in fall and winter; symptoms last 4-10 days
• No meds; tx symptoms

• Acute streptococcal pharyngitis
• Usually kids 4-7 yrs; rare under 1 year
• Tonsillitis
• Complications: Rhematic fever and Glomerulonephritis
• Tx: Pain control, antibiotics when appropriate
• Tonsillectomy: Not recommended for under 3 years of age (Post op: pain, halitosis, fluids, avoid acid juices, carbonate beverages, red fluids, ice cream)
• Halitosis: bad breath b/c of old blood from tonsillectomy
• If they are swallowing often, could be bleeding from wound site

• Very common: 80% will have at least 1; 50% will have 3 or more by 3 y/o
• At most risk: 6 months - 2 years
• Risk Factors: Siblings w/ Otitis Media, large groups of people in household, smokers in household, lying down position while eating (with bottle)
• Symptoms: not the same for all kids; temperature and loss of appetite (N&V), irritability, pulling at ear, unable to sleep, runny nose
• Otoscopy: dull gray membrane w/fluid behind eardrum and/or membrane red and bulging (normal color is light pearly pink or gray)
• Positioning of ear for inspection:
• pull lower pinna down and back (6-9 o'clock range) infant
• pull upper pinna up and back (10 o'clock position) child over 3
• Tx: teaching, pain control, antibiotics (waiting 3 days recheck), immunization, hearing evaluation, surgery (tubes)

• Usually viral
• Larngotraeobronchitis (LTB) most common
• Acute Spasmaodic Laryngitis (Spasmodic Croup)
• SOUNDS WORSE THAN LOOKS

• Viral or Bacterial
• LIFE THREATENING!
• 4 "D"s: Dysphonia, Dysphagia, Drooling, Distressed (respiratory effort)
• LOOKS WORSE THAN SOUNDS

• Dysphonia (inability to produce sound)
• Dysphagia (difficulty swallowing)
• Drooling
• Distressed (respiratory effect)

6 months - 3 years; younger than 5 yr

vs.

3 - 6 years

Late Fall/Winter

vs.

Anytime

URI, low fever, worse at night

vs.

URI, high fever, suddenly very ill

Retractions and Stridor

vs.

Drooling, chin thrust

Barky

vs.

Muffled, if any

Humidity, fluids and steroids

vs.

Antibiotics, airway protection

• Risk Groups: 1-3 years, adolescents (esp w/ drugs and drinking)
• Location of Blockage: mainly on the right side, 20% in trachea, 5% distal portions
• Common Item: food, latex balloons, coins, toys, buttons, hot dogs, hard candy, peanuts, grapes
• Signs and Symptoms: not all kids gag or cough effectively
• Parents: fear, anger, guilt

• Damage to Airways: water enters larynx, laryngospasms, relaxes and fills lungs with water (90% wet), loss of surface-active material, capillary leakage and pulmonary edema, Acute Respiratory Distress Syndrome
• Risk Groups: toddlers (1-3 years; esp. 2-4 yr boys), teenage boys (risk-taking), seizure disorders
• Tx: hypoxia (Brain 4-6 min, Heart and Lungs 30 min), hypothermia (risk from large body surface area)
• Prevention: effective barriers, parental supervision, CPR education, alcohol/drug use, approved flotation devices/boat safety

• Bronchitis
• Tracheobronchitis
• Bronchiolitis
• Respiratory Syncytial Virus (RSV)
• Tuberculosis (TB)
• Asthma
• Bronchopulmonary Dysplasia (BPD or Chronic Lung Dx)
• Respiratory Distress Syndrom (RDS)

• Inflammation of large airways, usually with URI
• Symptoms: dry hacking & non-productive cough
• Worse at night

• Symptoms: wheezing, retractions, tachypnea, decrease breath sounds, increased mucus secretions, cough
• 80% caused by RSV, rare in kids over 2 years

• MUCUS, MUCUS, MUCUS!
• Mucus production causes hyperinflation and obstructive airway
• Effects epithelial cells of respiratory tract
• Symptoms:
• Most common cuase of lower respiratory infections in kids less than 3 years
• Dx: N/P wash-nasopharynx wash; can suction or insert some fluid in a tube and push it out so that is comes out of the nose or suction it back
• Tx: Fluids, positioning, mist, O2, suctioning

• Most important chronic infection worldwide morbidity
• Children under 2 years at risk
• Testing: Mantoux-false negative if done 4 weeks w/i MMR immunization; Gastric washing-usually for children younger tha 9-10 years, done 3 days consecutively

• Major Chronic disease of Childhood
• Leading cause of school absences
• Especially at risk are children: living at home with smokers, living in lower socioeconomic and/or inner cities, indoor allergens (cockroaches, rodents and mold)

• Bronchospasms
• Inflammation of broncho mucosa
• Increase secretions (mucus) which causes airway injury

• Frequency of daytime vs. nightime symptoms
• Coughing
• Wheezing (especially expiratory)
• Shortness of breath, Chest tightness
• Changes in feeding (infants) or activity
• Retractions
• Peak expiratory rates or spirometry
• X-ray and/or CBC to rule out other infections

• Medication: Beta-agonist; steroids; albuterol (SE-tachycardia)....if albuterol is needed more than 4 hours then they need to go into the hospital
• Support of family and child (assess school and financial needs)
• Education (especially inhaler technique, medication adherence, and environmental exposures)
• Daily Management and Emergency Plan: Green, Yellow, and Red Plans

• Underdevelopment of lungs associated with alveoli surfactant
• Lack of surfactant leads to alveoli collapse on end expiration-increase respiratory effort
• Strongly associated with premature infants
• Tx: Promote growth; avoid complications in ventilation, hyperthermia, electrolyte status, hydration, acid/base balance, and tissue perfusion

• BPD also associated with CHD (congenital heart defects), prolonged intubations and fluid overload
• Alveoli walls thicken and lose elasticity
• 20-30% of RDS babies
• No specific treatment
• Tx: promote growth; at risk for G/D delays, pulmonary hypertension, sepsis
• Goal is to increase number of alveoli growth
• At risk for: ventilator dependence, short guts, pulmonary hypertension, sepsis, G/D delays