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Smaller airway diameter result in...
- Increased resistance to flow
- Increased work in the act of breathing
- Decreased ability to compensate for swelling, trauma, or spasms
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Airway differences
- 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
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Infant Airway differences
- 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
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Respiratory Disorders
- 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
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S/S of Respiratory Disorders
- Rate
- Rhythm
- Retractions
- Flaring
- Depth
- Stridor
- Ease
- Wheeze
- Drooling
- Color Changes (pale, blue)
- Does crying improve/worsen color
- Change in voice
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Change in voice obstructions (high, tonsil, level or below glottis)
- High: muffled or hoarse
- Tonsil: sounds like a hot potatoe stuck
- Level or below glottis: bark
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Cough Sounds
- Wet: productive
- Dry: non-productive
- Brassy: noisy
- Croupy: barking like a seal
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Rhonci
Airway obstructed by thick secretions, muscular spasms, tumor or external pressure (rumbling sound is more pronounced during expiration and usually clears with coughing)
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Rales = ...
- 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
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Choanal Atresia (Birth Defect)
- Obstruction of posterior nares by membranes or bone growth
- Unilateral or bilateral
- Food intolerance
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Pierre Robin Syndrom-Cranial facial (Birth Defect)
- Abnormalities involving, mandible, tongue and possibly the palate
- Most have trachs or screws that are turned to move jaw forward
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Acute Nasopharyngitis (Upper Airway Disorder)
- "Common cold"
- More common in fall and winter; symptoms last 4-10 days
- No meds; tx symptoms
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Sore Throats (Upper Airway Disorder)
- 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
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Otitis Media (Upper Airway Disorder) - Ear Infection
- 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)
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Croup Syndromes
- Usually viral
- Larngotraeobronchitis (LTB) most common
- Acute Spasmaodic Laryngitis (Spasmodic Croup)
- SOUNDS WORSE THAN LOOKS
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Epiglottitis
- Viral or Bacterial
- LIFE THREATENING!
- 4 "D"s: Dysphonia, Dysphagia, Drooling, Distressed (respiratory effort)
- LOOKS WORSE THAN SOUNDS
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4 "D"s of Epiglottitis
- Dysphonia (inability to produce sound)
- Dysphagia (difficulty swallowing)
- Drooling
- Distressed (respiratory effect)
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Age Group (Croup vs. Epiglottitis)
6 months - 3 years; younger than 5 yr
vs.
3 - 6 years
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Season (Croup vs. Epiglottitis)
Late Fall/Winter
vs.
Anytime
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Onset Pattern (Croup vs Epiglottitis)
URI, low fever, worse at night
vs.
URI, high fever, suddenly very ill
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Appearance (Croup vs Epiglottitis)
Retractions and Stridor
vs.
Drooling, chin thrust
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Cough (Croup vs Epiglottitis)
Barky
vs.
Muffled, if any
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Treatment (Croup vs Epiglottitis)
Humidity, fluids and steroids
vs.
Antibiotics, airway protection
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Foreign Body Aspiration (Upper and Lower Airway Disorders)
- 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
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(Near) Drowning (Upper and Lower Airway Disorders)
- 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
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Lower Airway Disorders
- Bronchitis
- Tracheobronchitis
- Bronchiolitis
- Respiratory Syncytial Virus (RSV)
- Tuberculosis (TB)
- Asthma
- Bronchopulmonary Dysplasia (BPD or Chronic Lung Dx)
- Respiratory Distress Syndrom (RDS)
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Bronchitis/Tracheobronchitis
- Inflammation of large airways, usually with URI
- Symptoms: dry hacking & non-productive cough
- Worse at night
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Bronchiolitis
- Symptoms: wheezing, retractions, tachypnea, decrease breath sounds, increased mucus secretions, cough
- 80% caused by RSV, rare in kids over 2 years
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Respiratory Syncytial Virus (RSV)
- 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
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Tuberculosis
- 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
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Asthma
- 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)
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Increasing Sensitivity to Triggers of Asthma
- Bronchospasms
- Inflammation of broncho mucosa
- Increase secretions (mucus) which causes airway injury
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Assessment of Asthma
- 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
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Asthma Management
- 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
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Respiratory Distress Syndrome (RDS)
- 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
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Bronchopulmonary Dysplasia or Chronic Lung Dx (BPD)
- 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
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