Chapter 40 Pediatrics - Respiratory

Inhaled Corticosteroids

(beclomethasone, budesonide, fluticasone, mometasone) Actions/Indications - Exert a potent, locally acting anti-inflammatory effect to decrease the frequency and severity of asthma attacks. May also delay pulmonary damage that occurs with chronic asthma. - Also used for chronic lung disease and croup syndromes Nursing Implications - Not for treatment of acute wheezing - Rinse mouth after inhalation to decrease incidence of fungal infections, dry mouth, and hoarseness. - Minimal systemic absorption makes inhaled steroids the treatment of choice for asthma maintenance program.

Nasal Canula

22%-44% oxygen o Nursing Implications: § Must be used with humidification to prevent drying and irritation of airways § Can provide very small amounts of oxygen (as low as 25 mL/min) § Maximum recommended liter flow in children is 4 L/min. § Children can eat or talk while on oxygen. § Inspired oxygen concentration affected by mouth breathing § Requires patent nasal passages

Simple Mask

35%-60% oxygen flow rate of 6-10 L/min o Nursing Implications § Must maintain oxygen flow rate of at least 6 L/min to maintain inspired oxygen concentration and prevent rebreathing of carbon dioxide § Mask must fit snugly to be effective but should not be so tight as to irritate the face.

Bronchiolitis: Complications/Diagnostics/Symptoms

80-90% is RSV • Bronchiolitis is an acute inflammatory process of the bronchioles and small bronchi. • The peak incidence of bronchiolitis is in the winter and spring (September or October and continues through April or May.) • The severity of disease is related inversely to the age of the child. The frequency and severity of RSV infection decrease with age. Causes o Nearly always caused by a viral pathogen, RSV accounts for the majority of cases of bronchiolitis, with adenovirus, parainfluenza, and human meta-pneumovirus also being important causative agents. Pathophysiology o Highly contagious; Respiratory secretion spread o RSV infection causes necrosis of the respiratory epithelium of the small airways, peribronchiolar mononuclear infiltration, and plugging of the lumens with mucus and exudate. o The small airways become variably obstructed; this allows adequate inspiratory volume but prevents full expiration. o This leads to hyperinflation and atelectasis. o Serious alterations in gas exchange occur, with arterial hypoxemia and carbon dioxide retention resulting from mismatching of pulmonary ventilation and perfusion. o Hypoventilation occurs secondary to markedly increased work of breathing. Signs and Symptoms o Onset of illness with a clear runny nose (sometimes profuse) o Pharyngitis o Low-grade fever o Development of cough 1 to 3 days into the illness, followed by a wheeze shortly thereafter o Poor feeding o Air hungry, cyanosis and respiratory distress: - tachypnea - retractions - accessory muscle use - grunting - periods of apnea Diagnostics § Pulse oximetry: oxygen saturation might be decreased significantly. § Chest radiograph: might reveal hyperinflation and patchy areas of atelectasis or infiltration. § Blood gases: might show carbon dioxide retention and hypoxemia (low oxygen concentration in blood). § Nasal-pharyngeal washings: positive identification of RSV can be made via enzyme-linked immunosorbent assay (ELISA) or immunofluorescent antibody (IFA) testing.

Racemic Epinephrine

Actions/Indications - Produces bronchodilation - Indicated for croup - treats bronchospasms - helps reduce edema - Indicated for bronchiolitis Nursing Implications - Assess lung sounds and work of breathing. - Observe for rebound bronchospasm.

Diphenhydramine

Actions/Indications - Treatment of allergic conditions such as allergic rhinitis, asthma Nursing Implications - May cause drowsiness or dry mouth

Pancreatic Enzymes

Actions/Indications • Insufficiency of pancreatic enzymes (amylase, lipase, pancrease) necessary for digestion and absorption due to cystic fibrosis Nursing Implications - Administer pancreatic enzyme supplements (pancrelipase [Creon, Pancreaze, Zenpep]) must be administered with all meals and snacks to promote adequate digestion and absorption of nutrients. - The number of capsules required depends on the extent of pancreatic insufficiency and the amount of food being ingested. - The dosage can be adjusted until an adequate growth pattern is established and the number of stools is consistent at one or two per day. - Children will need additional enzyme capsules when high-fat foods are being eaten. - In the infant or young child, the enzyme capsule can be opened and sprinkled on cereal or applesauce.

Pediatric Respiratory Assessment

Inspection and Observation § Color: pallor or cyanosis § overall appearance § respiratory rate § hydration status § inspect the nose and oral cavity · drainage, swelling, or redness · color of pharynx, presence of exudate, tonsil size, and status of presence of lesions anywhere in the oral cavity § inspect nailbeds for clubbing § observing work of breathing · Retractions (Document the severity of the retractions: mild, moderate, or severe.) · Note the use of accessory neck muscles. · Note the presence of paradoxical breathing (lack of simultaneous chest and abdominal rise with the inspiratory phase). § audibly listen for cough and other airway noises · sound of the cough (Is it wet or productive, dry and hacking, tight? When does the cough occur? Is it only or mainly at night?) · noises associated with breathing are present (e.g., grunting, stridor, or audible wheeze) § Anxiety and restlessness § Hydration status · Palpate the infant's fontanels to determine if sunken · Assess the oral mucosa for color and moisture. · Note skin turgor, presence of tears, and adequacy of urine output. · The child with a respiratory illness is at risk for dehydration. o Pain related to sore throat or mouth lesions may prevent the child from drinking properly. o Nasal congestion interferes with the infant's ability to suck effectively at the breast or bottle. o Tachypnea and increased work of breathing interfere with the ability to safely ingest fluids. Palpation § Palpate the sinuses for tenderness in the older child. § Assess for enlargement or tenderness of the lymph nodes of the head and neck. § Document alterations in tactile fremitus detected on palpation. · Increased tactile fremitus might occur in the case of pneumonia or pleural effusion. Fremitus might be decreased in the case of barrel chest, as with cystic fibrosis. Absent fremitus might be noted with pneumothorax or atelectasis. § Compare central and peripheral pulses. · Note the quality of the pulse as well as the rate. · With significant respiratory distress, perfusion often becomes compromised. Poor perfusion might be reflected in weaker peripheral pulses (radial, pedal) when compared to central pulses. Percussion § When percussing, note sounds that are not resonant in nature. · Flat or dull sounds might be percussed over partially consolidated lung tissue, as in pneumonia. · Tympany might be percussed with a pneumothorax. · Note the presence of hyperresonance (as might be apparent with asthma). Auscultation § Assess lung sounds via auscultation § Note adventitious sounds heard on auscultation. · Wheezing, a high-pitched sound that usually occurs on expiration, results from obstruction in the lower trachea or bronchioles. Wheezing that clears with coughing is most likely a result of secretions in the lower trachea. Wheezing resulting from obstruction of the bronchioles, as in bronchiolitis, asthma, chronic lung disease, or cystic fibrosis, does not clear with coughing. · Rales (crackling sounds) result when the alveoli become fluid filled, such as in pneumonia. Note the location of the adventitious sounds as well as the timing (on inspiration, expiration, or both). Tachycardia might also be present. An increase in heart rate often initially accompanies hypoxemia.

Pharyngitis: Interventions/Treatment/Education

Interventions o salt water gargles for children old enough o acetaminophen and ibuprofen may ease fever and pain o sucking on throat lozenges or hard candy may also ease pain o cool mist humidity helps to keep the mucosa moist o Encourage the child to ingest popsicles, cool liquids, and ice chips to maintain hydration. Treatment o Group A streptococcal pharyngitis requires antibiotic therapy o If either the rapid diagnostic test or throat culture (described below) is positive for group A streptococci, penicillin is generally prescribed o Alternative antibiotics include amoxicillin and, for those allergic to penicillin, macrolides, and cephalosporins. Family Education: § Parents may often need additional education about treatments as they may be accustomed to "sore throats" being treated with antibiotics. However, teach parents that in the case of a viral cause antibiotics will not be necessary and the pharyngitis will resolve in a few days. § For the child with streptococcal pharyngitis, urge parents to have the child complete the entire prescribed course of antibiotics. · After 24 hours of antibiotic therapy, instruct the parents to discard the child's toothbrush to avoid reinfection. · Educate parents that children may return to day care or school after they have been receiving antibiotics for 24 hours; they are considered noncontagious at that point.

Epiglottis: Complications/Diagnostics/Symptoms

MEDICAL EMERGENCY • Cause: inflammation and swelling of the epiglottis is most often caused by Haemophilus influenzae type b o has become a rare occurrence with the extensive use of the Hib vaccine since the 1980s. This vaccine will help to decrease the severity of this illness o Croup can affect your epiglottitis: very severe cases can lead to this • 1 - 8 years old Symptoms o Airway inflammation -> obstruction o Significant respiratory distress o Rapid onset (within hours) o Dysphagia o Irritability o Drooling (they can't swallow) o Increased pulse o Restlessness o Increased anxiety o Inspiratory Stridor o Retractions o Overall toxic appearance o High fever o Refusing to speak or speaking softly o Refuses to lie down and sits forward with the neck extended (tripoding) o Cough is usually absent • Complications o Respiratory arrest and death may occur if the airway becomes completely occluded. o Pneumothorax o Pulmonary edema • Diagnosis o A lateral neck radiograph may be performed to determine whether epiglottitis is present. § This is done cautiously, so as not to induce airway obstruction with changes in position of the child's neck. o CBC for WBC § Looking for infection

Cystic Fibrosis: Interventions/Treatment/Education

Nursing Management o Maintaining Patent Airway - chest physiotherapy several times a day - Breathing exercises - Encourage physical exercise - Ensure that Pulmozyme is administered, as well as inhaled bronchodilators and anti-inflammatory agents, if prescribed. o Preventing Infection § Ensure parents and older children understand that vigorous pulmonary hygiene to mobilize of secretions is critical to prevent infection. § Administer aerosolized antibiotics as prescribed either in the hospital or teach parents to provide them at home. § Children with frequent or severe respiratory exacerbations might require lengthy courses of intravenous antibiotics. o Maintaining Growth § Administer pancreatic enzyme supplements (pancrelipase [Creon, Pancreaze, Zenpep]) · Children will need additional enzyme capsules when high-fat foods are being eaten. · In the infant or young child, the enzyme capsule can be opened and sprinkled on cereal or applesauce. § Provide a well-balanced, high-calorie, high-protein diet is necessary to ensure adequate growth. § In infants, breastfeeding should be continued with enzyme administration. § Administer vitamins A, D, E, and K supplementation. Administer gavage feedings or total parenteral nutrition as prescribed to provide for adequate growth. o Promoting Family Coping o Preparing the Child and Family for Adulthood with Cystic Fibrosis Treatment § Relieve obstruction § Remove secretions § Infections o Mucolytics § Mucomyst and Pulmozyme o Antibiotics: § PO or IV & aerosolized § Pseudomonas aeruginosa (Colonized: Tobramycin) o Steroids (po/inhaled) o NSAIDS o Lung Transplant

Croup: Interventions/Treatment/Education

Nursing Management: o The child with fever, a toxic appearance, and increasing respiratory distress despite appropriate croup treatment needs to be reported to provider immediately o advise parents about the symptoms of respiratory distress and instruct them to seek treatment if the child's respiratory condition worsens. o Teach parents to expose their child to humidified air (via a cool mist humidifier or steamy bathroom o Administer dexamethasone if ordered or teach parents about home administration. o Explain to parents that the effects of racemic epinephrine last about 2 hours and the child must be observed closely as occasionally a child will worsen again, requiring another aerosol. Home Care of Croup § Keep the child quiet and discourage crying. § Allow the child to sit up (in your arms). § Encourage rest and fluid intake. § If stridor occurs, take the child into a steamy bathroom for 10 minutes. § Administer medication (corticosteroid) as directed. § Watch the child closely. Call the physician or nurse practitioner if: · the child breathes faster, has retractions, or has any other difficulty breathing. · the nostrils flare or the lips or nails have a bluish tint. · the cough or stridor does not improve with exposure to moist air. · restlessness increases or the child is confused. · the child begins to drool or cannot swallow. Treatment o Croup is usually managed on an outpatient basis, with affected children rarely requiring hospitalization. § Help stop coughing: · Vicks vapor rub · Bring them outside in the cold to help decrease inflammation · Calming environment o Corticosteroids (usually a single dose) are used to decrease inflammation o Racemic epinephrine aerosols demonstrate the α-adrenergic effect of mucosal vasoconstriction, helping to decrease edema. o Children with croup may be hospitalized if they have significant stridor at rest or severe retractions after a several-hour period of observation

Pediatric Respiratory Health History

Past medical history § recurrent colds or sore throats § atopy (genetic tendency toward asthma, allergic rhinitis, or atopic dermatitis) § prematurity § respiratory dysfunction at birth § poor weight gain § history of recurrent respiratory illnesses or chronic lung disease § exposure to second-hand smoke · Children exposed to environmental smoke have an increased incidence of respiratory illnesses such as asthma, bronchitis, and pneumonia Family history § asthma or might reveal contacts for infectious exposure History of present illness § onset and progression § fever § nasal congestion § noisy breathing § presence and description of cough § rapid respirations § increased work of breathing § ear, nose, sinus, or throat pain § ear pulling; headache § vomiting with coughing § poor feeding § lethargy Treatments used at home Immunization history

Tonsilectomy Interventions

Promoting Airway Clearance § Until fully awake, place the child in a side-lying or prone position to facilitate safe drainage of secretions. § Once alert, the child may prefer to sit up or have the head of the bed elevated. § Suctioning, if necessary, should be done carefully to avoid trauma to the surgical site. § Note that dried blood may be present on the teeth and the nares, with old blood present in emesis. Since the presence of blood can be very frightening to parents, alert them to this possibility. Maintaining Fluid Volume § Though unusual postoperatively, monitor for hemorrhage as it may occur any time from the immediate postoperative period to as late as 10 days after surgery. · Inspect the throat for bleeding. · Mucus tinged with blood may be expected, but fresh blood in the secretions indicates bleeding. · Watch for continuous swallowing of small amounts of blood while awake or sleeping as this may indicate early bleeding. · Monitor for other signs of hemorrhage including tachycardia, pallor, restlessness, frequent throat clearing, and emesis of bright red blood. · To avoid trauma to the surgical site, discourage the child from coughing, clearing the throat, blowing the nose, and using straws. · Upon discharge, instruct the parents to immediately report any sign of bleeding to the physician or nurse practitioner. § To maintain fluid volume postoperatively, encourage children to take any fluids they desire; popsicles and ice chips are particularly soothing. § Citrus juice and brown or red fluids should be avoided: the acid in citrus juice may irritate the throat, and red or brown fluids may be confused with blood if vomiting occurs. § No milk: can generate mucous and make them cough § No carbonation Relieving Pain § Educate families that for the first 24 hours after surgery, the throat is very sore. § Provide adequate pain relief (acetaminophen may be with or without narcotics) in order to establish adequate oral fluid intake. § Apply an ice collar if prescribed. § Counsel parents to maintain pain control upon discharge from the facility, not only for the child's sake, but also to enable the child to continue to drink fluids. § Teach the patient to sneeze with mouth open § Can go back to school after at least 7 days or when they are ready § No sports until you are fully healed

Nonrebreathing Mask

Simple facemask with valves at the exhalation ports and an oxygen reservoir bag with a valve to prevent exhaled air from entering the reservoir Provides 95% oxygen concentration 80-100% O2 Nursing Implications: § Must set liter flow rate at 10-12 L/min to prevent rebreathing of carbon dioxide. § The reservoir bag does not completely empty when child inspires if flow rate is set properly. · Fill up the reservoir bag before putting this device on

Bronchiolitis: Interventions/Treatment/Education

Therapeutic Management o Management of RSV focuses on supportive treatment. § Supplemental oxygen § Nasal and/or nasopharyngeal suctioning § Oral or intravenous hydration § Inhaled bronchodilator therapy (racemic epinephrine or albuterol/levalbuterol) are used. § Many infants are managed at home with close observation and adequate hydration. § Hospitalization is required for children with more severe disease. § The infant with tachypnea, significant retractions, poor oral intake, or lethargy can deteriorate quickly, to the point of requiring ventilatory support, and thus warrants hospital admission. Nursing Management o Children with less severe disease may be managed at home and might require only: antipyretics, adequate hydration, and close observation. § Teach parents or caregivers to watch for signs of worsening and to seek care quickly should the child's condition deteriorate. o Hospitalization is required for children with more severe disease, and children admitted with RSV bronchiolitis warrant close observation. o Maintaining Patent Airway § Position the child with the head of the bed elevated to facilitate an open airway. § Frequently assess airway patency and suction as needed. · Use a Yankauer or tonsil-tip suction catheter to suction the mouth or pharynx of older infants or children, rinsing the catheter after each suctioning. · Nasal bulb suctioning may be sufficient to clear the airway in some infants, while others will require nasopharyngeal suctioning with a suction catheter. · Adjust the pressure ranges for suctioning infants and children between 60 and 100 mm Hg (40 and 60 mm Hg for premature infants). o Promoting Gas Exchange § Assess work of breathing, respiratory rate, and oxygen saturation as infants and children with RSV bronchiolitis might deteriorate quickly as the disease progresses. § Adjust the percentage of inspired oxygen (FiO2) as needed to maintain oxygen saturation within the prescribed range. § Position the infant with the head of the bed elevated to improve gas exchange. § Frequent assessment is necessary for the hospitalized child with bronchiolitis. § In the tachypneic infant, slowing of the respiratory rate does not necessarily indicate improvement: often, a slower respiratory rate is an indication of tiring, and carbon dioxide retention may soon be followed by apnea o Reducing Risk for Infection § Since RSV is easily spread through contact with droplets, isolate inpatients according to hospital policy to decrease the risk of nosocomial spread to other children. § Safely cohort children with RSV. Maintain attention to hand washing, as droplets might enter the eyes, nose, or mouth via the hands. o Providing Family Education § Educate parents so they can recognize signs of worsening distress. § Tell parents to call the physician or nurse practitioner if: · The child's breathing becomes rapid or more difficult · If the child cannot eat secondary to tachypnea § Inform families that children who are younger than 1 year of age or who are at higher risk (those who were born prematurely or who have chronic heart or lung conditions) might have a longer course of illness. § Instruct parents that cough can persist for several days to weeks after resolution of the disease, but infants usually act well otherwise. o Preventing Respiratory Syncytial Virus Disease § Teach strict adherence to hand washing policies in day care centers and when exposed to individuals with cold symptoms for all age groups. § Administer palivizumab (Synagis), a monoclonal antibody vaccination to prevent severe RSV disease in those who are most susceptible. Give intramuscularly once a month throughout the RSV season to children younger than 2 years of age with qualifying factors. Qualifying factors include: · Prematurity · Chronic lung disease (bronchopulmonary dysplasia) requiring medication or oxygen · Certain congenital heart diseases · Certain neuromuscular disorders

Asthma: Interventions/Treatment/Education

Treatment o EMERGENCY MANAGEMENT § Short acting Beta-2 agonists: Albuterol § Anticholinergics: Ipratropium (Atrovent) § Steroids: IV o LONG-TERM MANAGEMENT § Inhaled beta 2 agonists Long acting: Salmeterol § Leukotriene modifiers: Montelukast § Inhaled corticosteroids/PO: Flovent (fluticasone) o Current goals of medical therapy are avoidance of asthma triggers and reduction or control of inflammatory episodes. STEPWISE APPROACH TO ASTHMA TREATMENT: 1) (intermittent asthma) Short acting Beta-2 agonist (albuterol 2) low-dose inhaled corticosteroid 3) medium-dose inhaled corticosteroid (all ages) OR low-dose inhaled corticosteroid AND leukotriene modifier OR long acting Beta-2 agonists (children > 4yo) 4) medium-dose inhaled corticosteroids and long-acting Beta-2 agonist 5) high-dose inhaled corticosteroids and long-acting β2-agonist 6) high-dose inhaled corticosteroids, long-acting β2-agonist, and oral systemic corticosteroids Nursing Management o Initial nursing management of the child with an acute exacerbation of asthma is aimed at restoring a clear airway and effective breathing pattern as well as promoting adequate oxygenation and ventilation (gas exchange) o Educating the Child and Family · An action plan that may be helpful to families in the management of asthma. Instruct parents to ensure the action plan is kept on file at the child's school, and relief medication is available to the child at all times. · Avoidance of allergens o Promoting the Child's Self-Esteem § Through education and support, the child can gain a sense of control. § Children need to learn to master their disease. § Transferring control of asthma care to the child is an important developmental process that will increase the child's feeling of control over the illness. o Promoting Family Coping

Croup vs Epiglottitis

croup- barking cough, hoarseness of voice, subglottic narrowing epiglottitis- toxic appearing, high grade fever, strider and drooling- triad is swollen epiglottis, thickened art epiglottis folds, and obliterated vallecula

Oral or Parenteral Corticosteroids

prednisolone, prednisone Actions/Indications - Suppress inflammation and normal immune response - Used for acute asthma exacerbations, wheezing with chronic lung disease, and severe croup Nursing Implications - May cause hyperglycemia - May suppress reaction to allergy tests - Consult physician or nurse practitioner if vaccinations are ordered during course of systemic corticosteroid therapy. - Short courses of therapy are generally safe. - Very effective, but long-term or chronic use can result in peptic ulceration, altered growth, and numerous other side effects. Children on long-term dosing should have growth assessed

Long acting bronchodilators

β2-Adrenergic agonists (long acting) (i.e., formoterol, salmeterol) Actions/Indications - Long-acting bronchodilator used in chronic asthma management and for prevention of exercise-induced asthma - Long-term control in chronic asthma - Prevention of exercise-induced asthma Nursing Implications - Administered via inhalation - Used only for long-term control or for exercise-induced asthma. Not for relief of bronchospasm in an acute wheezing episode

Short acting bronchodilators

β2-Adrenergic agonists (short acting) (i.e., albuterol, levalbuterol, pirbuterol) Actions/Indications - Relax airway smooth muscle, resulting in bronchodilation - Used for acute and chronic treatment of wheezing and bronchospasm in asthma, bronchiolitis, cystic fibrosis, chronic lung disease. Also used to prevent wheezing in exercise-induced asthma Nursing Implications - Administered via inhalation - Can be used for acute relief of bronchospasm - May cause nervousness, tachycardia, and jitteriness - Inhaled agents result in fewer systemic side effects.

Foreign Body Aspiration

• 3 "C's": o Cannot speak o Cyanotic o Collapses • Foreign body aspiration occurs when any solid or liquid substance is inhaled into the respiratory tract. • The object may lodge in the upper or lower airway, causing varying degrees of respiratory difficulty. • Foreign body aspiration occurs most frequently in children between 6 months and 3 years of age o Children this age are growing and developing rapidly. They tend to explore things with their mouths and can easily aspirate small items. • Items smaller than 1.25 in (3.2 cm) can be aspirated easily. A simple way for parents to estimate the safe size of a small item or toy piece is to gauge its size against a standard toilet paper roll (not double roll), which is generally about 1.5 in in diameter. Treatment • The child often coughs out foreign bodies from the upper airway. If the foreign body reaches the bronchus, then it may need to be surgically removed via bronchoscopy. • Postoperative antibiotics are used if an infection is also present. Complications o Pneumonia o abscess formation o hypoxia o respiratory failure o death Assessment o Evaluate the history of the infant or young child for usually sudden onset of cough, wheeze, or stridor, though the onset of respiratory symptoms can be more gradual. § Stridor suggests that the foreign body is lodged in the upper airway. o Auscultate the lungs for wheezing, rhonchi, and decreased aeration can be heard on the affected side. o A chest radiograph will demonstrate the foreign body only if it is radiopaque Nursing Management o The most important nursing intervention related to foreign body aspiration is prevention. § Anticipatory guidance for families with 6-month-olds should include a discussion of aspiration avoidance. § Repeat this information at each subsequent well-child visit through age 5. o Tell parents to avoid letting their child play with toys with small parts and to keep coins and other small objects out of the reach of children. o Teach parents not to feed peanuts and popcorn to their child until he or she is at least 3 years old. o When children progress to table food, teach parents to chop all foods so that they are small enough to pass down the trachea should the child neglect to chew them up thoroughly. o Carrots, grapes, and hot dogs should be cut into small pieces. o Harmful liquids should be kept out of the reach of children. o Prevent young children from playing with latex balloons. When popped, small pieces pose an aspiration danger

Asthma: Complications/Diagnostics/Symptoms

• Asthma is a chronic inflammatory airway disorder characterized by airway hyperresponsiveness, airway edema, and mucus production. • Airway obstruction resulting from asthma might be partially or completely reversed. • Severity ranges from long periods of control with infrequent acute exacerbations in some children to the presence of persistent daily symptoms in others. Triggers o Allergies o Cold o Cold weather o Exercise Complications o Children with asthma are more susceptible to serious bacterial and viral respiratory infections. o Status asthmaticus (A quiet chest in an asthmatic child can be an ominous sign) o Respiratory failure o Death Signs and Symptoms o Cough, particularly at night: hacking cough that is initially nonproductive, becoming productive of frothy sputum o Difficulty breathing: shortness of breath, chest tightness or pain, dyspnea with exercise o Wheezing is the hallmark of airway obstruction and might vary throughout the lung fields. Diagnostics o Pulse oximetry: oxygen saturation may be decreased significantly or normal during a mild exacerbation. o Chest radiograph: usually reveals hyperinflation. o Blood gases: might show carbon dioxide retention and hypoxemia. o Pulmonary function tests (PFTs): can be very useful in determining the degree of disease but are not useful during an acute attack. Children as young as 5 or 6 years might be able to comply with spirometry. o Peak expiratory flow rate (PEFR): is decreased during an exacerbation. o Allergy testing: skin test or RAST can determine allergic triggers for the asthmatic child

Croup: Complications/Diagnostics/Symptoms

• Children between 3 months and 3 years of age are the most frequently affected with croup, rarely affecting children over age 6. o Croup is also referred to as laryngotracheobronchitis because inflammation and edema of the larynx, trachea, and bronchi occur as a result of viral infection. o Parainfluenza is responsible for the majority of cases of croup, though other viruses may also be implicated Symptoms: o The inflammation and edema obstruct the airway, resulting in symptoms. o Mucus production also occurs, further contributing to obstruction of the airway. o Narrowing of the subglottic area of the trachea results in audible inspiratory stridor. o Edema of the larynx causes hoarseness. o Inflammation in the larynx and trachea causes the characteristic barking cough of croup (or a seal) o Symptoms occur most often at night, presenting suddenly, with resolution of symptoms in the morning. o Croup is usually self-limited, lasting only about 3 to 5 days. o Onset is usually sudden, often at night o Temperature may be normal or slightly elevated Diagnosis: o Croup is usually diagnosed based on history and clinical presentation, but a lateral neck radiograph may be obtained to rule out epiglottitis. Complications: o worsening respiratory distress o hypoxia o bacterial superinfection (as in the case of bacterial tracheitis).

Cystic Fibrosis: Complications/Diagnostics/Symptoms

• Cystic fibrosis is an autosomal recessive disorder that affects 30,000 children and adults in the United States (1 in 4 chance of having a baby with CF) • Cystic fibrosis is the most common debilitating disease of childhood among those of European descent. The median age for survival is 39.3 years • DNA testing can be used prenatally and in newborns to identify the presence of the mutation. • Complications o Hemoptysis o Pneumothorax o bacterial colonization o cor pulmonale o volvulus o intussusception o intestinal obstruction o rectal prolapse o gastroesophageal reflux disease o diabetes o portal hypertension o liver failure o gallstones o decreased fertility. · ♀: Cervical mucous plug · ♂: Structural; less sperm Laboratory and Diagnostic Tests o Newborn screening § Fecal fat § LFT § Pulmonary function tests § CXR/sputum culture o Sweat chloride test: considered suspicious if the level of chloride in collected sweat is above 50 mEq/L and diagnostic if the level is above 60 mEq/L. o Pulse oximetry: oxygen saturation might be decreased, particularly during a pulmonary exacerbation. o Chest radiograph: may reveal hyperinflation, bronchial wall thickening, atelectasis, or infiltration. o PFTs: might reveal a decrease in forced vital capacity and forced expiratory volume, with increases in residual volume. Common Signs and Symptoms o A salty taste to the child's skin (resulting from excess chloride loss via perspiration) o Meconium ileus or late, difficult passage of meconium stool in the newborn period o Abdominal pain or difficulty passing stool (infants or toddlers might present with intestinal obstruction or intussusception at the time of diagnosis) o Bulky, greasy stools (Steatorrha) o Poor weight gain and growth despite good appetite o Chronic or recurrent cough and/or upper or lower respiratory infections o Chronic hypoxemia: clubbing, barrel chest o Decreased pancreatic enzymes o Rectal prolapse o Thick, sticky mucous o Abdominal distention

Pharyngitis: Complications/Diagnostics/Symptoms

• Inflammation of the throat mucosa (pharynx) • A bacterial sore throat most often occurs without nasal symptoms (with nasal congestion would indicate viral) • Group A streptococci account for 20% to 30% of cases, with the remainder being caused by other viruses or bacteria Complications o peritonsillar or retropharyngeal abscess o acute rheumatic fever o acute glomerulonephritis (strep A) Diagnostics o Rapid diagnostic test or throat culture § The rapid strep test is a sensitive and reliable measure, rarely resulting in false-positive readings. If the rapid strep test is negative, the second swab may be sent for a throat culture. § When obtaining two swabs for rapid strep testing and throat culture, swab the applicators simultaneously to decrease perceived trauma to the child. Symptoms o Abrupt onset o High fever o Look sick /Not active o Not eating R/T to sore throat o Exudate o Headache o Hurts to swallow, ear pain o strawberry tongue o petechiae on palate o headache o abdominal pain o enlargement/tenderness of cervical lymphnodes o Streptococcus rash (red, sandpaper)

Tonsillitis

• Inflammation of the tonsils often occurs with pharyngitis and, thus, may also be viral or bacterial in nature. o Viral infections require only symptomatic treatment. o Treatment for bacterial tonsillitis is the same as for bacterial pharyngitis. o Occasionally surgical intervention is warranted. § Tonsillectomy (surgical removal of the palatine tonsils) may be indicated for the child with recurrent streptococcal tonsillitis or massive tonsillar hypertrophy or for other reasons. When hypertrophied adenoids obstruct breathing, then adenoidectomy (surgical removal of the adenoids) may be indicated. Assessment o Fever o Past Medical History o History of recurrent pharyngitis or tonsillitis. o Note if the voice sounds muffled or hoarse o Inspect the pharynx for redness and enlargement of the tonsils. § the child may experience difficulty breathing and swallowing. § When tonsils touch at the midline ("kissing tonsils" or 4+ in size), the airway may become obstructed. § Also, if the adenoids are enlarged, the posterior nares become obstructed. The child may breathe through the mouth and may snore. o Palpate the anterior cervical nodes for enlargement and tenderness. Diagnostic - Rapid test or culture may be positive for streptococcus A.

Changes in Pediatric Anatomy and Physiology

• Nose o Newborns are nose breathers until at least 4 weeks of age. The nares must be patent for breathing to be successful while feeding. Newborns breathe through their mouths only while crying. o Newborns produce very little mucus, making them more susceptible to infection. However, the newborn and young infant have very small nasal passages, so when excess mucus is present, airway obstruction is more likely. • Throat o The tongue of the infant relative to the oropharynx is larger than in adults. o Posterior displacement of the tongue can quickly lead to severe airway obstruction • Trachea o The airway lumen is smaller in infants and children than in adults. The infant's trachea is approximately 4 mm wide compared with the adult width of 20 mm. o A small reduction in the diameter of a child's airway (resulting from the presence of edema or mucus) will result in an exponential increase in resistance to airflow. Increased work of breathing (effort or labor associated with respiration) then occurs. • Lower Respiratory Structures o This difference in placement of the bifurcation of the trachea also contributes to risk for foreign material aspiration. The bronchi and bronchioles of infants and children are narrower in diameter than the adult's, placing them at increased risk for lower airway obstruction. Lower airway obstruction during exhalation often results from bronchiolitis or asthma or is caused by foreign body aspiration into the lower airway. o Alveoli are developed at approximately 24 weeks' gestation. Term infants are born with about 150 million alveoli. At some point between the age of 3 and 8 years, the child has developed the adult number of alveoli of around 300 million • Chest Wall o Infants' chest walls are highly compliant (pliable) and fail to support the lungs adequately. Functional residual capacity can be greatly reduced if respiratory effort is diminished. This lack of lung support also makes the tidal volume of infants and toddlers almost completely dependent upon movement of the diaphragm. If diaphragm movement is impaired (as in states of hyperinflation, such as asthma), the intercostal muscles cannot lift the chest wall and respiration is further compromised. • Metabolic Rate and Oxygen Need o Children have a significantly higher metabolic rate than adults. Their resting respiratory rates are faster and their demand for oxygen is higher. o Infants consume 6 to 8 L/min o In any situation of respiratory distress, infants and children will develop hypoxemia more rapidly than adults.

Epiglottis: Interventions/Treatment/Education

• Treatment o Therapeutic management focuses on airway maintenance and support. o Intravenous antibiotic therapy is necessary. o The child will be managed in the intensive care unit • Nursing Management o Do not under any circumstance attempt to visualize the throat: reflex laryngospasm may occur, precipitating immediate airway occlusion. o Epiglottitis is characterized by dysphagia, drooling, anxiety, irritability, and significant respiratory distress. Prepare for the event of sudden airway occlusion. o Do not leave the child unattended. o Keep the child and parents as calm as possible. o Allow the child to assume a position of comfort. o Do not place the child in a supine position, as airway occlusion may occur. o Provide 100% oxygen in the least invasive manner that is acceptable to the child. o If the child with epiglottitis experiences complete airway occlusion, an emergency tracheostomy (incision in trachea to permit breathing) may be necessary. o Ensure that emergency equipment is available and that personnel trained in intubation of the pediatric occluded airway and percutaneous tracheostomy are notified of the child's presence in the facility. o Cool mist humidification o No oral fluids o IV access immediately and fluids o ASSESS AND REASSESS