Pediatric Respiratory Issues

• obstructive inflammation of the upper airway mainly the larynx resultin in effects on voice and breathing
• hoarseness
• characterized by: inspiratory stridor, barky (seal like) cough

• viral
• resp infections are the biggest acute illness in kids

• age: certain groups more prone to certain things
• anatomical differences: ie peds have shorter ear tube
• seasonal variations: RSV in winter and early spring
• immunity: everyones system different
• health status: do they have something else going on
• environment: allergies, toxins, etc

• ear canal: shorter in length, leads to reflux of secretions into middle ear which leads to ear infection
• eustacian tubes: shorter and underdeveloped which leads to poor drainage of secretions, leading to middle ear infections
• nasal and lung passages: smaller and more narrow so they are easily obstructed which can lead to respiratory infection/distress
• tongue: larger and floppier so a potential airway obstruction
• neck muscles: underdeveloped, floppier which can be a potential airway obstruction

the narrow passageway

• acute laryngotracheobronchitis
• a subglottic viral infection (below the glottis)
• human parainfluenza viruses (HPIVs) almost always caused by viral infection, but these are most common
• spread by coughing, sneezing, touching objects or surfaces containing the virus and then touching your mouth

those who are 6 months to 3 years

2-7 days

kids with croup who have stridor at rest

• 0-3 scale in each category, 3 being the worst
• stridor, retractions, air entry, color, level of consciousness
• 0 for all is normal
• <6= mild croup
• 7-8= moderate
• 8-15= severe

• fever
• poor appetite
• sneezing, nasal congestion, rhinorrhea
• sore throat
• cough
• abnormal breath sounds
• tachypnea
• retractions

• viral (80-90%)
• RSV, Rhinovirus, adenovirus, parainfluenza
• the viral infection rate is highest in the toddler and preschool periods

• head bobbing
• nose flaring
• grunting
• increase work of breathing
• retractions
• seasaw respirations

the higher up the retractions, the more severe the respiratory distress

• chest falls on inspiration and rises on expiration bc theres so much struggle to get air out
• this is a sign of impending respiratory failure

• may cause mild disease in older child or adult, but can be life threatening to infant
• requires frequent monitoring and interventions
• with severe distress and tachypnia, infants tire more easily, cant feed to keep up glucose levels and quickly get resp. failure

• acute streptococcal pharyngitis
• tonsilitis
• otitis media
• infectious mononucleousis
• croups

• RSV bronchiolitis
• asthma
• pneumonia

• pertussis
• cystic fibrosis

• reddened throat
• hyperemia
• swelling of pharynx

acute pharyngitis is viral 80-90% of the time but you have to rule out strep throat

• group a beta hemolytic streptococcus (GABHS)
• use rapid strep test- has high specificity
• if it comes back positive they have it but if neg you have to send for cultures bc the sensitivity is low

• abrupt onset
• fever, sore throat, sometimes just abdominal pain
• enlarged tonsils (day 2) with or without exudate
• lymphadenopathy (swollen lymph nodes)
• painful difficult swallowing
• mashed potato voice
• strawberry tongue
• scarlet rash
• strep breath - distinct smell

• sounds like their eating mashed potatoes while they talk 
• the inflammation muffles the speech

• sandpaper rash on trunk, groin and axillary
• certain strains of GABHS cause scarlett fever

• spread by droplets an contact with secretions
• incubation period: 2-5 days
• if uncomplicated usually resolves in 3-5 days with abx
• complicated can involve peritonsillar or retropharyngeal abscess

can lead to rheumatic fever and glomerulonephritis

• tonsils are lymphoid tissue and they are at their largest from age 10-12
• they are protective lymph tissue and filter things but can become a problem when the airway is compromised

• antibiotics- need to be on them for 24 hours AND afebrile before they are considered not contageous and can go back to school
• cold packs
• low saline gargles
• liquid analgesics
• oral fluids to prevent dehydration

• inflammation of the tonsils that often occurs with both viral and bacterial pharyngitis
• can be of palatine tonsils or pharyngeal tonsils

• these are the ones you can see on visual inspection
• "kissing tonsils" tonsils that touch lead to obstruction of the air/food passage
• the 2 tonsils are coming together and kissing in the back of the throat
• a tonsilectomy is removal of these tonsils

• aka the adenoids
• located posteriorly
• enlargement of these can lead to sleep apnea
• children may be candidates for an adenoidectomy if thats the case

• not unless necessary (blocking airway/foodway)
• not recommened at all for thsoe with cleft lip or palate as they can help with speach
• cant have surgery if they have an infection bc hemorrhage risk
• theres also always an anesthesia risk

• connect the middle ear to the nasopharynx
• proper functioning of these tubes protects the middle ear- they are preventing secretions from the nasopharynx from entering the middle ear and also allow secretions that do build up in the middle ear to flow to the nasopharynx
• they also equalize pressure

• results in accumulation of fluid (effusion) in the middle ear
• fluid in the middle ear becomes a perfect medium for infection leading to acute otitis media
• kids can have unilateral or bilateral otitis media

• fever and otalgia (ear pain)
• refuse feeding
• pulling/tugging at ears
• irritability
• hearing impaired
• otorrhea may or may not be present

• scarring and perforation can occur
• this can affect long term hearing

• ear infection with fluid in the tympanic membrane
• the fluid in there makes the tympanic membrane immoble, opaque, and orangy red
• if its a serous effusion from change in pressure, the eustachian tubes dont have a chance to equilibrate
• if not red, bulging purulent its not infectious. serous effusion may be bubbly looking, but not infectious

• its one of the most prevalent diseases in early childhood
• occurs most frequently in children 2 years and younger and then spikes at 5-6 when entering school
• familiar component- if parent had it as a kid their kid is more likely
• most is viral and occurs after or with a URI
• most common in the winter months

• most is viral, but the bacterial agents are 
• s. pneumonia and h influenza

• exposure to passive tobacco smoke
• family history
• day care
• cleft lip/palate
• down syndrome

bc of the viral nature, vaccines are important in preventing these infections

• never bottle prop
• never smoke around child
• immunize against pneumococcal strains and flu
• breast feed for at least 6 months
• analgesics can be given
• watch and wait approach- dont overprescribe ABX, its usually viral

• tympanostomy tube placement "t-tubes" 
• for severe eustachian tube dysfunction
• placed by autolaryngologist and can be placed as young as 6mo but is usually placed between 1-3 years
• tube is inserted into the ear and allows for fluid drainage

• tubes left in place for 6-18 months, usually not more than 2 years
• most fall out in 6-9 months on their own and then its just a decision on if it needs to be replaced
• if they dont fall out on their own they are surgically removed
• they may be scarring or failure of eardrum to close after tube comes out- RARE

• the kissing disease- common in adolescents-young adults
• fever, malaise, myalgias
• exudative pharyngitis
• palatine petechiae 
• extreme fatigue
• cervical adenopathy
• hepato-splenomegaly

• most commonly caused by epstein barr virus
• symptomatic EBV infections occur usually in teens and young adults more than young kids
• transmitted through saliva by direct intimate contact
• incubation period: 4-6 weeks
• Mono= More time to incubate

• supportive- fluids, rest, analgesia/antipyretic
• symptoms usually improve ~4 weeks, but fatigue, myalgia and need for sleep may persist for several months after acute infection resolved
• NO CONTACT SPORTS FOR AT LEAST 4 weeks- risk of splenic rupture

• dyspnea
• severe abdominal pain
• severe sore throat to the point they cant drink
• stridor

• strep throat- this is why they usually test for both
• treatment for strep is penicillin but if someone that also has mono gets this treatment they can get a rash bc EBV can cause temporary sensitivity to penicillin

• acute laryngotracheobronchitis
• a subglottic (below glottis) viral infection

• varying severity determines if it will be managed at home or hospital
• narrow airway of infants puts them at risk for obstruction, so infants with acute croup can get ARDS

• human parainfluenza viruses causes it- get a flu shot
• incubation period: 2-7 days
• most common in 6mo-3years 
• spread by cough, sneezing, touching objects/surfaces containing the virus and then touching mouth/nose eyes

• related to stridor, retractions, air entry, color and LOC
• the higher the score the worse the croup
• <6= mild
• 7-8= moderate
• >8= severe

• a lateral soft tissue radiograph- done to rule out acute epiglotitis, foreign body aspiration and retropharyngeal abscess
• look for steeple sign- throat looks like church steeple on xray

• home treatment
• no stridor at rest
• keep an eye out for signs of respiratory distress
• humidtiy with cool mist
• a self limiting ilness

• stridor at rest, retractions, labored breathing
• child hospitalized
• maintain the airway and resp status
• keep child calm-agitation worsens stridor
• humidified oxygen

• humidified oxygen
• recemic (nebulized) epinepherine: rapid onset peaks at 2 hours. watch for rebound constriction a few hours after treatment. 
• oral steroids: dexamethasone- has a long half life- less treatments
• IVF if unable to tolerate feeds- but remember an IV may stress them out and worsen stridor
• cluster the care

• sore throat
• painful swallowing
• high fever
• tripoding
• no spontaneous cough or hoarsness
• retractions
• drooling

• a SUPRAglottlal bacterial infection
• unlike croup which is a SUBglottic viral infection
• AN EMERGENCY

• keep them calm
• have emergecny airway equipment
• DO NOT attempt to look in the mouth unless emergency, not even for a culture
• humidified oxygen
• steroids and abx started STAT
• epiglottal swelling usually improves within 24 hours of ceftriaxone/cephalosporine
• if child has siblings under 4 or goes to daycare give contacts rifampin

• age: croup is less than 5, epi is 2-5yrs
• causative agent: croup viral, epi bacterial
• progression: croup- slow progression, epi- rapid progression
• stridor: croup- general stridor on rest or movement, epi stridor worsens lying down
• cough: croup- barking seal cough, epi- no cough
• appearance: croup- irritable, nontoxic, epi- toxic and frightened looking
• fever: croup- lowgrade fever, epi- high fever
• other sx: croup- uri symptoms, epi- cant swallow/drooling

• respiratory syncytial virus
• inflammation of the small airways in the lung- causes them to swell, connect to one giant cell and lose cilia
• most common cause of brochiolitis and pneumonia in kids under 1
• can cause SIGNIFICATN resp disease in infants and is most frequent reason for hospitalization of them

• not routinely bc its so common
• most kids have gotten it by 3 
• if they do test for it is an RSV nasal secretion wash

• Premature infants
• multiple birth siblings too
• during the time of november to may

• infants with this on contact precautinos
• it can live for a long time (hours) on fomites
• may also be on droplet precautions too
• transmited from exposure with contaminated secretions

• initial: sneezy, runny nose, cough (may get wheezing), intermittent fever, anorexia
• progression: copious nasal and pulmonary secretions, increased coughting, post-tussive emesis, musical lung sounds, 40-50breaths per min, retractions, trouble feeding
• severe: listlessness, poor air exchange, deminished breath sounds, tachypnea >70bpm, apneic spells, resp failyre

• positioning to protect airway
• frequent nasal suctioning (neosucker)
• humidified oxygen as needed (ie to feed)
• antipyretics
• modified feeds- pedialyte, 1/2 strength, bf moms need to pump
• IVF if poor intake or signs of dehydration
• mostly supportive management

• its a mucolytic and can cause bronchospasm so is not recommended
• may try a bronchodilator but typically just keeping the airway free of secretions

• lower airway disease
• most common chronic disease of childhood
• primary cause of school absences
• third leading cause of hospitalizations in children under 15

4-5 years

hospitalizations and deathrates are 3x higher, may be related to pollution, underdiagnosis, premature infants

increasing in african americans

• lower airway inflammation
• obstruction secondary to airway edema and accumulatiion of mucous
• hyperresponsiveness resulting in bronchospasm
• treatment directed at reducing inflammation

• wheezing: inspiratory, experiatory or both
• deminished breath sounds is OMINOUS
• breathlessness
• chest tightness
• use of accessory muscles, hunched shoulders
• cough esp at night or early morning
• cough is non productive
• prolonged expiratory phase (they cant blow out)- metabolic acidosis
• pectus carinatum
• status asthmaticus

• pigeon breast
• breastbone sticks out
• can be seen in undiagnosed asthma cases that have been going on for a while
• may result with chronic frequent severe episodes of asthma

• inflammation of the lung parenchyma
• viral pneumonia is most common and associated with URIs, but bacterial can develop secondaryily

• fever- usually quite high
• non or productive cough
• tachypnea
• chest/abdominal pain with lower lobe involvement
• pallor to cyanosis
• retractions
• nasal flaring
• irritable restless lethargic
• anorexia, v/d

• rhonchi/fine crackles
• tachypnea
• dullness on percussion

• positioning
• supplemental oxygen
• coughing/deep breathing
• chest percussion
• early frequent ambulation
• increased fluid intake/ivf
• analgesics antibiotics if needed
• monitor response to treatment

• whooping cough
• highly contageous respiratory disease
• causes uncontrollable violent coughing spells
• after coughing spell, the child needs to take a deep breath which causes the whooping sound

• spring and summer
• kids under 4, particularly the unvaccinated
• life threatening in infants under 1

• supportive
• hydration
• fever reduction
• hospitalization if resp. distress, apneic spells
• antibiotics

• 6-10 weeks
• can be longer

• inherited- autosomal recessive
• defect in sodium-chloride channels on the surface of epithelial cells

• increased viscosity of mucous gland secretions
• increased nacl in sweat and saliva
• abnormalities in autonomic ns function
• meconium ileus in the newborn is the earliest postnatal sign of CF
• thicker than normal protein ends up blocking the small passageways in certain organs

• wheezing
• rhonchi
• dry non-productive cough

• increased dyspnea
• paroxysmal cough
• obstructive emphysema and atelectasis

• barrel chest
• clubbing of digits
• cyanosis
• repeated bronchitis and bronchopneumonia

• airway clearence
• cpt with postural drainage (chest vibrators)
• positive experiatory thearapy (flutter device)
• active-cycle-of-breathing techniques
• aerosolized medications (pulmozyme)
• oxygen PRN
• physical exercise
• agressive treatment of pulmonary infections

• malabsorption
• large, bulky, loose, frothy, foul-smelling stools
• steatorrhea
• azotorrhea (foul smelling stool)
• vaoracious appetite followed by later loss of appetite
• failure to thrive

• distended abdomen with thin extremeties
• deficiency of fat soluble vitamins
• anemia
• diabetes mellitus
• biliary obstruction may lead to cirrhosis

• replacement of pancreatic enzymes
• pancrelipase given within 30 mins of meal or snack. titrated it based on stools
• high protein-high calorie diet, supplemented with ADEK and multivitamins
• treat GERD and constipation 
• cf related diabetes management