5Rhinitis Interdisciplinary Interventions Avoid offending allergen – smoke / petsPharmacologic management:Oral or nasal antihistamines - BenadrylLeukotriene modifiers - SingulairMast cell stabilizers – cromylin – nasal / ophthalmic / inhaledAllergen-specific immunotherapyDo not use combination OTC medications especially those that contain pseudoephedrineNo OTC Antihistamines for children under 6 years of age.
7Assessment Fever Purulent rhinorrhea Nasal congestion Pain in facial areaMalodorous breathChronic night-time coughChildren more prone to sinusitis: children with asthmaand cystic fibrosis.
8Interdisciplinary Interventions Normal saline nose dropsWarm pack to faceAcetaminophen for painIncrease po fluid intakeAntibioticsRecent studies question their effectiveness
9TonsillitisTonsils and adenoids are important to the normal development of the body’s immune system.Serve as part of the body’s defense against infectionCan become the site of acute or chronic infectionRepeated acute infections cause the tonsil tissue to swellEnlarged tonsils and adenoids impinge on the pharyngeal opening of the eustachian tube
10Assessment Child may refuse to drink Fever Reddened pharynx and tonsilsMost common causative agent = group A beta-hemolytic stretococciChronic tonsillitis may result in snoring due to enlarged tonsils and adenoids
11Tonsilitis“Kissing tonsils” occur when the tonsils are so enlarged they touch each other.
12Interdisciplinary Interventions Throat culture to determine causative agentAntibiotics for ten days if throat culturepositive for beta strepAcetaminophen for painCool fluidsSaline garglesAntiseptic spraysViral throat infections will not get better faster with antibiotics.
13Tonsillectomy Done if child’s respiratory status is compromised Post operative care:Side lying positionIce collarWatch for swallowingCool fluids / soft diet
14Croup Most common acute respiratory condition seen in early childhood. Highest incidence from 6 months to about 3 yearsRespiratory symptoms are caused by inflammation of the larynx and upper airway, with resultant narrowing of the airway.Severity depends on the area of the upper airway that is inflamed and narrowed.Most often viral – antibiotics are not needed
19Acute EpiglottitisAcute inflammation of supraglottic structures, the epiglottis and aryepiglottic folds.True pediatric emergencyDelayed treatment may result in complete airway obstructionMost often seen in children 2 to 7 yearsMost common causative agent – H. influenzae type B
20Assessment Sudden onset High fever – 102.2 or greater Dysphasia and droolingAgitation, irritability and restlessnessEpiglottis is cherry red and swollenNote: Do not look into the mouth – diagnosis often made by presenting symptoms or lateral neck x-ray
21Interdisciplinary Interventions Keep child quiet in a controlled medical environment with emergency airway equipment readily available.Do not put tongue blade in mouth to look in the throat – may cause epiglottis to spasm and shutAssess respiratory statusGive humidified oxygen by mask and keep HOB elevated.Mild sedation may help the child relax
22ApneaApnea is cessation of respirations lasting longer than 20 seconds.Monitor in hospital for underlying problemsDischarge home with monitor
23Foreign Body Severe inspiratory stridor Symptoms depend on location Unilateral chest movementChest x-rayBronchoscope to remove object
25TeachingNo small hard candies, raisins, popcorn or nuts until age 3 or 4 yearsCut food into small piecesNo running, jumping, or talking with food in mouthInspect toys for small partsKeep coins, earring, balloons out of reach
26Influenza Associated with community epidemic Febrile, URI, achy joints Management:Acetaminophen for feverFluidsKeep away from othersWatch for signs of pneumonia
27Bronchiolitis Acute obstruction and inflammation of the bronchioles. Most common causative agent: Respiratory Syncytial Virus (RSV)Bronchioles become narrowed or occluded as a result of inflammatory process, edema, mucus and cellular debris clog alveoli
30Interdisciplinary Interventions Oxygen to maintain oxygen saturation >than 95%Pulse oximeterNasal suction as neededChest percussion to mobilize secretionsInhalation therapy – not sure if it is beneficialMechanical ventilation as needed if increased work of breathing is seenIncreased heart rate, poor peripheral perfusion, apnea, bradycardia and hypercarbia
31RSV Positive - Isolation Respiratory Syncytial Virus is spread from respiratory secretions through close contact with infected persons or contact with contaminated surfaces or objects.Patient should be on contact and respiratory isolationCan be placed with other RSV + patients
32PneumoniaAn inflammatory condition of the lungs in which alveoli fill with fluid or blood resulting in poor oxygenation and air exchange.Can be primary illness or develop as a complication of another illness.Incidence: 34 to 40 cases per 1000 children younger than 5 yearsMost likely to develop when the body is unable to defend against infectious agents.
35Assessment High fever Thick green, yellow, or blood tinged secretions Grunting respirationsRales, crackles, diminished breath soundsCough and cyanosisDiagnostic tests: Infiltrate seen on x-ray
36Interdisciplinary Interventions Assess for respiratory distressNPO (respiratory rate > 60 = high risk for aspiration)IV fluids for hydrationSupplemental Oxygen to keep oxygen saturation equal to or > 92%Chest percussionNasal suctioning as neededAcetaminophen for feverAntibiotics – ampicillin and an aminoglycoside (Gentamicin)
37Pneumonia Isolation Respiratory isolation May be taken off isolation if RSV negative and on antibiotics for 24 hours.
38Cystic FibrosisInherited autosomal recessive disorder of the exocrine glandsGene responsible for CF is located on chromosome 7Life span is about 37 yearsComplex disease requiring a holistic approach
39CFTR GeneMutation of the CFTR gene disrupts the function of the chloride channels, preventing them from regulating the flow of chloride ions and water across cell membranes. As a result cells that line the passage ways of the lungs, pancreas and other organs produce mucus that is thick and sticky
42Assessment History of Meconium ileus at birth Foul smelling, greasy, bulky stools / constipationVoracious appetite with poor weight gainRecurrent respiratory infectionsPersistent chronic coughSalty tasting skin
43DiagnosisPositive sweat test – Gold standardGenetic marker
44Medications Pancreatic enzymes to help digest food Inhaled antibiotics – antimicrobial for lung treatmentAerosol bronchodilators to open airwaysMucolytic enzyme – to thin mucusH2 blocker – alters gastrointestinal acidic environmentTagametProkinetic agents – enhances gastrointestinal motilityReglanVitamin C to improve absorption of other medsVitamins E, A, D, K / fat soluble vitaminsOral and IV antibiotics – S. aureus, H. influenzae, P aeruginosa
45Long Term Complications Nasal polypsSinusitisRectal polyps / rectal prolapseHyperglycemia / diabetesInfertility - male
46AsthmaAsthma is a chronic, inflammatory lung disease involving recurrent breathing problems.Third leading cause of hospitalization among children younger than 15 years.Most common, chronic health problem in children
47PathophysiologyReversible changes in airway that lead to bronchoconstriction, airway hyper-responsiveness and airway edema.At the cellular level mast cells release histamine causing smooth muscle contraction and bronchoconstriction.Increased mucous secretion by goblet cells causes epithelial damageIncreased mucus secretion results in airway edema, mucus hypersecretion and plugging, airway narrowing, leading to airway obstruction
48Assessment Wheezing Cough Tightness of chest Prolonged expiratory phase
49AssessmentHypoxemia – universal in child with moderate to severe symptomsHypercarbia – carbon dioxide retention from air trapping in the alveoli and ventilation – perfusion mismatchMonitor blood gases – PaCO2 level more than 50 mm Hg indicated ventilatory failureDiagnostics: chest x-ray = hyper-expansion of lungs
53Peak Flow Meter Peak flow meters are used to measure PEFR and are designed for monitoring purposes rather than diagnosis of asthma.
54Home MedicationsRescue drugs: short acting albuterol beta 2 agonist – used as a quick-relief agent for acute bronchospasm and for prevention of exercise induced bronchospasm.Anti-inflammatory or preventative: low-dose inhaled corticosteroid: inhaled or oral prednisoneAllergy: leukotrines such as Singulair
55BronchodilatorsBronchodilators rapidly relax the airway smooth muscle cells, thus reversing the bronchospasm until anti- inflammatory effect of steroids is attained.AerosolsVia mouth piece 3 years and olderVia facial mask for less than 3 years
58CorticosteroidsSteroids reduce the inflammatory component of bronchial obstruction, decrease mucus production and mediator release, as well as the late phase (cellular) inflammatory process.Methyl prednisone IV in severe casesMay need histamine H2 receptor antagonists (cimetadine or ranitidine) if experiencing GI upsetPO prednisone – always give with food to decrease GI upset
59Inhaled Corticosteroids Inhaled corticosteroids: Pulmicort, AeroBid, FloventInfant: mask should fit firmly to prevent cataractsOlder child: rinse and spit after treatment to prevent thrush
60Family Teaching Teach how to use medication When to use and how often No OTC drugsIncrease fluid intakeSigns and symptoms of respiratory distress
62HistoryIt occurs in newborns who are born prematurely and or have a variety of pulmonary disorders and who require ventilatory support with high pressure and oxygen in the first 2 weeks of life.
63PathophysiologyFibrosis of airways and marked hyperplasia of the bronchial epitheliumIncreased fluid in the lungs, as a result of disruption of the alveolar-capillary membraneOver distention due to damage to alveolar supporting structures resulting in air trappingFibrosis, airway edema, and broncho-constriction
64BPD Assessment Persistent respiratory distress Dependent on supplemental oxygenFailure to thriveGastro-esophageal refluxPulmonary hypertension
66Long Term Management Supplemental oxygen CPT Bronchodilators Diuretics (pulmonary hypertension)Anti-inflammatory medicationNutritional support: po formula + NG supplementGastrostomy tube (GER)Bicarbonate in formula due to chronic state of acidosis