Module 4a

• Croup (Laryngotracheobronchitis)


  Inflammation of the larynx, trachea and major bronchi

  
• Croup


  • One of the most frightening diseases of early childhood for both parents & child
  • Occurs between 6 months - 3 years of age
  • Caused by Parainfluenza virus
• Assessment of Croup


  • Characterized by inspiratory stridor, barking cough, and hoarseness
  • Low grade fever may be present
  • Cough may be hard and brassy
  • At night, develop barking cough, inspiratory stridor and marked retractions leading to extreme respiratory distress
  • Cyanosis (rare) due to glottal obstruction secondary to laryngeal inflammation leading to hypoxemia

  
• Therapeutic Management of Croup

  1. Attach patient to pulse oximetry

  2. Cool moist air + corticosteroid (Dexamethasone, Budesonide, Prednisolone, Prednisone, Betamethasone) to reduce inflammation and produce bronchodilation

  3. Nebulized epinephrine for moderate to severe croup

  4. IV therapy

  5. Monitor input and output to ensure adequate hydration

  
• Antibiotics have no role in the routine management of uncomplicated croup, since most cases are caused by viruses. Antibiotics should be used only to treat specific bacterial complications, such as tracheitis.
• Nonprescription antitussive agents and decongestants are of unproven benefit for croup.
• Epiglottitis


  Inflammation of the epiglottis, the flap that covers the opening of the larynx to keep out food and fluid during swallowing

  
• Epiglottitis


  • Occurs between 2 years - 8 years of age
  • Caused by Haemophilus Influenza Type B
  • Mild URTI progresses to severe inspiratory stridor, high fever, hoarseness, very sore throat, and difficulty swallowing (drooling of saliva)
  • Never attempt to visualize the epiglottis directly or obtain throat culture unless an artificial airway is provided
  • Lateral X-ray shows Thumbprint Sign
  • Leukocytosis and septicemia on blood culture

  
• Therapeutic Management of Epiglottitis

  1. Attach patient to pulse oximetry and provide O2 via nasal prong

  2. Provide moist air to reduce epiglottal inflammation

  3. Give third generation cephalosporin (Cefotaxime) empirically

  4. Provide IV therapy

  5. Perform prophylactic Tracheostomy or Endotracheal intubation

  6. Monitor input and output to ensure adequate hydration

  
• Bronchiolitis

  Inflammation of the fine bronchioles and small bronchi, the most common lower respiratory illness in children younger than 2 years of age, peaking in incidence at 6 months of age

  
• Bronchiolitis


  • Caused by Adenovirus, Parainfluenza virus, and Respiratory Syncytial Virus
  • Starts with 1-2 days of URTI, then increased respiratory rate, nasal flaring, intercostal and subcostal retractions
  • Mild fever, leukocytosis, increased ESR
  • Wheezing, tachycardia, cyanosis
  • Chest X-ray shows pulmonary infiltrates
  • Pulse oximetry shows low O2 saturation

  
• Therapeutic Management of Bronchiolitis

  1. Provide antipyretics

  2. Ensure adequate hydration

  3. Observe the patient

  4. Provide oxygen support

  5. Use nebulized bronchodilators and corticosteroids

  
• Bronchial Asthma


  Chronic inflammatory disorder of the airways characterized by recurring symptoms, airway obstruction, and bronchial hyperresponsiveness

  
• Bronchial Asthma


  • In susceptible children, inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough
  • Asthma episodes are associated with airflow limitation or obstruction, reversible either spontaneously or with treatment
  • Increase in bronchial hyperresponsiveness
  • Most common chronic disease of childhood, the primary cause of school absences, and the third leading cause of hospitalizations in children under the age of 15 years

  
• Extrinsic Asthma Triggers


  • Cockroach particles
  • Cat hair and saliva
  • Dog hair and saliva
  • House dust mites
  • Mold or yeast spores
  • Metabisulfite
  • Pollen
  • Smoke

  
• Intrinsic Asthma Triggers


  • Exercise
  • Gas, wood, coal, and kerosene heating units
  • Natural gas, propane, or kerosene used as cooking fuel
  • Fumes
  • Smog
  • Viral respiratory infections
  • Wood smoke
  • Weather changes
• Risk Factors for Persistent Asthma

  • Parental Asthma
  • Allergy
  • Severe LRTI
  • Male Gender
  • Low Birthweight
  • Environmental tobacco smoke exposure
  • Atopic Dermatitis
  • Allergic Rhinitis
  • Inhalant Allergen sensitization
  • Wheezing apart from colds
  • Reduced lung function at birth

  
• Etiology of Asthma


  • A combination of environmental and genetic factors in early life shape how the immune system develops and responds to ubiquitous environmental exposures
  • In the susceptible host, immune responses to common airways exposure can stimulate prolonged, pathogenic inflammation and aberrant repair of injured tissues

  
• Pathogenesis of Asthma


  • Airflow obstruction is the result of bronchoconstriction of bronchiolar smooth muscle, cellular inflammatory infiltrate and exudates filling and obstructing the airways, and epithelial damage and desquamation into the airways lumen
  • Helper T lymphocytes and other immune cells produce proallergic, proinflammatory cytokines (IL-4, IL-5, IL-13) and chemokines (eotaxins) that mediate the inflammatory process
  • Pathogenic immune responses and inflammation may result from a breach in normal immune regulatory processes

  
• Clinical Manifestations of Asthma

  • Intermittent dry coughing
  • Respiratory wheezing
  • Shortness of breath
  • Chest congestion and tightness
  • Intermittent, nonfocal chest pain
  • General fatigue
  • Rhonchi/crackles/rales
  • Self-imposed limitation of physical activities
  • Intercostal retractions
  • Nasal flaring
  • Accessory respiratory muscle use

  
• Clinical Manifestations of Severe Asthma

  • Tripod sitting position
  • Older children have a tendency to sit upright with shoulders hunched over, hands on the bed or chair, and arms braced to facilitate the use of accessory muscles of respiration
  • May speak with short, panting, broken phrases
  • Infants and small children are restless, irritable, and unable to be comforted
  • Display supraclavicular, intercostal, suprasternal, subcostal, and sternal retractions
  • Hyperresonance on percussion
  • Breath sounds are coarse and loud, with sonorous crackles throughout the lung fields
  • Expiration is prolonged
  • Coarse rhonchi and generalized inspiratory and expiratory wheezing that becomes more high pitched as obstruction progresses

  
• Diagnostic Tests for Asthma

  • Spirometry
  • Peak expiratory flow rate (PEFR)
  • Bronchoprovocation testing

  
• Nursing Diagnoses for Asthma

  • Impaired breathing pattern
  • Ineffective airway clearance
  • Ineffective health management
  • Impaired gas exchange
  • Readiness for enhanced knowledge (family)

  
• Classification of Asthma Severity

  • Mild
  • Moderate
  • Severe/Life-threatening

  
• Approach to Diagnosis of Asthma in Children <6 Years Old

  • Less likely to be asthma
  • Asthma suspect
  • More likely to be asthma

  
• Classification of Asthma Exacerbation (PAPP Asthma Guidelines 2021)

  • Mild (Age <6 years old)
  • Moderate (Age <6 years old)
  • Severe/Life-threatening (Age <6 years old)
  • Mild (Ages 6-18 years old)
  • Moderate (Ages 6-18 years old)
  • Severe (Ages 6-18 years old)

  
• Wheezing


  Heavy breathing for >10 days during URTI
• Coughing, wheezing, heavy breathing

  For >10 days during URTI
• FREQUENCY OF SYMPTOMS


  • 2 to 3 episodes per year
  • More than 3 episodes per year OR severe episodes and/or night worsening
  • More than 3 episodes per year OR severe episodes and/or night worsening
• PROPORTION OF YOUNG CHILDREN WITH ASTHMA

  • FEW have asthma
  • SOME have asthma
  • MOST have asthma
• SYMPTOMS BETWEEN EPISODES


  • NO symptoms
  • Between episodes, the child may have occasional cough, wheeze, or heavy breathing
  • Between the episodes, the child has cough, wheeze, or heavy breathing during play or when laughing • Known to have allergic sensitization, AD, food allergy, of family history of asthma

  
• ASTHMA CATEGORY


  • Less likely to be asthma
  • Asthma suspect
  • More likely to be asthma

  
• PARAMETERS / CLASSIFICATION


  • MILD
  • MODERATE
  • SEVERE/ LIFE-THREATENING
  • MILD
  • MODERATE
  • SEVERE
  • LIFE-THREATENING
• ACTIVITY / SENSORIUM


  • Able to talk
  • Breathless, unable to talk, confused, or drowsy
  • Able to talk
  • Able to talk only in phrases
  • Breathless or unable to talk
  • Drowsy, confused
• RESPIRATORY RATE, CPM


  • No increase
  • < 40/min
  • > 40/min
  • No increase
  • < 30/min
  • > 30/min
  • Proceed or triage immediately to an acute care facility or Emergency Department
• CARDIAC RATE, BPM

  • 100
  • 120/min
  • <140/min
  • >140/min
  • 100-120/min
  • 100-120/min
  • >125/min
• PULSE OXIMETRY


  • >95%
  • >92%
  • <92%
  • 95%
  • 90-95%
  • < 90%
• LUNG FUNCTION


  • N/A
  • > 50% of personal best
  • 30% to 50% of personal best
• Target O2 sat for 6-11 y/o is 94-98% and in adolescents is 93-95%
• < 92% is a predictor for hospitalization and less than 90% warrants aggressive therapy