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Lower Respiratory Disorders . Debbie King NP June 2006. Croup. An acute upper airway obstruction typically caused by a virual infection of the larynx Etiology Parainfluenza Most common in children 3 months to 6 years of age Males more often affected than females. Croup.

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lower respiratory disorders

Lower Respiratory Disorders

Debbie King NP

June 2006

croup
Croup
  • An acute upper airway obstruction typically caused by a virual infection of the larynx
  • Etiology
    • Parainfluenza
    • Most common in children 3 months to 6 years of age
    • Males more often affected than females
croup3
Croup
    • Peak during late fall and winter
  • Signs and Symptoms
    • Low grade fever
    • Rapid onset of “barky” cough
    • Symptoms worse at night
    • Improvement with cool night air
croup4
Croup
  • Differential Diagnosis
    • Bacterial infections of upper respiratory tract
    • Laryngotracheomalacia (Look up)
    • Foreign body aspiration
    • Acute laryngeal edema
    • Severe asthma
croup5
Croup
  • Physical Findings
    • Inspiratory stridor
    • Brassy, barky cough
    • Dyspnea
    • Chest sounds are usually clear
  • Diagnostic Tests/Findings
    • White blood cell count- normal or elevated
croup6
Croup
    • Pulse oximetry
    • Radiographic image of airway (steeple sign)
    • Viral cultures of nasopharyngeal secretions
  • Management/Treatment
    • Mild disease
      • Outpatient care
      • Family education
croup7
Croup
  • Moderate to severe
    • Hospitalize for supportive care
    • 1 to 5% requite intubation
  • Medication
    • Dexamethasone 1mg/ml 0.6mg/kg x 1dose
    • Nebulized racemic epinephrine
    • Corticosteroid orapred 15/5 2mg/kg/bid x 2day
  • Isolation
  • prevention
foreign body aspiration
Foreign Body Aspiration
  • Inhalation of foreign body that lodges in upper trachea or lower airways
  • Etiology/Incidence
    • Food or object
    • 80% are <3 years of age
    • 2/3 of cases are males
foreign body aspiration9
Foreign Body Aspiration
  • Signs and Symptoms
    • Sudden violent cough with gagging
    • History of witnessed choking
    • May be asymptomatic if object is not obstructing airway
  • Differential Diagnosis
    • Acute phase
    • Chronic phase
foreign body aspiration10
Foreign Body Aspiration
  • Physical Findings
    • Rarely still coughing
    • Unilateral wheezing and decreased breath sounds on side of aspiration
    • Voice changes
    • If foreign body is present persists, brochiectasis and abscess formation is likely
foreign body aspiration11
Foreign Body Aspiration
  • Diagnostic Tests/Findings
    • Pulse oximetry
    • Chest radiograph
    • Expiratory chest, decubitus, or fluoroscopy
  • Management/ Treatment
    • Institute cardiopulmonary resuscitation if needed
foreign body aspiration12
Foreign Body Aspiration
  • Immediate transport to hospital for evaluation and removal
  • Refer to endoscopy team
  • May need antibiotics
  • Chest radiograph in 6 to 8 weeks
bronchitis
Bronchitis
  • Acute- transient inflammation of larger lower airways
  • Chronic- symptoms persist for more than 2 weeks
  • Etiology/Incidence
    • Most commonly viral
    • Bacterial causes
    • Most common in winter and early spring
bronchitis14
Bronchitis
  • Signs and Symptoms
    • Initial phase includes symptoms of upper respiratory illness
    • Cough
    • May have pain with cough
  • Differential Diagnosis
    • Asthma
    • Allergic disease
    • pneumonia
bronchitis differentials con t
Bronchitis- differentials con’t
  • Gastroesophageal reflux
  • Inhalation or irritants
  • Cystic fibrosis
  • Immune deficiency
  • Chronic sinusitis
  • Immotile cilia syndrome
  • Foreign body aspiration
  • Airway deformity
bronchitis16
Bronchitis
  • Physical Findings
    • Brassy cough
    • Coarse breath
    • May have tracheal tenderness
  • Diagnostic Tests/Findings
    • Based on history and physical
    • Radiograph of chest may be normal
    • Pulmonary function tests may be normal
bronchitis17
Bronchitis
  • Management/Treatment
    • Avoidance of irritants
    • Expectorants, increase fluid intake
    • Bronchodilators
    • Inhaled steroids
bronchiolitis
Bronchiolitis
  • An acute viral infection of the smaller airway
  • Etiology/Incidence
    • RSV
    • Parainfluenza
    • Almost all children have it at least once before age 3
    • Gerd
bronchiolitis19
Bronchiolitis
    • If <6 months must be hospitalized or if they have cardio-respiratory disease
    • mid-winter to early spring (usually)
  • Signs and symptoms
    • Congestions, cough, and low-grade fever
    • Work of breathing
    • May present as apnea
bronchiolitis20
Bronchiolitis
  • Differential diagnosis
    • Bacterial or chlamydia pnuemonia
    • Aspiration pneumonia
    • Asthma
    • Foreign body aspiration
    • Retropharyngeal abscess
    • Salicylate poisoning
bronchiolitis21
Bronchiolitis
  • Physical Findings
    • Symptoms of rhinorrhea
    • Often low grade fever
    • Nasal flaring
    • Wheezing
    • Hypoxia
bronchiolitis22
Bronchiolitis
  • Diagnostic Tests/Findings
    • Based on history and physical
    • Chest radiograph
    • Pulse oximetry
    • White blood cell count
    • Viral culture with rapid diagnostic techniques
bronchiolitis23
Bronchiolitis
  • Management/Treatment
    • Oxygen therapy
    • Fluid and nutritional support
    • Brochodilators
    • Corticosteroids
    • Ribavirin may be used with caution
    • RSV IV
pneumonia
Pneumonia
  • Infectious- infection which involves small airways in children
  • Aspiration- caused by ingestion of food, saliva, or gastric content into air passages
  • Etiology/ Incidence
    • Common viral agents- RSV
pneumonia25
Pneumonia
  • Newborns- most common bacterial causes group B strep, gram-negative enteric bacilli
  • Infant and young children < 6 years- streptococcus pneumoniae is primary cause
  • Older children and adolescents- streptococcus pneumoniae most likely
  • Aspiration pneumonia occurs in specific settings
  • 4% preschool children
pneumonia26
Pneumonia
  • Signs and Symptoms
    • Cough
    • Fever
    • Chest pain
    • May have change in level of activity
    • May have nasal flaring
pneumonia27
Pneumonia
  • Differential Diagnosis
    • Athelctasis
    • Foreign body aspiration
    • Asthma
    • Cystic fibrosis
    • Tuberculosis
pneumonia28
Pneumonia
  • Physical Findings
    • Fever
    • May have tachypnea
    • May have wheezing
    • Localized dullness to percussion
pneumonia29
Pneumonia
  • Diagnostic Tests/Findings
    • Chest radiograph
      • Atelectasis
      • Viral usually begins with scattered perihilar and peribronchial infiltrations
      • Bacterial- patchy infiltrates in infants
      • Acute aspiration usually develops in portion of lung that is dependent at time of aspiration
pneumonia30
Pneumonia
  • White blood cell count may or may not elevate
  • Viral cultures of nasopharyngeal secretions
  • Blood cultures
  • Sputum cultures
  • Positive cold agglutinin screen or titer > 1:32 suggestive of Mycoplasma Pneumonia
  • Pulse oximetry- decreased O2 saturations
pneumonia31
Pneumonia
  • Management/Treatment
    • Antimicrobial treatment based on etiology
    • Bronchodilators and chest physiotherpy may improve airway clearance
    • Flu vaccine for those with chronic illness
    • Other supportive therapy may include additional fluids and/or oxygen
    • Can progress rapidly and should be monitored
pleurisy pleural effusion and empyema
Pleurisy, Pleural Effusion and Empyema
  • Pleurisy- inflammation of the pleural lining
  • Pleural Effusion- accumulation of fluid in pleural space
  • Empyema- inflammation and purulent exudate
pleurisy pleural effusion and empyema33
Pleurisy, Pleural Effusion and Empyema
  • Etiology/Incidence
    • Often caused by disease process else where in the body
    • Parapneumoic effusions
  • Signs and Symptoms
    • Chest pain
    • High fever
    • effusions
pleurisy pleural effusion and empyema34
Pleurisy, Pleural Effusion and Empyema
  • Differential diagnosis
    • Tuberculosis
    • Neoplasm
    • Connective tissue disorder
    • Sarcoidosis
  • Physical Findings
    • Unilateral decrease in chest expansion during inspiration
pleurisy pleural effusion and empyema35
Pleurisy, Pleural Effusion and Empyema
    • Splinting toward the affected side
    • Dullness to percussion
  • Diagnostic Tests
    • Chest radiograph
    • Thracentersis for evaluation of the pleural liquid
    • Mantoux test- PPD
    • Blood cultures
    • Pulse oximetry
pleurisy pleural effusion and empyema36
Pleurisy, Pleural Effusion and Empyema
  • Management/Treatment
    • May involve treatment of an underlying systemic illness
cystic fibrosis
Cystic Fibrosis
  • Defective epithelial chloride transport results in dehydrated viscous secretion which obstruct the exocrine ducts
  • Signs and Symptoms
    • Extremely viscid meconium
    • Weight loss despite voracious appetite
    • Recurrent respiratory infections
    • Liquid, large, foul smelling stools
cystic fibrosis signs con t
Cystic Fibrosis- signs con’t
    • Frequent flatulence
    • Recurrent wheezing
    • Salty-tasting skin
    • Heat prostration
  • Differential Diagnosis
    • Asthma
    • Immunologic deficiencies
    • Antitrypsin deficiency (rare)
cystic fibrosis differentials con t
Cystic Fibrosis-differentials con’t
    • Airway abnormalities
    • Gastroesophageal reflux
  • Physical Findings
    • Respiratory
      • Chronic cough
      • Altered lung exam
      • Increased work of breathing
      • Increased anteroposterior diameter of chest
cystic fibrosis respiratory sx con t
Cystic Fibrosis-respiratory SX con’t
    • Dyspnea on exertion
    • Recurrent otitis media
    • Chronic rhinorrhea
    • Nasal polyps
  • Gastrointestional
    • Meconium ileus
    • FTT
    • Abdominal distention
    • Abdominal pain
cystic fibrosis gi sx con t
Cystic Fibrosis-GI SX con’t
      • Enlarged liver and spleen
      • Rectal prolapse
      • Evidence of vitamins A,E, and/or K deficiences
    • Other-digital clubbing
  • Diagnostic Tests
    • Pilocarpine iontophoresis sweat test
    • Genetic testing from buccal mucosa
    • Chest radiograph
cystic fibrosis tests con t
Cystic Fibrosis-tests con’t
    • Pulmonary function tests
    • Sputum culture
    • Oximetry
    • Hyponatremia, hypochloremic alkalosis
  • Treatment will be managed by Pulmonary and GI MD’s through CF clinic- meds are very expensive and not all are covered by ins.
asthma
Asthma
  • Chronic lung disease characterized by:
    • Airway inflammation
    • Airway hyper-responsiveness to variety of stimuli
    • Variable airway obstruction
  • Etiology
    • Triggers
      • Indoor allergens
asthma etiology con t
Asthma-etiology con’t
    • Outdoor allergens
    • Respiratory infection
    • Weather
    • Exercise
    • Gastroesophageal reflux
    • Irritants
    • Food allergies
    • Medications
  • Approximately 10% of children affected
asthma45
Asthma
  • Signs and Symptoms
    • Recurrent episode of cough
    • Symptoms often worse at night
    • A subset of patients present with chronic cough without wheezing or exercise intolerance
asthma46
Asthma
    • Differentials
      • aspiration
      • Cystic fibrosis
      • Cardiac defects
      • Lower respiratory tract infections
  • Physical Findings
    • Cough
    • Diffuse wheezes
    • Respiratory distress
    • Allergic appearance
    • Concurrent respiratory infection
    • Barrel chest
asthma47
Asthma
  • Diagnostic Tests
    • Spirometry
    • Chest radiograph
    • Allergy testing
    • Nasal and sinus evaluation
    • Pulse oximetry
asthma48
Asthma
  • Management/Treatment
    • Diagnose asthma and initiate partnership with family
    • Classify severity
    • Medication classification
    • Identify and reduce child-specific triggers
    • Provide clear written instructions
    • Educate child/family
asthma management con t
Asthma-management-con’t
  • Long term care
  • Provide smoking cessation counseling as needed

Review medications-use rescue meds as little as possible!!!

Albuteral

Xopenex

Pulmicort

Advair

Flovent

Allergy medications