RESPIRATORY DISORDERS

CROUP (laryngotracheobronchitis) = an acute inflammatory disease of the upper airway and larynx caused
by a viral infection – Occurs in children 6 months to 5 years old (60% < 2 years)
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT & TREATMENT
Para-influenza most common, Rhinitis for 3-4 days MILD (no hypoxemia, dyspnea or dehydration) –
RSV, influenza A & B Low grade fever Supportive outpatient care (increase fluids,
Sore throat antipyretics, calm/non-intrusive care)
Inspiratory stridor/hoarseness MODERATE (stridor at rest, dyspnea,
Rapid onset of “barky” cough hypoxemia, dehydration) – Supportive care in the
Worse at night hospital (O2 supplementation, meds, IV fluids)
Chest sounds may be clear MEDICATIONS:
Radiographic image shows Nebulized racemic or L-epinephrine (always
“steeple sign” where the monitor for rebound respiratory distress)
trachea tapers inward Dexamethasone (PO: single dose of 0.15-0.6
mg/kg, IV: single dose of 0.6 mg/kg )

FOREIGN BODY ASPIRATION = inhalation of a foreign body that lodges in the upper trachea or lower
airways resulting in total or partial airway obstruction with local injury and inflammation (mostly < 3 years)
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT & TREATMENT
Nuts most common, seeds, hot Depends on size and location of Institute CPR and immediately send to ER
dogs, candy, grapes, raw object. Chest physiotherapy if suspect that FB is
fruits/veggies, latex Sudden, violent coughing with high
balloons, small toy parts, gagging choking followed by Chest radiograph if child can remains still
other objects with slick stridor, wheezing, and cyanosis. Rigid or flexible bronchoscopy for removal
surfaces, Unilateral wheezing and localized Humidification, bronchodilators, anti-
decrease in breath sound. inflammatory medications after removal
Persistent cough, voice changes,
stridor, dyspnea, sputum
production, emesis.
May progress to bronchiectasis,
abscess, or pneumonia

BRONCHITIS = nonspecific inflammation of the larger lower airway and leads to a cough. If last longer then
2 wks., considered chronic but rarely occurs in children (suspect more serious underlying problem if persists)
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT & TREATMENT
VIRAL most common: Brassy cough Purulent Supportive Bronchodilators for
parainfluenza, RSV, Coarse bronchial sputum outpatient care wheezing
rhinovirus breath sounds (increase fluids) Avoid expectorants,
Low or no fever antihistamines, &
BACTERIAL: Rhinitis, Cough lasts Antibiotics that cough suppressants
Mycoplasma pneumonia, nasopharyngitis, >10-14 cover Mycoplasma Avoid irritants,
Bordetella pertussis (if conjunctivitis days & Chlamydia overcrowding. Wash
immunization incomplete), during acute phase Inhaled steroids if hands often.
Chlamydia pneumonia chronic infection

BRONCHIOLITIS Most common acute lower respiratory illness in children = an acute viral infection of the smaller airways.
Characterized by edema, epithelial cell necrosis of small airways, ↑mucous production, & bronchospasm.
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT & TREATMENT
RSV INITIAL SYMPTOMS: rhinorrhea, congestions, Careful monitoring of respiratory status
cough, ↓appetite, & low-grade fever (use O2 if hypoxic)
PROGRESSES TO: ↑ WOB, tachypnea, ↓appetite or Palivizumab 15 mg/kg IM given in 5
poor suck, ΔLOC or activity level monthly doses starting in November or
Wheezing, crackles, ↑RR w/shallow breathing, December (indicated as a preventative
retractions, nasal flaring, prolonged expiratory phase measure for children < 2 years with
Spleen & liver palpable due to hyper-inflated lungs chronic lung disease, history of
Chest radiograph shows focal infiltrates, prematurity, congenital heart disease)
hyperinflation, peribrochial thickening, air-trapping, Strict contact precautions
patchy atelectasis Decrease environmental irritants
PNEUMONIA = an inflammation of the pulmonary parenchyma
ETIOLOGY SIGNS/SYMPTOMS RADIOGRAPH MANAGEMENT & TREATMENT
V Cough
I Bronchodilators
R Tachypnea Chest physiotherapy
I A (w/ retractions, ↑fluids
N L nasal flare, Supplemental O2
RSV parainfluenza, Hyperinflation
F
influenza A&B, adenovirus expiratory Wheezing Bilateral interstitial Self-limiting
E grunting,
( rhinovirus infiltrates
C cyanosis, rash)
T 8
I 0
Neck, chest,
O % abdominal
U ) pain
S Neonates: B strep, Patch infiltrates
enterococcus, L. depending on Lobar
location Abrupt
monocytogenes, E.coli, consolidation
P B onset of
ureaplasma urealyticum Pleural effusion
N A Nausea/Vomit fever,
1-3 mo.: S. aureus (rapidly
E C chills,
toxic), S. pneumonia, H.
U T cough, &
influenza, B. pertussis,
M E chest pain
Chlamydia pneumonia
O R ↑WBC
4mo-4year: S. pneumonia, Amoxicillin
N I ✚agglutini
S. aureus, H. influenza, 12mg/kg/day
I A n
A L titer(>1:64) Azithromycin 12
✚PCR mg/kg/day OR
≥ 5 years: S. pneumonia
Amoxicillin 80-
100mg/kg/day
Ingestion of food, saliva,
gastric contents, or other
ASPIR
substance into the air Diffuse or
ATIO
passage. (common in localized mottled
N
children with airway infiltrates in the Clindamycin
PNEU
abnormalities, neurological dependent area of
MONI
problems, GERD) the obstruction
A
Ingestion of water while
drowning or EtOH in teens

CYSTIC FIBROSIS = Autosomal recessive disorder of cystic fibrosis transmembrane regulation causing defective epithelial ion
transport (↓Na reabsorption, ↑chloride secretion) which results in dehydrated, viscous secretions which obstruct the exocrine ducts in the
respiratory hepatobiliary, gastrointestinal and reproductive tracts (more common in causation people – life expectancy is 37 year with
respiratory failure as the leading cause of death)
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT & TREATMENT
Mutation in a single Delayed passage of extremely viscid meconium in newborns Genetic testing for confirmatory diagnosis
gene in the long arm Poor growth despite ↑appetite Inhaled mucolytic agents
of chromosome 7 Recurrent respiratory infections Recombinant human DNase (pulmozyme)
Large, bulky, foul smelling, greasy stools Inhaled Tobramycin
Respiratory Flatulence Oral azithromycin for chronic respiratory
infections most Chronic, productive, blood-streaked mucous infections caused by P. aeruginosa
commonly results Salt tasting skin
from P. Infertility (more so in males)
aeruginosamost common, Barrel chest
S. aureus, H. Delayed puberty
influenza, P. Nasal polyps
aeruginosa, B. Digital clubbing
capacia ↑WOB, wheezing, crackles
Two pilocarpine iontophoresis sweat test with chloride levels
> 60mmal/L
↓Na, ↓protein, ↓chloride
↑ALT/AST
Vitamin A, E, and K deficiency
ASTHMA: chronic lung disease characterized by airway inflammation and narrowingultimatly leading to airway remodleing
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT & TREATMENT
IgE mediated Recurrent episodes of coughing, wheezing, Age appropriate step-wise asthma management guidelines
response to common mucous, chest tightness, breathlessness, ↓ based on…
allergens leading to endurance (due to bronchospasm) 1) frequency of symptoms
inflammatory cell Worsening symptoms at night or with exercise 2) timing of symptoms
infiltration with Allergic shiners 3) interference with daily activity’s
neutrophils, Nasal congestions and mouth breathing 4) Pulmonary function tests (PFT’s)
eosinophil’s, Atopic dermatitis 5) need for short acting medications
lymphocytes, and Barrel chested, hypoxia Follow up every 1- 6 months – review asthma actions plan
mast cell activation PFTs show ↓FEV1, FEV1/FVC that ↑ w/ short- and step ↑ or ↓ as needed
acting inhaled β2 agonist Ensure proper administration by patient
TRIGGERS: viral Chest radiograph shows bilateral hyperinflation Reduce environmental triggers
respiratory ↑Eosinophil’s on CBC MEDICATIONS
infections, dust ↑IgE LONG-TERM CONTROL (daily) QUICK-RELEIF (prn)
mites, roaches, ✚Radioallergosorbent test (RAST) Inhaled corticosteroids [ICS] via Inhaled short-acting
mold, animal nebulizer or inhaler beta2agonists
dander, seasonal (beclomethasone, budesonide, (albuterol, levalbuterol)
tree, grasses, weeds, flunisolide, fluticasone, Anticholinergics
pollens, molds, triamcinolone) (ipratroprium bromide)
whether changes, Leukotriene modifiers Short course of
excersise, GERD, (montelukast, zafirlukast) systemic
tobacco smoke, Long-acting beta2 agonists corticosteroids
pollution, strong [LABA] (salmeterol, formoterol) –
odors, food allergies, not used in immunotherapy
ASA, beta-blockers, without subsequent ICS
NSAIDS, anxiety Omalizumab - prevents binding of
and other extreme IgE and only used in step 5 & 6
emotional states Chromolyn sodium or
nedocromil – for exercise induced
bronchospasm

BRONCHOPULMONARY DYSPLASIA (BPD): any child requiring supplemental oxygen at 36 weeks or greater with radiographic
changes of chronic lung disease
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT & TREATMENT
Premature and Low birth weight Acute respiratory distress in the first few Maintain adequate oxygenation (at least > 92%) by
babies (<1000g/2lbs) weeks of life providing supplemental oxygen
Respiratory complications in the Poor growth, poor feeding Monitor for desaturation during sleeping and feeding
first few weeks of life (respiratory Fussy with decreased endurance Nutritional supplementation (high caloric formulas)
distress syndrome, meconium Tachypnea with retractions Supplemental tube feed as needed
aspiration, persistent pulmonary Diffuse crackles and wheezing Inhaled bronchodilators
HTN, severe lower respiratory Pale with cyanotic episodes Diuretics (not for long term use)
infection, chronic aspiration, Chest radiograph show hyperinflation, Inhaled beta2agonists with corticosteroids can be
maternal infection) emphysema, cyst formation, fibrosis, used in older children
Lung immaturely, barotrauma from CV changes Palivizumab 15 mg/kg IM & RSV immunoglobulin
mechanical ventilation, Cardiac insufficiency leading to fluid Close follow up every 1 to 3 months
malnutrition, fluid overload overload Reduce environmental irritants
Avoid high density daycares
Refer for early intervention, financial assistance,
home nursing and equipment, family
counseling/support, case management
APNEA: Respiratory pause lasting > 20 seconds or associated with cyanosis, bradycardia, marked pallor, or hypotonia
TYPES AND ETIOLOGY
CENTRAL APNEA: ↓CNS stimuli to
respiratory muscles leading to cessation
of airflow without respiratory effort
OBSTRUCTIVE SLEEP APNEA:
cessation of airflow despite
accompanying respiratory effort
MIXED APNEA: both central and
obstructive sleep apnea
APNEA OF INFANCY: pathologic apnea performance, hyperactivity, poor growth,
in infants that are >37 wks. gestation at
onset (demand diagnostic evaluation)
APNEA OF PREMATURITY: periodic
breathing with pathologic apnea in
premature infants that are <37 wks.
gestation at onset (in the absence of
disease)
PERIODIC BREATHING: 3 or more
respiratory pauses of >3 seconds duration
with < 20 seconds of respiration between
pauses
APPARENT LIFE THREATENING
EVENT: an episode that an observer
believes is life threatening and leads to a
combination of apnea, Δ in skin color, Δ
in muscle tone, choking or gagging
(requires intervention to restore breathing.
SIGNS/SYMPTOMS MANAGEMENT & TREATMENT
During event, respiratory pause is Management dependent on cause
accompanies by marked pallor, cyanosis, ABG’S to indicate episode severity and
hypertonia, and bradycardia current stability
OBSTRUCTIVE SLEEP APNEA: Check electrolytes for elevated CO2
Loud, habitual snoring, apnea followed by Sleep study (overnight polysomnogram)
gasping, choking, and arousal, restless
sleep, diaphoresis.
May have behavioral Δ’s, poor school
or sleepiness during the daytime.
Mouth breathing Referral for adenoteonsillectomy, weight
Upper airway narrowing from loss, or a CPAP device
inflammation or structural defects (i.e.
adenoid hypertrophy)
Allergic stigmata
Sometimes obese
Lungs usually clear
Apnea monitor with an event recorder
(only detects central apnea) – requires
close supervision & does not prevent all
deaths

TUBERCULOSIS (TB): chronic, serious granulomatous infection which may lead to pulmonary, extrapulmonary, disseminated dx
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT & TREATMENT
Mycobacterium tuberculosis Usually asymptomatic Complete risk assessment every 6 months
Spread through aerosol droplets Dry, hacking, or brassy paroxysmal cough till the child is 2 then annually thereafter –
through person-to-person contact Localized wheezing, crackles, rales, dyspnea more frequent skin testing warranted if risk
Risk factors include any contact with a Lymphadenopathy factor identified
person with confirmed or suspected Abdominal pain, diarrhea, poor weight Tuberculin skin test (TST)(i.e. Mantoux)
TB, foreign born persons, travel to, or gain/weigh loss, anorexia, poor suck ✚ if >15 mm or greater (14 mm in certain
contact with a person from high risk Fever, lethargy, night sweats, chills high risk groups)
countries (Asia, Africa, Latin America, Splenomegaly, Hepatomegaly chest radiograph
Middle East, Soviet Union), homeless, Late symptoms include TB of middle ear and Interferon-gamma release assays
migrants, institutionalized, prisoners, mastoid, bones, joints, skin, and kidneys (IGRAs) (i.e. Quantiferon-TB Gold)
native American, immunodeficiency, Chest radiographs vary from normal to lobar More specific then skin test
immunosuppression, IV drug use, DM, or segmental parenchymal lesion, collapsed Useful for BCG immunized children with
chronic renal failure, malnourishment consolidation, lymphadenopathy, pleural false positive TST
effusion, or miliary disease (snowflake) Not for children < 5 years
LATENT TUBERCULOSIS LTBI requires 9 months treatment with
INFECTION (LTBI): ✚ tuberculin isoniazid once a day (longer if
skin test without clinical, radiographic, immunocompromised)
or laboratory evidence of disease
TUBERCULOSIS DISEASE: When a
child has s/s of disease or radiographic When a child is diagnosed with TB, this
evidence of disease, which persists 1-6 represents a recent transmission of TB in
months after infection (children < 10 the community → must ID the cause,
not contagious) report it to the local health department,
Pulmonary tuberculosis - lung is the Pulmonary tuberculosis – chest radiograph complete an epidemiological investigation
primary site of infection shows pulmonary infiltrates (may be and isolate individual. Evaluate
Extrapulmonary tuberculosis -
miliary tuberculosis that may involve
any part of the body (lymph nodes most
common
, CNS, meningitis)
subtle/difficult to detect) compliance with therapy and resolution of
disease via directly observed therapy
(DOT)