A CHILD WITH RESPIRATORY DYSFUNCTIONS

ASSESSMENT
A. Physical 1. Cough 2. Rate and depth of Respiration 3. Retractions 4. Restlessness 5. Cyanosis 6. Clubbing 7. Ad entitious sounds !. Chest dia"eters #. $A#% 1. #lood &as %tudies a. A#& b. Pulse o'i"etry c. (ranscutaneous )2 "onitoring 2. *asopharyngeal culture 3. R%+ *asal ,ashing 4. %putu" analysis C. -.A&*)%(.C% 1. Chest /0ray 2. C( scan 3. #ronchography 4. Pul"onary function tests

TREATMENTS
A. 1'pectorant (herapy 1. )ral fluids 2. $i2uifying agents 3. 3u"idifications 4. Coughing 5. CP( 6. 4ucus Clearing -e ices #. )'ygenation 1. )2 ad"inistration 2. Phar"acologic (herapy 3. .ncenti e spiro"etry 4. #reathing (echni2ues 5. (racheosto"y 6. 1ndotracheal .ntubation 7. Assisted +entilation C. $ung (ransplantation

UPPER RESPIRATORY TRACT

CHOANAL ATRESIA
A unilateral or bilateral congenital obstruction of the posterior nares by an obstructing "e"brane or bony gro5th6 pre enting a ne5born fro" dra5ing air through the nose and do5n into the nasopharyn' Sx: -yspnea6 Restlessness6 7r ! or 18 catheter cannot pass thru the nares6 ,ill struggle and beco"e cyanotic during feedings 5hen "outh and nostril occluded Mgt: .+76 )ral air5ays6 $ocal piercing of the obstructing "e"brane6 9 %urgical re"o al of the bony gro5th

ACUTE NASOPHARYNGITIS
4ost fre2uent infectious disease in children .C: 203 days6 Caused by rhino irus6 co'sac;ie irus6 respiratory syncytial irus <R%+=6 adeno irus6 parainfluen>a and influen>a irus. Sx: *asal congestion6 ,atery rhinitis6 $o5 grade fe er6 1de"atous?infla"ed "ucus "e"brane6 Cough6 Pharyngitis6 %5ollen and palpable cer ical ly"ph nodes6(hic; purulent nasal discharge6 +o"iting and diarrhea6 -ehydration Mgt: *ot specific6 Antibiotics not effecti e6 Antipyretic for fe er6 Ad"inister saline nose drops6 Clean a5ay nasal "ucus6 Ad"inister &uiafenesin 5hich loosens secretions but don@t suppress cough6 Cool "ist apori>ers6 Rest and fluids6 )bser e for otitis "edia

PHARYNGITIS
Caused by group A #0 he"olytic streptococci <&A#3%= Affected children are at ris; for serious se2uela such as: <1= AR7 < 2= A&* SxA 3eadache6 7e er6 Abdo"inal pain6 Bsually subsides in 305 days Dx (hroat culture Mgt: )ral penicillin <rapid response in 24 hours=6 other antibiotics6 Penicillin C Rifa"picin0 reco""ended for carriers and resistant to penicillin6 )btain throat s5abs6 Analgesics for pain6 Cold?5ar" co"press to the nec; to pro ide relief6 )ffer 5ar" saline gargle6 -on@t force child to eat

TONSILLITIS
.nfla""ation of palatine tonsils often as a result or a iral or bacterial pharyngitis6 18D to 15D caused by &roup

beta he"olytic streptococci6 Adenitis0 infection and infla""ation of the adenoid <pharyngeal= tonsils Sx 1nlarged red tonsils6 fe er6 %ore throat6 3alitosis6 drooling of sali a6 ,hite patches of e'udates6 1nlarged cer ical ly"ph nodes6 $ethargy6 *asal 2uality of speech6 -ifficulty in hearing TxA Pro ide soft or li2uid diet6 Bse cool "ist apori>ers6 Ad"inister salt 5ater gargles6 throat lo>enges6 Analgesics for pain6 Antibiotics for bacteria infection6 usually penicillin or erythro"ycin on a 18 day course6 Antipyretic for fe er6 (onsillecto"y Pre0op: 3istory6 Physical e'a"6 $ab tests6 )bser e for loose teeth Post0op: Place the child on the side or abdo"en 5ith pillo5 under the chest6 Assess for signs of he"orrhage including PR or RRE fre2uent s5allo5ingE throat clearing and feeling of an'iety6 $i2uid analgesics6 %ips of 5ater or ice chips6 Restrict child@s acti ity after 7th day6 Return appoint"ent 2 5ee;s pots surgery6 A oid acid Fuices6 carbonated be erages6 and red fluids

CROUP
.nfla""ation of the laryn'6 trachea and "aFor bronchiE 6 "onths0 3 years0caused by 3e"ophilus influen>a Sx: 4ild upper respiratory tract infection during the night6 *o fe er or lo5 grade only6 #ar;ing cough6 .nspiratory stridor6 Retractions6 ,a;es up in e'tre"e respiratory distress Mgt: As; the parents to run the sho5er or hot 5ater tap in bathroo" until the roo" fills 5ith stea"E then ;eep the child in this 5ar"6 "oist en iron"ent6 .f sy"pto"s unrelie ed6 bring to the e"ergency depart"ent6 Cool "ist air 5ith budesonide6 steroid or race"ic epinephrine -e'a"ethasone gi en orally6 .+ therapy

EPIGLOTTITIS
.nfla""ation of the epiglottis <the flap of tissue that co ers the opening of the laryn' to ;eep out food and fluid during s5allo5ing6 An e"ergency situation because the s5ollen epiglottis is unable to rise and allo5 the air5ay open6 306 years of age6 3. influen>a type #6 pneu"ococci6 streptococci6 1cho irus and R%+ Sx: 4ild BR( infection6 .nspiratory stridor 6 3igh fe er6 3oarseness6 %ore throat6 -rooling of sali a6 Cherry red epiglottis6 $eu;ocytosis Mgt: )26 "oist air6 Cefuro'i"e for 3. influen>a6 .+ ad"inistration6 Prophylactic tracheosto"y? endotracheal intubation

FOREIGN OBJECT ASPIRATION Inhalation of a foreign obFect into the air5ay6 -islodge the obFect by purposeful coughing
Mgmt: 7or children: 3ei"lich subdiaphag"atic abdo"inal thrust6 7or infants: bac; blo5s and chest thrust Bronchi ! o"#tr$ction Sx: Coughs iolently6 -yspneic6 3e"optysis6 7e er6 Purulent sputu"6 $eu;ocytosis6 $ocali>ed 5hee>ing Dx: /0ray Mgt: Rule: *uts?Popcorns should not be gi en to children under school age6 #ronchoscopy6 %edation6)bser e closely for signs of bronchial ede"a and air5ay obstruction6 +% "onitoring6 *P) for 10 hour post procedure6 Chec; for return of gag refle'6 Cool fluids6 4ist airs6 .ce collar6 Parent education

LOWER RESPIRATORY TRACT

BRONCHITIS

.nfla""ation of the large air5aysE 4ycoplas"a pne"oniae preschool and school0aged children S%: fe er6 rhonchi and coarse ralesE -ry6 hac;ing cough 5orse at night6 producti e in 203days Mgt: analgesics6 antipyreticsE 3u"idity and cough suppresants

BRONCHIOLITIS
.nfla""ation of the fine bronchioles and s"all bronchiE adeno irus6 parainfluen>a irus6 R%+E G2 y?o6 pea;ing at age 6"onths S%: BR(.6 nasal flaring6 HRR6 retractions6 "ild fe erE prolonged e'piratory phase6 5hee>ing6 HPR6 leu;ocytosis6 H1%R6 cyanosis Mgt: antipyretics6 ade2uate hydration6 rest <hospitali>ation=6 )26 +%6 A#&6 entilatory supportE se"i07o5ler@s or prone positionE bronchodilators6 steroidsE .+ (herapy

PNEUMONIA
.nfla""ation of the pul"onary parenchy"aE .nfancy and early childhood TYPES: Accdg to "orphology: 1.$obar 1.$obar 2.#ronchopneu"onia? 2.#ronchopneu"onia? lobular pneu"onia 3..nterstitial 3..nterstitial pneu"onia Accdg to etiologic agents: 1.+iral 1.+iral 2.Atypical 2.Atypical <"ycoplas"al= 3.#acterial 3.#acterial 4.Aspiration 4.Aspiration of foreign substances

S%: high fe er6 cough <p?np= 5hitish sputu"E irritable6 restless6 lethargicE nasal flaring6 HRR6 retractions6 ronchi or fine crac;les6 dullness on percussionE pallor to cyanosis6 chest painE anore'ia6 o"iting6 diarrhea6 abdo"inal pain Mgt: Rest6 postural drainage6 suctioningE .+ (herapy6 antitussi es6 antibiotic therapyE "ist tent 5ith )2

SUDDEN INFANT DEATH SYNDROME &SIDS'

%udden une'plained death6 infants G 1yrE Cause un;no5n I brainste" abnor"ality <neurologic regulation of cardio0 respi control= 4ore co""on in 4A$1%6 J5D occur at 6"os lo5er socio0econo"ic class High(r inci)(nc( in: 1.Pre"ature 1.Pre"ature infants? $#, 2.4ultiple 2.4ultiple births 3.*eonates 3.*eonates 5ith lo5 AP&AR score 4..nfants 4..nfants 5ith C*% disturbance and respi disorders 5..ncreasing 5..ncreasing birth orders 6..nfants 6..nfants 5ith recent history of illness PREDISPOSING FACTORS: Prone positionE Bse of soft beddingsE ) erheatingE Co0sleeping 5ith adultsE &reater incidence in infants of young "others6 cigarette s"o;er esp during pregnancy6 poor prenatal care6 substance abuse

ASTHMA
.""ediate hypersensiti ity <(ype 1= responseE 4ost co""on chronic illness6 before 5yrs Affects the s"all air5ays and in ol es 3 separate processes: 1. #ronchospas" 2. .nfla""ation of bronchial "ucosa 3. .ncreased bronchial secretions S%: 5hee>ing6 no fe erE e'haustion6 frightenedE thic; "ucus secretions Mgt: a oidance of allergenE H oral fluid inta;eE s;in testing6 hyposensiti>ation to identified allergenE phar"acological agents6 .+ (herapyE a oid "il;?"il; products

DIPHTHERIA
corynebecteriu" diphtheriae .P: 206 daysE PC: 204 5;s if untreatedE 102 days05ith A#E 4(: direct or indirect .""unity I $asting ? Acti e artificial <-taP= ? Passi e artificial <antito'in= S%: gray "e"brane on the nasopharyn'6 purulent nasal discharge6 brassy cough C)4P$.CA(.)*%: 1. 4yocarditis 5ith heart failure<d18014= 2. Conduction disturbances <d18011= 3. %e ere neuritis 5ith paralysis of the diaphrag" <d3057=

PERTUSSIS

#ordatella pertussis .P: 5021 daysE 4(: direct or indirectE PC: catarrhal stage .44B*.(K: $asting ? Acti e artificial <-taP= ? Passi e artificial <seru" globulin= A.Catarrhal stage <1025;s= cory>aE snee>ingE $acri"ationE 4ild coughE $o5 grade fe erE .rritable and listless #. Paro'ys"al stage <406 5;s= Paro'ys"al cough <5hoop=E Cyanotic6 red facedE (hic;6 tenacious "ucusE +o"iting Con alescent stage &radual cessation of coughing and o"iting Mgt: #ed rest6 re"o e factors that "ay initiate coughE )ffer fre2uent6 s"all "ealsE -roplet precautionE 18 days A# course < erythro"ycin or penicillin

TUBERCULOSIS
3ighly contagious pul"onary disease 4ycobacteriu" tuberculosis <tubercle bacilli=E 4(: inhalation of infected dropletsE .P: 2018 5;s S%: %light cough due to pri"ary6 .nfla""ation6 Anore'ia6 $oss of 5eight6 *ight s5eats6 $o5 grade fe er D%: (ine test6 4antou' test6 Chest /0ray6 %putu" analysis

RESPIRATORY DISTRESS SYNDROME &HYALINE MEMBRANE DISEASE'

preter" infants6 diabetic "others6 C% lo5 le el? absence of surfactants S%: L body te"p6 nasal flaring6 sternal M subcoastal retractions6 tachypnea6 grunting seesa5 respirations6 ede"a of e'tre"ities6 pale gray color6 bradycardia6 Chest /0ray: radiopa2ue areas6 A#&: respiratory acidosis

Mgt: Ade2uate entilation and )2 assisti e entilation <CPAP=6 Acid0base balance6 *eutral ther"al en iron"ent6 Ade2uate tissue perfusion6 P hypotension6 3ydration6 electrolyte status6 1'ogenous surfactant by endotracheal tube Nsurfactant rescueO

A CHILD WITH CARDIO*ASCULAR DYSFUNCTION

ASSESSMENT
A.3istory 1. fa"ilial history of heart disease 2. teratogens during pregnancy 3. chro"oso"al abnor"alities 4. poor 5eight gain?feeding beha ior 5. fre2uent respiratory infections 6. prior "ur"urs 7. cyanosis !. respiratory difficulties J. recent streptococcal infection #. Physical Assess"ent 1. nutritional state 2. color 3. chest defor"ities 4. unusual pulsations 5. respiratory e'cursion 6. clubbing of the fingers 7. chest si>e !. abdo"inal circu"ference J. peripheral pulses 18. heart rate and rhyth" 11. character of heart sound C. -.A&*)%(.C 1+A$BA(.)* A. 1. 1chocardiography 2. Phonocardiography 3. Cardiac 4agnetic Resonance ."aging 4. 1'ercise %tress (est 5. Cardiac catheteri>ation 6. $aboratory 1'a"s

RE*IEW OF FETAL CIRCULATION

B"bilical ein -uctus enosus 7ora"en o ale -uctus arteriosus B"bilical arteries Placental illi

ACYANOTIC TYPES
COARCTATION OF THE AORTA
locali>ed narro5ing near the insertion of the ductus arteriosus S+: H #P and bounding pulses in upper e'tre"ities6 ,ea; or absent fe"oral pulses6 Cool lo5er e'tre"ities Mgt: #alloon angioplasty6 Resection of the coarcted portion 5ith an end0to0end anasto"osis6 1nlarge"ent of the constricted portion6 %' done 5ithin the first t5o years of life6 Post0op 3P* treated 5ith .+?oral hypertensi e drugs

PATENT DUCTUS ARTERIOSUS

7ailure of the ductus arteriosus to close6 5herein blood 5ill be shunted fro" the aorta because of H aortic pressure to pul"onary artery6 causing $0R shunt6 R entricular hypertrophy6 H pressure in the pul"onary circulation %/: Asy"pto"atic6 %igns of C376 4achinery0li;e "ur"urs6 ,ide pulse pressure6 $o5 diastolic pressure6 1C&: *? entricular enlarge"ent if the shunt is large 4gt: )ral? .+ .ndo"ethacin <prostaglandin inhibitor= 0repeatedly0as "any a s 3' 12024 hrs apart6 side effects: <reduced glo"erular filtration6 platelet aggregation6 &. and cerebral flo5=6%urgical ligation6 +A(%

*ENTRICULO,SEPTAL DEFECTS

4ost co""on congenital defect6 opening in the septu" b?5 the 2 entricles6 entricular hypertrophy6 H pressure in the pul"onary artery S+: 4ay not be e ident at birth6 $oud6 harsh systolic "ur"ur6 1cho?1C&?4R.: R entricular hypetrophy and pul"onary artery dilatation Mgt: Closes spontaneously6 .nter entional cardiac catheteri>ation6 )pen heart surgery

ATRIAL SEPTAL DEFECTS &ASD'

Abnor"al opening bet5een the atria allo5s blood to flo5 fro" $0R atriu" S+: 4aybe asy"pto"atic6 4ay de elop C376 4ur"urs6 Ris; for atrial dysrhyth"ias and e"boli for"ation Mgt: %urgery

PULMONIC STENOSIS
*arro5ing at the entrance of the pul"onary artery6 causes R+ hypertrophy6 "ay lead to pul"onary atresia

AORTIC STENOSIS
*arro5ing or stricture of the aortic al e6 resistance to blood flo56 L cardiac output6 $+ hypertrophy6 pul"onary ascular congestion (KP1%: 1. al ularE 2. sub al ularE 3. supra al ular

CYANOTIC TYPES
TRANSPOSITION OF THE GREAT *ESSELS &TOG*-TOGA'
Pul"onary artery lea es the left entricle6 aorta e'its right entricle6 no co""unication bet5een the syste"ic and pul"onary circulation S+: Severely cyanotic and depressed at birth6 4ay ha e sy"pto"s of C376 Cardio"egaly Mgt: Ad" of .+ Prostaglandin 116 Rash;ind procedure0balloon septosto"y6 Arterial s5itch

TETRALOGY OF FALLOT &TOF'

.ncludes four defects: 1. entricular septal defectE 2. pul"onic stenosisE 3. o erriding aortaE 4. entricular hypertrophy S+: Acutely cyanotic at birth6 4ur"urs6 #lue spells? tet spells ? ano'ic spells6 Clubbing of the fingers6 %2uatting6 Poor gro5th6 Polycythe"ia Mgt: s2uatting position6 "orphine sulfate ? beta bloc;er6 #laloc; (aussig shunt6 Co"plete repair <#roc;= during 1 st year of life

TRUNCUS ARTERIOSUS
7ailure of nor"al septation and di ision of the e"bryonic bulba trun; into the pul"onary artery and aorta6 resulting in a single essel that o errides both entricles S+: Asy"pto"atic6 4oderate to se ere C376 Poor gro5th6 Cyanosis6 Acti ity intolerance6 Ris; for brain abscess and bacterial endocarditis Mgt: %urgery Post0op co"plications: persistent heart failure6 bleeding6 pul"onary artery 3P*6 dysrhyth"ias6 residual +%-

AC.UIRED
RHEUMATIC FE*ER - RHEUMATIC HEART DISEASE
.nfla""atory disease6 affecting heart6 Foints6 C*%6 and subcutaneous ly"ph nodes6 R3- I da"age and scarring of the "itral al e6 usually follo5s a &A#3% infection S+: Carditis6 Polyarthritis6 1rythe"atous "acules <erythe"a "arginatu"=6 Chorea <%t. +itus dance?%ydenha" chorea=6 *ontender s5elling6 Arthralgia6 7e er6 1le ated 1%R6 <C= throat culture to streptococci Mgt: #ed rest6 Penicillin therapy6 )ral salicylates6 Corticosteroids6 Phenobarbital

/AWASA/I DISEASE
4ucocutaneous ly"ph 6 node syndro"e6 occurs before puberty6 asculitis6 un;no5n cause <genetic predisposition possible= S+: ACB(1 P3A%1 <%(A&1 1= H fe er ' 5days or "ore6 $ethargic6 irritable6 Reddened6 s5ollen hands and feet6 ConFuncti itis6 N%tra5berryO tongue and red6 crac;ed lips6 rashes6 enlarged cer ical ly"ph nodes6 Abdo"inal pain6 anore'ia6 diarrhea6 %5ollen and reddened Foints6 H ,#C and 1%R %B#ACB(1 P3A%1 <18 days after onset= -es2ua"ation of hands and soles6 H platelet count C)*+A$1%C1*( P3A%1 <%(A&1 ..= 15th day and lasts up to 25th days %(A&1 ... 7ro" 26th day till 1%R returns to nor"al Mgt: %alicylic acid6 .+ ga""aglobulin6 )bser e for signs of heat failure6 supporti e *.6 Care of the fa"ily: <elp fa"ily adFust6 educate6 help cope 5ith the effects of the disorder=