7. Croup syndromes (including laryngitis, tracheitis, epiglottitis)
1. Definition: several airway-blocking infections, common in children (illustration)
1. signs of croup:
1. inspiratory stridor
2. harsh/brassy cough, barking cough
3. hoarse voice
4. respiratory distress
2. types, by primary area affected:
1. subglottal area: acute spasmodic croup, laryngitis, laryngotracheobronchitis (LTB), tracheitis
2. supraglottal area: epiglottitis (illustration)
2. Etiology
1. usually viral
2. occasionally bacterial (tracheitis, epiglottitis)
3. younger children with "true croup" (spasmodic croup)
4. older children with tracheitis and epiglottitis
3. Pathophysiology: mucosa inflamed; edema narrows the airway
4. Findings
1. classic: "barky" harsh cough, stridor, hoarseness,fever, purulent secretions, dyspnea if severe
2. bacterial: child looks "sicker"
3. epiglottitis manifests the four "D's"
1. drooling
2. dysphagia (difficulty swallowing)
3. dysphonia (hoarse voice)
4. distressed inspiratory efforts
   
5. Management
1. viral
1. cool air/mist; fluids
2. if inpatient, nebulized racemic epinephrine and inhaled steroids
3. antipyretics
2. bacterial: same as above with antibiotics, possible intubation
3. concerns: if you suspect epiglottitis, never attempt to directly visualize epiglottis with tongue depressor; it could precipitate laryngospasm.
4. epiglottitis is a medical emergency; tracheotomy may be necessary
6. Nursing intervention
1. teach parent and child signs of impending airway obstruction
2. report increased pulse, respirations, retractions, increased restlessness
   

Lower Airway Disorders

12. Bronchiolitis: acute infection at bronchiolar level
1. Etiology
1. viral: RSV (respiratory syncytial virus) most common
2. occasionally bacterial
2. Pathophysiology
1. virus spreads via direct contact
2. enters body via nose or eye
3. leads to edema, mucus accumulation and cellular debris which obstruct bronchioles
4. can progress to atelectasis
3. Findings
1. usually mild URI
2. sneezing, productive cough, low-grade fever, nasal discharge, adventitious lung sounds
4. Diagnostics: history, RSV/viral nasal washing, chest x-ray
5. Management depends on severity
1. mild: fluids, humidification, rest
2. severe: antiviral, IV fluids, possibly bronchodilators, steroidsand mechanical ventilation. Maintain contact secretion precautions.
3. prophylaxis: respiratory syncytial virus immune globulin in high risk infants
   
6. Pneumonia: inflammation of lung parenchyma (illustration)
1. Etiology: usually classified by anatomic distribution or pathogen
1. most commonly viral
2. sometimes bacterial
3. sometimes aspiration of foreign substance
2. Pathophysiology
1. triggers terminal airways, alveoli infiltrate and cell destruction
2. cellular debris falls into lumen
3. bacterial agent can reach circulatory system via pulmonary lymphatics
3. Findings
1. can be abrupt or insidious
2. adventitious lung sounds, fever, malaise, nonproductive cough
3. progressing to more severe with retractions, respiratory distress, productive cough
4. Management depends on type
1. viral - oxygen, chest physiotherapy, fluids
2. bacterial - antibiotics, oxygen, chest physiotherapy, fluids
3. aspiration - supportive therapy, treatment of secondary complication
   
7. Aspiration of foreign body
1. Etiology: child aspirates solids, liquids, vegetative matter into air passages, most common in older infants and children up to three years of age
2. Pathophysiology: most substances become lodged in bronchi, and severity is determined by location, substance aspirated and extent of obstruction
3. Findings: sudden coughing, gagging, wheezing, cyanosis, dyspnea, and stridor
4. Diagnostics: chest x-ray, fluoroscopy, bronchoscopy
5. Management: direct laryngoscopy or bronchoscopy to remove object, then supportive therapy
   
8. Asthma/reactive airway disease
1. Definition: chronic inflammatory disorder, manifested by periods of exacerbations and remissions; has an allergic component
2. Etiology
1. genetic predisposition
2. triggers are: allergens, infection, stress, exercise, medical conditions, medications.
3. types: intrinsic, extrinsic, occupational
3. Pathophysiology (illustration)
1. trigger leads to an immediate phase reaction (cell activated, with mast cell, eosinophils and histamine released with other mediators of inflammation)
2. resulting in bronchoconstriction with additional granulocyte response with more inflammatory presence (illustration)
3. later phase reaction (additional inflammation and hyperresponsiveness)
4. Findings
1. classic: hacking cough, wheeze on expirations, dyspnea
2. cough may be nonproductive at first, to productive with mucus
3. change in LOC, restlessness
5. Diagnostics
1. physical exam, history
2. pulmonary function tests(PFT)
3. bronchodilator treatments, chest x-ray, skin testing, CBC with differential
   
6. Management
1. goals: normal growth and development, patent airway, good control
2. preventive: allergen control and avoidance
3. use of peak flow meter
4. medications
1. long term control (preventor) medications: to achieve and maintain control of inflammation; also called controllers
• corticosteroids
• cromolyn sodium
• nedocromil
• long acting beta adregenics
• methylxanthines
• leukotriene modifiers
2. quick relief (rescue) medications to treat acute symptoms and exacerbations:
• short acting beta adrenergics
• anticholinergics
• systemic corticosteroids
7. Acute management
1. use of bronchodilators
2. steroids (inhaled, IV and/or oral)
3. oxygen, IV fluids, possibility of intubation
8. Concerns
1. child and family must comply with medications and treatments
2. use of metered-dose inhaler (MDI) with a spacer
3. risks include overuse of bronchodilators
9. Complications
1. exercise-induced bronchospasm
2. status asthmaticus