Respiratory Disorders of the Pediatric Patient
I Pediatric Patients Are Classified by Age as Follows
A Premature: <37 weeks gestational age
C Infant: 30 days to 12 months
II Evaluation of the Pediatric Patient for Respiratory Distress
1. Is the problem acute, recurrent, or chronic?
2. Is the problem from ingestion, inhalation, trauma, or accident?
E The majority of pediatric admissions are for respiratory-related problems.
F Causes of respiratory problems
G Clinical identification of respiratory distress
3. Tracheal tug (suprasternal retractions)
5. Seesaw (paradoxical) breathing
H Other signs of clinical significance
a. Normal temperature: 36.1° C to 37° C
b. Low-grade fever: 37.1° C to 38.4° C (normally viral infection)
c. High-grade fever: ≥38.4° C (normally bacterial infection)
III Croup (Laryngotracheobronchitis or LTB)
1. Viral infection involving the larynx and subglottic area
2. Infectious agent: Parainfluenza virus (most common) or Mycoplasma pneumoniae and respiratory syncytial virus (RSV)
C Radiologic presentation (Figure 29-1)
1. Most children are treated at home after consult with a physician.
3. Keep child calm, prevent agitation and crying.
4. Audible stridor and restlessness may require hospitalization.
5. Cool aerosol therapy via mask (mist/croup tents are no longer the standard).
6. Inhaled racemic epinephrine via small volume nebulizer every 1 to 2 hours.
7. Intramuscular or intravenous steroids; dexamethasone 0.6 mg/kg is the treatment of choice.
8. Severe cases may require He/O2 therapy for maximum deposition of aerosolized medication.
9. Sedation is contraindicated secondary to possible respiratory depression.
10. Monitor using pulse oximetry and use of arterial or capillary blood gases once patient is stabilized.
11. Observe for signs of impending respiratory failure, including
1. Bacterial infection affecting the supraglottic structures
2. Causative agent in >80% of cases is Haemophilus influenzae type B bacteria.
3. Produces an enlarged cherry red epiglottis, which can either partially or completely obstruct the airway
4. Decreased incidence of complete obstruction secondary to conjugate H. influenzae vaccinations
2. Noticeable signs of upper airway obstruction
8. Drooling (inability to swallow)
9. Hyperextension of the neck and chest thrust forward (characteristic sitting or tripod position)
C Radiologic findings (Figure 29-2)
1. For typical clinical presentations, radiographs may not be needed.
2. A lateral neck film may differentiate croup from epiglottitis.
3. Lateral neck radiograph revealing classic “thumb sign” of a swollen epiglottis and enlarged aryepiglottic folds.
1. Keep child as calm as possible.
2. Deliver cool mist aerosol to patient as tolerated.
3. Have parent or guardian hold child if possible to keep calm.
4. Have intubation and resuscitation equipment ready at the bedside.
5. Child’s mouth, tonsils, or oropharynx should not be examined unless under controlled situation.
6. If intubation required, patient should be taken to an operating room.
7. Only skilled anesthesiologists should intubate.
8. Standby tracheotomy/cricothyroidotomy equipment should also be available.
9. Use of an oral or nasal endotracheal tube (ETT) should be 0.5 mm smaller than predicted to prevent possible trauma.
10. After the airway is secured, provide patient with good pulmonary toilet.
11. Sedate patient as necessary.
12. Obtain sputum and blood cultures.
13. Hydrate patient intravenously.
14. Initiate antibiotic therapy.
15. Maintain patient intubated for 24 to 48 hours.
17. Extubate only when an audible leak is heard around the ETT.
18. Aerosolized racemic epinephrine may be required after extubation.
19. Also provide patient with cool mist aerosol, and look for signs of possible tracheal/glottic swelling postextubation.
20. Table 29-1 compares and contrasts the signs and etiology of croup and epiglottitis.
TABLE 29-1
Comparison of Croup and Epiglottitis
| Factor | Croup | Epiglottitis |
| Etiology | Virus: Parainfluenza | Bacteria: Haemophilus influenzae |
| White blood cell count | Normal | Elevated |
| Onset | Gradual | Sudden |
| Cough | Dry, barking | Muffled |
| Lateral neck radiographic film | Subglottic inflammation | Supraglottic inflammation |
| Treatment | Symptomatic | Symptomatic, artificial airway frequently required |
1. An inflammatory disease of the bronchioles
2. The most common cause of lower respiratory tract obstruction in the young child
3. Most common in children aged <2 years
4. Most common infectious agents are RSV and parainfluenza viruses.
5. Other infectious agents include parainfluenza types 1 and 3, adenovirus, and M. pneumoniae.
6. Chemical factors may also precipitate condition (e.g., cigar, cigarette smoke).
7. Occurs most frequently in the fall and winter
8. Viruses are transmitted via contact with infected secretions.
1. A lower respiratory tract infection after 2 to 3 days of
2. It may be difficult to differentiate bronchiolitis from asthma in the younger patient.
1. Usually made by analysis of nasopharyngeal cultures
3. Clinical signs and symptoms
4. Use immunofluorescent staining techniques for presence of RSV antigen.
F Management of severe symptoms
a. Respiratory rate: >45 breaths/min
b. Distant or inaudible breath sounds
a. Its use in the clinical arena is highly controversial and has fallen out of favor in most institutions.
b. Ribavirin is delivered via small particle aerosol generator (SPAG) unit.
c. Patient must have underlying cardiac disease.
d. Underlying chronic lung disease (e.g., bronchopulmonary dysplasia [BPD])
e. Immunosuppressed children (e.g., HIV, organ transplant)
3. Monitor the Pao2 and Paco2 for impending respiratory failure.
4. Monitor patient’s fluid status.
5. Follow weight loss and gain closely.
b. The patient is lethargic and difficult to arouse.
c. The patient appears exhausted.
d. Desaturation continues despite increased FIO2 requirement.
a. Provide patient with adequate sedation.
b. Vigorous chest physiotherapy (CPT) should be performed.
c. Continue bronchodilator treatment through mechanical ventilator.
d. Maintain appropriate fluid status.
e. Monitor input and output closely.
f. Look for resolution of symptoms 3 to 5 days postintubation.
g. May take longer if patient has underlying disease process.
