SIDs, AW disorders,
Asthma, & Plural
Disorders
Chapters: 31,32,33 & 43
Walsh
E. Chavez RRT-NPS
Definition of SIDS
• Sudden and unexpected death of an
infant for which sufficient cause
cannot be found by a death scene
investigation, review of the history,
and a postmortem
• 1week-1 year old (2-4 months < 6months)
• ALTE (Apparent life-threatening
event)
– Color change
– Hypotonia
– 70% found in the morning…..
Risk Factors
• Lending for intervention
– Prone positioning
– Maternal smoking
– Bottle-feeding vs Breast feeding????
Normal Control of Heart
Rate and Breathing
• Breathing
– Brainstem
• Heart rate
– Autonomic nervous system
SIDS
• Etiology:
• Brainstem: controls breathing (Prematurity?)
• Central Apnea & periodic breathing
• Tests for assessing risk factors
– NO test that predicts risk for SIDS
– Polysomnography/ pneumogram
– Frequency of apnea
Polysomnography
• Parameters: Pg. 547 Fig 31-3
– EEG (Brain activity)
– EOG (Bilateral Eye Movement)
– EMG (Muscle tone) impendence belt
-EtcO2
-POX/ TCOM
-ECG
-Ph Probe
graph Figure 31-2 (pg 546)
• Laboratory Supervision: Pediatrician Who Scores?
• Setting: Pediatric Staged with Parent near
• Personnel: knowledge of the child's
behavior developmental stages
Polysomnography (cont.)
• Normal sleep development:
– REM and NON-REM
• Apnea (3 categories)
–
–
–
–
–
–
–
–
–
Rapid base line
Central: (B’sD’s andColor change) 10-25%
Obstruction:hypopnea & apnea
OB lasting >10sec or 6-8 sec (UAW OB)
Complications: Desat/ > CO2;Day time Sleepiness,
behavior changes, cor pulmonale
Treatment:
Removal of adenoidal & tonsils
NCPAP
NICU: Reflux, PofA, Hypoxia, anemia, IVH,
Seditaives, seizures, incoordiation with feedings
Home Cardiorespiratory
Monitors= Apnea Monitors
• Alert the caregiver to a
cardiorespiratory abnormality
• Diagnostic devices
• Training
• Social/parental implications
Chapter 32
Pediatric Airway
Disorders and Parenchymal
Lung Diseases
Pediatric Airway
Upper airway (Pg. 555 fig. 32-1)
Above C3-4 Peds
non expandable Cricoid rings (Narrowest portion)
-obligate nose breathers 3-6 months
Poor coronation between rr& oropharngeal
motor skills & large tongues
Developement up to 8 years of age
• Lower airway:
• Trachea > Subdivisions 17-16: adults23
generations…..RSV ?
• Airway obstruction:
• AP/ Lateral Neck-XRAY
• Assessments: RDS, Auscultate UAW: Air movement
muffled/stridor
Upper Airway Disorders
lesions, inflammatory, abnormal tissue, tone
• Supralaryngeal obstruction
–
–
–
–
Choanal atresia
Pierre Robin syndrome
Deep neck infections
Tonsillar enlargement/Peritonsillar
abscess
– Obstructive apnea
Upper Airway Disorders
(cont.)
• Periglottic obstruction
(around the glottis)
– Epiglottis
– Laryngotracheobronchitis (LTB-CROUP)
– Table 32-1 Differential Diagnosis
– Pg. 559
Epiglottitis
Life Threatening =Bacterial infection (H influenza B)
• Incidence and etiology
– <6 years old
– Noninfectious: aspiration of hot liquid, traumatic
intubations, blind finger sweep
• Signs and symptoms: ABRUPT
• Fever, soar throat, dysphagia(drooling)
• MUFFLED, retractions, RDS, upright sniffing
position
• Diagnosis: lateral NECk (Thumb sign) C&S, ABG
• Treatment: (small?) ETT, RSI, ceftriaxone,
Extubate leak?Bronchoscope, antibotcs
Epiglottitis (cont.)
Laryngotracheobronchitis
LTB-CROUP
(6 months-6 years)
• Incidence and etiology:
• Parainfluenza Virus 1
• Over several days
• Signs and symptoms:
• Low grade fever, malasise, rhinorrhea, hoarse voice
BARKY COUGH
• Diagnosis:
• Lateral neck-xray: Steeple sign (SUBglottic)
• Treatment: Racemic Epi, hydration, temp
……………..control, humidification, Mist tents, O2,
>0.35Fio2= impending resp Failure
Intubations
Laryngotracheobronchitis
(cont.)
Lower Airway Disorders
• Obstruction of the trachea and
major bronchi
– Tracheomalacia
– Congenital tracheal or bronchial stenosis
Lower Airway Disorders
pg563
• Foreign body aspiration
– Incidence:
• Leading cause of accidental death
– Signs and symptoms:
–
–
–
–
–
–
• Degree of AW OB
• Unilateral Wheezing/ reoccurring PNA
Diagnosis: AP CXR/neck and lateral
Laryngeal level
Hyperinflation/Ball valve effect
Bronchoscopy
Treatment:
Removal of object continue to monitor
patient
Foreign Body Aspiration
Lower Airway Disorders
• Atelectasis
– Etiology and pathophysiology:
• Failure to reinflate
– Signs and symptoms:
• Dyspnea
• (Severe) V/Q mismatch
• RDS
– Diagnosis: CXR, B/S, tracheal deviation
– Treatment: Hyperinflation therapy,
Bronchial hygiene therapy,
Lower Airway Disorders
• Bronchiectasis:
• Irreversible dilation of the bronical tree
– Etiology and pathology
• CF/ frequent respiratory infections
• Left lower lobes mostly involved
– Signs and symptoms:
• Chronic cough w/ copious amts of purulent
sputum
– Diagnosis: CXR and CT
– Treatment: CPT, hydration, antibotics,
Lower Airway Disorders
• Acute bronchiolitis
– Etiology: Viral Respiratory Tract infection
related to RSV
– Incidence:<1 year of age with BPD, CF, PPHN &
CHD
– Signs and symptoms: coryza, cough, RDS,
wheezing (APNEA), dehydration
– Diagnosis:Nasal Swab: +RSV
– Treatment:O2, (MV), IV, Supportive care
– Prognosis: GOOD
Pneumonia
• Viral
– 1st:Respiratory syncytial virus (RSV)
• Coryza, NASAL CONGESTION, cough & fever
• Supportive Care vs. Ribavirin
– 2nd:Parainfluenza virus Types1(LTB), 2, and
3(children<5yr)
• O2 and supportive care
– Influenza virus:
• Winter seasons
• Vaccinations yearly
– Adenovirus:
– High rates of M & M.
– Overwhelming sepsis
– Supportive care
Pneumonia
• Bacterial
– Incidence: Compromised immune function,
recurrent aspiration, malnutrition, daycare,
passive cigarette
– Etiology: microorganisms colonize in the URT
– Signs and symptoms: same as viral
– Diagnosis: CXR, > total band count>1500, CRP,
Blood Culture
– Treatment: oral/ IV antibiotics
– 7-14 days
– Pox & ABG
Chapter 33
PG. 582-597
Asthma
Most common chronic childhood
disease
Pathogenesis
• Definition:Chronic inflammatory
disorder of the AWs
– Mast cells, eosinophils, T lympocytes,
IgE, Macrophages, neutrolphils, &
epithelial cells
– Wheezing &Breathlessness
Pathogenesis of Asthma
• Pathophysiology
– Chronic airway inflammation
– Bronchial hyperresponsiveness
– Hypersecretion of mucus
• Components of Asthma:
–
–
–
–
Inflammation
-A remodeling
Bronchial constriction
-Mucous plugging
AW edema
-AW Hyperreponsiveness
RESULTS:
• HYPERinflation, atelectasis, hypoxia, V/Q mismatch,
Hypercarbia
Risk Factors for Developing
Asthma
• Allergic response:
– IgE
– Reversible vs. irreversible
– AW remoding=fibrosis
• Environmental triggers
– Intervention
– Remediate & eliminate
• Tobacco
• Cockroaches/ Dust mites
• Molds
National Asthma Education
and Prevention Program
• Purpose:
• to serve as a comprehensive tool to
diagnosis and manage asthma
• Goals: Box 33-1:
– Prevent: Chronic asthma, recurrent
– Maintain: NL ADLs, NL/near NL
pulmonary function
– Optimal pharmacology
– Meet family & patient’s expectations
Diagnosis
• Medical history:
– Symptoms & triggers
• Physical examination:
– History a stronger factor
– Prolongs expiratory phase
– RDS, Hyperexpansion
• Pulmonary function testing:
– FVC, FEV1 <80% predicted, FEV1/FV(<
65% predicted), FEF25-75%
• Bronchoprovocational challenges
(methacholine 20% decrease=+test)
•
Exercise: running/biking
– Less sensitive HR > 170
Management
• Pharmacologic therapy
– Long-term control medications
• Taken daily
• Antiinflammatoryagents/ corticosteroids
• Long acting B2 agonist(LABAs)
•
•
•
•
– Salmeterol & Formoterol 30-90 minutes
Methylxanthines
Leukotriene modifiers: inhibits
Cromolyn sodium (Stablizes mast cells)
Immnuomodulators: Binds to IgE
Management
– Quick-relief medications: (5-15 minutes)
• Short acting B-agonist last 4-6 hours
• “rescue”
• Anticholenergics
– Delivery systems
• MDI (Spacers & holding chambers)
• DPI
• SVN
Management (cont.)
• Control of triggers
– Identification of allergens
– Avoidance and control measures
– Immunotherapy
• controversial
Management (cont.)
• Peak flow monitoring
–
–
–
–
Peak flow meter
Peak flow diary
Personal best reading
Peak flow zone system
– Pg. 593
Patient and Family
Education
•
•
•
•
Asthma disease process
Medication skills
Identification and control of triggers
Self-monitoring techniques
Managing Asthma
• Exacerbations in the ED
– Assessment: PF of airflow, POX
– Beta-2 agonists
– Corticosteroids
Managing Asthma (cont.)
• Hospitalization and respiratory
failure
BOX 33-8 (Criteria for hospitalization)
– Intubation
• Elective
• Respiratory Fatigue
– Mechanical ventilation
• Low Vt
– PS ventilation Based on the degree of sedation
– I:E ratio for adequate ventilation
– Prone to pneumothorases, barotrauma, per > PIP,
& hypotension
Asthma
• Exercise-induced bronchospasm
(EIB)
– 5-10 minutes after activity
• Asthma at school
– Teachers
– Self esteem
• Asthma camps
– AHA
• SCAMP CAMP
Chapter 43
Pg. 706-714
Disorders of the Pleura
Pleural Effusion
• Clinical signs:
– Decrease in B/S, Dullness to percussion
compared to the contralateral
– Tachypnea and pain
• Diagnosis: CXR
• Tx:Thoracentesis
• Laboratory studies: Transudate vs.
Exudate, empyema (-Tube)
• Causes:BOX 43-2 & 43-3 (pg. 708)
• Complications:
•
•
•
pneumothorax
Hemorrhage
Infections
PLEURAL EFFUSION
Pneumothorax
• Clinical signs:
– Chest pain & SOB
– Decrease breathsounds on affected
side with hyperresonnance
• Diagnosis: CXR
• Treatment:
– Nitrogen washout
– Needle aspiration
– CT
HydroPneumothorax
(cont.)
Thoracostomy Drainage
• Indications: Drainge of air/ fluid
• Procedure for placement
–
–
–
–
Conscious sedation
Role of the respiratory therapist
Assist/ Place
Drainages system (3 bottles)
Thoracostomy Drainage
(cont.)
Surgery in the Pleural
Space
• Treatment of empyema
• Thoracoscopy
• Chemical pleurodesis