Restrictive Processes
Restrictive disease is less common in pediatric patients and is characterized by decreased lung
compliance with relatively normal flow rates. Examples of causative factors include
neuromuscular weakness, lobar pneumonia, pleural effusion or masses, severe pectus
excavatum, or abdominal distention. Key findings of restrictive lung disease are rapid
respiratory rate and decreased tidal volume/capacity (Carter and Marshall, 2011).
Defense Systems
The respiratory defense system includes mechanical and biologic processes. Mechanical
defenses include:
• Filtering of particles
• Warming and humidifying of inspired air
• Clearing of airway through mucociliary and coughing actions
• Spasm and breathing changes
Approximately 75% of inspired air is warmed as it passes through the nose, paranasal sinuses,
pharynx, larynx, and upper portion of the trachea. Final warming and humidifying of the
airstream take place in the trachea and large bronchi. Heat and moisture are removed during the
expiratory phase of respiration. The nose has a large surface area on which particles larger than
5 mm are trapped and filtered to prevent them from entering the lower airways. The trachea and
bronchioles are lined with various defensive cells and mucus glands. Goblet cells secrete the
mucous layer that lies on the tip of cilia. Particles entering the conducting airway are quickly
cleared by the mucociliary defenses. Coughing is a reflex mechanism that has three phases: (1)
inspiratory, (2) compressive, and (3) expiratory. Through forceful expiration FBs and other
materials can be removed from the airways; coughing propels particles. Young infants and
children cannot effectively expectorate mucus, so they swallow it. Loss of the cough reflex
leads to aspiration and pneumonia. Temporary breathing cessation, reflex shallow breathing,
laryngospasm, and even bronchospasm are compensatory efforts aimed at stopping foreign
matter from further entry into the lower respiratory tract. 797However, these respiratory efforts
offer limited protection and have significant drawbacks.
Biologic processes that protect the respiratory system include:
• Phagocytosis
• Absorption of noxious gases in the vasculature of the upper airway
• Absorption of particles by the lymph system
Phagocytosis, aided by the secretory IgA plus interferon, lysozyme, and lactoferrin, is the
principal antimicrobial defense. Particles reaching the alveoli can be phagocytized by alveolar
macrophages and polymorphonuclear (PMN) cells, cleared from the lung by the mucociliary
system, or carried by lymphocytes into regional nodes or the blood. These particles can take
days to months to clear.
, The respiratory defense system is at risk for compromise from numerous environmental
factors. Damage to epithelial cells is caused by a variety of substances and gases, such as sulfur,
nitrogen dioxide, ozone, chlorine, ammonia, and cigarette smoke. Hypothermia, hyperthermia,
morphine, codeine, and hypothyroidism can adversely alter mucociliary defenses. Dry air from
mouth breathing during periods of nasal obstruction, tracheostomy placement, or inadequately
humidified oxygen therapy results in dryness of the mucous membrane and slowing of the cilia
beat. Cold air is also irritating to the lower airways.
Phagocytic ability is also reduced by many substances, including ethanol ingestion and
cigarette smoke. Hypoxemia, starvation, chilling, corticosteroids, increased oxygen, narcotics,
and some anesthetic gases also impair phagocytosis. Recent acute viral infections can reduce
antibacterial killing capacity. Damage from infection and chemical irritants may or may not be
reversible.
Recurrent respiratory infections in children merit investigation for immunodeficiency or other
underlying diseases, such as primary ciliary dyskinesia or CF. The mnemonic SPUR (Bush,
2009) can help determine which children need further workup:
Severe infection
Persistent infection and poor recovery
Unusual organisms
Recurrent infection
Immunodeficiencies should be considered if the child has four or more new ear infections in a
year, two or more serious sinus infections, two or more pneumonias in a year, persistent oral
candidiasis, failure to thrive, two or more deep seeded skin abscesses, 2 or more months on
antibiotics without improvement, and/or the need for intravenous (IV) antibiotics to clear
infections. Also consider immunodeficiencies if there is a family history of immunodeficiency
or two or more deep skin infections (Modell et al, 2014).
Assessment of the Respiratory System
The history provides valuable information about the causes, progression, and potential
complications of a child's respiratory condition. The physical examination and diagnostic
testing allow the provider to determine the extent of respiratory distress.
History
History of the present illness can be assessed using the mnemonic PQRST:
• Promoting, preventing, precipitating, palliating factors
• Contacts: Are any family members or close contacts (e.g., day care, school) ill with similar
signs and symptoms?
• Prevention: Do you give your child any medications or supplements (include any herbs,
botanicals, or vitamins) to try to prevent a cold? What are your hand washing practices?
Do you encourage fluids when your child has a URI? Are the child's immunizations up to
date?
• Progression: Are the respiratory signs or symptoms increasing in severity, lessening, or
about the same? Is the child easily fatigued, less active, having trouble sleeping, or
working harder to breathe?
, • Treatment: Have any OTC, prescription drugs, herbs, supplements, or botanicals been
used? Have any other treatment modalities been used, including folk cures or home
remedies?
• Quality or quantity
• How severe are the symptoms? Is the illness interfering with school attendance or play?
Are breathing problems affecting the child's ability to sleep and eat?
• Region or radiation
• Does the child complain of chest pain?
• Severity, setting, simultaneous symptoms or similar illnesses in the past
• Key signs and symptoms: Has the child had symptoms or signs of a daytime or nighttime
cough, fever, vomiting, malaise, rhinorrhea, sore throat, lesions in the mouth, retractions,
cyanosis, dyspnea, or increased respiratory effort? Table 32-1 lists key characteristics and
causes of cough.
TABLE 32-1
Key Characteristics of Cough, Common Causes, and Questions to Ask in a Pediatric
History
Key Characteristics
Description and Questions to Ask
to Consider
Age factor Infants have a weak, nonproductive cough.
Staccato-like (Chlamydia trachomatis in infants); barking or brassy
Quality (croup, tracheomalacia, habit cough); paroxysmal or inspiratory
whoop (pertussis or parapertussis); honking (psychogenic).
Is the cough wet or dry?
Acute (most causes are infectious and last less than 2
Duration weeks), subacute (cough lasts from 2 to 4
weeks); recurrent (associated with allergies and asthma),
or chronic (lasting greater than 4 to 8 weeks [e.g., CF, asthma]).
Is the cough continuous or intermittent?
Productivity Mucus producing or nonproductive?
Timing During the day, night (associated with asthma), or both?
, Key Characteristics
Description and Questions to Ask
to Consider
Effect on parent and Are parents frustrated with the cough? Is it causing them to lose sleep
child and work time? Are they concerned that the child may have
something serious?
Associated Fever: May indicate bacterial infection (pneumonia).
symptoms
Rhinorrhea, sneezing, wheezing, atopic dermatitis: Associated with
asthma and allergic rhinitis.
Malaise, sneezing, watery nasal discharge, mild sore throat, no or low
fever, not ill appearing: Typical of URI.
Tachypnea: Pneumonia or bronchiolitis in infants (infants may not
have a cough).
Exposure to infection Has the child been out of the country (tuberculosis)? Is there a member
or travel of the household being treated for “bronchitis” or another cough
illness?
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller ATIHUB. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $11.49. You're not tied to anything after your purchase.
