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NR 602 WEEK 2 QUIZ-STUDY GUIDE
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NR 602 WEEK 2 QUIZ-STUDY GUIDERestrictive 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.
,NR 602 WEEK 2 QUIZ-STUDY GUIDE
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.
,NR 602 WEEK 2 QUIZ-STUDY GUIDE
Key Characteristics
Description and Questions to Ask
to Consider
Staccato-like (Chlamydia trachomatis in infants); barking or brassy (croup,
Quality 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 weeks), subacute (cough
Duration 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?
Effect on parent and Are parents frustrated with the cough? Is it causing them to lose sleep and work
child time? Are they concerned that the child may have something serious?
Associated symptoms Fever: May indicate bacterial infection (pneumonia).
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).
, NR 602 WEEK 2 QUIZ-STUDY GUIDE
Key Characteristics
Description and Questions to Ask
to Consider
Exposure to infection Has the child been out of the country (tuberculosis)? Is there a member of the
or travel household being treated for “bronchitis” or another cough illness?
Causes
Congenital anomalies Tracheoesophageal fistula, vascular ring, laryngeal cleft, vocal cord paralysis,
pulmonary malformations, tracheobronchomalacia, congenital heart disease
Infectious agent Viral (RSV, adenovirus, parainfluenza, HIV, metapneumovirus, human bocavirus),
bacterial (tuberculosis, pertussis, Streptococcus pneumoniae), fungal, and
atypical bacteria (C. and M. pneumoniae)
Allergic condition Allergic rhinitis, asthma
Other FB aspiration, gastroesophageal reflux, psychogenic cough, environmental triggers
(air pollution, tobacco smoke, wood smoke, glue sniffing, volatile chemicals),
CF, drug induced, tumor, congestive heart failure
CF, Cystic fibrosis; FB, foreign body; HIV, human immunodeficiency virus; RSV, respiratory syncytial
virus; URI, upper respiratory infection.
Adapted from Chang AB: Cough, Pediatr Clin North Am 56(1):19–31, 2009; Cherry JD: Croup (laryngitis,
laryngotracheitis, spasmodic croup, laryngotracheobronchitis, bacterial tracheitis, and
laryngotracheobronchopneumonitis). In Cherry J, Kaplan S, Demmler-Harrison G, et al, editors: Feigin &
Cherry's textbook of pediatric infectious diseases, ed 6, vol 1, Philadelphia, 2009, Saunders/Elsevier, pp 254–
268.
• Associated symptoms: Has there been a decrease in appetite or feeding? Any rashes, headaches, or
abdominal pain?
• Similar illnesses in the past: Does the child have a history of respiratory tract infections, allergies, or
asthma? How many similar infections has the child had (e.g., croup, pneumonia, rhinosinusitis,
streptococcal tonsillopharyngitis, or frequent colds)?
• Temporal factors
• When did the illness begin?
• Was the onset acute or insidious or proceeded by the common cold?
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