Airway diseases
Shirley Chugani
South University

Airway diseases
Most pediatric patients suffer from upper and lower infections. Most children with these diseases are going to be managed in primary care, however some of them will show up in the emergency room.
Let us start with bronchiolitis. I am familiar with this condition since my daughter had this when she was 5 months old. She is 8 years old now, so my memory is a bit fuzzy. I remember taking her to her pediatrician and he ordered a test and it confirmed that she had Respiratory Synctial Virus (RSV). She was admitted to the hospital that same day. Her oxygen saturation was 93% and she had difficulty breathing and did not want to nurse at all. My daughter recovered and we were sent home in 2 days.
Bronchiolitis is a viral illness that affects the lower airways. It is usually seen in children under 2 years of age but it is most severe in infants who are 6 months or younger (Porth & Matfin, 2009, p. 694). RSV is responsible for 50 to 90% of all cases of bronchiolitis and results in 20, 000 hospital admissions per year (Kelsall-Knight, 2012, p. 29). Other pathogens that can cause RSV are parainfluenza, adenovirus, Influenza A & B, Human metapneumovirus, rhinovirus, enterovirus and Mycoplasma pneumonia (Kelsall-Knight, 2012, p. 29).
The virus causes epithelial necrosis and destruction of the cilia. The epithelial cells destruction triggers an inflammatory response that leads to edema of the submucosa. There is also increased secretion of mucus from goblet cells which combine with desquamated epithelial cells to form thick mucus plugs. The mucus plugs cause an obstruction in the bronchioles which result in air trapping and lobular collapse (this is why the patient is able to take air in but has have a difficult time in expiration) (Kelsall-Knight, 2012, p. 30).
Usually, with children or infants who have bronchiolitis, there is a history of a mild respiratory infection prior to the onset of the symptoms that are typical of bronchiolitis. This respiratory illness may be accompanied by a fever and a diminished appetite followed by respiratory distress (Porth & Matfin, 2009, p. 697).
Signs and symptoms are usually: tachypnea, normal to low oxygen saturations, harsh cough, poor feeding, dehydration (as evidenced by less than 8 wet diapers a day if patient is an infant), fever, wheezing, fine crackles bilaterally (Paul, 2011, p. 22). Croup may be both bacterial and viral in nature. It affects the trachea, bronchi and trachea. Croup that is bacterial in origin is epiglottitis. The bacteria that causes most of the epiglottitis cases are Haemophilus influenzae typ B, although numerous other agents may cause this life threatening illness (Chapman MD, Sandstrom MD, & Parnell MD, 2012, p. 12). It usually affects children 2 to 8 years old. This disease has a rapid onset (within a matter of hours). This is a lethal condition and warrants an immediate intervention that may require an artificial airway (Paul, 2011, p. 23). Typical signs and symptoms of a patient with epiglottitis are: the barking cough, drooling, the child will appear anxious and toxic and will position themselves in a tripod position to optimize airway patency (Chapman MD et al., 2012, p. 13). Laryngotracheobronchitis is croup that is viral in origin and is usually caused by Parainfluenza virus type 1 (Chapman MD et al., 2012, p. 12). Viral croup has a gradual onset and affects children between 6 months and 3 years. Signs and symptoms are: a history of an upper respiratory illness prior to the onset of typical signs and symptoms associated with croup, inspiratory stridor, hoarseness and a brassy seal-like barking cough (due to subglottic narrowing), mild fever and restlessness (Chapman MD et al., 2012, p. 12). Stridor and slight dyspnea are also some manifestations of viral croup, but that is usually the worst of it before the patient begins to recover (Porth & Matfin, 2009, p. 696). If a child is exposed to moist air (for example cool night air, shower vapors) the symptoms will subside (Porth & Matfin, 2009, p. 696). The diagnosis of epiglottitis and croup may be confused as some signs and symptoms are similar (like stridor, fever, the typical seal-like bark cough). Early recognition and of epiglottitis is vital to avoid a life threatening acute airway obstruction (Chapman MD et al., 2012, p. 14). If a stridulous child has a cough and not drooling it is likely to be croup. If the patient is drooling, no coughing, agitated and in a tripod position then it is more likely that it is epiglottitis (Chapman MD et al., 2012, p. 14). Respiratory distress syndrome (RDS) or hyaline membrane disease is the term that what is used to refer to respiratory dysfunctions and the preterm infant (Porth & Matfin, 2009, p. 693). Decreased production and secretion of lung surfactant is the main cause of RDS. Deficiency in surfactant leads to unequal inflation of alveoli on inspiration and the collapse of alveoli on end inspiration (Caring for The Child with a Respiratory Condition, 2009, p. 756). Signs and symptoms are evident within a few minutes after birth. These are:
Rapid, shallow respirations with a rate of 60 breaths per minute or greater, audible grunting, intercostal and subcostal retractions, nasal flaring and cyanosis. As the condition worsens, flaccidity and apnea occurs. Respiratory failure may occur with progression of the disease (Caring for The Child with a Respiratory Condition, 2009, p. 756).

References
Chapman MD, T., Sandstrom MD, C., & Parnell MD, S. (2012, April). Pediatric emergencies of the upper and lower airway [Magazine]. Applied Radiology, 10-18. Retrieved from http://web.ebscohost.com.southuniversity.libproxy.edmc.edu/ehost/pdfviewer/pdfviewer?sid=61d0f14a-2222-45dc-9756-a5a0b691bc8d%40sessionmgr110&vid=2&hid=122
Kelsall-Knight, L. (2012, October). Clinical assessment and management of a child with bronchiolitis [Magazine]. Nursing Children and Young People, 24(8), 29-34. Retrieved from http://web.ebscohost.com.southuniversity.libproxy.edmc.edu/ehost/pdfviewer/pdfviewer?sid=cadd44a9-64a4-49d1-bbd4-c8cb42507cb4%40sessionmgr111&vid=4&hid=122
Maternal Child Nursing Care: Optimizing Family Outcomes for Mothers, Children & Families. [Southuniversity]. (2009). Retrieved from
Paul, S. (2011, December). Treating lower respiratory tract ailments in children and infants [Magazine ]. Emergency Nurse, 19(8), 21-25. Retrieved from http://web.ebscohost.com.southuniversity.libproxy.edmc.edu/ehost/detail?vid=5&sid=51ec51bb-7a83-4f13-b3ae-1c9f068380df%40sessionmgr111&hid=122&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#db=rzh&AN=2011399542
Porth, C., & Matfin, G. (2009). Pathophysiology: Concepts of Altered Health States (8 ed.). [Digital Bookshelf]. Retrieved from http://www.digitalbookshelf.southuniversity.edu