Chronic Respiratory

Question 1

Asthma

Answer 1

Chronic inflammatory airway disorder; Consists of airway obstruction, bronchial irritability, edema of mucous membranes, congestion, and spasms of smooth muscles of the bronchi and bronchioles

Question 2

Asthma Patho

Answer 2

• type 1 hypersensitivity immune response
• IgE mediated. Mast cells release histamine and leukotrienes that result in diffuse obstructive and restrictive airway disease from inflam and edema of mucus membranes, accum of secretion from mucus glands, spasm of smooth muscle of bronchi and bronchioles

Question 3

How is asthma classified?

Answer 3

frequency and severity of sx (mild intermittent, mild, moderate, severe persistent) and level of control (controlled or partly controlled)

Question 4

Asthma triggers

Answer 4

pets, exercise, pollen, bugs in home, chemical fumes, cold air, fungus spores, dust, smoke, strong odors, pollution, anger, stress

Question 5

Asthma risk factors

Answer 5

age, heredity, gender, obesity, ethnicity; allergens, infection, tobacco smoke, indoor/outdoor air pollution, presence of food allergies

Question 6

Asthma CM

Answer 6

• Dyspnea
• Expiratory wheezing
• Cough
• Diaphoresis
• Paroxysmal, hacking, & nonproductive cough at onset; becomes rattling
  and productive of clear sputum
• Prolonged expiratory phase
• Anxious expression, restlessness
• Setting position
• Coarse rhonchi
• Signs of respiratory distress; nasal flaring, cyanosis, intercostal retractions

Question 7

Asthma Diagnosis

Answer 7

• Can be hard to establish, may call it bronchitis; usually diagnosed by medical hx, physical exam, lab results (no specific test to determine tho)
• PFTs helpful in confirming diagnosis and evaluating response to tx
• peak expiratory flow rate (PEFR)

Question 8

Peak expiratory flow rate (PEFR)

Answer 8

• measured with peak expiratory flow meter
• maximum flow of air that can be forcefully exhaled in 1 sec and measure in L/min
• each child needs to determine personal best during 2-3wk period when asthma is stable; recorded at least 2x/day and determines severity of sx
• used for short and daily long-term monitoring, managing exacerbation
• NOT used to diagnose asthma severity

Question 9

Green zone

Answer 9

80-100% personal best; well-controlled asthma

Question 10

Yellow zone

Answer 10

50-79% personal best; recognize which sx to pay attn to and add or inc meds accordingly

Question 11

Red zone

Answer 11

under 50% personal best; recognize sx of asthma emergency–rescue meds and call 911; take bronchodilators

Question 12

Asthma action plan (AAP)

Answer 12

Helps treat and prevent asthma attacks

Question 13

Therapeutic management of asthma

Answer 13

enviro control, dec triggers, humidity btwn 35-50%, use A/C, dec underlying inflam, chest physiotherapy, patient edu

Question 14

Drug therapy for asthma

Answer 14

Controllers (Preventer medications)
– Corticosteroids: QVAR, pulmicort, flovent
– Long Acting Beta 2 adrenergic agonists: Advair, Serevent
– Mast cell stabilizers: cromolyn
– Leukotriene inhibitors; singulair
– Methylxanthines (not used much- theophylline b/c of easy toxicity)
– Omalizumab is a monoclonal antibody used for patients with moderate to severe
persistent allergic asthma whose asthma symptoms are not controlled by inhaled
corticosteroids.

Relievers (Rescue medications)
– Short Acting Beta 2 adrenergic agonists/ Bronchodilators: Proventil, xopenex, albuterol
– Magnesium sulfate: acts to decrease inflammation and improves pulmonary function and
peak flow rate. Used in the ED or ICU with moderate to severe asthma.

Question 15

How to assess outpatient asthma?

Answer 15

• precipitating factors
• tx
• physical assessment
• meds admin properly?
• UTD AAP (revew q6M)
• modify enviro
• UTD immunizations
• URI prevention
• pulmonary exercises

Question 16

Asthma exacerbation

Answer 16

• progressively worsening shortness of breath, cough, wheezing, chest tightness
• Airways narrow because of bronchospasm, mucosal edema, and mucus plugging, with air being trapped behind occluded or narrowed airways
• Functional residual capacity rises because breathing uses total lung capacity; hyperinflation enables the child to keep the airways open and permits gas exchange
• Hypoxemia can occur because of the mismatching of ventilation and perfusion. This is seen with increasing carbon dioxide tension and decreasing oxygen tension levels

Question 17

Interventions for asthma exacerbation

Answer 17

• High Fowler’s Position
• Assessment
• Oxygen and monitoring O2 and HR and
  BP monitoring
• Teach child to use diaphragm to pull in
  and expel air
• Control Panic, maintain calm approach
• May need IV Access
• Administer Rescue Drugs
• Transition to regular meds

Question 18

PRAM

Answer 18

pediatric respiratory assessment measure; captures asthma severity

Question 19

Exercise induced bronchospasm (EIB)

Answer 19

• Asthma
• self-terminating airway obstruction that develops during or after vigorous activity
• peaks in 5-10 minutes
• sx: cough, SOB, chest pain or tightness, wheezing, endurance prob
• children should NOT be excluded from sports
• pre-medicate to prevent exacerbation

Question 20

Cystic fibrosis

Answer 20

• most common lethal inherited disease in Caucasians
• every child with one parent carrier has 25% chance of having
• autosomal recessive

Question 21

CF Patho

Answer 21

• Disrupts the normal functions of the exocrine glands
  related to sodium & chloride transport via the cystic
  fibrosis transmembrane regulator (CFTR) protein.
• Mutation on long arm of chromosome 7
• impaired sodium-chloride regulation
• abnormally thick exocrine secretions.
• Gene mutations differ in severity.
• Life Expectancy increasing

Question 22

GI tract effects of CF

Answer 22

• small intestine; intestinal obstructions
• pancreatic ducts—degeneration of pancreas, pancreatic acrylic, malabsorption syndrome, diabetes
• s/s—appetite chx, steaorrhea, azotorrhea, wt loss, tissue wasting, distended abdomen, sallow skin, anemia

Question 23

Pulmonary effects of CF?

Answer 23

• repeated episodes of bronchitis and chronic bronchial pneumonia
• generalized obstructive emphysema
• s/s—wheezy cough, inc dyspnea, thick rattling productive cough, cyanosis, pneumonia, polyps in nose, clubbed digits, chronic sinusitis

Question 24

Endocrine effects of CF

Answer 24

• Isles of Langerhans may Dec in number as pancreatic fibrosis develops and progresses
• incidence in CF-related diabetes (CFRD) greater in kids which may be cause by chx in pancreatic architecture and dec blood supply over time
• high chance of having type 2 DM

Question 25

Hepatic effects of CF?

Answer 25

- bile ducts—biliary fibrosis—biliary cirrhosis—portal hypertension - s/s—ascites, GI bleed, jaundice

Question 26

Reproductive and fluid effects of CF

Answer 26

- Reproductive system—delayed puberty, infertility (males especially) - salivary and sweat glands—electrolyte loses, salty sweat, dehydration, hyponatremia, heat stroke

Question 27

How is CF diagnosed?

Answer 27

- prenatal diagnosis--DNA analysis of chorionic villi or amniotic fluid samples - newborn screening - Pilocarpine electrophoresis (sweat chloride test) over 60mEq/L - stool for fecal fat

Question 28

CF prognosis and life extension

Answer 28

- dec life expectancy (around 50) - maximize health potential with nutrition, pulmonary hygiene, prevention/early aggressive tx of infection

Question 29

Goal of CF therapy

Answer 29

- Prevent or minimize pulmonary complications - Ensure adequate nutrition for growth - Encourage appropriate physical activity - Promote a reasonable quality of life.

Question 30

Medical management of CF

Answer 30

- in future, gene therapy, activation of mutant CFTR, protein replacement therapy - for now CFTR modulation, aggressive pulm toilet, nutritional therapy, antibiotic use

Question 31

Respiratory management of CF

Answer 31

- aggressive airway clearance (BID)--percussion manually, with positive expiratory pressure (PEP mask), vest, airway oscillators like Flutter device - airway clearance therapy - postural drainage - breathing exercises - physical exercise - oxygen (caution in kids bc can develop chronic O2 retention - aerosols, nebulizers

Question 32

Drugs for CF

Answer 32

- bronchodilators - Mucolytics--Dornase Alfa (Pulmozyme) - Chloride channel activators and sodium channel blockers - antibiotic therapy--therapy prophylactics

Question 33

CFTR Modulators

Answer 33

Meds that improve function of defective CFTR protein--regulate sodium and fluids in cells, dec chance of developing sticky mucus

Question 34

GI management of CF

Answer 34

- pancreatic enzymes by mouth - fat-soluble vitamins (A, D, E, K) - PRN stool softeners - NaCl tablets added to diet in hot weather - oral iron supplements - monitor blood gluocse

Question 35

Other management of CF

Answer 35

- anti-inflam agents and protease inhibitors - immunizations UTD including yearly flu - lung transplant

Question 36

NC for child with CF

Answer 36

- resp assessment and vigilance on chest PT and resp tx - constant assessment of IV site and admin of antibx - enzyme replacement - exercise and fun - isolation? from other CFers - high cal food and shakes, nutritional eval - impact of chronic condition on fam