Chapter 32: Eye, Ear, Throat, and Respiratory Disorders

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Welcome to the Deep Dive.

Today we're really getting into it with common eye, ear, throat, and respiratory disorders in kids.

Yeah, it's a big topic and we're drawing from the Saunders NCLE -XPN Review 7th edition.

Good stuff in there.

Definitely.

So think of this as like your focused guide.

Our mission is to give you a clear, pretty concise, but still, you know, thorough look at these conditions.

We'll hit the key concepts, assessment points, interventions, important nursing considerations, all that jazz.

Basically, a way to get up to speed quickly on pediatric ENT and respiratory stuff.

And two big ideas will keep circling back to our gas exchange.

Right.

Oxygen in, CO2 out.

And sensory perception vision.

Hearing how kids take in the world.

Thinking about these really helps tie it all together.

Totally.

And hey, let's start with a little critical thinking.

Picture this.

You're looking after a kid with pneumonia and they say, ow, it hurts when I breathe.

What's your move?

Good question.

We'll circle back and tackle that one later.

Okay, cool.

So let's dive in.

Eyes first.

Sounds good.

Let's start with strabismus.

You might notice squint or maybe cross -eye.

It's essentially misaligned eyes.

The extraocular muscles, the ones controlling eye movement, just aren't coordinating properly.

Those tiny muscles that make your eyes track together.

Exactly.

Those could be a muscle imbalance, maybe paralysis, or sometimes it's congenital.

They're born with it.

And what happens if it's just left like that?

Is that a big deal?

It really can be.

It can lead to amblyopia or lazy eye.

See, the brain gets two different pictures.

And to avoid double vision, it starts ignoring the input from the weaker misaligned eye.

So the brain just tunes one out.

Pretty much.

And if that goes on too long, especially in young kids,

the vision in that eye might never develop properly.

Permanent vision loss is a real risk.

Wow.

So catching it early is crucial.

Though, it's worth noting, a little bit of eye -crossing is actually normal in infants up to about, say, four months.

Oh, okay.

Good to know.

But after that, it's definitely something to investigate.

The brain's visual pathways are developing so rapidly then.

So what signs should you be looking for besides the obvious crossed eyes?

Well, kids might squint a lot or tilt their head funny, maybe close one eye to focus.

They lose that binocular vision, you know.

That affects depth perception, right?

Exactly.

They might also get headaches, complain of double vision that's diplopia, or be really sensitive to light, which we call photophobia.

Okay.

So what are the fixes?

Options range from corrective lenses, maybe glasses,

to patching the good eye.

Ah, occlusion therapy.

Force the weaker eye to work.

Precisely.

Sometimes surgery is needed to adjust the eye muscles, ideally before age two.

And follow -up is key.

You've got to track progress.

Makes sense.

Okay.

What about conjunctivitis, pink eye?

Yep, pink eye.

Inflammation of the conjunctiva, that thin membrane covering the white part of the eye and inner eyelid.

What causes that?

Allergies?

Infections?

All of the above.

Allergies, bacterial or viral infections, those are the really contagious ones, or even just like trauma to the eye.

And it feels awful, right?

Itchy burning.

Yeah, itchy burning, scratchy feeling.

The white part, the sclera, and the conjunctiva get red.

You might see swelling, edema, just general redness.

Anything else important to know?

There's a serious point here.

If you see chlamydial conjunctivitis in an older child who isn't sexually active, that's a major red flag.

It could indicate sexual abuse.

That's really important to remember.

Okay, so how do you manage pink eye?

Infection control is huge if it's bacterial or viral.

Lots of hand washing, don't share towels, you know the drill.

Sure.

Treatment is usually antibiotic or antiviral eye drops or ointment.

Severe cases might need oral antibiotics.

And getting the drops in can be tricky with kids.

Any tips?

Oh yeah.

Gentle restraint might be needed.

Have them lie down, tilt their head back, make a little pocket with the lower eyelid to put the drops in, don't touch the tip of the bottle to the eye.

Right.

And when can they go back to school or daycare?

General rule is 24 hours after starting antibiotic drops for bacterial conjunctivitis.

And tell them,

don't rub your eyes.

Good advice.

And contacts.

Makeup.

No contacts until it's totally cleared up and they'll need a fresh pair.

Same for eye makeup.

Toss the old stuff, get new once the infection's gone.

Okay, good rundown on eyes.

Shall we move to ears?

Let's do it.

Ears are all about that sensory perception concept too, obviously.

So first up, oceidus media.

Ear infection central.

Exactly.

Middle ear inflammation or infection.

Usually happens because the eustachian tube gets blocked.

The drain pipe from the ear to the throat?

Kind of, yeah.

It was supposed to drain fluid and equalize pressure.

If it gets blocked, fluid builds up, bacteria can grow.

Boom, infection.

Can be acute or chronic.

And it often follows a cold or flu.

Very common complication.

RSV, influenza,

those respiratory infections often lead to it.

Why are little kids more prone to them?

It's anatomy.

Their eustachian tubes are shorter, wider, and more horizontal than in adults.

Easier for germs to travel up from the throat.

Ah, okay.

Can parents do anything to prevent them?

Some things help.

Feeding babies upright, not propping bottles.

Keeping up with immunizations.

Breastfeeding gives some protection.

And avoiding exposure to tobacco smoke and known allergens.

What are the classic signs?

Pain,

fever.

Definitely fever, acute ear pain, otalgia.

Kids might be crying, irritable, lethargic, off their food.

Babies might tug or rub their ear.

Do you always see drainage?

Not always, but sometimes you'll see purulent drainage pus if the eardrum ruptures.

If you look inside with an otoscope, the tympanic membrane in the eardrum might be red, bulging, maybe opaque, and it won't move like it should.

And chronic infections can cause hearing loss.

Yes, that's a significant concern with recurrent or chronic otitis media.

Can impact speech development too.

So treatment,

fluids, pain relief.

Yep, encourage fluids.

Avoiding heavy chewing might help with pain.

Local heat or cold compress on the ear.

Lying with the affected ear down can sometimes feel better.

Clean any drainage from the outer ear carefully.

And analgesics and antipyretics, acetaminophen or ibuprofen for pain and fever.

What's the deal with antibiotics now?

I hear docs are more cautious.

They are.

Especially for healthy kids over six months.

There's concern about drug -resistant bacteria like streptococcus pneumonia.

So sometimes they'll do watchful waiting for up to 72 hours to see if it resolves on its own.

Interesting.

But if antibiotics are prescribed, it's crucial to finish the whole course.

And hearing screening might be needed later, especially with repeat infections.

And giving ear drops, you mentioned a specific technique.

Right.

For kids under three, gently pull the outer ear, the pinna, down and back.

For kids over three, pull it up and back.

Helps straighten the ear canal.

Down and back, under three, up and back, over three.

Got it.

What if infections keep happening?

Then surgery might be on the table.

A maryngotomy is a small incision in the eardrum to drain fluid.

And they often put tubes in then?

Yeah.

Tympanostomy tubes or PE tubes.

They help keep the middle ear ventilated and allow drainage, equalized pressure.

What's the post -op care like?

The main thing is keeping the ears dry.

Ear plugs for baths, maybe swimming, depending on the surgeon's advice.

Definitely no diving or going deep underwater.

Pain relief as needed.

No forceful nose blowing.

Right.

Avoid that for a week or two.

And if a tube falls out, they're tiny, white, look like little spools.

It's usually not an emergency, but parents should let the provider know.

Okay, makes sense.

Let's move up to the throat area.

Tonsillitis and adenoiditis.

Inflammation or infection of the tonsils.

Those are the lymphoid tissues you see in the back of the throat, the pharynx.

And adenoids are similar tissue, but higher up behind the nose and the knees of pharynx.

And sometimes they need to come out.

Tonsillectomy, adenoidectomy.

Correct.

Especially if infections are frequent or severe, or if they're causing breathing problems like sleep apnea.

What are the signs?

Just a sore throat.

Persistent or recurrent sore throat, yeah.

Tonsils might look enlarged, red, maybe have white patches or exudate.

Difficulty swallowing dysphagia.

Kids might breathe through their mouth, have bad breath, fever, cough.

And enlarged adenoids cause different issues.

They can.

Like nasal sounding speech, chronic mouth breathing, hearing difficulties if they block the Eustachian tubes, snoring, and obstructive sleep apnea.

Before surgery, what prep is needed?

Make sure there's no active infection.

Check bleeding and clotting studies.

Prepare the child, explain they'll have a sore throat but need to drink liquids.

Also, check for any loose teeth.

Don't want those getting dislodged.

Good point.

And after the surgery, positioning.

Position them prone or side -lying initially to help drainage.

Have suction ready, but use it cautiously, only if there's an obstruction.

Bleeding is a big risk, right?

Yes,

definitely.

Monitor closely for signs of bleeding.

Frequent swallowing is a key sign the child might be swallowing blood.

If you suspect bleeding, turn them onto their side immediately and notify the RNR provider.

Okay.

Turn to side, call for help.

What else?

Discourage coughing, clearing the throat, blowing the nose forcefully.

An ice collar can help with pain and swelling.

Pain meds, of course.

Maybe anti -mimetics if they're nauseous.

What about diet?

Start with clear, cool, non -citrus, non -carbonated fluids.

Think crushed ice, popsicles.

Avoid red, purple, or brown liquids.

They can be mistaken for blood if vomited.

And milk products.

Avoid milk, ice cream, pudding initially.

They can coat the throat and make the child want to clear it, which you want to avoid.

Progress to soft foods after a day or two.

No straws, forks, or sharp objects in the mouth.

What's considered normal post -op versus cause for concern?

Some mouth odor, slight ear pain, maybe a low -grade fever are expected.

But parents should call if there's any sign of bleeding, persistent earache, or a fever that doesn't go down.

And keep them away from crowds.

Yeah, for about one to two weeks until they're healed to reduce infection risk.

And remember, bleeding risk is highest in the first 24 hours, but also around 7 -10 days post -op when the scabs might come off.

Got it.

Okay, what about epistaxis?

Nose bleeds.

Pretty common.

The nose, especially the septum dividing the nostrils, has a rich blood supply.

What usually causes them in kids?

Picking.

That's a big one.

Trauma.

Foreign bodies stuck up there.

Nose picking.

Inflammation from colds or allergies.

Usually straightforward causes.

But if they're recurrent or really severe, it could point to an underlying issue.

So a kid has a nose bleed.

Priority actions.

Stay calm yourself.

Keep the child calm and quiet.

Have them sit up and lean forward.

Forward, not back.

Definitely forward.

Leaning back makes them swallow the blood.

Pinch the soft part of the nose firmly for at least 10 minutes, continuously.

What if that doesn't work?

You could try inserting some cotton or tissue into the nostril.

An ice pack or cold cloth on the bridge of the nose might help constrict vessels.

If it persists, they need to see a provider packing or cauterization might be needed.

And after it stops?

A little petroleum jelly or water -soluble jelly inside the nostril can help prevent crusting and re -bleeding.

But if bleeding lasts over 30 minutes, despite these measures, they really need evaluation for a possible bleeding disorder.

Okay, now let's shift to some more serious upper airway problems.

Epiglottitis.

Sounds scary.

It is scary.

It's a bacterial infection causing severe inflammation of the epiglottis, that little flap covering the windpipe.

Often caused by hemophilus influenza type B, HYBE, or sometimes streptococcus pneumonia.

But the HYBE vaccine helps prevent it.

Massively.

It's much less common now because of the vaccine, but it's still a true medical emergency.

Usually affects kids 2 to 8, comes on super fast, often in winter.

It can lead to rapid airway obstruction.

What are the hallmark signs?

The 4 D's.

Exactly.

Dysphonia, muffled voice, dysphagia, difficulty swallowing, drooling, and distress.

Respiratory distress.

Also high fever, very sore throat.

The epiglottis itself looks cherry red and swollen and visualize, but don't try to look.

Right.

Big warning there.

Huge warning.

Also, a key finding is the absence of a spontaneous cough.

They might have inspiratory stridor that's worse when lying down.

Retractions, dachycardia, tympania.

They often assume that classic tripod position.

Leaning forward, hands on knees, trying to get air in.

That's the one.

It's their way of maximizing the airway opening.

This situation can quickly progress to hypoxia, hypercapnia, acidosis, and decreased consciousness.

Okay.

Absolute priority intervention.

Maintain a patent airway, period.

On a respiratory status, constantly work of breathing, stridor, O2 sats.

Have emergency airway equipment ready, intubation gear, possibly tracheotomy setup.

Things not to do.

Critically important, do not attempt to visualize the throat with a ton depressor or get a throat culture if you suspect epiglottitis.

Don't take an oral temperature.

Any of that could trigger complete airway obstruction.

Okay.

What else?

Keep the child calm.

Avoid making them lie supine.

Don't restrain them if possible.

NPO nothing by mouth.

4V fluids are needed, but maybe delay starting the IV until the airway is secured to avoid agitation.

Medications.

5V antibiotics stat, followed by oral.

Amnesiacs, antipyretics.

Corticosteroids to reduce swelling.

Maybe nebulized epinephrine in some protocols, but usually it's about securing the airway first.

Cool -miss oxygen.

And never, ever leave the child unattended.

Whew.

Okay.

Serious stuff.

Let's contrast that with laryngo -tracheobronchitis, or CRUPE.

Right.

CRUPE is also inflammation, but lower down larynx, trachea, bronchi.

Most common type of CRUPE, usually viral, affects younger kids, typically under five.

What viruses usually cause it?

Perinfluenza is a big one.

Also RSV, mycoplasma pneumonia, influenza A and B.

Unlike epiglottitis, CRUPE usually has a gradual onset, maybe after a cold.

And the classic sound is that seal bark cough.

That's the one.

Also hoarseness, inspiratory stridor.

It tends to worsen at night.

There are stages described.

Walk us through those briefly.

Stage one, barky cough, hoarseness, stridor when agitated, maybe low fever.

Stage two, continuous stridor, even at rest, retractions, use of accessory muscles, labored breathing.

Stage three, signs of anoxia, hypercapnia, start restlessness, pallor, sweating, rapid breathing.

Stage four, sinosis, maybe apneic episodes, leading towards respiratory arrest if untreated.

So interventions for CRUPE.

Airway is still key, right?

Always maintain airway, monitor respiratory status closely, elevate the head of the bed, keep the child calm and rested.

Humidified air is a mainstay.

Cool mist.

Yeah, cool mist is generally preferred.

In the hospital, maybe a cool mist, tent.

At home, a cool air vaporizer.

Sometimes taking the child in a cool night air or even opening the freezer door for them to breathe that cold air can help reduce airway swelling.

Fluids, meds.

Encourage fluids, foivy if needed.

Analgesics for fever.

Importantly, avoid cough syrups or cold medicines.

They don't help and can sometimes make secretions thicker.

Corticosteroids, like dexamethasone, are often given, orally or injected, to reduce inflammation.

For moderate to severe CRUPE with stridor at rest, nebulized epinephrine, racemic epinephrine, can provide temporary relief by constricting blood vessels in the airway.

Antibiotics only if a bacterial cause is suspected.

And have resuscitation gear handy.

Always.

And provide reassurance to parents CRUPE can sound very frightening.

Isolation precautions if they have URI symptoms until the cause is known.

Okay, let's move down the airway, bronchitis.

Inflammation of the tracheobronchitis usually follows a cold, typically viral, and fairly mild.

Symptoms.

Cough.

Yeah, starts with a dry, hacking, non -productive cough, often worse at night.

Then after a few days, it usually becomes productive, they start coughing up mucus.

Might have a low fever.

Treatment is mostly supportive.

Pretty much.

Symptomatic treatment.

Monitor for any respiratory distress.

Cool, humidified air helps.

Push fluids.

Antipyretics for fever.

Rest.

Okay.

Now bronchiolitis and respiratory syncytial virus, RSV, are they the same thing?

Not exactly.

Bronchiolitis is the conditioned inflammation of the bronchioles, those tiny airways.

They get clogged with thick mucus.

RSV is the most common cause of bronchiolitis, especially in infants.

But other viruses can cause bronchiolitis too.

Yes, like adenoviruses, parainfluenza.

But RSV is the big player, especially in winter and spring.

It's super contagious through direct contact with secretions.

Who's most at risk?

Primarily infants and young toddlers.

Peak incidence is around six months.

Older kids usually just get cold -like symptoms.

But infants, especially preemies or those with underlying heart or lung conditions, can get very sick.

How do you diagnose it?

Usually based on symptoms, but testing nasal secretions for RSV, like a nasal swab, can confirm it.

Can it be prevented?

Good hand washing is key.

Avoid smoke exposure.

Breastfeeding helps.

And for high -risk infants, there's a monoclonal antibody called Pellivzumab, synagis, given monthly during RSV season, usually November to March.

What does RSV bronchiolitis look like?

It often starts like a cold.

Runny nose, maybe eye -year drainage, sore throat, cough, sneezing, maybe a low fever.

Then it progresses.

To more breathing problems.

Yeah.

Increased coughing and wheezing, signs of air hunger, tachypnea, fast breathing, retractions, maybe cyanosis.

In severe cases, breathing can get really rapid, like over 70 breaths a minute.

Breath sounds might diminish, signs of poor air exchange, listlessness, even apnea.

How do you manage these kids?

Supportive care is the main thing.

Maintain the airway.

Cool humidified oxygen if their sats are low.

Monitor pulse oximetry closely.

Encourage fluids 5E if they can't drink enough.

Suctioning helps.

Yes.

Gentle suctioning of the nose, especially before feeds, can make a big difference.

Positioning them with the head slightly elevated, maybe 30, 40 degrees, can help breathing.

What about medications?

Bronchodilators, steroids.

Kind of controversial.

Bronchodilators are sometimes tried, but don't always help in bronchiolitis.

Steroids generally aren't recommended.

Ribavirin, an antiviral, is sometimes used for very high -risk infants, but its use is limited.

Cough suppressants are generally avoided.

Hospitalization needed.

Often.

Yes, especially for infants with respiratory distress or dehydration.

They'll need isolation contact and standard precautions.

Gown and gloves for care.

Ideally, cohort RSV patients together or put them in single rooms.

Nurses caring for RSV patients ideally shouldn't care for other high -risk kids.

Okay.

Let's tackle pneumonia.

This seems like a big one for gas exchange.

Absolutely.

Pneumonia is inflammation of the lung tissue itself, the pulmonary parenchyma, and the alveoli, those tiny air sacs.

When they get inflamed and filled with fluid or pus, gas exchange is directly impaired.

Less oxygen gets in, less CO2 gets out.

What causes it?

Viruses.

Bacteria.

Both, and other things too.

Viral pneumonia is actually more common, often follows a viral URI.

Mycoplasmal, or walking pneumonia, primary atypical pneumonia, is common in school -aged kids, especially in fall -winter, spreads in crowded places.

Bacterial pneumonia can be quite serious, sometimes leading to complications like fluid around the lung, pleural effusion, or pus and pima.

Streptococcus pneumonia is a common bacterial culprit.

And aspiration.

Aspiration pneumonia happens if a child inhales food, vomit, liquids, even foreign objects into their lungs.

Causes inflammation, often with foul -smelling sputum and worsening symptoms.

Prevention.

Vaccines help.

Yes.

The pneumococcal conjugate vaccine, PCV, protects against many types of streptococcus pneumonia and has significantly reduced bacterial pneumonia rates.

Let's break down the types.

Viral pneumonia, often gradual onset, can range from mild fever and cough to high fever.

Severe cough, looking quite unwell.

Cough might be dry or productive of whitish sputum.

You might hear wheezes or crackles.

Treatment is supportive.

Oxygen, if needed.

Cool humidity, fluids, rest, fever control.

Chest physiotherapy, CPT, might be ordered.

Primary atypical pneumonia, walking pneumonia.

Also gradual onset, usually.

Fever, chills, headache, muscle aches, malaise.

Might have sore throat, runny nose.

The cough is often dry and hacking initially.

Then might produce mucus, sometimes blood streaked.

Again, treatment is mostly symptomatic.

Usually resolves in 7 -10 days, though the cough can linger.

Antibiotics, like macrolides, might be used if mycoplasma is confirmed or strongly suspected.

And bacterial pneumonia?

Sounds more severe.

It often is.

Onset can be abrupt.

Infants might be irritable, lethargic, feed poorly, have a sudden high fever, risk of seizures.

Show significant respiratory distress, air hunger, dachypnea, cyanosis around the mouth.

Older kids might have headache, chills, chest or abdominal pain.

Cough starts dry hacking, then becomes productive of purulent sputum.

You might hear crackles, wheezing.

If there's consolidation, lung area filled with fluid, breath sounds will be decreased there.

How is bacterial pneumonia treated?

Antibiotics are key, started promptly, often IV in the hospital initially.

Oxygen for distress, cool mist, maybe.

Fuctioning, if needed.

CBRT and postural drainage might be ordered.

Rest is important.

What about positioning?

If the pneumonia is just in one lung, unilateral, having the child lie on the affected side can act like a splint, reducing pain from pleural rubbing and potentially improving ventilation profusion matching in the good lung.

But always follow specific orders.

Fluids.

Fever control.

Encourage fluids.

For beta, if needed.

Watch for aspiration risk.

Antipyretics for fever.

Monitor temperature closely due to febrile seizure risk.

Isolation precautions might be needed depending on the bacteria.

Cough suppressants may be before rest if the cough is really disruptive and non -productive, but generally you want them to cough up secretions.

Complications like empyema might need drainage.

Yes.

Sometimes chest tubes are needed to drain pus.

Thoracentesis might be done to remove fluid for testing or relieve pressure.

And always, with any respiratory illness, monitor hydration status and nutrition carefully.

Weight loss and dehydration are common problems.

That pneumonia explanation connects perfectly back to gas exchange.

Let's shift to chronic issues.

Asthma.

So common.

Very common.

It's a chronic inflammatory disorder of the airways.

Airway hyperresponsiveness is the key feature.

It's classified by severity, right?

Yes.

Intermittent, mild persistent, moderate persistent, severe persistent.

Management focuses on medications,

controlling environmental triggers, and lots of education.

What happens during an asthma attack?

Basically, exposure to a trigger causes inflammation,

bronchoconstriction, airways tighten, bronchospasm, and increased mucous production.

All this narrows the airways, making it hard to breathe out.

Air gets trapped.

What kind of things trigger asthma?

So many things.

Allergens like pollen, dust mites, pet dander, mold, irritants like smoke, strong smells, air pollution, exercise, cold air, weather changes, respiratory infections, stress, strong emotions, even GERD.

How is it diagnosed?

Based on symptom patterns, physical exam, maybe chest x -ray to rule other things out, omenary function tests, spirometry are key, peak flow monitoring.

Allergy testing can help identify triggers.

What's status asthmaticus?

That's a severe life -threatening asthma attack that doesn't respond to usual rescue treatments, requires immediate emergency care, could lead to respiratory failure.

How does asthma affect gas exchange?

The narrowed airways and air trapping directly impede airflow, leading to less oxygen getting into the blood, hypoxemia, and in severe attacks, difficulty getting CO2 out, hypercapnia.

What does an asthma attack look like?

Signs and symptoms?

Classic symptoms are recurrent episodes of wheezing, shortness of breath, dyspnea, chest tightness, and cough, often worse at night or early morning.

And during an acute attack?

It gets worse.

Increased work of breathing, retractions, maybe audible wheezing, cough might start dry and hacking them, become rattling with clear, sticky sputum.

They might look pale or flushed, maybe cyanotic around the lips or nail beds if it's severe,

often restless, anxious, sweaty, might speak in short phrases.

Younger kids might use tripod position.

Older kids often sit upright, hunched over, bracing themselves.

They usually refuse to lie down.

What about exercise -induced asthma?

Symptoms like coughing, shortness of breath, chest tightness, wheezing pop up during or shortly after exercise.

Is there a danger sign if wheezing decreases?

Yes.

A silent chest during a severe attack is ominous.

It means airflow is so reduced that there's not even enough movement to create a wheeze.

Big emergency.

Okay, priority nursing actions during an acute attack?

Assess airway and breathing immediately.

Provide supplemental oxygen, usually humidified.

Administer quick relief.

Rescue meds typically inhaled short -acting beta agonists like albuterol via nebulizer or MDI with spacer.

Start an IV.

Monitor O2 sats, respiratory status.

Color continuously.

Stay with a child.

Be ready for potential intubation if their tiring or gas exchange is failing.

Prepare for chest x -ray, maybe ABGs.

You mentioned rescue meds.

What are the main types of asthma meds?

Two main groups.

Quick relief rescue meds for acute symptoms.

Short -acting beta agonists, SABAs like albuterol,

anticholinergics like epitropium, and systemic corticosteroids, oral or IV, for more severe exacerbations.

And long -term control preventer meds.

Taken daily to control inflammation and prevent symptoms.

Inhaled corticosteroids, ICS, are the mainstay.

Others include long -acting beta agonists, lay bays, usually combined with ICS, leukotriene modifiers, mass cell stabilizers, and sometimes biologics like anti -IGE antibodies for severe allergic asthma.

Why are they usually given?

Inhalers, nebulizers, or meter dose inhalers, MDIs.

Often with a spacer device, especially for corticosteroids, to improve lung deposition and reduce oral thrush risk.

Dry powder inhalers, DPIs, are another option for older kids.

Proper technique is crucial.

Important to monitor growth with inhaled corticosteroids.

Yes, especially at higher doses.

Monitor growth, though the benefits usually far outweigh any small potential effect on final height.

What about chest physiotherapy for asthma?

Generally not recommended during an acute attack.

Breathing exercises might be part of long -term management, but not for exacerbations.

And allergen control is huge, right?

Absolutely.

Identify triggers through testing or history, then educate families on avoidant strategies, dust mite covers, air purifiers, keeping pets out of bedrooms, etc.

What are key home care points?

Educate on recognizing early warning signs, proper medication use,

rescue versus controller, inhaler technique, peak flow meter use, keep a written asthma action plan,

avoid triggers, ensure adequate hydration, encourage appropriate exercise, keep immunizations up to date, especially flu shots, communicate with the school, foster age -appropriate self -management.

Okay, let's switch to cystic fibrosis, CF.

This one affects multiple systems, doesn't it?

It does.

It's a genetic disorder, autosomal recess, of affecting exocrine glands throughout the body.

The basic defect affects chloride transport, leading to thick, sticky mucus production.

And that thick mucus causes problems everywhere.

Pretty much.

Lungs, pancreas, intestines, liver, reproductive system, sweat glands.

How is it diagnosed, sweat test?

The quantitative sweat chloride test is the gold standard.

Abnormally high salt levels in the sweat.

Newborn screening, testing immunoreactive trypsinogen, IRT, picks up most cases now, often followed by genetic testing and air sweat testing.

Let's talk respiratory effects first.

How does the thick mucus impact gas exchange?

It clogs the small airways, trapping bacteria, leading to chronic infection, inflammation, and progressive lung damage, like bronchiectasis, emphysema, atelectasis.

This scarring and obstruction severely impairs gas exchange over time.

Leads to chronic hypoxemia.

Yes, and that can cause pulmonary hypertension and eventually corpulmenel right -sided heart failure due to lung disease.

Other complications include pneumothorax, collapsed lung, and hemoptysis, coughing up blood.

Common symptoms are chronic cough, wheezing, dyspnea, clubbing of finger stows, barrel chest, recurrent bronchitis, pneumonia.

What about the GI system?

Pancreas problems.

The thick mucus blocks pancreatic ducts.

Digestive enzymes can't reach the intestine.

This causes poor digestion and absorption, especially of fats.

Leads to statorrhea, fatty, bulky, foul -smelling stools.

Malnutrition, failure to thrive.

Deficiency in fat -soluble vitamins, ADEK.

Newborns might have meconium myelitis?

Yes.

That's often the earliest sign bowel obstruction caused by thick meconium.

Older kids can get Distal Intestinal Obstruction Syndrome, DIOS.

Rectal prolapse can occur due to bulky stools.

Pancreatic damage also increases the risk of developing CF -related diabetes.

And the sweat glands, they taste salty.

Increased sodium and chloride in sweat.

Makes them prone to dehydration and electrolyte imbalances, especially in hot weather or with fever.

Reproductive issues too.

Often delayed puberty in females.

Many women have reduced fertility due to thick cervical mucus.

Most men with CF are infertile due to blockage or absence of the vas deferens.

Okay, managing CF seems complex.

Respiratory interventions.

Huge focus on airway clearance.

Chest physiotherapy, CPT, percussion, and postural drainage is vital, often multiple times a day.

Newer techniques include oscillating PP devices like the flutter or acapella, or high -frequency chest wall oscillation vests.

Huff coughing, forced expiratory technique, helps mobilize mucus.

Medications for the lungs.

Inhaled bronchodilators are often used before CPT.

Inhaled bucolytics like dornase alpha, pulmozyme, help thin mucus.

Inhaled hypertonic saline draws water into airways to thin mucus.

Frequent courses of antibiotics, oral, inhaled, or IV via central lines, are needed to treat chronic infections.

Anti -inflammatory meds might be used.

Oxygen for hypoxemia.

Lungs transplant is an option for end -stage disease.

Regular exercise is also really important for lung health.

And GI management, those pancreatic enzymes.

Need pancreatic enzyme replacement therapy?

Pierre.

With every meal and snack, Capsules contain enzymes like lipase, protease, amylase.

Dosage is adjusted based on growth and stool character.

They need a high -calorie, high -protein, high -fat diet to compensate for malabsorption.

Supplementation with fat -soluble vitamins, ADEK, is essential.

Monitor weight, growth, stool patterns.

Treat constipation deals.

Manage GI read if present.

Other things to monitor.

Blood glucose for CF -related diabetes.

Ensure adequate salt intake, especially when sweating.

Monitor bone health.

Provide tons of education and psychosocial support for the child and family.

Encourage independence as they grow.

Connect them with resources like the Cystic Fibrosis Foundation.

It's a lifelong intensive condition.

Okay, shifting gears to something sudden and tragic.

Sudden Infant Death Syndrome, SIDs.

Yeah, SIDs is the sudden, unexpected death of an infant younger than one year that remains unexplained after a thorough investigation, including autopsy, death scene investigation, and review of clinical history.

We don't know the exact cause.

Still unknown, though there are theories involving brain stem abnormalities affecting arousal, breathing, or heart rate control, combined with environmental stressors.

It's most common in winter, usually occurs during sleep, let always night, peaks between two, three months.

Higher rates in certain demographics, lower rates with breastfeeding, and pacifier use during sleep.

What are the known risk factors, things parents can control?

Huge one is sleep position.

Prone, stomach, sleeping significantly increases risk.

Soft bedding pillows, quilts, bumpers in the crib, sleeping on adult beds or sofas.

Overheating, co -sleeping under certain circumstances.

Example, parental smoking, alcohol use, soft surfaces, maternal smoking during pregnancy, postnatal smoking spasher.

How might an infant who died of SIDs be found?

Often found apneic, blue, lifeless, sometimes frothy, blood -tinged fluid around the nose mouth.

Maybe in any position, bedding might be disturbed.

Diaper might be wetful.

Clutched bedding, sometimes noted.

Prevention is all about safe sleep, then.

Absolutely.

The Back to Sleep campaign now, Safe to Sleep, emphasizes placing infant supine on their back.

For every sleep, use a firm, flat sleep surface, crib, bassinet, peck and play, with only a fitted sheet.

No soft bedding, blankets, pillows, toys in the sleep area.

Room sharing, infant sleeps in parent's room but on separate surface, is recommended for at least six months.

Avoid overheating, pacifier use at napped head is protective.

Avoid smoke exposure, breastfeeding is protective.

What about tummy time and flat heads?

Supervised tummy time when the infant is awake is important for development and helps prevent positional plagiocephaly, flat spots on the back of the head.

Varying the infant's head position during sleep also helps.

Avoid excessive time in car seats bouncers.

And supporting families after a SID's death must be incredibly difficult.

Devastating.

Requires immense sensitivity, support, providing information, connecting them with grief resources.

Avoid any implication of blame.

Okay, let's talk about foreign body aspiration.

Kids putting things in their mouths.

Yep, swallowing or inhaling a foreign object into the airways.

Can lodge anywhere, often in the main stem or low bar, a bronchus.

Usually the right side because it's wider and more vertical.

What kinds of things are common culprits?

Food?

Food is a big one, especially small round foods.

Hot dogs, hard candy, nuts, especially peanuts, popcorn, whole grapes.

Also small toys, parts of toys, coins, latex, balloons, anything small enough to be inhaled.

What are the signs?

Choking.

Initial reaction might be choking, gagging, coughing, maybe retractions.

If it causes severe obstruction, cyanosis.

Laryngotracheal obstruction causes dyspnea, stridor, cough, hoarseness.

Bronchial obstruction might cause wheezing, often unilateral.

Asymmetrical breath sounds, cough, dyspnea.

If it's a complete obstruction, they can't speak or cry, become cyanotic, collapse leads to unconsciousness and asphyxiation quickly.

Sometimes a partial obstruction causes less traumatic symptoms initially.

Emergency response?

Heimlich.

Yes, back blows and chest thrusts for infants under one.

Abdominal thrusts, only for older children, following basic life support guidelines.

If the object isn't expelled, need immediate medical help, often bronchoscopy to visualize and remove the object under anesthesia.

After removal.

Onager closely for airway edema, respiratory distress.

May need cool mist.

Medications.

Prevention is key.

Keep small objects away.

Supervise eating.

Cut food into appropriate sizes.

Avoid high -risk foods for young children under three to four.

Educate parents and caregivers on hazards and emergency procedures.

Okay, last one in this section.

Tuberculosis, TB.

TB is a contagious disease caused by the bacterium mycobacterium tuberculosis.

Spreads through airborne droplets when someone with active pulmonary TB coughs, sneezes, speaks.

We worry about drug -resistant strains.

Yes, multidrug -resistant TB, MDR -TB, is a major concern, often due to poor adherence to the long -trencment regimen.

Incidence is higher in certain populations.

Kids usually get infected from close contact with an adult with active TB.

What are the symptoms in kids?

Can be asymptomatic initially, latent TB infection.

If it progresses to active TB disease, symptoms might be vague.

Malaise, fever, cough, weight loss, anorexia, swollen lymph nodes, lymphadenopathy.

Specific symptoms depend on where the infection is.

Lungs most common, but can affect brain, bones, kidneys.

Later lung signs might include asymmetrical expansion, decreased breath sounds, crackles.

How was it diagnosed?

Skin test.

The tuberculin skin test, TST, or MANTU test, is common.

A positive reaction indicates infection sensitivity, but not necessarily active disease.

It usually turns positive two -ten weeks after infection.

Once positive, usually stays positive.

Newer blood tests, IGRAs, are also used.

Does a positive test mean they need treatment?

Yes.

Even latent TB infection is usually treated to prevent it from becoming active disease later.

Definitive diagnosis.

Sputum culture for M.

tuberculosis is definitive for active pulmonary TB.

Chest x -ray is supplemental.

In infants' young kids who can't cough up sputum, gastric washings might be done early morning to get swallowed respiratory secretions.

Treatment involves long -term antibiotics.

For latent TB,

usually isoniazid INH daily for nine months.

For active TB disease, it's typically a multi -drug regimen for at least six months, often INH, rifampin, RAF, purezenamide, PZA, and sometimes ethambutol initially, then dropping to two drugs.

Adherence is critical.

Rifampin causes orange -red discoloration of body fluids, important teaching point.

What about isolation?

Respiratory isolation,

airborne precautions, negative pressure room, N95 respirator for staff, is needed for hospitalized patients with active, contagious pulmonary TB until they're on effective treatment.

Sputum smears improve and cough is decreasing.

Adequate rest and nutrition are also important.

Patient and family education on transmission prevention is crucial.

Public health follow -up of contacts is essential.

Okay, we've covered a ton.

Let's circle back to that critical thinking question from the beginning.

Right, the child with pneumonia complaining of plural pain when breathing.

What should the nurse do?

A key intervention, as mentioned in the Saunders text, is to encourage the child, if the pneumonia is unilateral, to lie on the affected side.

Why does that help?

It acts like a splint for the chest wall on that side, which can reduce the pain caused by the inflamed pleural layers rubbing together during breathing.

It can make them more comfortable.

Of course, you'd also assess the pain, follow provider orders, and administer prescribed analgesics.

Good practical tip, lying on the affected side for splinting.

Okay, the Saunders review usually has practice questions.

Any key takeaways from those for this chapter?

Yeah, they hit on important points, like for RSV bronchiolitis, remembering interventions like isolation, elevating the head, cool humidified air, and contact precautions.

What about post -tonsillectomy?

A question likely emphasized monitoring for bleeding, and remembering that turning the child to the side is often the first action if bleeding is suspected, before even suctioning necessarily.

Group care.

Questions might test understanding of home care, like avoiding steam vaporizers due to burn risk, using cool mist instead, and knowing that cough suppressants aren't recommended.

Epiglottitis signs.

Recognizing those danger signs like tripod positioning and dyspnea as indicators of potential airway obstruction.

Anything else jumped out?

Let's see.

Knowing antibiotics aren't used for viral pneumonia, understanding the high calorie, high protein diet needed for CF, Correcting misconceptions about SIDs like knowing breastfeeding and pacifier use are actually protective.

Remembering the nine -month duration for INH treatment for latent TB.

Strabismus conjunctivitis eardrop.

Yeah, knowing strabismus needs intervention after four months, it's not something they just outgrow.

Using cool, not hot, compresses for bacterial conjunctivitis.

Recognizing that small reddish drainage after my ringotomy tube insertion can be normal initially.

And recalling the eardrop technique, down and back for under threes, up and back for over threes, those questions really reinforce the core nursing actions.

Excellent summary.

So we've really done a deep dive today into a whole range of common and some less common but serious eye, ear, throat, and respiratory issues in children, all based on that Saunders NCLE -XTN review.

Absolutely.

Understanding these conditions, the assessments, the priority actions, it's crucial for providing safe and effective care.

And especially for recognizing those critical situations like epiglottitis or severe asthma attacks where quick action is vital.

Okay, final provocative thought for everyone listening.

We've talked about these systems, eyes, ears, nose, throat, lungs, somewhat separately.

But think about how interconnected they really are.

How might a seemingly minor issue in one area, like chronic allergies or untreated ear infections, potentially escalate or impact another system down the line?

Yeah, thinking about the body holistically, how inflammation or infection in one spot can have ripple effects.

Definitely something to keep in mind.

Something I'm all over.

So that wraps up our comprehensive look at this chapter from the Saunders review.

We covered it all.