WEEK 9 Mycoplasma pneumonia

- Mycoplasma organisms are similar to but

PEDIATRIC DISORDERS ACROSS larger than viruses. It occurs more
frequently in older children (over 5 years of
OXYGENATION PROBLEMS age) and more often during winter.

Pneumonia Assessment
- Inflammation of pulmonary parenchyma or - Fever, cough and feels ill
alveoli or both, caused by a virus, - Cervical lymph nodes are enlarged
mycoplasma agents, bacteria or aspiration - Persistent rhinitis
of foreign substances. - Acute/insidious onset
- The causative agent usually is introduced - Fever (lasting several days to 2 wks), chills,
into the lungs through inhalation or from the anorexia, headache, malaise and myalgia
bloodstream. (muscle pain)
- The disease is commonly divided into two - Sore throat and dry hacking cough
types: - Nonproductive cough initially progressing to
● Hospital acquired (pneumococcal production of seromucoid sputum that
or streptococcal pneumonia) becomes mucopurulent or blood-streaked
● Community acquired (chlamydia or
viral) Therapeutic management
- Most common pulmonary cause of death in - Macrolide antibiotic
infants younger than 48 hours of age (erythromycin/tetracycline)
- Erythromycin is preferred for children
Viral Pneumonia younger than 8 years
- Occurs more frequently than bacterial - Tetracycline tends to stain teeth brown and
pneumonia, is seen in children of all ages possibly stunts long bone growth
and often is associated with a viral upper
respiratory infection. Bacterial pneumonia
- Often a serious infection requires
Assessment hospitalization when pleural effusion or
- Acute/insidious onset empyema accompanies the disease;
- Mild fever, slight cough and malaise to high hospitalization is also necessary for children
fever, severe cough and diaphoresis with staphylococcal pneumonia
- Nonproductive/productive cough of small (Streptococcus pneumoniae is a common
amounts of whitish sputum cause).
- Wheezes or fine crackles - Generally abrupt and follows an upper
respiratory tract infection
Interventions - In infants, infection tends to remain as
- Treatment is symptomatic bronchopneumonia w/ poor consolidation
- Administer oxygen w/ cool humidified air as (infiltration of exudate into the alveoli).
prescribed - In older children, pneumonia may localize in
- Increased fluid intake a single lobe and full consolidation may
- Administer antipyretics for fever as occur.
prescribed ● Blood-tinged sputum - exudative
- Administer chest physiotherapy and serum and red blood cells invading
postural drainage as prescribed the alveoli.
● Thick purulent sputum - fibrin,
Chlamydial Pneumonia leukocytes and pneumococci fill the
- Chlamydia trachomatis pneumonia is most alveoli; alveoli are no longer filled w/
often seen in newborns up to 12 wks of age RBCs and serum; this is usually
because the chlamydial organism is observed after 24-48 hrs.
contracted from the mother’s vagina during
birth. Assessment
- Breath sounds are diminished and bronchial
Assessment (sound is transmitted from trachea)
- Nasal congestion and sharp cough - Lung space is filled with exudate and the air
- Fail to gain back birth weight either no longer or only poorly enters
- Progresses to tachypnea, wheezing and fluid-filled alveoli.
rales audible on auscultation - Crackles are present as a result of fluid
- Dullness on percussion = total consolidation
Therapeutic management
- Macrolide antibiotic (erythromycin)
Therapeutic management mucous membranes and decreased tear
- Antibiotics production.
● Ampicillin and third-generation
cephalosporins effective against Bronchial Asthma
pneumococci - Chronic inflammatory disease of the airways
● Amoxicillin-clavulanate prescribed - Classified on the basis of disease severity;
for penicillin-resistant organism management includes medications,
environmental control of allergens, and child
Interventions and family education.
- Antibiotic therapy is initiated as soon as the - Mast cells release histamine leads to a
diagnosis is suspected; in a hospitalized bronchoconstrictive process, bronchospasm
infant or children, IV antibiotics are usually and obstruction. Made on the basis of
prescribed. children’s symptoms, history and physical
- Administer oxygen for respiratory distress examination, chest and radiograph and
as prescribed, and monitor oxy sat via pulse laboratory tests. Precipitants may trigger an
oximetry. asthma attack
- Place the child in a cool mist tent as
prescribed; cool humidification moistens the Assessment
airways and assists in temperature - Episodes of dyspnea, wheezing,
reduction. breathlessness, chest tightness and cough,
- Suction mucus from the infant, using a bulb particularly at night or early in the morning
syringe, to maintain a patent airway if the is or both
unable to handle secretions. - Acute asthma attacks include progressively
- Encourage fluid intake (administer worsening shortness of breath, cough,
cautiously to prevent aspiration); wheezing, chest tightness, decreases in
intravenously administered fluids may be expiratory airflow secondary to
necessary. bronchospasm, mucosal edema and mucus
- Administer antipyretics for fever and plugging; air is trapped behind
bronchodilators as prescribed. occluded/narrow airways and hypoxemia
- Monitor temperature frequently because of can occur.
the risk for febrile seizures. - Attack begins w/ irritability, restlessness,
- Institute isolation precautions w/ headache, feeling tired/chest tightness; just
pneumococcal or staphylococcal before the attack, the child may present
pneumonia. itching localized at the front of the neck or
- Administer cough suppressant as over the upper part of the back
prescribed before rest times and meals if - Respiratory symptoms may include a
the cough is disturbing. hacking irritable, nonproductive cough
- Continuous closed chest drainage may be caused by bronchial edema.
instituted if purulent fluid is present (as - Accumulated secretions stimulate the
noted w/ staphylococcus infections). cough, becoming rattling and there is a
- Fluid accumulation in the pleural cavity may production of frothy, clear, gelatinous
be removed by thoracentesis; thoracentesis sputum.
provides a means for obtaining fluid for - Retractions
culture and instilling antibiotics directly into - Hyperresonance on percussion of the chest
the pleural cavity. is noted
- Breath sounds are coarse and loud, w/
Aspiration pneumonia crackles, coarse rhonchi and inspiratory and
- Occurs when food, secretions, liquids or expiratory wheezing, expiration is
other materials enter the lung and cause prolonged.
inflammation and a chemical pneumonitis. - Child may be pale or flushed and the lips
may have a deep, dark, red color that may
Assessment progress to cyanosis (also observed in nail
- Increasing cough beds and skin, especially around mouth)
- Fever w/ foul-smelling sputum - Restlessness, apprehension and
- Deteriorating results on chest x-ray diaphoresis occur
- Signs of airway involvement - Children speak in short, broken phrases,
younger children assume the tripod sitting
Remember: position; older children air upright with the
● Children with a respiratory disorder should shoulders in a hundred-over position.
be monitored for weight loss and for signs of - Exercise-induced attack: Cough shortness
dehydration. Signs of dehydration include of breath, chest pain/tightness, wheezing
sunken fontanelle (infants), non-elastic skin and endurance problems occur during
turgor, decreased and concentrated UO, dry exercise
 - Severe spasm or obstruction: breath sounds the child cannot exhale, resulting in CO2
and wheezing cannot be heard (silent accumulation.
chests) and cough is ineffective (lack of air
movement) Therapeutic Management
- Ventilatory failure and asphyxia shortness of - Oxygen is given via face mask/nasal prongs
breath w/ air movement in the chest to maintain PO2 at more than 90 mmHg.
restricted to the point of absent breath These methods supply good oxygen
sounds is noted; accompanied by sudden concentrations and yet leave the child’s face
increase in RR. unobscured for easy observation. It is best
administered at a concentration of
● Three goals of allergic disorders 30%-40% not 100%; if concentration greater
1. Avoidance of allergen by than 40% needed, a Venturi mask that
environmental control allows for rebreathing may be used.
2. Skin testing and - During the acute stage of status
hyposensitization to identified asthmaticus, children need increased fluid
allergens intake to combat dehydration and combat
3. Relief of symptoms by airway secretions. Drinking tends to
pharmacologic agents aggravate coughing, so intravenous infusion
- Pulmonary function studies - good such as 5% glucose in 0.45% saline is
pulmonary function depends on good usually prescribed to supply fluid. If a child
ventilation (both drawing adequate air into can drink, do not offer cold fluids because
the lungs and expelling it again). Adequate these tend to aggravate a bronchospasm.
transfer of gases across the alveolar
capillary membranes and adequate volume
and distribution of pulmonary capillary blood
flow to transport oxygen to body cells.

Interventions

Medications
- Cough suppressants are contraindicated w/
asthma as a rule as long as children can
continue to cough up mucus, they are not in
serious danger.
- Mild, persistent asthma: inhaled
anti-inflammatory corticosteroid such as
fluticasone (flovent) either daily/every other
day (not taking the steroid everyday may Acyanotic heart disease
allow for more growth). - Ineffective pump and make the child prone
- Severe, persistent asthma: high doses of to CHF
both oral corticosteroid and inhaled Cyanotic heart disease
corticosteroid daily as well as a long-acting - Blood is hunted from the venous to arterial
bronchodilator at bedtime. system as a result of abnormal
communication b/w the 2 systems
Status Asthmaticus (deoxygenated blood - oxygenated blood or
- Acute asthma attack and child displays right to left shunts)
respiratory distress despite vigorous
treatment measures ACYANOTIC - Left-right
- Medical emergency that can result in CYANOTIC - Right-left
respiratory failure and death if not treated
- Oxy sat and PO2 are low; PCO2 is elevated Ventricular Septal Defect (VSD)
because both bronchi are so constricted - Opening is present in the septum b/w the 2
ventricles
Assessment increased pulmonary blood flow and fixed
- 4-8 wks as shunting begins, the infant S2 splitting.)
begins to demonstrate easy fatigue; a loud, - An ECG often will reveal 1st-degree heart
harsh systolic murmur becomes evident block as impulse conduction is halted before
along the left sternal border at the third or the AV node. Echo-cardiography will confirm
fourth interspace; and a thrill (vibration) also diagnosis.
may be palpable.
Management
Diagnosis - Surgery has always been necessary for a
- Chest x-ray, 12 lead ECG, final repair because these disorders tend to
echocardiography w/ color flow doppler or be too large to close spontaneously.
MRI Because the surgery may involve a valve
- (+) right ventricular hypertrophy repair as well as a septal repair, mitral and
- (+) pulmonary artery dilatation tricuspid insufficiency from poor valve
function may occur at a later date.
Management - Postoperatively, closely observe children for
- Close observation jaundice resulting from red blood cell
- Administration of diuretic/digoxin to help destruction if RBCs are destroyed by the
prevent fluid accumulating in the lungs newly constructed valves. Both prophylactic
- Placement of septal occluder device during anticoagulation and antibiotic therapy will be
cardiac catheterization prescribed postoperatively if artificial valve
- If it doesn't close spontaneously, put in replacement are necessary. With the
place to prevent chronic pulmonary artery artificial valves in place, children should be
hypertension from developing or the heart able to lead an active life afterward.
from becoming infected (endocarditis)
because of the recirculating and stagnant Patent Ductus Arteriosus
blood flow. - Ductus arteriosus is an accessory to fetal
structure that connects to the pulmonary
Atrial septal defect (ASD) aorta.
- Opening in the septum b/w the 2 atria. - Shunted blood returns to the atrium of the
heart, passes to the left ventricle, out to the
Assessment aorta and shunts back to the pulmonary
- Harsh systolic murmur heard over the artery, causing increased pressure in the
second/third interspace (pulmonic area) pulmonary circulation from the extra
- Echocardiography w/ color flow doppler shunted blood; this leads to the right
- (+) right side of the heart and increased ventricle hypertrophy and ineffective heart
pulmonary circulation action.

Management Assessment
- Surgery to close the disorder is usually - Child has wide pulse pressure (difference
done electively by cardiac catheterization b/w systolic and diastolic bp)
b/w 1-3 years of age - Twice as common in girls as in boys and
- Important to close in girls, because the occur at higher incidence at higher altitudes.
abnormal flow can cause emboli during Management
pregnancy. - Closure of the ductus is necessary or the
- In the cardiac catheterization laboratory, child will remain at risk for CHF from the
edges of the opening in the septum are increased amount of blood pouring back
approximated and filled in w/ a septal into the pulmonary artery and infectious
occluder device. endocarditis developing from the
- Postop, carefully observe the child for recirculating blood and potential stasis in
arrhythmias because edema of the right the pulmonary artery.
atrium could interfere with SA node function.
Pulmonary Stenosis
Atrioventricular canal defect - Narrowing of the pulmonary valve or
- Endocardial cushion defect, results from pulmonary artery is just distal to the valve,
incomplete endocardial cushion/septum of accounting for about 10% of congenital
the heart at the junction of the atria and the heart anomalies.
ventricles possibly involving both the mitral
and tricuspid valve. Assessment
- Cyanosis (inability of adequate blood to
Assessment reach lungs)
- The disorder leads to the same symptoms - Right-left shunting across the foramen ovale
as ASDs (right ventricular hypertrophy, because of increased right-sided heart
pressure.
Management
- Balloon angioplasty by way of cardiac
catheterization is the procedure of choice.

Transposition of the great arteries

- Aorta arises from the right ventricle instead
of the left and the pulmonary artery arises
from the left ventricle instead of the right.

Aortic Stenosis Assessment

- Stricture of the aortic valve prevents blood - No murmurs/various murmurs depending on
from passing through freely from the left the shunting of blood through
ventricle to the aorta. atrial/ventricular defects or through the
ductus arteriosus, which usually remains
Assessment open.
- Typical murmur, rough systolic sound heard
loudest in the second right interspace (aortic Management
space). - Balloon atrial septal pull-through operation
- Growing = angina chest pain-like more likely may be done by cardiac catheterization to
to occur because the arteries cannot enlarge the septal openings.
receive adequate amounts of blood w/
strenuous activities. Truncus arteriosus
- Sudden death can occur when the amount - Rare disorder (1% of initial cardiac lesions)
of oxygen needed by the heart muscle on - Major artery (trunk) arises from the left and
exertion far exceeds that is available. right ventricles in place of separate aorta
and pulmonary artery vessels.
Management
- Stabilization w/ a beta-blocker or Assessment
calcium-channel blocker to reduce - There is a VSD accompanying this; the child
ventricular hypertrophy before correction. is cyanotic and may have a typical VSD
- Balloon valvuloplasty or insertion of murmur.
homograft valve (human donor).
Total anomalous pulmonary venous return
Coarctation of the aorta - Pulmonary veins return from the right atrium
- Narrowing of the lumen of the aorta due to a or the superior vena cava instead of left.
constricting band.
- Children under 3 yrs of age have difficulty Management
describing these sensations, exceptional - Balloon atrial septal pull through the
irritability is the main clue. procedure may be done to enlarge a small
- At preschool, the elevated upper body blood foramen ovale to allow better mixing of
pressure begins to produce headaches and blood.
vertigo.
- School age = epistaxis and cerebrovascular Tricuspid Atresia
accidents, can occur. - Extremely serious disorder (tricuspid valve
is completely closed, allowing no blood to
Assessment flow from the right atrium to the right
- Slight = absence of palpable femoral pulses ventricles or reach the lungs.
from the decreased bp in the lower body is
the only symptom. Management
- Bp in arm should be at least 20 mmHg - Surgery consists of the construction of a
higher than legs, reversal of the normal vena cava to pulmonary artery shunt, which
pattern. deflects more blood to the lungs or a Fontan
procedure (Glenn shunt baffle), which
Management restructures the right side of the heart.
- Interventional angiography (balloon catheter
or surgery).
Tetralogy of fallot
- Four anomalies present: pulmonary
stenosis, VSD (large), dextroposition
(overriding) of the aorta and hypertrophy of
the right ventricle.

Assessment
- Extremely serious heart disease but no high
degree of cyanosis immediately after birth.
But as they become active, skin acquires
bluish tint.
Hemophilia B (Factor IX deficiency/Christmas
disease)
Management
- Transmitted as a sex-linked recessive trait.
- Surgery to correct heart disorders as early
- 15% of people with hemophilia. Treatment is
as newborn period.
with a concentrate of a factor IX which is
- Streptococcal infection = incident of
available for home administration.
pharyngitis, tonsillitis, scarlet fever, “strep
throat” or impetigo.
Hemophilia A (Factor VIII deficiency)
- Deficiency of the coagulation component
factor VIII, the antihemophilic factor and
transmitted as a sex-linked recessive trait.
- A female carrier may have slightly lowered
but sufficient levels of the factor VIII
component so that she does not manifest a
bleeding disorder.
- Males with the disease also have varying
levels of factor VIII; their bleeding
tendencies varies accordingly from mild to
severe.

Assessment
- Recognized first in infants who bleeds
excessively after circumcision.

Management
- Even minor abrasions, bleeding can be
controlled by the administration of factor VIII
supplied by fresh whole blood, fresh or
frozen plasma, or a concentrate of factor
VIII.

Acute Lymphocytic (Lymphoblastic) Leukemia

- 75% of leukemia and involves lymphoblasts
(immature lymphocytes).
- Rapid proliferation of immature
lymphocytes, production of RBCs and
platelets falls; invasion of rapidly increasing
WBC elements begins; immature “blast cell”
or “stem cell”.
 - Slightly higher in boys than girls and more
often in Hispanic and white children than in Acute Myeloid Leukemia
children of other races. - Overproliferation of granulocytes
(neutrophils, basophils and eosinophils).
- Most common seen in adults and accounts
for only about 20% of a;; childhood
leukemias.
- Frequency increases in late adolescents.

Assessment
- Decreased RBC production (anemia) such
as pallor, low-grade fever and lethargy.
- Bone and joint pain after bone periosteum
invasion.
- CNS invasion symptoms such as headache
or unsteady gait.

Diagnostics
- Elevated leukocyte count w/ cells almost
stopped at blast cell stage. Platelet count
and hematocrit value will be low and RBCs
are normocytic and normochromic (normal
size and color) but few in number.
- X=rays of the long bone may reveal lesions
caused by the invasion of abnormal cells.
- Lumbar puncture may show evidence of
blast cells in the CSF. Management
- BMA and biopsy.
Management - Chemotherapy remission begins with
- Up to 95% of children will achieve first cytarabine (Ara-C), etoposide (VePesid) and
remission. daunorubicin (DaunoXome).
- Relapse = long-term survival reduced
approximately 70%.
- Length of each subsequent remission tends
to be shorter and less effective.
- Chemotherapy program aims to achieve a
complete remission or absence of leukemia
cells (induction phase); preventing leukemia
cells from invading/growing in CNS
(sanctuary/consolidation phase);
administering delayed intensive therapy;
maintaining the original remission
(maintenance phase).
- Third phase of therapy (intensification)
strengthens the assault against leukemic
cells again using vincristine, prednisone,
I-asparaginase, doxorubicin and
methotrexate. Leucovorin (leucovorin
rescue) administered after systemic
methotrexate to neutralize its action and
protect normal cells from the effects of the
drugs.