• newborn = 40-60
• infant = 20-40
• child = 20-30
• adolescent = 14-20

Factors = sleeping/awake, anger/fear/hydration, fever, meds

• newborn = 80-180, 140
• infant = 75-160, 130
• toddler = 60-110, 103
• child = 60-110, 95
• adolescent = 50-90, 85

1. RR > 60 or slow irregular respirations in acutely ill child
2. HR in child <5yo that is >180 or <80
3. HR in child >5yo that is >160 or <60
4. increased work of breathing---> retractions, grunting, nasal flaring
5. cyanosis
6. irritability (toxic/fussy but consolable) vs. lethargy

1. post nasal drip
2. GERD
3. asthma

• premature glottic closure accompanying late expiratory contraction of the diaphragm
• increases airway pressure
• Seen in: pneumonia, atelectasis, edema

1. suprasternal
2. intercostal
3. abdominal breathing
4. subcostal
5. substernal

• wheezing
• tachypnea

• high pitched INSPIRATORY sound
• UPPER airway obstruction
• made worse if upset or crying
• Seen in: croup, FB, allergic reaction, laryngomalacia, hemangioma, etc.
• epiglottitis not common today because of immunizations

• high-pitched EXPIRATORY sound, may also be inspiratory
• LOWER airway obstruction
• Seen in: asthma, bronchiolitis, edema, FB
• prolonged expiratory phase of respiration

1. expiration far greater than inspiratiion
2. inabiity to speak (count to 10, say alphabet)
3. decreased ability to blow (ask pt. to keep piece of paper up)
4. PEFR (peak expiratory flow rate)

• measures RATE, not volume
• different than PFT, but convenient and quick

• admit if PEFR <50% after initial treatment
• do  not discharge until PEFR is about 75-80% of predicted for age, sex, or size

• 10-15 L/min
• 60-80% oxygen
• actually PARTIAL non-rebreathing mask because missing one valve

• 1-6 L/min (usually 2L)
• 24-40% oxygen
• SE: nosebleeds, dries nose, uncomfortable
• do not use in young children or at 6L (ears hurt because so much air blowing)

• 6-10 L/min
• 40-60% oxygen

• usually infants
• & oxygen unpredictable
• usually only used if slightly hypoxic

• symptoms less than or equal to 2 times a week
• nighttime sx less than or equal to 2 times a month
• using less than 2 cannisters per year
• FEV1 or peak flows greater than or equal to 80% & peak flow variability less than or equal to 20%

1. no daily meds for long term control
2. quick relief- short acting beta agonists- albuterol MDI 2 puffs BID prn wheezing
3. education on environmental controls,  role and use of medications, self-management

• symptoms greater than 2 times a week
• nighttime sx greater than 2 times a month
• FEV1 or peak flows greater than or equal to 80% predicted
• peak flow variability 20-30%

1. long-term control- once daily inhaled LOW dose CS (Flovent or Pulmicort) OR leukotriene inhibitors (Singulair) which is only an alternative
2. quick relief-albuterol
3. education

• daily sx, daily use on short-acting bronchodilators, exacerbations affect daily activity level, exacerbations greater than or equal to 2 times a week-may last days
• nighttime sx greater than 1 time per week
• FEV1 or peak flows between 60-80% predicted
• peak flow variability greater than 30%

1. long-term control- LOW-MEDIUM dose CS, long-acting bronchodilator (ADVAIR= 2 drugs), leukotriene inhibitors, cromolyn
2. quick relief- albuterol
3. education

• continual sx, limited physical activity, frequent exacerbations
• frequent nighttime sx
• FEV1 or peak flows less than or equal to 60% predicted
• peak flow variability greater than 30%

1. long-term control- HIGH dose inhaled CS, long acting bronchodilator, ORAL CS needed like PREDNISONE, maybe theophylline
2. quick relief- albuterol MDI or nebulizer maybe QID treatments
3. education

• albuterol (Proventil, Ventolin, Proair)
• levalbuterol (Xopenex)
• pirbuterol (Maxair)

nebulized, metered dose inhaler, autohaler

inhaled anti-inflammatory= cromolyn (intal), nedocromil (tilade)

• not useful in acute exacerbations
• slow onset of action
• MAST CELL STABILIZERS
• hardly ever used today

• flunisolide (aerobid) - bad taste
• beclomethasone (Qvar)
• fluticasone (flovent)
• mometasone (asmanex)
• budesonide (pulmicort)

• montelukast (singulair)
• zafirlukast (accolate)

ORAL AGENTS, not steroid, chewable

potent biochemical mediators that contribute to airway obstruction by:

1. contracting smooth muscle
2. increasing vascular permeability and mucus secretion
3. attracting inflammatory cells

• salmeterol (in advair)
• formoterol (in symbicort and dulera)

up to 12 hours relief, not effective for acute sx, mixed with a STEROID

• theophylline (slo-bid)

MOA:

1. bronchodilatory
2. diaphragmatic contractility
3. anti-inflammatory
4. mucociliary clearance

usually only prescribed by pulmonologist

• chronic disease characterized by airway obstruction that is at least partially reversible, airway hyperresponsiveness to a variety of external stimuli, and chronic inflammation of the airway
• 80% of sx begin before age 5

1. asthma
2. allergic rhinitis
3. eczema

• increase HR
• N/V
• jittery