MINISTRY OF HEALTH OF UKRAINE

Zaporozhye state medical university

ADOPTED
by methodical conference
department of faculty pediatrics
______________________________
Head of the department- professor Nedel'ska S.M.

METHODICAL RECOMMENDATIONS
FOR STUDENTS

Educational discipline Faculty pediatrics

Module 2 Widespread general infectious, allergy diseases, illnesses of the
respiratory system in children
Substantial module 5 Respiratory disease in children

Topic of lesson 12 Acute respiratory infections in children

Course 4
Faculty medical

Zaporozhye 2015
 2
I. Concrete aims :

1. To determine the etiologic and pathophysioligic factors of acute respiratory infections of

overhead respiratory tracts (acute nasopharyngitis, pharyngitis, obstructive laryngitis,
acute laryngopharyngitis, acute tracheitis).
2. To classify the acute respiratory infections of overhead respiratory tracts, respiratory
deficiency, fever, cramps; to analyse the typical clinical picture of acute nasopharyngitis,
acute pharyngitis, acute obstructive laryngitis (groats), acute laryngopharyngitis, acute
tracheitis, respiratory deficiency in children, hyperthermal syndrome and cramps in
children.
3. To determine the features of acute respiratory infections for new-born children and make
a provisional and clinical diagnosis.
4. To make the plan of inspection and analyse information of laboratory and instrumental
inspections at typical acute nasopharyngitis, acute pharyngitis, acute obstructive
laryngitis (groats), acute laringopharyngitis, acute tracheitis in children: common and
biochemical blood tests; immunological and serum researches; washings off are from
pharyngs for determine the antigens of viruses; bacteriological analysis of sputum,
pharynx and nasal mucus; X-ray investigation of lungs.
5. To demonstrate some aspects of treatment, rehabilitation and prophylaxis of acute
nasopharyngitis, acute pharyngitis, acute laryngopharyngitis, acute tracheitis in children.
6. To diagnose and render an urgent help at acute obstructive laryngitis (to the groats),
hyperthermal syndrome, cramps in children.
7. To conduct differential diagnostics and put the previous diagnosis of acute respiratory
infections of overhead respiratory tracts.
8. To carry out the prognosis of life at the acute respiratory infections of overhead
respiratory tracts, cramps.
9. To demonstrate the skills of moral and deontology principles of medical specialist and
principles of professional deference to the rank in pulmonology.
10. Acquired immunodeficiency syndrome (AIDS). Clinical manifestations of human
immunodeficiency virus (HIV) infection in children. Diagnosis of HIV-infection in
clinical and laboratory. Triatment of AIDS.
 3
2. Base level of preparation.

Names of previous Skills

disciplines To know To able
1. Anatomy Anatomy and physiology of To inspect the condition of the
respiratory system in children respiratory system in children

physiology regulation To define and identify the signs

2. Physiology mechanisms of respiratory of defeat of respiratory system
system, basic defens mechanisms organs at ARVI, to classify them
against infections with determination heaviness

biochemical, histological, to define and interpret changes

structural changes are in the of laboratory and X-ray
3. Patology, patophysiology organism of child with ARVI, inspection
groat, cramps
semiotics of defeats at GRVI in to define principal factors, which
children assist development of croup,
cramps at ARVI in children
4. Propedevtika of child
deseases changes of X-ray picture at acute to sign up the complex of
laryngopharyngitis, tracheitis in prophylaxis and treatment of
children. ARVI in children

5. Radial diagnostics mechanisms of the influence,

dosage, metabolism, indirect
actions of medications for
treatment of ARVI,
hypertemperature and
anticonvulsants
6. Pharmacology

3. Content of educational material

Some of the most common problems in the pediatric age-group are related to disturbed
respiratory function, and respiratory failure is the chief cause of morbidity in the newborn
period. Respiratory illness can be caused by disease, trauma, or physical anomalies or can be
seen as a manifestation of a disturbance in another organ or system, such as neurologic disorders
 4
involving the respiratory center or innervation to the respiratory musculature. Most
communicable diseases have respiratory symptoms. The type and pattern of respiratory
disturbances also vary according to the age of the child. There are differences in susceptibility to
infections and in response to various organisms and conditions at various ages. Acute infection
of the respiratory tract is the most common cause of illness in infancy and childhood. Young
children ordinarily have four or five such infections each year that manifest a wide range of
severity from trivial to severe or even fatal illness. The type of illness and the physical response
are also related to a variety of factors, including the type of infectious agent, the age of the child,
and the integrity of the child's defense mechanisms.

Upper Respiratory Tract Infections

Upper reparatory infections (URI) include infections processes involving any or all of the
structures in the upper respiratory tract. Most are caused by viruses and are self-limited.
However, secondary infection or extension of URIs can cause serious or long-lasting effects,
especially in infants and very young children. A primary site for extension is the middle ear.

Acute nasopharyngitis
Acute nasopharyngitis (the equivalent of the common cold in adults) is caused by any of a
number of different viruses, usually rhinoviruses, respiratory syncytial virus, adenovirus,
influenza virus, or parainfluenza virus. Symptoms of nasopharyngitis are more severe in infants
and children than in adults. Fever is common, especially in young children, although very young
infants may be afebrile. Older children have low-grade fevers. The fever appears early and
suddenly in children 3 months to 3 years of age in association with irritability, restlessness, and
sneezing. Nasal discharge begins in a few hours. Other symptoms (e.g., vomiting and diarrhea)
may be evident in some children. The initial symptoms in older children are dryness and
irritation of nasal passages and sometimes the pharynx, followed in a few hours by sneezing,
chilly sensations, muscular aches, an irritating nasal discharge, and sometimes cough. Nasal
inflammation may lead to obstruction, and continual wiping away of secretions causes skin
irritation to nares. The disease is self-limited and usually resolves within 4 to 10 days without
complications. The most common complication is otitis media, especially in infants, athis should
be suspected if fever recurs. Pneumonia is a less frequent complication and found more often in
infants. Children with nasopharygitis are managed at home. There are no specific treatment, and
these children are managed symptomatically with antipyretics and decongestants.
Nasopharygitis is so widespread in the general population that it is impossible to prevent. In
addition, children are more susceptible to colds because they have not yet developed resistance
to many types of viruses. Because nasopharyngitis is spread from secretions the best means for
prevention is avoiding contact with affected persons.

Acute pharygitis
Acute pharygitis (sore throat) may be part of a generalized upper respiratory infection or the
dominant feature of the illness. The term refers to all acute infections of the pharynx, including
the tonsils and pharyngotonsilltis. Pharygitis may be viral or bacterial. Viral pharyngitis. In
general, viral infections have a relatively gradual onset, produce a shorter and milder illness with
less intense inflammation, and cause few complications. The sore throat may be present initially
or appear a day or two after the onset of other symptoms to reach a peak by the second or third
day. Hoarseness, cough, and rhinitis are common. The pharyngeal inflammation may be
relatively slight but occasionally is severe. Cervical lymph nodes are usually enlarged slightly,
and laryngeal involvement is common. The illness can last from 24 hours to over 5 days, but
complications are rare.
Streptococcal pharyngitis. The onset a bacterial infection is more rapid. Children over 2 years of
age may complain of headache and abdominal pain associated with a high fever (40 C or 104
F), although fever may not be noted for 12 hours or more. Sore throat appears in a few hours
 5
accompanied by tonsillar enlargement, exudation, and a variable amount of pharyngeal
erythema. Pain can be relatively mild to severe enough to make swallowing difficult. Antetior
cervical lymphadenopathy usually occurs early and the nodes are often tender. Fever may
continue for 1 to 4 days. Severe illness may last up to 2 weeks.

Tonsillitis
Several pairs of tonsils are part of a mass of lymphoid tissue encircling the nasal and oral
pharynx; know as Waldeyer tonsillar ring.

Tonsillitis usually occurs in association with pharyngitis. Because of the abundant lymphoid
tissue and the frequency of upper respiratory infections, tonsillitis is a very common cause of
morbidity in young children.
 6
The causative agent may be viral or bacterial. The manifestations of tonsillitis are chiefly caused
by inflammation. As the palatine tonsils enlarge from edema, they may meet in the midline
(kissing tonsils obstructing the passage of air or food. The child has difficulty in swallowing and
breathing. Enlargement of the adenoids blocks the space behind the posterior nares, making it
difficult or impossible for air to pass from the nose to the throat. As a result, the child breathes
through the mouth. If mouth breathing is continuous, the mucous membranes of the oropharynx
become dry and irritated. There may be an offensive mouth odor and impaired senses of taste and
smell. Because air cannot be trapped for proper speech sounds, the voice has a nasal and muffled
quality. A persistent harassing cough is also common. Because of the proximity of the adenoids
to the Eustachian tubes, this passageway is frequently blocked by swollen adenoids, interfering
with normal drainage and frequently resulting in otitis media and/or difficulty hearing.

Otitis media
Otitis media (OM) is one of the most prevalent diseases of early childhood. The incidence is
highest in children age 6 months to 2 years. Otitis media is primarily the result of dysfunction
Eustachian tubes.

Several factors predispose infants and young children to development of otitis media:
1.The Eustachian tubes are short, wide, and straight and lie in a relatively horizontal plane.
2.The cartilage lining is undeveloped, making the tubes more distensible and therefore more
likely to open inappropriately.
3.The normally abundant pharyngeal lymphoid tissue readily obstructs the Eustachian tube
openings in the nasopharynx.
4.Immature humoral defense mechanisms increase the risk of infection.
5.The usual lying-down position of infants favours the pooling of fluid, such as formula, in the
pharyngeal cavity.
Clinical Manifestations
As purulent fluid accumulates in the small space of the middle ear chamber, pain results from the
pressure on surrounding structures. Infants become irritable and indicate their discomfort by
holding or pulling at their ears and rolling their head from side to side. Young children will
usually verbally complain of the pain. A temperature as high as 40 (104 F) is common, and
postauricular and cervical lymph glands may be enlarged. Rhinorrhea, vomiting, and diarrhea as
well as signs of concurrent respiratory or pharyngeal infection may also be present. Loss of
appetite is common and sucking or chewing tends to aggravate the pain. As the exudate
accumulates and pressure increases, the tympanic membrane may rapture spontaneously. As a
result, there is immediate relief of pain, a gradual decrease in temperature, and the presence of
purulent discharge in the external auditory canal. Severe pain or fever is usually absent in
with effusion in middle ear space, and the child may not appear ill. Instead there is a feeling of
"fullness" in the ear, a popping sensation during swallowing, and a feeling of "motion" in the ear
 7
if air is present above the level of fluid. Since chronic serous otitis media is the most frequent
cause of conductive hearing loss in young children, audiometry may reveal deficient hearing.
Diagnostic Evaluation
In AOM otoscopy reveals an intact membrane that appears bright red and bulging, with no
visible landmarks or light reflex. The usual landmarks of the bony prominence from the long and
the short process of the malleus are obscured by the bulging membrane. In the with effusion
in middle ear space otoscopic findings may include a slightly injected, dull gray membrane,
obscured landmarks, and a visible fluid level or meniscus behind the eardrum if air is present
above the fluid. Normally the tympanic membrane moves inward with positive pressure and
outward with negative pressure to the external auditory canal. Presence of fluid or high negative
pressure within the middle ear diminishes tympanic membrane mobility.

Croup Syndromes
Crou is a general term applied to a symptom complex characterized by hoarseness, a resonant
cough described as barking" or "brassy" (croupy), varying degrees of inspiratory stridor, and
varying degrees of respiratory distress resulting from swelling or obstruction in the region of the
larynx. Acute infections of the larynx are of greater importance in infants and small children than
they are in older children, in part because of the increased incidence in children in this age-group
and the smaller diameter of the airway, which renders it subject to significantly greater
narrowing with the same degree of inflammation.

Acute respiratory infections of the nonreactive airway involve all areas to some extent and are
seldom restricted to one area. Croup syndromes affect to varying degrees the larynx, trachea, and
 8
bronchi. However, the laryngeal involvement often dominates the clinical picture because of the
severe effects on the voice and breathing. Croup is usually described according to the primary
anatomic area affected, that is, epiglottitis, laryngitis, laryngotracheitis, laryngotracheobronchitis,
and spasmodic laryngitis (spasmodic croup). In general, laryngotracheobronchitis tends to occur
in very young children, whereas epiglottitis is more characteristic of older children.

Table compares and contrasts the major types of croup.

Croup appears more often in males, commonly between the ages of 3 months and 3 years and is
more prevalent in the winter months; laryngitis tends to recur in the same child. The principal
etiologic agents in croup are viruses, except those cases associated with diphtheria, pertussis, and
epiglottitis. The viral croup is more common in children in the younger age-group, 3 months to 5
years of age, whereas croup caused by H. influenzae and C. diphtheriae is more often seen in
children ages 3 to 7 years. A positive family history for croup is a common finding. In most
children the disease is relatively mild, with cough, stridor, and mild retractions and gradual
improvement to recovery in 3 to 7 days. However, complications of viral croup occur in a
number of children, the most common of which are extensions of the infection to other areas of
the respiratory tract to cause otitis media, bronchiolitis, and pneumonia. The most serious
complication, and the one responsible for most deaths from croup, is laryngeal obstruction.

ACUTE LARYNGITIS
Mild laryngitis is characterized by hoarseness and a barking cough that is usually worse at night.
There can be a wide range of manifestations from few symptoms to severe obstructive laryngitis.
There may be a low-grade fever, loss of appetite, and malaise but there is little or no difficulty
breathing. A more severe type, acute infectious laryngitis, begins in the same manner as the mild
disease but progresses rapidly to the stage of obstruction. Breathing becomes rapid and labored,
with inspiratory stridor, retractions, and restlessness. Physical examination reveals evidence of
inflammation. The main area of obstruction is below the vocal cords. The mucosa is deep red and
velvety. If the disorder is limited to the larynx, the lungs are clear to auscultation except for
inspiratory stridor and generally diminished aeration. Radiograph of an airway of a patient with
croup, showing typical subglottic narrowing (steeple sign)
 9

Therapeutic Management and Nursing Considerations

Afebrile children with mild laryngitis and a croupy cough are usually managed at home with
symptomatic treatment. Rest in bed and humidified air during sleep may be helpful. Severe cases
often require hospitalization.

ACUTE LARYNGOTRACHEOBRONCHITIS
Acute laryngotracheobronchitis (LTB) is the most common form of croup. The disease is usually
preceded by an upper respiratory infection for several days. The infection rapidly proceeds to
laryngitis, and then descends rapidly to the trachea and sometimes the bronchi. Fever and
prostration increase. There is respiratory distress with inspiratory dyspnea, substernal and
suprasternal retractions, and expiratory difficulty with prolonged expirations. The child is
irritable and restless and may be pale or cyanotic. Auscultation reveals scattered rales of various
types, rhonchi, expiratory wheeze, and localized areas of diminished to absent breath sounds
bilaterally. As distress increases, the child becomes increasingly restless and anxious. He dozes,
wakens startled, and makes visible efforts to draw in air. Intubation is 36 usually performed at
this stage of distress. If not, the inspiratory stridor and retractions progress until he becomes
markedly pale or ashen, his skin is cold and clammy, and all his attention and effort are focused
on fighting for air. He becomes nrasingly agitated, thrashes about in his efforts to breathe. His
status is critical. An artificial airway is mandatory for survival. The child may or may not be
cyanotic; cyanosis is often a late sign.
 10

Nursing Considerations
The most important nursing function in the care of children with croup is vigilant observation
for sings of respiratory embarrassment and relief of laryngeal obstruction. The child is placed in
a cool high-humidity environment with oxygen. Vital signs are monitored frequently, and the
childs appearance and behavior are observed to detect early signs of impending airway
obstruction, such as increased pulse and respiratory rate; substernal and suprasternal and
intercostals retractions; flaring nares; and increased restlessness. Equipment for performing an
 11
endotracheal intubation should be at hand in case an artificial airway must be supplied
immediately.

ACUTE EPIGLOTTITIS
Acute epiglottitis, or acute supraglottitis, is a serious obstructive inflammatory process that
occurs principally in children between 2 and 6 years of age and requires immediate attention.
The obstruction is supraglottic as opposed to the subglottic obstruction of laryngitis. The
responsible organism is usually H. influenzae; croup and epiglottitis do not occur together.
Clinical Manifestations
The onset of epiglottitis is abrupt and rapidly progressive to severe respiratory distress. The
child usually goes to bed asymptomatic to awaken later complaining of sore throat and pain on
swallowing. The child has a fever, appears toxic out of proportion to the clinical findings, and
presents a classic picture; the child generally insists on sitting upright, leaning forward, with chin
thrust out, mouth open, and tongue protruding (tripod position). Drooling of saliva is common
because of the difficulty or pain on swallowing and excessive secretions. The child is irritable
and markedly restless, and has an anxious, apprehensive, and frightened expression. He has a
thick, muffled voice and a "froglike" croaking sound on inspiration. The child is not hoarse.
Suprasternal and substernal retractions may be visible. The child seldom struggles to breathe,
and slow quiet breathing provides better air exchange. The sallow color of mild hypoxia may
progress to cyanosis. The throat is red and inflamed, and a distinctive large, cherry-red,
edematous epiglottis is visible on careful throat inspection.

Therapeutic Management
The course of epiglottitis may be fulminant with respiratory obstruction appearing suddenly.
Progressive obstruction leads to hypoxia, hypercapnia, and acidosis followed by decreased
muscular tone, reduced level of consciousness, and when obstruction becomes more or less
complete, a rather sudden death. A presumptive diagnosis of epiglottitis constitutes an
emergency. The child is best transported while sitting in a parent's lap to reduce distress.
Examination of the throat with a tongue blade (depressor) is contraindicated until properly
experienced personnel and equipment are at hand to proceed with immediate intubation in the
event that the examination precipitates further or complete obstruction. Laryngoscopy reveals
intense inflammation of the epiglottis and sometimes of the surrounding area as well. If
epiglottitis is thought to be reasonably possible, although not probable, the patient should have a
 12
lateral roentgenogram of the nasopharynx and upper airway before physical examination of the
pharynx.

Epiglottitis. Lateral roentgenogram of the upper airway reveals the swollen

epiglottis.

Endotracheal intubation or, less often, tracheostomy is, usually considered for H. influenzae
epiglottitis with severe respiratory distress. Whether the child has an artificial airway or not he
requires intensive observation by experienced personnel. The epiglottal swelling usually
decreases after 24 hours and is near normal by the third day.
Adenovirus Infection - Causes and Symptoms
Definition:
Adenoviruses are are DNA viruses (small infectious agents) that cause upper respiratory tract
infections such as a common cold, conjunctivitis (an infection in the eye), croup, bronchitis,
bronchiolitis (inflammation of the lower airways), or pneumonia.
Adenoviruses are responsible for about 3-5% of acute respiratory infections in children and 2%
of respiratory illnesses in civilian adults. They are very common among military recruits and
other young people who live in institutional environments. Outbreaks among children are
frequently reported at boarding schools and summer camps. Adenoviruses can also cause
infections in the urinary tract or intestinal tract. In children, adenoviruses usually cause
infections in the respiratory tract and intestinal tract.
Causes of Adenovirus Infection
Anyone can get adenoviral infections, from newborns to the elderly - but, are more common
among children of ages 6 months and 2 years. Children in day care are most likely to get
repeated adenoviral infections.
Adenovirus can spread via direct contact, airborne transmission , fecal-oral transmission, and
occasionally waterborne transmission. Because the virus is stable in the environment, fomites are
a common cause of spread. Spread has been documented from contaminated swimming pools
and towels. Some types of adenoviruses are capable of establishing persistent asymptomatic
infections in the tonsils , adenoids , and intestines. Shedding of the virus can occur for months or
years after the initial infection.
Symptoms of Adenovirus Infection
Outbreaks of adenovirus-associated respiratory disease have been more common in the late
winter, spring, and early summer. However, adenovirus infections can occur throughout the year.
Children who have normal immune systems usually experience only very minor symptoms when
infected with adenovirus. The course of infection tends to be more serious in children who are
immunocompromised, such as those undergoing chemotherapy or those who have a disease that
 13
disrupts normal immune response (e.g. human immunodeficiency syndrome [HIV]). In such
children, the virus more often affects organs such as the lungs, liver, and kidneys, and the risk of
fatality increases.
Other Symptoms associated with adenovirus infections may be:
Cough.
Fever.
Runny Nose.
Sore Throat.
Watery Eyes.
Treatment of Adenovirus Infection
Most infections are mild and require no therapy or only symptomatic treatment. Supportive
treatment includes bed rest, antipyretics, and analgesics. Ocular infections may require
corticosteroids and direct supervision by an ophthalmologist. Because there is no virus-specific
therapy, serious adenovirus illness can be managed only by treating symptoms and complications
of the infection. In a very few cases, hospitalization may be required - like in case of pneumonia
(in infants) to prevent death and in epidemic keratoconjunctivitis (EKe) to prevent blindness.
Some other Treatment options which may make healing fast are:
Increased Fluid Intake - Keeping your child well hydrated by encouraging fluids by
mouth is important. If necessary, an intravenous (IV) line may be started to give your child fluids
and essential electrolytes.
Bronchodilator Medications - Bronchodilator medications may be used to open your
child's airways. These medications are often administered in an aerosol mist by a mask or
through an inhaler.
Preventing Adenovirus Infection
Live vaccines have been developed against adenovirus types 4 and 7 and can prevent
adenoviral infection. These vaccines are recommended for high-risk groups such as military
recruits.
Adequate amount of Chlorination of drinking water, wastewater.
High hygiene standards in opthamology practice.
Measures to prevent nosocomial transmission.
To help minimize the incidence of adenoviral disease, instruct all patients in proper hand
washing before taking food to reduce fecal-oral transmission.
Adenovirus infection can also be prevented by sterilizing ophthalmic instruments,
adequate chlorination in swimming pools, and avoiding swimming pools during EKC epidemics.
Influenza - Causes, Symptoms and Treatment
Influenza Definition
A viral illness producing a high temperature, sore throat, runny nose, headache, dry cough, and
muscle pain. The illness is widespread, especially during winter months, and can sometimes be
fatal. Influenza that caused several waves of pandemic in 1918-1919, resulting in over 20 million
deaths worldwide. Humans are only rarely affected.
Influenza occurs sporadically or in epidemics (usually during the colder months). Epidemics tend
to peak within 2 to 3 weeks after initial cases and subside within 1 month. Influenza is also
called the grippe, fowl plague , avian flu, and bird flu.
Influenza Causes
Influenza in humans is an acute, usually self-limited, febrile respiratory illness caused by
infection with influenza virus type A or B that occurs in outbreaks of varying severity almost
every winter. Influenza may be Caused by influenza A virus H5 and H7. All types of birds are
susceptible to the virus but outbreaks occur most often in chickens and turkeys. these viruses do
not commonly infect humans, there is little or no immune protection against them in the human
population. If an avian virus were able to infect people and gain the ability to spread easily from
person to person, an influenza pandemic, a global outbreak, could begin.
 14
Past influenza pandemics have led to high levels of illness, death. One of the remarkable features
of the influenza virus is its capacity for antigenic variation. Such variation leads to infection by
strains of the virus to which little or no immunologic resistance is present in the population at
risk.
Influenza Symptoms
The infection may be brought by migratory wild birds which can carry the virus but show no
signs of disease. The typical incubation period for influenza is in between 1-4 days, with an
average of 2 days. Adults can be infectious from the day before symptoms begin through
approximately 5 days after illness onset.
The other symptoms of the influenza may be included:
Fever
Chills
Headache
Malaise
Myalgia
Sore throat
Muscle aches
Pneumonia
Laryngitis
Hoarseness
Conjunctivitis
Rhinitis
Rhinorrhea
Viral pneumonia
Nonproductive cough
Acute respiratory distress
Influenza Treatments
Uncomplicated influenza is treated with bed rest, adequate fiuid intake.
Medication for influenza must be started within 48 hours of the appearance of symptoms.
aspirin to relieve fever and muscle pain, and guaifenesin or another expectorant to relieve
nonproductive coughing.
As with many medicines, if taken with a light snack, milk, or a meal, the potential for stomach
upset may be reduced.
Stridor
A loud, harsh, musical respiratory sound, stridor results from an obstruction in the trachea or
larynx. Usually heard during inspiration, this sign may also occur during expiration in severe
upper airway obstruction. It may begin as low-pitched croaking and progress to high-pitched
crowing as respirations become more vigorous.
Life-threatening upper airway obstruction can stem from foreign-body aspiration, increased
secretions, intraluminal tumor, localized edema or muscle spasms, and external compression by a
tumor or aneurysm.
Emergency interventions
If you hear stridor, quickly check the patients vital signs including oxygen saturation and
examine him for other signs of partial airway obstructionchoking or gagging, tachypnea,
dyspnea, shallow respirations, intercostal retractions, nasal flaring, tachycardia, cyanosis, and
diaphoresis. (Be aware that abrupt cessation of stridor signals complete obstruction in which the
patient has inspiratory chest movement but absent breath sounds. Unable to talk, he quickly
becomes lethargic and loses consciousness.)
If you detect any signs of airway obstruction, try to clear the airway with back blows or
abdominal thrusts (Heimlich maneuver). Next, administer oxygen by nasal cannula or face mask,
or prepare for emergency endotracheal intubation or tracheostomy and mechanical ventilation.
(See Emergency endotracheal intubation, page 734.) Have equipment ready to suction any
 15
aspirated vomitus or blood through the endotracheal or tracheostomy tube. Connect the patient to
a cardiac monitor, and position him upright to ease his breathing.
History and physical examination
When the patients condition permits, obtain a patient history from him or a family member.
First, find out when the stridor began. Has he had it before? Does he have an upper respiratory
tract infection? If so, how long has he had it?
Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent
exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms.
Does stridor occur with pain or a cough?
Then examine the patients mouth for excessive secretions, foreign matter, inflammation, and
swelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the
patients chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes,
rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or
flatness. Finally, note any burns or signs of trauma, such as ecchymoses and lacerations.
Medical causes
Airway trauma
Local trauma to the upper airway commonly causes acute obstruction, resulting in the sudden
onset of stridor. Accompanying this sign are dysphonia, dysphagia, hemoptysis, cyanosis,
accessory muscle use, intercostal retractions, nasal flaring, tachypnea, progressive dyspnea, and
shallow respirations. Palpation may reveal subcutaneous crepitation in the neck or upper chest.
Anaphylaxis
With a severe allergic reaction, upper airway edema and laryngospasm cause stridor and other
signs and symptoms of respiratory distress: nasal flaring, wheezing, accessory muscle use,
intercostal retractions, and dyspnea. The patient may also develop nasal congestion and profuse,
watery rhinorrhea. Typically, these respiratory effects are preceded by a feeling of impending
doom or fear, weakness, diaphoresis, sneezing, nasal pruritus, urticaria, erythema, and
angioedema. Common associated findings include chest or throat tightness, dysphagia and,
possibly, signs of shock, such as hypotension, tachycardia, and cool, clammy skin.
Anthrax, inhalation
Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain.
The disease generally occurs in two stages with a period of recovery after the initial symptoms.
The second stage develops abruptly with rapid deterioration marked by stridor, fever, dyspnea,
and hypotension generally leading to death within 24 hours. Radiologic findings include
mediastinitis and symmetric mediastinal widening.
Aspiration of a foreign body
Sudden stridor is characteristic in this life-threatening situation. Related findings include abrupt
onset of dry, paroxysmal coughing, gagging or choking, hoarseness, tachycardia, wheezing,
dyspnea, tachypnea, intercostal muscle retractions, diminished breath sounds, cyanosis, and
shallow respirations. The patient typically appears anxious and distressed.
Epiglottiditis
With this inflammatory condition, stridor is caused by an erythematous, edematous epiglottis that
obstructs the upper airway. Stridor occurs along with fever, sore throat, and a croupy cough.
Hypocalcemia
With this disorder, laryngospasm can cause stridor. Other findings include paresthesia,
carpopedal spasm, and positive Chvosteks and Trousseaus signs.
Inhalation injury
Within 48 hours after inhalation of smoke or noxious fumes, the patient may develop laryngeal
edema and bronchospasms, resulting in stridor. Associated signs and symptoms include singed
nasal hairs, orofacial burns, coughing, hoarseness, sooty sputum, crackles, rhonchi, wheezes, and
other signs and symptoms of respiratory distress, such as dyspnea, accessory muscle use,
intercostal retractions, and nasal flaring.
Laryngeal tumor
 16
Stridor is a late sign and may be accompanied by dysphagia, dyspnea, enlarged cervical nodes,
and pain that radiates to the ear. Typically, stridor is preceded by hoarseness, minor throat pain,
and a mild, dry cough.
Laryngitis (acute)
This disorder may cause severe laryngeal edema, resulting in stridor and dyspnea. Its chief sign,
however, is mild to severe hoarseness, perhaps with transient voice loss. Other findings include
sore throat, dysphagia, dry cough, malaise, and fever.
Mediastinal tumor
Commonly producing no symptoms at first, this type of tumor may eventually compress the
trachea and bronchi, resulting in stridor. Its other effects include hoarseness, brassy cough,
tracheal shift or tug, dilated neck veins, swelling of the face and neck, stertorous respirations,
and suprasternal retractions on inspiration. The patient may also report dyspnea, dysphagia, and
pain in the chest, shoulder, or arm.
Retrosternal thyroid
This anatomic abnormality causes stridor, dysphagia, cough, hoarseness, and tracheal deviation.
It can also cause signs of thyrotoxicosis.
Thoracic aortic aneurysm
If this aneurysm compresses the trachea, it may cause stridor accompanied by dyspnea,
wheezing, and a brassy cough. Other findings include hoarseness or complete voice loss,
dysphagia, jugular vein distention, prominent chest veins, tracheal tug, paresthesia or neuralgia,
and edema of the face, neck, and arms. The patient may also complain of substernal, lower back,
abdominal, or shoulder pain.
Diagnostic tests
Bronchoscopy or laryngoscopy may precipitate laryngospasm and stridor.
Treatments
After prolonged intubation, the patient may exhibit laryngeal edema and stridor when the tube is
removed. Aerosol therapy with epinephrine may reduce stridor. Reintubation may be necessary
in some cases. Neck surgery, such as thyroidectomy, may cause laryngeal paralysis and stridor.
Special considerations
Continue to monitor the patients vital signs closely. Prepare him for diagnostic tests, such as
arterial blood gas analysis and chest X-rays.
Pediatric pointers
Stridor is a major sign of airway obstruction in children. When you hear this sign, you must
intervene quickly to prevent total airway obstruction. This emergency can happen more rapidly
in a child because his airway is narrower than an adults.
Causes of stridor include foreign-body aspiration, croup syndrome, laryngeal diphtheria,
pertussis, retropharyngeal abscess, and congenital abnormalities of the larynx.
Therapy for partial airway obstruction typically involves hot or cold steam in a mist tent or hood,
parenteral fluids and electrolytes, and plenty of rest.
17
 18
Acquired immunodeficiency syndrome (AIDS). Clinical manifestations of
human immunodeficiency virus (HIV) infection in children. Diagnosis of HIV-
infection in clinical and laboratory. Triatment of AIDS.

4. A plan and organizational structure of lesson.

means of studies
Time
(objects which are used in an
distribu-
Stages of lesson Types of control educational process as carriers
tion
of data and instruments of
teachers and student)
1. Preparatory stage 30 min. (writing work, (equipment, textbooks, manuals
structured)
1.1 Organizational questions. the writing and reference books, atlases,
computer testing, methodical recommendations,
1.2 Forming of motivation. practical tasks, preparations, plaster casts,
situational tasks, results of researches (sciagrams),
1.3 Control of initial level of verbal questioning is results of analyses and
preparation (control is after the standardizedinspections, computers with the
standardized). lists of questions) proper informative providing,
electronic reference books, and
others like that)
2. Basic stage 150 min.
(curation of patients, making a
plan of inspection, treatment,
differential diagnosis)

3. Final stage 45min.

3.1. Control of eventual level of

preparation.
3.2. General estimation of
educational activity of student.
 19
3.3 Informing students about the
theme of next lesson.

5. A method of organization of educational process on practical

(seminar) lessons
Basic stages of Educational Methods of Materials of the Time
lesson, their aims during control and methodical providing (min)
function and the levels of studies ( control, instructions
maintenance. mastering
1 2 3 4 5
1. Preparatory See pt.1 Actuality of
stage: theme; 30 min.
1. Organization of See pt. the Concrete
employment aims
2. Raising of II Interview.
educational aims Individual Questions for the
3. Control of initial questioning. individual questioning.
level of Test control.
knowledge Tests.

2. Basic stage Practical Curation of thematic

Forming of the III professional patients. 150 min.
system of training for Case histories. Case
professional abilities the decision of records.
and skills. various Archival case histories.
Table of contents - (typical and Situational tasks.
See pt. the Concrete offtype)
aims clinical tasks .

3.Final stage Individual Tests

1. Control and III control of Situational tasks 45 min
correction of level practical skills
 20
of professional and
skills and abilities professional
2. Working out the abilities of
totals of lesson students.
3. A home task with Analysis of
the list of thematic typical
educational mistakes.
literature (basic, Test control.
additional)

6. Additions. Methods for control:

Test tasks.
Situational tasks.
Control questions.
1) The methods of authentication of virusis are .
2) What symptoms to suspect joining of otitis
In little child.
3) Explain the necessity of inhalation therapy in case of stenosis of larynx.
4) Why easily form obstructive syndrome at a bronchitis for the children of
early age.
5) Why there is an arises up at stenosis of larynx .
6) What to explain weight of respiratory insufficiency at a bronchiolitis.
7) What cases antibiotics at the impression of respiratory tracts for
children in.
8) What medications have an etiotropic action at SRI.
9) It is needed to treat a fever at SRI?
10) You will transfer symptomatic preparations for of SRI.
11)Transfer a testimony for a roentgenologic inspection organs of thorax at
a bronchitis.
12) Describe the roentgenologic signs of bronchial obstruction syndrome .
13) Children have of neurotoksicosis at SRI.
14) Clinic of neurotoksicosis.
15) Children have of cramps at SRI.
16) What preparations stop cramps at SRI in children.
17) Name veritable febrifuges. A testimony for their setting at SRI.
18) Acquired immunodeficiency syndrome (AIDS). Clinical
manifestations of human immunodeficiency virus (HIV) infection in
children. Diagnosis of HIV-infection in clinical and laboratory.
Triatment of AIDS.
7. Literature
1. Basic: Pediatrics: Manual on Faculty Pediatrics for Foreign Students/Y.V.
Odynets, A.F. Ruchko, I.N. Poddubnaya. Kharkov: Kruk, 2003.-224p.
2. Pediatric clinical methods/Kaushal Singh. SAGAR PUBLICATIONS,
 21
2006. 333p.
3. Basic Clinical Pediatrics/Mohammed El-Naggar. National library, 2006.
84p.
4. Jamaica Gleaner : Pieces of the Past: A Pioneer, A Survivor: Dr. Cicely
Williams". Retrieved on 2007-09-18.
5 Centers for Disease Control and Prevention (2007). Prevention and control of
influenza: recommendations of the Advisory Committee on Immunisation
Practices (ACIP). MMWR, 56, 154. Atlanta, GA. [Reviews the disease burden of
influenza and the use of vaccines and antiviral therapy.]
5. Kim YJ, Boeckh M, Englund JA (2007). Community respiratory virus
infections in immunocompromised patients: hematopoietic stem cell and solid
organ transplant recipients, and individuals with human immunodeficiency virus
infection. Semin Respir Crit Care Med, 28, 22242. [Reviews the management of
respiratory viral infections in the immunocompromised patient.][CrossRef] [Web
of Science].
6. Mallia P, Johnston SL (2006). How viral infections cause exacerbation of
airway diseases. Chest, 130, 120310.[Abstract/Full Text]
7. Treanor J (2009). Respiratory infections. In: Richmond DD, Whitley RJ,
Hayden FG (eds) Clinical Virology, 3rd edition, pp. 727. ASM Press, Washington,
DC. [Reviews viral respiratory infections.]

Tests are for determination of initial level of knowledges.

1 Anatomic and physiological features that cause frequent development of larynx stenosis in
AVRD, except:
A rich vascularization of mucouse
B a small lumen of a larynx
C short nasal ways (paths)
2 Respiratory count in newborn per minute is:
A 40-60
B 100-120
C 15-20.
3 Inspiratory dyspnea is characterized by such features:
A prolonged exhalation
B prolonged inhalation
C nasal respiration
4 What kind of cough is typical for laryngitis:
A wet
B with reprises
C barking
5 Antipyretics are prescribed to a child with hyperthermia of:
A 37-37,5C
B 37,5-37,9C
C more than 38,5 C.
6 A single dose of 50% solution ofAnalginum for a one-year-old child is:
A 2 ml
B 1 ml
C 0,1 ml
7 The reason of hyperthermia caused by AVRD is:
A influence of toxic products on the center of a thermoregulation
 22
B acute disturbance of cerebral circulation
C purulent inflammation of brain structures
8 The V degree larynx stenosis is characterized by everything, except:
A a cyanosis of skin
B unconsciousness
C frequent superficial respiration ( prominent dyspnea)
D a loud cry
9 Prednisolonum is prescribed in such cases:
A an acute rhinitis
B an acute otitis
C a - degrees stenosis of larynxs
10 Antibiotics are prescribed in a case of:
A an acute bronchitis
B a purulent medium otitis
C a rhinopharyngitis (or nasopharyngitis)
11 A radiological picture of obstructive bronchitis is characterized by:
A presence of infiltration shadows
B a level of a liquid in pleural cavity
C peribronchial infiltration that makes the picture of lungs more stressed, an
emphysema of lungs

12 Application of antipyretics for children is necessary in cases :

A body temperature rises up to 38,0 C
B febrile seizures in anamnesis
C a body temperature of 37,2 C
13 Children have cramps (seizures) at AVRD as a result of:
A cranial - cerebral trauma
B tumours of brain
C influence of high temperature and toxins on cerebral structures
D hypocalciemia due to disease
14 An emergency help for children with cramps includes everything except:
A an aspiration of mucus from the top respiratory ways
B a submission of oxygen
C an intravenous injection of Seduxenum (diazepam)
D an intramuscular injection of Penicillinum
15 A single dose of Seduxenum (diazepam) for intramuscular injection for a one year old child
is:
A 0.5 ml
B 2 ml
C 0,1 ml
16 Respiratory failure in obstructive bronchitis is:
A ventilatory one
B parenchymous damage
C mixed one
17 What anatomic features of infant predispose to otitis development in AVRD, except:
A wide and short Eustachian tube
B remnants of embryo tissue
C horizontal position of child
D tympanic membrane structure
18 Trachea intubation is prescribed at:
A a I degree larynx Stenosis
B in Laryngitis
 23
C in III degree larynx Stenosis
19 A bronchitis of viral etymology is characterized by:
A dystrophy of a bronchial epithelium, its tearing away
B purulent (festering) exudation
C deformation of walls of bronchial tubes
20 An acute bronchitis is characterized by everything, except:
A a clear pulmonary sound
B rigid respiration (hard breathing)
C dry crepitation (wheezes, rattles)
D no breathing (respiration) above lungs
21 An obstructive bronchitis in children is not characterized by everything, except:
A dry tussis (cough)
B whistling, heterogeneous moist rales
C a box-like sound above lungs
D Hyperemia of skin

22 The most often bronchiolitis arises at the age of:

A 1-3 month
B 3-5 years
C 10-12 months
23 The level of a respiratory failure is mostly expressed at/in:
A an acute rhinitis
B bronchiolitis
C an otitis
24 A patient infected by SOB is characterized by everything, except:
A contact with AVRI-patients
B being eosinophile
C arise of body temperature
D became ill at first
25 Recurrent is called bronchitis which arises sometime in a year:
A one
B two - three
C three and more
26 Available complications after AVRI like bacterial (bacteriemic) pneumonias, testifies
everything except:
A fibre fever that lasts more than 6 days
B neutrophile leukocytosis
C augmentation of RI heaviness
D edema of lower extremities
E local symptomatology of lungs
27 What factor enables to speak certainly about a degree of respiratory failure:
A Hematocrit
B ESR
C creatine phosphokinase
D partial pressure of oxygen in blood
28 What medication will you choose for profilaxis in infant after contact with father
onsymptoms ARVD?:
A Penicillinum IM injection
B Remantadinum
C Interferon
29 Name the medication with antiviral action:
A Streptomycinum
 24
B Aspirinum
C Remantadinum
30 The mechanism of afebrile action of NSR is grounded on:
A. oppression of bradikinine synthesis
B. oppression ofinterferone production
C. intensifying synthesis of interleukine 1
D. oppression of cycloxygenase -1
E. oppression of cecloxygenase- 2
31 Block of cycloxygenase synthesis results as:
A. depression of leucotriens synthesis
B. reducing of prostoglandines synthesis
C. intensifying of interleukine 1 synthesis
D. intensifying of prostoglandine synthesis
E. All listed above

32 Cycloxygenase 1 is responsible for synthesis of

A. Prostoglandines in normal conditions
B. Prostiglandines at inflammation
C. Leukotriens in normal condition
D. Leucotriens at inflammation
E. All listed above
33 Cycloxygenase 2 is responsible for synthesis of
A. Prostoglandines in normal conditions
B. Prostiglandines at inflammation
C. Leukotriens in normal condition
D. Leucotriens at inflammation
E. All listed above
34 Anti-inflammatory and antipyretic effect after NSR is caused by:
A. oppression of COG 1
B. opression of COG-2
C. oppression of lipoxygenase
D. activization of lipoxygenase
E. All listed above
35 The gastro toxic side effects gastrotoxicity after non-steroid drugs are caused by:
A. oppression of COG 1
B. oppression of COG 2
C. activization of COG 2
D. activization of lipoxygenase
E. activization of lipoxygenase and COG 2
36 Choose the proper drug for child with fever:
A. Analginum
B. Acetylsalicylic acid
C. Phenacetinum
D. none of listed
E. all of listed are possible
37 What medications are forbidden for children less than12 years old
A. Amidopyrine
B. Acetylsalicylic acid
C. Phenacetinum
D. all of listed
 25
E. none of listed
38 Choose the medicine for children having fever:
A. Analginum
B. Acetylsalicylic acid
C. Ibuprofen, Paracetamolum
D. Phenacetinum
E. Any with listed

39 There is a high risk of the Ray-syndrome development on the background of virus infections
in children simultaneously taking:
A. Paracetamolum
B. Ibuprofenum
C. Analginum
D. Acetylsalicylic acid
E. none of listed

40 What children are of high risk to develop complications on the base of fever:
A. children with fibrile seizures in the anamnesis and diseases of central nervous system
B. two months old children with temperature of 38.0 C and more
C. children having chronic heart failure or congenital heart disease
D. all listed above
E. children fed by formula
41 Antipyretics ought to be administered at temperature 38,0-38,50 even in favorable course
of fever in such category of children:
A. children with fibrile seizures in the anamnesis and CNS diseases
B. two months old children having temperature of 38,0 C and above
C. children having chronic heart failure or congenital heart disease
D. all of listed
E. nothing of mentioned above
42 Paracetamolum is forbidden for children who have:
A. impaired liver function
B. impaired kidney function
C. glucose- 6- phosphatedehydrogenase deficiency
D. all listed conditions
E. deficiency of iron in an organism
43 Ibuprofen is forbidden for children who have:
A. erosive-ulcer lesions of GI tract during an exacerbation
B. impaired liver function o
C. optic nerve pathology
D. all listed conditions
E. none of listed
44 Paracetamolum has:
A. expressed antipyretic and anesthetic effects
B. expressed anti-inflammatory and anesthetic effects
C. antipyretic and adjuvant effects
D. expressed anti-inflammatory, anesthetic and antipyretic effects
E. antipyretic only
45 Ibuprofen has:
A. expressed antipyretic, anesthetic and reserved anti-inflammatory effects
B. weak anti-inflammatory and anesthetic effects
 26
C. expressed anti-inflammatory, weak anesthetic and weak antipyretic effects
D. antipyretic only
E. antipyretic and adjuvant effects
46 Choose the correct expression:
A. Ibuprofen has greater antipyretic activity than Paracetamolum if taking identical doses
B. antipyretic effect of Ibuprofen is due his anti-inflammatory activity
C. Paracetamolum and Ibuprofen are drugs of choice in treating fever in children
D. all listed above is true
E. none of listed is correct

47 Analginum can be taken:

A. in necessities of parenteral introduction of a antipyretics or intolerance of medicals like
(Paracetamolum, Ibuprofenum)
B. in any situation of high temperature above 38, 0
C. in any situation of high temperature above 38,50
D. in any situation of high temperature above 39, 0
E. at any temperature and pain
48 The Emergency treatment of an acyanotic fever:
A. It is held right after revealing antipyretic and vasodilating medicals (an antihistamine
if necessary) with the further physical methods of cooling are used.
B. an emergency treatment is not necessary
C. an emergency treatment is to be executed only after hospitalization of a child
D. an emergency treatment is to be provided with parental medicines only
E. disintoxication is enough
49 Hospitalization of children with a fever is obligatory in case of:
A. the Pyrexial syndrome.
B. Persevering temperature reaction, which is not mixed
C. the difficult and complicated course of an infectious and inflammatory disease
D. all of listed clinical situations.
E. Resorbtive fever
50 A fever with a high temperature, characterized by daily fluctuations (temperature drops)
not more than 1.0 , is called:
A. Febris continua (constant)
B. Febris remittens (aperient)
C. Febris intermittens (alternating)
D. Febris inversia (perverted)
E. Febris hectica (that exhausts)
51 A fever which is characterized by a high temperature with daily fluctuations of temperature
that exceed 1,0 , but do not decrease to normal, is called:
A. Febris continua (constant)
B. Febris remittens (destructive)
C. Febris intermittens (alternating)
D. Febris inversia (perverted)
E. Febris hectica (that exhausts)
52 A fever at which within the limits of pores alternate attacks of the normal and raised (high)
temperature or hypothermia, is called:
A. Febris continua (constant)
B. Febris remittens (destructive)
C. Febris intermittens (alternating)
D. Febris inversia (perverted)
 27
E. Febris hectica (that exhausts)
53 A Fever with observed deviation (rejection) of daily temperature rhythm is called:
A. Febris continua (constant)
B. Febris remittens (destructive)
C. Febris intermittens (alternating)
D. Febris inversia (perverted)
E. Febris hectica (that exhausts)

54 A fever which is characterized by rising of temperature to high digits and its very fast
depression is called:
A. Febris continua (constant)
B. Febris remittens (aperient)
C. Febris intermittens (alternating)
D. Febris inversia (perverted)
E. Febris hectica (that exhausts)
55 A fever with no regularity is called:
A. Febris intermittens (alternating)
B. Febris inversia (perverted)
C. Febris hectica (that exhausts)
D. Febris atipica (wrong)
E. Febris recurrens (returnable)
56 A fever with which attacks of a heating (2-7 days) alternate with the periods of apyreksiya
(1-2 days) is called:
A. Febris intermittens (alternating)
B. Febris inversia (perverted)
C. Febris hectica (that exhausts)
D. Febris atipica (wrong)
E. Febris recurrens (returnable)
57 The centers of a heat production are located:
A. at the back part of a hypothalamus
B. at the forward part of a hypothalamus
C. at the right hemisphere of the main brain
D. at the left hemisphere of the main brain
E. in the spinal cord
58 The centers of a thermolysis (term emission) are located:
A. at the back part of a hypothalamus
B. at the forward part of a hypothalamus
C. at the right hemisphere of the main brain
D. at the left hemisphere of the main brain
E. in the spinal cord
59 The temperature of internal organs, blood and brains in normal condition is:
A. 36,0
B. 37,0
C. 38,0
D. 39,0
E. 40,0
60 The temperature of axillary area is lower than the temperature of internal organs at about:
A. 1.0
B. 2.0
C. 3.0
 28
D. 4.0
E. 5.0
61 The process of heating is carried out by means of:
A. Hormones of a thyroid gland
B. Epinephral
C. stimulations of oxidizing processes in brown fat
D. stimulations of oxidizing processes in muscles and a liver
E. all listed above
62 The process of a thermolysis is regulated by means of:
A. the tonus of vessels of a skin and mucosas
B. frequency of cardiac reductions
C. frequency of respiration
D. intensity of hidrosis
E. all listed

63 What factors are essantial in restriction of a high temperature during infection:

A. the insufficient epinephral maturity
B. unsensitiveness of the thermoregulation center to leukocyte pyrogenes
C. Frequency of respiration
D. Frequency of palpitation
E. Prevalence of a thermolysis over a heat production