This document provides information on respiratory disorders in children. It discusses how to assess the respiratory system and identifies signs of respiratory distress. Specific respiratory conditions covered include respiratory distress syndrome, croup, epiglottitis, bronchitis, bronchiolitis, bronchopulmonary dysplasia, otitis media, tonsillitis, and asthma. For each condition, the document describes the etiology, pathophysiology, clinical manifestations, diagnosis, and treatment/management. Nursing interventions are provided for various respiratory disorders. The respiratory anatomy of children is also reviewed, noting how it differs from adults.
2. Respiratory Assessment
Count respiration for
1 full minute
Infants– obligatory
nose breathers
Identify signs of
respiratory distress
Listen to breath
sounds 1st!
Stridor- thrill harsh
sound
Rhonchi
Wheezing
3. Respiratory Assessment
Quality of respirations
Quality of pulse
Color- pale, cyanotic, mottling
Cough- croupy- loose, wet, dry
Behavior change- tired of breathing fast?, restless?,
lethargic?, change in LOC
Signs of dehydration- low I&O, L skin turgor- check in
abd or sternum, lack of tears in older children,
6. Retractions
Depth and location of retractions indicate
the severity of distress
Intercostal retractions- mild
Subcostal - moderate
Suprasternal – moderate
Supraclavicular- severe
Use of accessory muscles- severe
7. Anatomy is Different!
• Development
• Airways – shorter and more narrower
• Increase in airway resistance in children
• Flexible larynx
• Tongue is proportionally larger
– can cause obstruction
• Obligate nose breathers
– plugging can cause respiratory distress
9. Respiratory Distress Syndrome
Resultof a primary
absence,
deficiency, or
alteration in the
production of
pulmonary
surfactant
Prematurity
Surfactant
deficiency disease
10. Signs & Symptoms of RDS
Shortness of breath
Grunting
Nasal flaring
Cyanosis
Apneic spells
Increased work of
breathing –
tachypnea
1st sign of respiratory
distress
Retractions
11. Management/Treatment of RDS
Support adequate
ventilation
Surfactant
replacement
therapy
Monitor
for
Complications
12. Nursing Interventions
Risk for ineffective breathing pattern
Check prenatal meds
Monitor vitals and skin
Clear airway prn with bulb syringe
Give warm humidified O2
Ineffective thermoregulation
Warm all inspired gases. Cold air= more
need of O2 and high metabolic rate
Respiratory distress can lead to metabolic
acidosis. Check for acrocyanosis,
bradycardia, apnea, etc
13. Altered nutrition: less
If there is respiratory distress do not give oral
fluids. Start parenteral nutrition per MD
Give calories to prevent metabolic acidosis
due to starvation. TPN is an alternative
Risk for fluid vol deficit
Record I& O hourly and daily weights.
Circulatory overload= pulmonary edema
Check signs of dehydration: poor skin
turgor, pale mucous memb, sunken anterior
fontanelle. Specific gravity, etc
Check IV sites for infiltration, infection
(edema, and erythema)
14.
15. Croup Syndrome
Broad classification of upper airway illnesses that
result from swelling of the epiglottis and larynx
Viral
Spasmodic laryngitis
Laryngotracheitis
Laryngotracheobronchitis (LTB)
Bacterial
Bacterial trachitis
Epiglottitis
16. Laryngotracheobronchitis (LTB)
LTB,most common form of croup
Usually caused by virus;
Adenovirus,
Respiratory Syncytial Virus (RSV)
Influenza Virus
Inflammation and narrowing of the
laryngeal and tracheal areas.
17. Clinical Manifestations of LTB
Upper respiratory infection (URI) symptoms
that gradually progress to signs of distress.
Hoarseness, barky cough
Inspiratory stridor
Retractions
Restlessness and irritability
Pallor and cyanosis
Sometimes a low grade fever
Potential complication: airway obstruction
Difficulty swallowing or drooling= epiglotitis
18. Treatment/Management of
LTB
Lateral neck x-ray
confirms diagnosis
Maintain Airway
Patency
Supplemental
oxygen with
humidity
Cool mist tent
Meet fluid and
nutritional needs
19. Treatment/Management of
LTB
Medication
Racemic epinephrine
Bronchodilators – Albuterol
Side tachycardia
Steroid therapy- IV or inhaled
Keep calm and comfortable
NO Throat cultures or visual inspections of
the mouth
Continue to monitor- Respiratory effort,
responsiveness, signs of respiratory distress
Constant attendance
20.
21. Epiglottitis
• An inflammation of the epiglottis, the long
narrow structure that closes off the glottis
during swallowing
• A life-threatening condition!!!
This is a Medical Emergency
• Bacterial- Caused by strep, staph, and
haemophilus influenzae type B
• Hib vaccine reduces risk for epiglottitis
23. Diagnosis of Epiglottitis
Diagnosis confirmed by lateral neck films
High Oxygenation to reverse hypoxemia
Cool mist oxygen
Cools airway and lowers swelling!
Antipyretics,
ab, & steroids to decrease
inflammation
May use a tracheostomy to bypass the problem
24. Treatment/ Management
Epiglottitis
Closely
Monitor Respiratory status. Do not
attempt to examine the throat. Axillary
temp only!
Medications include antibiotics and
steroids to decrease inflammation
Minimize
fear and anxiety to decrease
oxygen consumption
25.
26. Bronchitis
Lower airway disorder
Inflammation of the
trachea and bronchi
Cause- mainly viral
Symptoms
Fever, dry hacking cough
non productive. Productive
in a couple of days
Management
Cool, humid air, increase
fluids, antipyretics, cough
suppressants
27.
28. Bronchiolitis
Caused when a virus
or bacterium causes
inflammation and
obstruction (mucus)
of the small airways
Occurrence- First 2
years
Peak: 6 months
Cause – Respiratory
Syncytial Virus (RSV)
29. Bronchiolitis
Pathophysiology
Cell debris- death virus after bursting to
invade
Irritation= Swelling/mucus
Bronchospasm
Inhalation, poor exhalation
Wheezing, hypoxemia, respiratory failure
30. Clinical Manifestation of
Bronchiolitis
Illness
may have been occurring for a few
days- upper respiratory
Lower respiratory
Severerespiratory distress. Thick mucus
occludes bronchioles
Initial: Rhinitis, cough, low fever, tachypnea,
poor feeding, v & d, dehydration, less
playful
31. Clinical Therapy For
Bronchiolitis
History and Physical
Chest x-ray
Hyperinflation, atelectasis and inflammation
Nasal swab- to find bacteria
Ribavirin – antiviral for RSV. Used for
immunocompromised
Bulb syringe & Saline
Isolation
Risk Factors – lung disease, low weight,
siblings that go to school, passive smoke,
premmie
32. Treatment/Management
Bronchiolitis
Rest& elevate HOB to 30
Clear fluids (NPO if resp rate >60)
I& O x 8 h & daily weights, mucous memb
Maintain respiratory functions. Use
suctioning- Also before feeding
Cool, humidified oxygen
Albuterol updrafts
Steroids
Infants often hospitalized due to feeding
difficulties, increased respirations
Hand washing!- RSV is recurrent
33.
34. Bronchopulmonary Dysplasia
(BPD)
Chronic Lung Disease
Results from an acute respiratory disorder that begins
during infancy
Risk Factors
Prematurity
Lung immaturity
High inspired oxygenation concentrations,
Positive pressure ventilation
Patent ductus arteriosus
Vitamin A deficiency
36. Tracheostomy
Keep small toys, dust away from child
Careful when bathing! No showers
Observe and clean skin daily
Suction prn
Only 5 sec, sterile gloves, intermittent
suction when withdrawing cath
Notifyif secretions increase or turn
purulent, or fever
Have an emergency bag w extra cath
and tubes
No smoking
O2 away from heat
37. BPD
Diagnoses
Chest x-ray shows hyperexpansion,
atelectasis, and interstitial thickening
Air trapping can cause “Barrel Shape”
Chest
Treatment
Support respiratory function- supplemental
O2 w humidity. Chest physiotherapy + meds
Medications
Nutrition
Prognosis
38.
39. Otitis Media
Inflammation of the
middle ear
Occurrence- 6-36 m
(winter)
Risk Factors
Causative
organisms
Streptococcus
pneumoniae
H. flu.
Moraxella catarrhalis
40. Otitis Media
Etiology
– Eustachian tube dysfunction
Pathophysiology
Preceding upper respiratory infection
Edema
Blocked air
Air reabsorbed to bloodstream
Fluid is pulled from mucosal lining
Tympanic membrane becomes infected
41. Otitis Media
S & Sx
Pulling at the ear
Diarrhea, vomiting, & fever
Irritability, awakens at night crying
Diagnosis
Otoscopic examination- Shows a red,
bulging, non-mobile tympanic membrane
Treatment
Antibiotics
Myringotomy/Tympanostomy (PE tubes)
Pain relief – Tylenol/Ibuprofen, anesthetic
ear drops- verify integrity of tympanic
membrane
42.
43. Tonsillitis
Infection or
inflammation of the
palatine tonsils
Clinical Manifestations
Frequent throat
infection
Breathing and
swallowing difficulties
Persistent redness
Enlargement of cervical
lymph nodes
44. Tonsillectomy
Before surgery
H&P
Are tonsils simply large or inflamed w
exudate?
Past tonsillar infections and lengh of present
discomfort
Free from sore throat, fever, respiratory
infection for week before surgery
No aspirin or ibuprofen for 2 weeks
Check other home medication
46. Tonsillectomy
After Surgery
May have sore throat for 7-10 days
Drink cool fluid and chew gum
Give Acetaminophen elixir
Apply ice collar around child’s neck
Side-lying position- difficult to swallow
47. Sore throat: cool fluids, chew gum, ice
collar, gargle ½ tsp. of each baking soda
and salt in water, rinse w viscous lidocaine
and swallow. No citrus liquids
Report bright red blood or increased
swallowing immediately
Avoid red, purple or brown liquids= difficult
to assess for bleeding
Normal: white, and odor on back of
throat in the first wk. Report fever 102 F
48.
49. Asthma
Chronicinflammatory disorder of
the airway
Airway obstruction
Increased airway responsiveness
Acute exacerbations or persistent
symptoms
Onset-before age 5
Causes of asthma & respiratory
problems in children
Smoking, pet dander
50. Pathophysiology of Asthma
After exposure to various “triggers”
Bronchospasm
Inflammation and edema of the bronchial
mucosa
Production of thick
mucus
Asthma triggers- perfume
51. Pathophysiology of Asthma
Reactive airway responses
Antigen binds to the specific
immunoglobulin E surface on the mucosal
mast cell
Histamine is released
Intercellular chemical mediators are
released- histamines, prostaglandins,
leukotrienes
Release cytokines that make permanent
airway remodeling- thickening
Result:
bronchospasm, mucosal edema, &
mucus secretion
52.
53. Clinical Manifestations of Asthma
Airway
Inflammation
Obstruction (narrowing)
Hyperreactivity
“Asthma Attack”- sudden cough,
wheeze, or SOB
“Silent” asthma- frequent coughing,
especially at night (airway is very
sensitive)
54. Clinical Manifestations of Asthma
Respirations
Appears tired
Nasal flaring- 4 wks
Intercostal retractions
Productive cough
Expiratory wheezing
Decreased air movement
Respiratory fatigue
In severe obstruction
55. Diagnosis of Asthma
4 key elements
Symptoms of episodic airflow obstruction
Partial reversal of bronchospasm with
bronchodilator treatment
Exclusion of alternative
Diagnosis confirmation by spirometry
56. Evaluation of Asthma
Spirometry
Shows how much a person can exhale-
evidence of episodic airflow obstruction
and airway hyper-responsiveness. Place
mouth covering entire mouth piece…
Breathe out as hard as possible and then
breathe in deeply
57. Evaluation of Asthma
Peak flow meter (expiratory flow meter)
Blow into it every morning to see if you need
treatment like a nebulizer to open up the airway.
Warns of impending attack
Green- ok
Yellow
Red- less than 50%= Warning!
Skin
testing- to id triggers
Medications
58. Medications Used for Asthma
Short-acting bronchodilators
Albuterol/ventolin/proventil-
drug of choice
Terbutaline- not very common
Long & short acting beta agonists
Salmeterol- can use for exercise and night sx
Mast cell inhibitor
Intal/cromolyn- Can be used in nebulizer
Ex Singulair- Minimizes allergies
Corticosteroids
Prednisone or solumedrol
59. Status Asthmaticus
Severe respiratory distress & bronchospasm in
an asthmatic
Itpersists in spite of pharmacologic and
supportive interventions
Considered a medical emergency
Without immediate intervention, it will progress
to respiratory failure & death
61. Cystic Fibrosis
CysticFibrosis is an autosomal recessive
multisystem disorder with dysfunction of
the exocrine glands
Genetic testing
Expected lifespan- 30 years (terminal
disease)
Results
in physiologic alterations in several
systems
62. Cystic Fibrosis
Abnormal secretion of thick, tenacious mucus
causes obstruction and dysfunction of all body
organs with mucous ducts.
This
includes the pancreas, lungs, salivary glands,
sweat glands, and reproductive organs.
65. Diagnostic & Evaluation of CF
3 presentations
Meconium ileus
Malabsorption- steatorrhea
Chronic recurrent respiratory infections
The Sweat test is the standard diagnostic test for CF
Spirometer
Sputum cultures
66. Treatment & Management
Chest physiotherapy (CPT): Can use
percussion to help move secretions
downward so they can cough it up. Position:
head of baby downward to use gravity
3-4 x day to prevent increase of
hospitalizations and infections
Do not perform immediately after eating
Give bronchodilator to open bronchi for
easier expectoration before therapy
AM
Exercise stimulates mucus expectoration
Use forced expiratory technique to mobilize
secretion- Huffing
67. Treatment & Management of CF
Antibiotics (oral, IV, & inhalation)
Pancreatic enzymes with meals,
Pancrease or Creon. To help digest food
Aerosol bronchiodilators
Steroids
Diet- high calorie & protein, extra salt in
hot weather, ADEK vitamins
Psychosocial concerns
69. Allergic
reaction - antigen-antibody reaction that
can manifest as anaphylaxis, atopic dermatitis,
serum sickness or contact dermatitis
Hypersensitivity response
70. Allergy Assessment
Physical exam- history of exposure to
allergens, itching, tearing, burning of eyes
and skin, rashes, nose twitching, stuffiness
Lab
X-ray
Pulmonary function studies
Nasal function
Skin testing
71. Treatment of Allergies
Avoidance
Desensitization
For skin allergies
Allergy alert bracelet
Teaching about allergens in the home
73. Question One:
Which of the following respiratory
conditions is always considered a medical
emergency?
A. Asthma
B. Epiglottitis
C. Cystic Fibrosis
D. Laryngotracheobronchitis
74. Question Two:
In a child with asthma, albuterol is
administered primarily to do which of the
following?
A. Dilate the bronchioles
B. Decrease postnasal drip
C. Reduce airway inflammation
D. Reduce secondary infections
75. Question Three:
When developing a care plan for a child
diagnosed with cystic fibrosis, which of the
following must the nurse keep in mind?
A. CF is an autosomal dominant hereditary
disorder
B. Pulmonary secretions are abnormally thick.
C. Obstruction of the endocrine glands occur
D. Elevated levels of K+
Hinweis der Redaktion
Naris expand Retractions Stridor: Thrill harsh sound Ronchi: Once you cough, rhonchi goes away. It’s the only one that goes away after coughing Rales- fine crackling sound. Associated with pneumonia- ab will help it go away; and CHF- Lasix will help it go away Make sure to listen to the lung bases
Check for this findings: Look for dyspnea, tachypnea, nasal flaring, retractions, child can’t pronounce P because of diminished expiratory effort, focus on breathing, anxious expression, upright position w neck extended, crying improves or worsens the color, low cap refill Quality of Respirations: 1. Depth 2. Clarity of breath sounds 3. Pain with breathing- dyspnea 4. Difficulty breathing – use of accessory muscles – sternocleidomastoid and intercostal muscles Quality of pulse: 0- absent pulse, -4-bounding Normal RR Newborn 30-35 1- 25-40 3- 20-30 6- 16-22 10- 16-20 17- 12-20 Cyanosis: check mucous membranes and tongue Valsalva maneuver or expiratory grunt: is a preventive mechanism to prevent atelectasis. Do not intubate Fixed heart rate indicates a decrease in vagal stimulation Displacement of point of maximal impulse could be due to hernia in diaphragm or pneumothorax Decreased muscle tone of unresponsiveness= deteriorating CNS
Tachycardia and tachypnea go together
Retractions- due to moving muscles to get more air in Intercostal- under the ribs. Seen in mild distress Substernal, and subcostal- severity increases Supraclavicular, and suprasternal- due to use of accessory muscles
Airway resistance: effort needed to move oxygen through the trachea to the lungs. Can intubate to help child
Atelectasis- bronchioles filled with fluid
Surfactant: reduces surface tension throughout the lung, thereby contributing to its general compliance. It gives alveolar stability by decreasing the alveoli’s surface tension and tendency to collapse. It gives better lung compliance and permits breathing w less work Leads to: atelectasis, hypoxia, acidosis (lack of gas exchange), and respiratory failure Collapsed alveoli= harder & harder to breath Hypoxia leads to Low pulmonary blood flow= fetal circulation= blood flow is moved around lungs Impaired response to cold Anaerobic metabolism Low perfusion to other organs Respiratory acidosis: Alveolar hypoventilation Metabolic acidosis Due to the anaerobic metabolism Atelectasis is the collapse of part or (much less commonly) all of a lung. Endotracheal tube pic RDS is only found in preterm babies
Grunting: abnormal, short, deep, hoarse sounds in exhalation that often accompany severe chest pain. Slow expiratory flow that prevents alveolar collapse during expiration Apneic- respirations lasting longer than 20 sec Respiratory failure: Early signs- restlessness, tachypnea, tachycardia Imminent RF: dyspnea, bradycardia, cyanosis Tachypnea: more than 60 respirations See-saw respirations: flat chest during inspiration and abd bulging out. Use ventilation bc there is more O2 need and more workload
Treat RDS Surfactant replacement with endotracheal tube + gas checkups + fix acid-base imbalance + regulate temperature + good nutrition + protection from infection. Treatment modalities: Increased humidified oxygen Continuous positive airway pressure (CPAP) Ventilation from a respirator High frequency ventilation (HFV) Treat cause of Resp failure Reverse hypoxemia w O2 Mechanical ventilation & Positive end expiratory pressure If decreased LOC: Endotracheal tube (ET) intubation Monitor vitals, respiratory status, O2 sat, LOC & changes in behavior Keep in upright position- elevate HOB Give O2 and keep emergency equipment at hand Pneumothorax- collapsed lung Intraventicular hemorrhage- bleeding in the brain?
Croup= barking of a seal
Symptoms worse at night. Progresses to retractions, increasing stridor and cyanosis Airway obstruction= intubation and ICU
Throat cultures and visual inspection of the inner mouth and throat= laryngospasm= complete airway obstruction. My note: Use XR instead! Cool, noncarbonated nonacidic drinks: rehydration fluids or fruit flavored drinks, gelatin, and popsicles
Beta agonist and betaadrenergics: albuterol, racemic w face mask? Temp relief in half an hour, side: tachycardia, HTN Corticosteroids: dexamethasone: decrease edema & stridor resolves faster, side: HTN Bronchodialator- xanapex? Quiet parent= quiet kid Once on steroids, wheezing should minimize O2 Sats should be above 92% Start with a quarter of a liter when giving O2 to a baby
Sudden illness that starts with sore throat and can’t swallow own spit Keep airway open + ab.
Epiglottis becomes cherry red, swollen and extremely edematous Use tripod position to breath in- also used with COPD Can’t swallow, no voice sounds (before intubation), acute onset of drooling, quiet child= CONCERN!
Remind parents that ET tube can be removed in 1- 2 days, and that child may be unable to make sounds temporarily
Assess breath sounds, nasal flaring, accessory muscle use, retractions, stridor, Axillary temp (Not the oral route!), pulse ox Keep NPO IV ab and antipyretics, corticosteroids, nebulized epinephrine (racemic epi)- vasoconstriction =lowers edema, Hib vaccine Do not leave child unattended until he is intubated, keep NPO, never supine, have resuscitation equipment av, prepare for endotracheal intubation, or tracheostomy, keep a relaxed athmosphere (crying= laryngospasm) Can insert ET tube to maintain the airway. Then take a culture of the epiglottis
Cough is worse at night. Some cracking & wheezing, sore chest & ribs
Greater incidence in Winter & Spring- keep supplies to treat condition at hand Bronchitis- large airways involved, bronchiolitis- small airways involved
Initial: rhinorrhea, ear drainage, coughing, sneezing, wheezing Progresses: More coughing and wheezing, air hunger, tachypnea, retractions, cyanosis Severe: tachypnea (more than 70), increased adventitious sounds, listlessness, apneic episodes
Viral- resolves by itself
Use cardiorespiratory monitor and place a pulse ox w alarm Small freq feedings. IV if risk of aspiration Encourage parents to hold child to reduce anx
Barrel chest
Wean off assisted ventilation
Bad nutrition bc of high metabolic needs and fatigue when feeding Meds: diuretics, bronchodilators, antiinflammatory, mehylxantines, Palivizumab to prevent RSV
Most common childhood disease RF: enlarged adenoids, allergic rhinitis, pacifiers alters function of eustachian tube, parents that smoke, day care centers
Tube becomes blocked due to edema from upper resp. inf.
Why is ab treatment delayed for 2-3 days in children of 6 m to 2 years? Pg 1291 Myringotomy- allow draninage, equalize pressure & allow ventillation Ab- amoxicillin, keflex, tetracycline, etc PE- pressure equalizing tube. Cover ear if going into water, careful if swimming. Drops for pain relief.
Drug of choice- penicillin Strep- sand paper rash, fever. Use saline gargles, ibuprofen x 8 h and tylenol x 6h alternating for inflammation, popsicles. Prevention, change tooth brush frequently
Mast cell releases histamine= pouring out of fluid
Smaller airway for gas exchange= wheezing
Tripod position used for breathing better Nasal flaring, H RR, intercostal retractions, productive cough, expiratory wheezing, respiratory fatigue, chest tightness. Wheezing might not be heard if lack of airflow!
Use bronchodilator before exercising Cta- abbreviation used for “clear to auscultation” Ronchi- clears with coughing, wheezes and rales don’t
Peak flow meter- the one I have
Short acting: Use bf inhaled steroid and wait 15 min. Hold breath 10 sec after inspiring. Rinse mouth. Side- tachycardia, headache, nervousness, n&v Long acting: not for acute asthma attack!. Pre exercise 30-60 min bf Mast cell inh- Up to 4 x d. Therapeutic in 2 wks. Careful w anaphylaxis, bronchospasm… Corticosteroids- decreases inflammation and obstruction, enhances effect of bronchodialators. Used for short courses until 80% of peak expiratory flow is achieved or no sx. Give w food in the AM. Side- decreased growth, unstable blood sugar, immunosuppresion Methylxantines: theophylline relaxes muscle bundles that constrict airway Pediapred- PO steroid, liquid? Use albuterol first and then steroid- Dilate vessels so that med can go into body Rinse mouth after using steroids
Tenacious- thick secretions. May need tracheostomy because of the secretions
Males are usually sterile & women may not be able to carry out pregnancy Meconium ileus- Unable to pass first meconium stool Sweat test-salty skin (Na in sweat) Steatorrhea- malabsorption due to cloggled pancreatic ducts + small intestine can’t absorb properly fats and proteins (short stature)
CPT- abbreviation means “child protection team” or “chest physiotherapy”
Vitamins A, D, E, K Don’t sprinkle enzymes on warm meals because heat will destroy the enzyme. Don’t put it in the baby‘s bottle either, can put a little amount of milk separate w the med and make sure the baby takes all of the milk.
Mold, pollen, house dust, pet dander Cow’s milk, eggs, wheat, chocolate, citrus fruits, peanuts, pepper, etc- document on chart Oral and injectables, animal serum/venom and insect stings Plants, dyes, chemicals