Children’s Respiratory Disorders

Epiglottis - RSV/Bronchitis - Pneumonia -

Asthma - Cystic Fibrosis

Marydelle Polk, Ph.D., ARNP-CS

Florida Gulf Coast University

Objectives

Describe factors that influence the etiology and course of respiratory infections in children.

Differentiate among Epiglottis, RSV/Bronchitis, Pneumonia, Asthma, and Cystic Fibrosis in terms of etiology, defining characteristics, and nursing management.

Respiratory System

The respiratory system permits ventilation through the process of inspiration and expiration

Respiratory Infections

Influencing factors* Age* Anatomical Size* Resistance* Seasonal Variations

Etiology* H. influenza, Group A -Hemolytic Streptococcus, Staphylococci, Chlamydia trachomatis, Mycoplasma, pneumoccoci

Epiglotitis

Definition A severe bacterial infection which causes inflammation of the epiglottis and surrounding areas.

Incidence Usually occurs between the ages of 2 – 5 years of age, but can occur from 7 mos. – 11 years – rarely to adulthood.

Epiglottitis

History Abrupt onset – History of pharyngitis.

Clinical Signs & Symptoms Wakes up looking very ill, fever, sore throat, dysphagia, drooling, dyspnea, “dog position.”

Epiglotitis

Clinical Signs & Symptoms * Anxious/apprehensive * Muffled, froglike croaking * Quiet inspiratory stridor

Always observe for the absence of cough, drooling and agitation – hallmarks of epiglottis.

REMEMBER !!!

1. Never examine the pharynx.

2. Leave the child in a sitting position – preferably in parent’s lap.

3. Child is anxious – Do not cause further distress and never leave the child alone.

4. Cyanosis is a late sign of hypoxia (PO2 < 50).

Nursing Diagnoses

Ineffective breathing pattern r/t inflammatory process.

Fear/anxiety r/t difficult breathing and unfamiliar place/procedures.

Nursing Coventions

Observe for progressive worsening ofrespiratory status.Prepare for tracheostomy.

Be prepared for administration of O2,IV antibiotics, sedation.

Monitor VS, LOC, O2 levels, fluid status.Provide calm reassuring support to child and parents.Prevention is via the H. influenza B vaccine.

Nursing Coventions

Administer antipyretic medication, tepid sponge baths, or cooling mattress if indicated.If needed, provide cool mist for humidifying air.Ensure adequate rest and provide a less stressful environment.Organize nursing care to give adequate rest periods.

Note the tripod (dog-like) position and the leaning forward

Early Epiglottitis

Progressive Epiglottitis

Bronchiolitis

Definition – An acute viral infection primarily occurring at the level of the bronchioles.

Etiology – Respiratory Syncytial Virus (RSV). Subgroup A > B in children developing bronchiolitis and pneumonia.

Incidence and Transmission

* URI of the infant – 2-5 mos. Rare in

children over 2 years. Considered to be the most important pathogen in the infant. Usually preceded by a viral URII (RSV).

* Increased incidence due to (1) direct contact – hands, eyes, nose, mucous membranes and (2) the virus has a long life span.

Clinical Manifestations

Mild (Initial phase)

* Rhinorrhea * Pharyngitis

* Coughing and sneezing * May present with ear or eye

infection * History of intermittent fever

Clinical Manifestations

Moderate (Progressive)

* coughing and wheezing* Air hunger and WOB* Tachypnea and retraction* Cyanosis

Sternal Retractions

When an infant/child is retracting like this – what else would you observe?

Clinical Manifestations

Severe

* Tachypnea > 70 breaths/minute* Listlessness* Apnea spells* Poor air exchange* breath sounds

Nursing Diagnoses

Ineffective breathing r/t poor gas exchange.

Altered activity level r/t work of breathing.

Potential of fluid volume deficit r/t poorfluid intake.

Nursing Coventions

Provide humidity – cool, moist oxygenAdequate fluid intakeOngoing assessment and monitoring of O2 status, VS, activity levelPossible administration of antiviral agents (RespiGam – used more for prophylactic value)

Nursing Coventions

Conserve child’s energy

Observe for signs of dehydration:

* Sunken fontanel * Poor skin turgor * Dry mucous membranes * Decreased and concentrated urinary output

Remember…

As this infection is due to a virus – standard Rx may not prove to be effective in non-complicated situations, including:

* antibiotics

* bronchodilators

* corticosteroids

* cough suppressants

Pneumonia

Inflammation of the alveoli caused by bacteria, virus, Mycoplasma organisms, aspiration, or inhalation.

Types of Pneumonia

Lobar – Large areas (segments) of one or both lungs are involved.

Broncho – bronchioles become clogged with thick mucopurulent mucus consolidates into patches in nearby lobes.

Types of Pneumonia – con’t.

Interstitial – Primarily occurs within the alveolar walls and interlobular tissues.

Incidence and Etiology

Incidence

10-20 % of the cases of pneumonia are bacterial;10 % are mixed – both viral and bacterial.70 – 80 % are viral.

Etiology

Mycoplasma pneumoniae – most common inchildren 5 – 12 years-of-age.

Chest x-rays - Pneumonia

Clinical Manifestations

feverCough (productive or nonproductive)TachypneaFine crackles and rhonchiChest painRetractions and nasal flaringPallor to cyanosisIrritability – restless – lethargicGI disturbances (nausea, diarrhea, pain, anorexia).

Nursing Diagnoses

Ineffective airway clearance r/t inflammation.

Pain r/t inflammatory process: pneumonia

Nursing CoventionsAdminister and monitor antibiotic therapy (bacterial).Monitor fluid intake, VS (especially thetemperature – give antipyretics in needed (fever/irritability), bed rest, cool mist humidifier.

In-hospital – monitor O2 if child develops respiratory distress.Avoid cough suppressants.Teach parents s/s of respiratory distress and dehydration.Conserve child’s energy.

Reactive Airway Disease - Asthma

Definition – inflammatory process of the large airways, which results in heightened airway reactivity.

An obstructive disorder – due to the inflammation and edema of the mucous membranes, in thick, tenacious secretions, spasms of the bronchial smooth muscle a diameter of bronchioles.

Types of Asthma

Mild Intermittent Asthma* S/S 2 times per week* Exacerbations are brief* Nighttime s/s 2 times per month* Asymptomatic between episodes* Does not require chronic drug therapy* Teach and encourage parents to exposure to allergens

Types of Asthma

Mild Persistent AsthmaS/S > 2 times per week - < 1/dayExacerbations may/may not affect exerciseNighttime s/s > 2 times per month

Tx with a nonsteroidal Rx - Cromolyn Sodium, a low dose inhaled cortico- steroid or a leukotriene inhibitor.

Types of AsthmaModerate Persistent Asthma

*Daily s/s*Daily use of short-acting 2-agonist or a low dose long-acting bronchodilator

*Exacerbations affect exercise*Exacerbations 2 times per week and may last for days*Nighttime s/s > 1 time per week*May see Nedocromil (Tilade) given in children 5 years or younger in place of long-acting bronchodilator

Types of Asthma

Severe Persistent Asthma* Continual s/s* Frequent exacerbations* frequent nighttime s/s* PEFR and/or FEV1 > 1 second and 60 % of predicted value * Tx - high dose inhaled corticosteroids (Vanceril, Flovent) plus oral steroids as needed to control s/s

Asthma

Educate child and family about the disease - assist them to identify the triggers - help them in developing an “asthma action” plan AND teach and encourage child to use a peak flow meter regularly as part of his/her action plan to determine management of their s/s.

Asthma

Guidelines for child:

80% of child’s baseline is acceptable.

50 - 80% of child’s baseline indicates obstruction.

50% of child’s baseline indicates an acute attack.

Nursing Diagnoses

Ineffective airway clearance r/t allergenic response and inflammatoryprocess in bronchial airways.

Risk for suffocation r/t bronchospasm,edema and tenacious mucus.

Nursing Coventions

Allergy control

Drug therapy

Chest PT

Hydration

Exercise

Keeping up with immunizations/flu vaccine

Desensitization therapy

O2 Delivery Devices

Metered Dose Inhaler-Spacer

Remember

Assessment - Teaching - Monitoring are hallmarks of effective care for the asthmatic child - whether in an acute care facility or community health center.

Cystic Fibrosis

Definition

An inherited, autosomal recessive disorder, which affects the exocrine glands and results in multisystem involvement.

Most significant factor - The viscosity of mucus gland secretions = obstruction

Cystic Fibrosis

Areas of involvement

* Respiratory system* Integumentary system* GI system* Reproductive system

Cystic Fibrosis

Major signs and symptoms due to:

* Lack of sufficient pancreatic enzymes.* Gradual obstructive lung disease* sweat gland function.

Nursing Diagnoses

Ineffective airway clearance r/t increased mucus production.

Alteration in nutrition - body requirements r/t malabsorption.

Nursing Coventions

Administer and monitor effects of antibiotic, bronchodilator, and nutritional management.

Teach chest PT - MAINSTAY of therapy!

Teach proper postural drainage technique.

Promote exercise, deep breathing and directed coughing.

Teach parents/child s/s of infection and complications i.e. pneumothorax

Nursing Coventions

Administer and/or monitor pancreatic enzyme replacement therapy. ** Always administer with meals and snacks - amount given relates to degree of insufficiency and the child’s response to the enzyme therapy. Goal is to prevent FTT and to number of stools.

Teach parents/child about s/s of Na+ depletion and rectal prolapse

The End...