Respiratory Alterations

NUR 264Pediatrics

Angela J. Jackson, RN, MSN

Respiratory Alterations: Developmental Differences Lungs require longer gestation time to form

than any other body system Children have a smaller nasopharynx – easily

occluded during infections Lymph tissue (tonsils, adenoids) grows rapidly

in early childhood, atrophies after age 12 Smaller nares – easily occluded during

infection. Infants are nose breathers Eustachian tubes are shorter and more

horizontal, facilitating transfer of pathogens into the middle ear

Respiratory Alterations: Developmental Differences Long, floppy epiglottis – vulnerable to swelling

and obstruction Thyroid, cricoid, tracheal cartilages are

immature and collapse when neck is flexed Diaphragmatic-abdominal breathing normal in

neonate until approximately 5y/o due to position of ribs which affect chest wall expansion

Chest wall is supple and very compliant Irregular patterns of breathing in newborns

and infants Pediatric arrests usually occur from respiratory

arrest or shock, not cardiac arrest

Choanal Atresia Congenital

membranous or bony obstruction between the nose and nasopharynx

Choanal Atresia Can obstruct one or

both posterior nasal openings

Unilateral can be overlooked until open nasal passage becomes obstructed

Bilateral – severe signs of distress in newborn

More common in girls Treatment: surgery

Congenital Laryngeal Stridor: Laryngomalacia Laryngeal cartilage

is soft and flaccid, causing the supraglottic structures to collapse into the airway, resulting in partial obstruction and stridor

Laryngomalacia

Stridor with retractions Infant’s cry is normal Cyanosis is uncommon Place in prone position to decrease

obstruction Occurs more frequently in boys Treatment: Tracheostomy

Acute Viral Nasopharyngitis (Common Cold) Inflammation of the nasopharynx Self-limiting viral infection The inflammatory process is

associated with tissue swelling and the formation of exudate.

Nasal congestion caused by edema and secretions impede airflow through the nasal passages

Acute Viral Nasopharyngitis: Clinical Manifestations Nasal stuffiness Rhinitis Sneezing Nasal discharge Coughing Sore throat Fever Irritability Malaise Poor feeding

Acute Viral Nasopharyngitis: Diagnosis and Treatment Diagnosis is based on client history and

physical exam Supportive care

Decongestants Saline nasal spray Fluids Vaporizer Antipyretics Cough suppressants

Acute Streptococcal Pharyngitis (Strep Throat) Bacterial pharyngitis Caused by Group A

beta-hemolytic streptococcus

Red throat, petechia on palate

Throat pain Fever Abdominal pain Fine raised rash Anterior cervical

adenopathy

Strep Throat Diagnosed with throat cultures, rapid

strep screen Treated with one dose IM penicillin or

10 day course of antibiotics Replace toothbrush Test and treat other members of

family Complications: acute

glomerulonephritis, Rheumatic Fever

Tonsillitis - Adenoiditis

Viral or bacterial infection of the palatine and or pharyngeal tonsils (adenoids)

Children are more prone to tonsillitis because of the large amount of lymphoid tissue and frequent respiratory infections

Tonsillitis – Adenoiditis: Clinical Manifestations

Sore throat Difficulty swallowing Fever Nasal congestion

Tonsillitis – Adenoiditis: Diagnosis Based primarily

on symptoms and visual inspection of the throat

Throat cultures and rapid strep screening are used to determine etiologic agents

Tonsillitis – Adenoiditis: Treatment

Tonsillectomy may be indicated for recurrent infection, or when enlarged tonsils interfere with eating or breathing

Viral infection: supportive care Warm saline gargles Antipyretics

Otitis Media Inflammation of

the middle ear One of the most

common infectious diseased in childhood

Primary causative factor: abnormal functioning of eustachian tube

Otitis Media: Clinical Manifestations

Pain Fever Irritability Diarrhea and vomiting May have decreased hearing

Otitis Media: Diagnosis

Otoscopic examination Red, bulging tympanic membrane Diminished movement with

pneumatic otoscopic assessment

Otitis Media: Treatment

Antibiotics for 10 days Tympanostomy tubes for recurrent

or unresolving OM and/or hearing loss

Acute Epiglottitis Serious obstructive

inflammatory process of epiglottis

Occurs principally in children between 2 and 5 years of age

Caused by infection with Haemophilus influenzae

Requires immediate treatment

Epiglottitis: Clinical Manifestations Abrupt onset Child complains of sore throat and pain on

swallowing Fever Child appears sicker than clinical findings suggest Insists on sitting upright and leaning forward, with

the chin thrust out, mouth open and tongue protruding (tripod position)

Drooling is common Child is irritable and extremely restless, has an

anxious, apprehensive and frightened expression Voice is thick and muffled Inspiratory stridor

Acute Epiglottitis: Treatment

Intubation or tracheostomy may be necessary for the child with respiratory distress

Antibiotics, initially given IV followed by PO administration, for 10 days

IV fluids, antipyretics, corticosteroids, keep child calm

The epiglottal swelling usually decreases after 24 hours of antibiotic therapy, and is near normal by the third day

Laryngotracheobronchitis (Croup) Viral syndrome manifested by a

croupy or “barking” cough, inspiratory stridor, and respiratory distress

Inflammation of the larynx, trachea, and bronchi causes narrowing of the airways

Seen predominately in children between 6months and 3 years of age

Croup: Clinical Manifestations

Hoarse or “barking” cough Nasal drainage Sore throat Low-grade fever Tachycardia Tachypnea Inspiratory stridor

Croup: Treatment

Nebulized racemic epinephrine Corticosteroids Fluids Rest Humidity

Bronchiolitis

Acute viral infection of the bronchioles, occurring most often in young children

RSV is the most common causative agent

95% of children have had bronchiolitis by the age of 3

Bronchiolitis: Pathophysiology

• Inflammation causes airway edema • The bronchioles are narrowed and

occluded• Occlusion causes air trapping, which

leads to hyperinflation of some alveoli and atelectasis in others

• Overall effect is hypoventilation

Bronchiolitis: Clinical Manifestations Rhinorrhea Sneezing Decreased appetite Low-grade fever Coughing Wheezing, nasal flaring, retractions Crackles Tachypnea

Bronchiolitis: Diagnosis

History and physical exam Nasopharyngeal washings Chest x-ray

Bronchiolitis: Treatment Humidified O2 Bronchodilators Suctioning Oxygen saturation monitoring IV fluids Strict handwashing and contact

precautions Prophylaxis: Synergis IM once a month

Pneumonia

Acute inflammation of the pulmonary parenchyma

Seen frequently in childhood, occurring most often in infancy and early childhood

Viruses are the primary causative agent except in neonatal cases of pneumonia

Pneumonia: Clinical Manifestations Cough Malaise Chest pain Fever Anorexia Headache Tachypnea Wheezing

Pneumonia: Treatment

Cough, deep breath, change position often

CPT, O2, IS IV fluids Antibiotics, antipyretics Cool mist, suctioning Rest

Asthma

Chronic inflammatory disorder of airways with bronchoconstriction and bronchial hyperresponsiveness

Most common pediatric chronic illness

Asthma: Pathophysiology Exposure to irritant causes constriction of

bronchial smooth muscles, edema, increased mucus production, airway narrowing

Bronchial muscles go into spasm, resulting in increased respiratory effort, increased airway resistance, air trapping, hyperinflammation of airway

Risk factors: hereditary, environmental stimuli, stress, weather changes, exercise, viral or bacterial agents, food additives

Asthma: Clinical Manifestations Recurrent episodes of wheezing Breathlessness Nasal flaring, retractions, head bobbing Chest tightness Cough Prolonged expiration Dyspnea Tachypnea, tachycardia, barrel chest

develops

Asthma: Diagnosis

Chest x-ray shows hyperinflation of the airways

PFT’s show decreased peak expiratory flow rate

Asthma: Treatment Avoidance of triggers Regular peak flow monitoring Medications

Short-acting beta-2 agonists (albuterol) Inhaled corticosteroids (beclomethasone) Systemic corticosteroids Antileukotrienes (Singulair) Long-acting bronchodilators (Serevent) Anticholinergics (atrovent)

Cystic Fibrosis Autosomal recessive disorder that

affects the exocrine glands Causes the body to produce thick,

sticky mucus that clogs the lungs, the GI tract and the GU tract

Affects approximately 30,000 children and adults in the United States

Median age of survival is 33.4 years

Cystic Fibrosis: Clinical Manifestations Salty taste to the skin Foul smelling, greasy stools Delayed growth Thick sputum Chronic coughing or wheezing Frequent chest and sinus infections with

recurring pneumonia or bronchitis Clubbing of fingers and toes Intussusception Rectal prolapse Meconium ileus

Cystic Fibrosis: Diagnosis

History and physical exam Sweat test DNA analysis

Cystic Fibrosis: Treatment

Antibiotics Mucus-thinning drugs (Pulmozyme) Bronchodilators Bronchial airway drainage Oral enzymes High calorie diets Lung transplant

Cystic Fibrosis: Complications Chronic respiratory infections Bronchiectasis (irreversible dilation and

destruction of the bronchial walls) Pneumothorax Cor pulmonale (failure of the right ventricle of

the heart) Chronic diarrhea Severe nutritional deficiencies Type 1 diabetes Liver damage Infertility

Cystic Fibrosis: Nursing Considerations

Infection control Maintain adequate nutrition Medication administration P&PD Family teaching Support groups

Bronchopulmonary Dysplasia Chronic lung disease that primarily

affects premature infants who have respiratory distress syndrome

9 out of 10 babies with BPD weighed 1500 grams or less at birth

1 out of 3 babies born weighing less than 1000 grams gets BPD

5,000 to 10,000 babies in the U.S. get BPD each year

BD: Pathophysiology Poor lung compliance requires

mechanical ventilation Trauma to the pulmonary structures

occurs, leading to interstitial edema and epithelial destruction

Inflammatory response causes airway obstruction

Tissue and pulmonary vasculature damage results in a ventilation/perfusion imbalance that leads to hypercapnia and hypoxemia

BP: Clinical Manifestations Rapid, shallow breathing Retractions Cough Wheezing Cor pulmonale Pulmonary edema Dependence on supplemental O2

for more than 28 days Respiratory acidosis

BP: Diagnosis

History and physical exam RDS that does not improve within

two weeks Prolonged mechanical ventilation Prolonged need for supplemental

O2 Chest x-ray

BP: Treatment

Prevention is the primary focus Prenatal steroids to promote the

maturation of fetal lungs Administration of surfactant Diuretics, steroids, bronchodilators Supplemental O2

BP: Potential Complications

Learning difficulties Poor coordination and muscle tone Trouble walking Activity intolerance Eye and ear problems Increased susceptibility to URI’s

and other infections

BP: Nursing Considerations Maintain mechanical ventilation Administration of medications (steroids,

diuretics, bronchodilators, antibiotics) Monitor I&O Provide adequate nutrition Family teaching:

Signs and symptoms of respiratory infection Importance of immunizations Medications O2 therapy CPR Follow-up

Any Questions?