peds respiratory

most common cause of hospitalization in children ages 1-9 yrs

resp conditions

what needs to be maintained in respiratory disorders?

adequate hydration and nutrition

child’s upper airway is

shorter and narrower than adults

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more easily occluded when secretions, edema, or foreign bodies enter upper airway

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nose breathers until 3-4 months

HEENT & respiratory assessment

head

eyes

ears

nose

throat/mouth

work of breathing

cyanosis

clubbing

breath sounds

retraction locations

supraclavicular

intercostal

suprasternal

substernal

subcoastal

respiratory distress

severe difficulty in achieving adequate oxygenation despite significant efforts to breathe

signs of resp distress

restlessness

tachycardia

tachypnea

diaphoresis

cyanosis: late sign

respiratory failure

body can no longer maintain effective gas exchange

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either o2 demand outweighs o2 supply (hypoxic) or co2 levels rise due to hypoventilation

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**most common cause of cardiopulmonary arrest in children**

viral: common cold

**cause:** RSV, rhinovirus, parainfluenza, metapneumovirus, COVID, others

**fever:** low

**body aches:** mild

**runny nose:** yes

**cough:** mild to mod

**n&v:** rare

**onset:** gradual

**itchy:** rare

**sore throat:** yes

**headache:** rare

viral: flu

causes: influ A & influ B virus

fever: yes

body aches: yes

runny nose: sometimes

cough: yes

n&v: sometimes, more common in children

onset: abrupt

itchy: no

sore throat: sometimes

headache: yes

viral: allergic rhinitis

causes: pollen, dust, mold, animal dander

fever: no

body aches: rare

runny nose: yes

cough: sometimes mild to mod

n&v: no

onset: gradual or abrupt

itchy: yes

sore throat: sometimes

headache: sometimes

viral: COVID

causes: Sar-CoV-2 virus

fever: yes

body aches: yes

runny nose: sometimes

cough: yes

n&v: sometimes

onset: gradual or abrupt

itchy: no

sore throat: yes

headache: sometimes

influenza

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droplet precautions

mild, mod, severe

flu signs

onset of fever, chills

dry cough

dry throat & nasal mucosa

flushed face

myalgia

fatigue

flu labs

nasal swab for rapid flu

flu meds

flu vaccine (>6months)

oseltamivir

* start w/i 48 hrs of symp
* PO for 5 days >1 yrs)

**NO ASPIRIN**

reye’s syndrome

rare but serious

unknown cause

can occur when recovering from viral inf. if taking aspirin

affects all organs, esp. brain and liver

causes inc ICP & fatty liver

reye’s signs

rapid breathing

vomiting

severe fatigue

confusion

seizures

LOC

reye’s treatment/prognosis

NO CURE

early diag to protect brain damage by dec ICP

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prognosis:

depends on severity of swelling

bacterial pharyngitis: strep throat causes and signs

causes: group a strep

signs:

* abrupt onset of pharyngitis, headache, fever, abdominal pain
* tonsils & pharynx can be inflamed & covered with exudate (day 2 of illness)

bacterial pharyngitis: strep throat labs/nursing interventions

labs:

* rapid antigen testing & throat culture

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nursing interventions:

* antibiotics (PO penicillin as least 10 days OR penicillin shot)
* treat pain
* encourage hydration
* return to school 12 hrs after 1st dose IF FEVER GONE
* new toothbrush after 3 days on antibiotics
* wash pillowcase
* follow up if not improved after 2-3 days

viral pharyngitis: mononucleosis causes/manifestations

cause: epstein-barr virus spread thru oral secretions

aka kissing disease

viral pharyngitis: mononucleosis manifestations/nursing interventions

manifestations:

* fever
* pharyngitis
* lymphadenopathy
* extreme fatigue

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nursing interventions:

* pain control
* hydration
* education: acute phase last up to 2 wks with prolonged symp. lasting several wks
* no contact sports
* can lead to enlarged spleen or rupture

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break out with rash treat with amoxicillin

tonsillectomy nursing considerations

**positioning**

* place in postion to facilitate drainage
* EHOB when awake

**assess for bleeding**

* most common at 1 wk after surg.
* tonsils: highly vascular (protect against inf.)
* evid. of bleeding
* frequent swallowing
* clearing of throat
* restlessness
* tachycardia
* pallor
* monitor for difficulty breathing related to oral secretions, edema, bleeding

**pharm and non-pharm interventions for pain**

* liquid analgesics or tetracaine lollipops
* admin. pain meds on regular schedule

**clear diet (NO REDS, NO ACID)**

* wait until gag-reflex returns
* advance diet as tolerated

**protect surg. site**

* limit activity
* 14 days to recover

ear infection: otitis media

inner ear infection

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infl. middle ear and middle ear effusion (fluid)

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**with acute infection**: fluid in middle ear is purulent causing tympanic membrane to appear erythematous, bulging, yellow

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usually accompanied by UTI

ear infection: otitis media nursing interventions

nursing interventions

* monitor airway
* antibiotic (azithromycin)
* o2 support
* feeding & hydration support
* report to health department

ear infection: otitis externa

inflammation of the external ear canal

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symp: ear pain, itchiness in the ear canal, discharge of liquid for ear

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itchy, redness

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ear drops antibiotics

inflam. steroids are added with ear drops

recurrent otitis media

3 epi in 6 months OR 4 epi in 1 yr

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tympanostomy can dec freq., severity, duration

* hole in ear, drain pressure and fluid out, and prevent recurrent

pertiusis

aka whooping cough

highly contagious: droplet

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cause: bordetella pertussis

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paroxymal cough

* start 2 wks after onset
* last several months
* difficult breathing during coughing fit
* cause post-tussive emesis
* cough fit last several minutes

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most at risk:

ear infection: otitis media s&s/meds/compli.

s&s: tugging ear

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need antibiotics with: **PO**

* severe pain
* bilateral OM in children

first DTaP

2 months

viral URI

* No antibiotics


* Cold, flu, COVID
* hydration loosens secretions and help get them out
* no cough suppressant in children

croup

Inflammation of the epiglottis, larynx, trachea, and possibly even the bronchi

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bc of inflammatory nature of croup & small diameter of child’s airway, croup can be life threatening, especially in younger children

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Classified as either viral or bacterial

* viral: spasmodic laryngitis or laryngotracheobronchitis
* bacterial: epiglottitis and bacterial tracheitis

Laryngotracheobronchitis

**barky cough with this one but not others**

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usually viral (parainfluenza)

Most common between ages 3 months & 8 years

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Laryngotracheobronchitis signs

* low grade fever
* restlessness
* hoarseness
* barky cough
* dyspnea
* inspiratory stridor
* retractions
* infants and toddlers: nasal flaring, intercostal retractions, tachypnea, continuous stridor
* can have stridor at rest & respiratory distress present in severe cases

Laryngotracheobronchitis treatment

* Mild: oral steroid – usually dexamethasone
* Severe: systemic corticosteroid & nebulized racemic epinephrine
* oxygen if needed
* systemic: methylpred, but normally just dex: epi helps decrease inflammation in airway (vasoconstrictor)

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if a child has stridor and suddenly stop hearing it = bad sign that airway has potentially completely closed

Epiglottitis

a hinged piece of cartilage found at back of tongue

* Job: close entry to trachea when swallowing 

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Epiglottitis : spread by infectious droplets

Most common cause: haemophilus influenza & strep pneumoniae

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Most preventable due to Hib vaccines

Is a MEDICAL EMERGENCY

Rapid onset, usually a few hours

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if this is swollen: have trouble breathing air in and swallowing

^^BIG THING IS DROOLING - NOT ABLE TO SWALLOW SECRETIONS, tripod position^^ 

muffled voice due to proximity of vocal cords

epiglottis findings/signs

\*\*do not try to assess throat\*\*

Findings: ADD AIR NURSE

* A: abnormal position (tripod)
* D: dysphagia
* D: difficulty speaking
* A: apprehension
* I: increased temp – high fever
* R: rapid onset
* N: nasal flaring 
* U: using accessory muscles
* R: retractions
* S: stridor
* E: enlarged epiglottis – visible on x-ray or on exam

epiglottis nursing interventions

never leave alone!!

* protect airway
* prepare for intubation
* never anything in their mouth – no oral temps, no tongue depressors, no throat cultures
* do not leave patient alone
* keep child calm
* NPO
* humidified oxygen
* IV corticosteroids & fluids (in OR)
* antibiotics & antipyretics

tracheitis

no drooling, will hear stridor, will have sudden onset and acute decompensation

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bacterial= secondary infection of upper trachea

* usually caused by staph aureus, staph pneumoniae, pseudomonas

viral laryngotracheitis leads to bacterial tracheitis

* most common viral causes: influenza a & b

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* rare, only about 2% of cases
* bacteria invade tracheal mucosa & cause inflammatory response

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* kids usually appear ill/toxic
* if untreated can lead to airway obstruction & respiratory arrest

tracheitis symp

usually have URI symptoms the week before then acute decompensation

* change in voice, stridor


* usually sudden decompensation with noisy breathing

high fevers

* drooling= absent, able to swallow secretions unlike epiglottitis
* thick purulent secretions

tracheitis treatment

need for intubation = common, should be done in OR

* if less severe, oxygen, racemic epi

lower: pneumonia

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Inflammation or infection of the lower airways (bronchioles and alveolar spaces)

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* Viral: both lungs, starts with cold symptoms
* CAP usually caused by RSV, parainfluenza, influenza
* Bacterial: usually unilateral, usually a bit sicker
* Bacterial pneumonia= more common in those over age 5
* PCV vaccine

lower: pneumonia risk factors

Risk factors:

* children exposed to cigarette or wood stove smoke
* chronic conditions such as asthma, CF, sickle cell disease, congenital heart disease or immunodeficiency

lower: pneumonia signs

signs:

* fever
* tachypnea
* cough
* poor oral intake
* vomiting
* abdominal pain
* cough
* may see retractions
* nasal flaring
* chest pain

lower: pneumonia diag/treatment

Diagnostic: chest x-ray

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Treatment: depends on cause

* anyone with tachypnea and nothing else will do CXR → tachypnea in kids with nothing else is often pneumonia

lower: bronchiolitis

Viral infection, affects bronchi & bronchioles

* Bronchial mucosa swells & fills with mucus & exudate

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occurs at the bronchiolar level

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primarily caused by Respiratory Syncytial Virus (RSV), but also can be caused by adenoviruses and parainfluenza

* The younger the infant = more severe
* Day 2= more severe symptoms, respiratory distress

lower: bronchiolitis assessment

__Initially__: rhinorrhea, intermittent fevers, pharyngitis, coughing, sneezing, wheezing, possible ear or eye infection

__With illness progression__: increased coughing and sneezing, fever, tachypnea and retractions, refusal to nurse or bottle feed, copious secretions

__Severe illness__: tachypnea (>70 resp/min), listlessness, apneic spells, poor air exchange, poor breath sounds, cyanosis 

lower: bronchiolitis labs/interventions/treatment

Lab testing: nasal swab, can test for different types of respiratory viruses

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Nursing Care:

* supplemental oxygen to maintain oxygen saturation >90% (over 4 = high flow)
* encourage fluid intake if able to tolerate, if not IV fluids until acute phase passed
* suction nasopharynx as needed

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Treatment:

* Supplemental oxygen (anything over 4L= high flow for peds)
* ^^Usually no steroids^^
* **Ribavirin**: inhaled antiviral medication for those hospitalized
* fluid hydration
* fever meds: tylenol/moltrin

bronchitis

inflammation of the trachea, bronchi, and bronchioles

* Usually occurs with viral respiratory tract infection
* Characterized by cough due to inflammation without evidence of pneumonia
* Inflammatory response in mucus membranes of bronchial passages produces hacking cough & thick phlegm
* Rarefy ever bacterial; always viral

bronchitis symp

Classic symptoms:

* coarse, hacking cough that worsens at night
* chest pain may develop due to cough

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May have vomiting at night due to swallowing of sputum

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^^No cough meds, honey can be given in children over 1 year of age^^

asthma

* Chronic lung disease causing narrowing and inflammation of airways
* One of leading causes of hospitalizations in children
* Issue = AIR TRAPPING

asthma risk factors

* family hx of asthma
* family hx of allergies
* exposure to smoke
* low birth weight
* being overweight
* pollution

asthma classifications

* Intermittent
* mild persistent
* moderate persistent
* severe persistent

asthma exam findings

* Dyspnea
* Cough
* audible wheezing
* mucus production
* use of accessory muscles
* sweating, anxiety
* decreased oxygen saturation
* tripod positioning
* inaudible breath sounds or crackles

asthma diag

pulmonary function tests: most accurate test for diagnosing asthma & severity 

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peak flow meter (done every 1-2 years, blow twice and take higher of two)

* Blow into device to measure amount of air coming out

asthma treatment

* Inflammation: Corticosteroids
* Methylprednisolone or Dexamethasone IV
* Prednisone PO
* fluticasone
* Bronchospasm: Beta 2 Agonists
* Albuterol (nebulizer or inhaler)
* Increased Mucus Production: Hydration/ mobilization
* Exaggerated Immune Response: Leukotriene Inhibitors
* Montelukast (Singulair)
* Oxygen as needed

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ER/PICU:

* Theophylline (high toxicity risk)
* Magnesium sulfate (potent vasodilator)

albuterol

short acting

emergent only

steroids

increases risk of infections

long acting

for severe

asthma assessment/education

* Assess airway patency, respiratory rate, symmetry effort and use of accessory muscles
* position child to maximize ventilation
* Education
* Trigger Identification
* Use of medications at home
* Steroids
* Aerosol Medications (Beta Agonists)
* Correct use of spacer
* Peak Flow Meters
* Home Management Plan
* Asthma action plan
* Treatments depending on zone

status asthmaticus

* Temporarily Irreversible Bronchospasm
* Life-threatening episode of airway obstruction, often unresponsive to common treatment

status asthmaticus signs

* wheezing


* labored breathing
* nasal flaring
* lack of air movement
* use of accessory muscles
* distended neck veins
* tachycardia
* tachypnea
* hypoxia
* diaphoresis

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\*risk for cardiac & respiratory arrest

status asthmaticus nursing actions

* Monitor oxygen saturation & cardiorespiratory monitor continuously
* Nebulizer X 3 or continuous, add ipratropium to increase bronchodilation
* IV access

cystic fibrosis

* Genetic disorder that causes exocrine glands to work incorrectly
* Basic Flaw in Chloride Exchange across cell membrane causing exocrine
* Genetics: 1 in 4 chance of transmission if both parents are carriers
* Autosomal recessive (must get gene from each parent)
* Discovered on prenatal screen or newborn screen, or sweat chloride test (

cystic fibrosis diag.

Pulmonary function testing

Sweat chloride test: measures amt of salt in sweat

* done on arms with gauze


* 39 mmol/L= negative
* 40-49 mmol/L= needs further testing
* 60 mmol/L= positive

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Meaning? Poor sodium exchange = thick mucus

cystic fibrosis expected findings

Respiratory:

* Stasis of mucus increases risk for infection
* Early manifestations: wheezing, rhonchi, dry, non-productive cough
* Increased involvement: dyspnea, paroxysmal cough, obstructive emphysema and atelectasis on chest x-ray
* Advanced involvement: cyanosis, barrel-shaped chest, clubbing of fingers and toes, multiple episodes of bronchitis or bronchopneumonia

Gastrointestinal:

* Large, frothy, bulky, greasy, foul-smelling stools
* Failure to gain weight or weight loss
* Delayed growth patterns
* Distended abdomen & thin arms and legs (infant)
* Reflux
* Prolapse of rectum (infant & child)

Integumentary:

* Sweat, tears, and saliva have excessively high content of sodium & chloride

Endocrine & Reproductive:

* Viscous cervical mucus, decreased or absent sperm, decreased insulin production

cystic fibrosis compl.

Respiratory

* Infections, colonization, bronchial cysts, emphysema, pneumothorax, nasal polyps

Gastrointestinal

* Meconium ileus, prolapse of rectum, intestinal obstruction, GERD

Endocrine

* Diabetes Mellitus

Worrisome Infections

* Pseudomonas Aeruginosa
* Burkholderia Cepacia
* Staph Aureus
* Hemophilus influenza
* Escherichia coli
* Klebsiella Pneumoniae

cystic fibrosis interventions

* Nutrition: need well balanced diet high in protein and calories
* Formula supplements in addition to breast feeding or through NG tube
* Add salt to food during hot weather / excess sweating
* Should receive regular nutrition evaluations with nutritionist
* Daily supplements of fat soluble vitamins (ADEK)
* Enzymes before meals (within 30 minutes)
* Encourage fluid intake
* Laxatives or stool softeners for constipation
* Exercise

respiratory treatments

* HFCC Vest
* Flutter Device
* “Huffing”
* Aerosol therapy
* Postural drainage
* Need aggressive antibiotic therapy - High dose antibiotics:, IV or inhaled
* Dornase Alfa (pulmozyme/recombinant human deoxyribonuclease)
* Can cause laryngitis (administer 1-2 times a day)
* Oxygen: as needed but monitor for carbon dioxide retention

resp assessments

* Lung sounds & respiratory status 
* Growth and development


* Obtain IV access – may have peripherally inserted central line or IV port if getting at home antibiotics
* Sputum for culture & sensitivity

resp education

* Stay up to date on vaccines including annual influenza and pneumonia vaccine
* Perform regular physical activity
* Palliative care for those in terminal stages
* May need transplant of heart, lungs, pancreas and liver for adolescents who have advanced disease
* Provide support to family and patient

acute non-infectious resp disorders

* foreign object asp
* pneumothorax
* congenital abnormalities of upper airway
* diaphragmatic hernia

foreign body asp

* Need to determine if cause of stridor 
* If foreign body, need to determine what it is 

pneumothorax

accumulation of air in the pleural space; air accumulates between visceral and parietal pleura increases intrapleural pressure making it difficult to expand affected lung

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* Peak incidence= 16 – 24 y/o
* Will have chest tube inserted

pneumothorax types

spontaneous, traumatic, tension

* primary spontaneous pneumo occurs in children with no hx of lung disease
* secondary occurs as complication of chronic lung disease such as Cystic fibrosis or asthma

pneumothorax assessment

* Dyspnea, tachypnea
* Tachycardia
* Diminished breath sounds
* Unequal chest expansion
* Chest pain

congenital abnormalities of upper airway

* **Laryngomalacia**: larynx = floppy
* Most common cause of stridor in newborns
* Not-life threatening, most outgrow by 18-20 months
* **Tracheomalacia**: excessive collapsibility of the trachea
* Depends on severity, may resolve on own or cause persistent resp distress
* **Tracheoesophageal fistula**: abnormal connection between these two tubes
* As a result, swallowed liquids or food can be aspirated into lungs
* Symptoms: difficulty breathing while feeding, coughing or choking while feeding, rounded abdomen, failure to gain weight
* **Subglottic stenosis:** narrowing of the airway below the vocal cords (subglottis) and above the trachea

Diaphragmatic Hernia

* Hole or opening in the baby’s diaphragm, the muscle that separates the abdomen from the chest
* Defect allows abdominal organs to move into chest cavity
* Causes crowding of lungs & improper development
* Breathing problems at birth
* Rare