N410.01 CH 18 Care of the Child with an Alteration in Gas Exchange/Respiratory Disorder

most common cause of illness and hospitalization in kids

respiratory disorders

#1 reason why kids code

respiratory issue

newborns prefer to breathe through their nose until

at least 4 weeks of age

when do newborns breath through their mouth

only when crying

how much mucus do newborns produce

very little mucus = increased risk of infection and ciliary tract is not effective

when do the frontal and sphenoid sinuses develop

age 6-8, they are not developed in newborns

what is special about newborn nasal passages

very small, more prone to obstruction

why do kids have an increased risk of airway obstruction

- tongue is larger in relation to oropharynx

- elarged tonsillar and adenoidal tissue

how wide is a infant's tracheal lumen?

4 mm

how wide is an adult's tracheal lumen

20 mm

a 1 mm circumferential edema in a infant's trachea causes

a 50 % reduction in the tracheal lumen, increasing pulmonary resistance by a factor of 16

what shape is the larynx in infants and young children

funnel shaped, and larynx and glottis are higher in the neck = higher chance of aspiration

when does the cricoid cartilage develop

after 10 years old

where does the bifurcation of the trachea occur in kids

the 3rd thoracic vertebra vs the 6th in adults

why does the bifurcation of the trachea in kids matter

important for suctioning/intubating, and also contributes to risk of aspiration

why are kids at increased risk for lower airway obstruction

bronchi and bronchioles of infants/children are narrower than adults

when are the alveoli developed

24 weeks gestation

how many alveoli do term infants have

150 million

how many alveoli do 3-8 year olds develop

300 million

how much oxygen do infants consume

6-8 L /min while adults consume 3-4 L/min

conditions that cause oxygen to become more tightly bound to hemoglobin (left shift)

alkalosis, hypothermia, hypocarbia, anemia, fetal hemoglobin

conditions that cause hemoglobin to decrease affinity for oxygen (right shift)

acidosis, hyperthermia, hypercarbia

common medical tx for respiratory disorders

- oxygen

- high humidity

- suctioning

- CPT and postural drainage

- saline gargles

- saline lavage

- chest tube

- bronchoscopy

high humidity tx

humidified oxygen used for common cold, croup, tonsillectomy. may need extra blankets and frequent changes of bedclothes bc of dampness

purpose of saline gargles

to relieve throat pain via a saltwater gargle, pharyngitis, tonsillitis

caution with saline gargles

kid needs to be old enough to understand the concept of gargling (avoid choking)

what is saline lavage

NS is introduced to the airway and then suctioned out

indications for saline lavage

any condition that has increased mucus production of the upper airway (common cold, bronchiolitis, flu)

what position does the child need to be in for a saline lavage

semi-upright

bronchoscopy

use of a bronchoscope into the bronchial tree for dx purposes and bronchiolar lavage

what to watch for after bronchoscopy

postprocedure airway swelling and c/o sore throat

common drugs for respiratory disorders

- expectorant (guaifenesin)

- cough suppressants (dextromethorphan, codeine, hydrocodone)

- antihistamines

- antibiotics (PO, parenteral)

- antibiotics (inhaled)

- beta 2 adrenergic agonist short/long acting

- racemic epinephrine

- anticholinergic (ipratropium)

- antiviral agents

- corticosteroids inhaled and oral

- decongestants

- leukotriene receptor antagonists

- mast cell stabilizers

- respiratory stimulants

- inhaled pulmonary enzyme (dornase alpha)

expectorant (guaifenesin) action/indication

- reduces secretion viscosity by increasing resp tract fluid

- common cold, PNA other conditions that need mucus expectoration

cough suppressant meds

dextromethorphan, codeine, hydrocodone

cough suppressants action/indication

- directly act on the cough center of the medulla, reduces irritating, nonproductive cough

- common cold, sinusitis, PNA, bronchits

cough suppressants should be used only with

a non productive cough in the absence of wheezing

antihistamines action

treat allergic conditions like allergic rhinitis, asthma

antihistamines may cause

drowsiness, dry mouth

PO or parenteral antibiotics

used to tx bacterial infections of resp tract: pharyngitis, tonsillitis, sinusitis, bacterial PNA, CF, empyema, abscess, TB

inhaled antibiotics are indicated in

kids with cystic fibrosis, given via nebulizer

short acting beta 2 adrenergic agonists medications

albuterol, levalbuterol, pirbuterol

SABA action/indication

- relax smooth muscle = bronchodilation

- acute/chronic tx of wheezing, bronchospasm, bronchiolitis, CF, chronic lung disease, prevent wheezing in exercise induced asthma

side effects of SABA

nervousness, tachycardia, jitteriness

LABAs meds

salmeterol, formoterol

LABAs actions/indications

long acting bronchodilator for chronic asthma management, prevention of exercise induced asthma

racemic epinephrine use

produces bronchodilation for croup

racemic epinephrine assessment

look for rebound bronchospasm, assess lung sounds and WOB

anticholinergic medication

ipratropium

Anticolinergic use

bronchodilation in asthma or chronic lung disease, usually with SABAs

oral antivirals

- amantadine

- rimantadine

- oseltamivir

inhaled antiviral

zanamivir

antiviral agent indication

tx and prevent influenza A

what to monitor for amantadine and rimantadine

confusion, nervousness, jitteriness

which antivirals are well tolerated

oseltamivir and zanamivir but expensive

inhaled corticosteroid meds

beclomethasone, budesonide, fluticasone, mometasone

inhaled corticosteroid action/indications

potent, locally acting antiinflammatory effect to decrease frequency and severity of asthma attacks, delay pulmonary damage associated w/ chronic asthma, chronic lung disease, croup

oral and parenteral corticosteroid meds

prednisolone, prednisone

oral/parenteral corticosteroid indications/use

suppress inflammation/normal immune response, acute asthma exacerbations, wheezing with chronic lung disease, severe croup

long term use of corticosteroids can cause

hyperglycemia, peptic ulcers, altered growth, ask HCP about vaccinations, short courses are safer

decongestant medication

pseudoephedrine

decongestant action/usage

tx for runny nose associated with common cold, sinusitis, or allergic rhinitis in kids > 6

decongestant side effects

excessive sleepiness, or increased activity

leukotriene receptor antagonists meds

montelukast, zafirlukast

leukotriene receptor antagonist action

Decrease inflammatory response by antagonizing the effects of leukotrienes to control asthma in children age 1 year and older

montelukast is used for

allergic rhinitis in kids ≥ 6 months

leukotriene receptor antagonists are given

once daily, in the evening

mast cell stabilizing medication

cromolyn, nedocromil

mast cell stabilizer action/indications

- Prevent release of histamine from sensitized mast cells = decreased frequency and intensity of allergic reactions in children with asthma + chronic lung disease

- preexposure treatment for allergens (10-15 mins before)

respiratory stimulants meds

methylxanthines: theophylline, aminophylline, caffeine

respiratory stimulant action/uses

provide continuous airway relaxation in moderate/severe asthma for long term control

inhaled pulmonary enzyme (dornase alfa)

Enzyme that hydrolyzes the DNA in sputum, reducing sputum viscosity in children with cystic fibrosis

what to monitor for if giving dornase alfa

dysphonia and pharyngitis

common lab and dx tests for respiratory disorders

- allergy skin testing

- ABGs

- chest radiograph

- fluorescent antibody testing

- fluoroscopy

- gastric washings for AFB

- peak expiratory flow

- pulmonary function tests

- pulse oximetry

- rapid flu test

- rapid stress test

- radioallergosorbent test (RAST)

- sinus radiographs, CT, or MRI

- sputum culture

- sweat chloride tests

- throat culture

- tuberculin skin test

what to note while collecting an ABG

if the child is crying excessively = can affect CO2 level, radial arterial sticks are very painful

what can a chest radiograph show

hyperinflation, atelectasis, PNA, foreign body, pleural effusion, abnormal heart/lung size

fluorescent antibody testing tests for

- respiratory syncytial virus (RSV)

- adenovirus

- influenza

- parainfluenza

- chlamydia in nasopharyngeal secretions

how to collect a nasopharyngeal specimen for fluorescent antibody test

instill 1-3 mL of sterile NS into one nostril, aspirate contents using sterile bulb syringe and place the contents into sterile container

nasal pharyngeal washing issues

can be traumatic, removes healthy mucous, fluid is in respiratory space and can lead to PNA

fluoroscopy

Radiographic examination that uses a fluorescent screen for real-time imaging, ID masses, abscesses

gastric washings for acid fast bacilli

looks for AFB in stomach bc kids swallow sputum, for TB

gastric washings for AFB procedure

NG tube is inserted and saline is instilled then suctioned out of the stomach

peak expiratory flow

maximum flow of air (in L/s) that can be forcefully exhaled in 1 second, for asthma control eval

how to determine the child's personal best peak expiratory flow

take twice daily readings over a 2 week period and the avg is the PB

pulmonary function tests

measure respiratory flow and lung volumes for asthma, CF, and chronic lung disease

when should a rapid flu test be done

in the first 24 hrs of the illness so medication adminsitraiton can begin

rapid flu test procedure

child gargles with NS and spit into sterile container

rapid strep test

Instant test for presence of streptococcus A antibody in pharyngeal secretions, if negative, follow up with throat culture

radioallergosorbent test (RAST)

Measures minute quantities of immunoglobulin E in the blood for asthma (food allergies)

sweat chloride tests

Collection of sweat on filter paper after stimulation of skin with pilocarpine, Measures concentration of chloride in the sweat for CF

how long does a throat culture need to be completed

24-48 hrs

the first sign of respiratory illness in infants and children is

tachypnea

grunting

occurs on expiration and is produced by premature glottic closure. an attempt to preserve/increase functional residual capacity

grunting can occur with

alveolar collapse or loss of lung volume (atelectasis, PNA, pulmonary edema)

stridor

high pitched, readily audible inspiratory noise, sign of upper airway obstruction

what kind of respiratory effort indicates lower respiratory involvment

increased WOB associated with restlessness and anxiety

paradoxical breathing

chest falls on inspiration and rises on expiration

conditions with increased tactile fremitus

PNA or pleural effusion

conditions with decreased tactile fremitus

barrel chest

conditions with absent tactile fremitus

pneumothorax or atelectasis

what can hyperresonance indicate

asthma