Pediatric Impaired Respiratory Function

Respiratory Issues of the Pediatric Patient

Upper Respiratory Infections (URI’s) trigger other problems

Infants and toddlers can have up to 6-8 URI’s per year

Respiratory infections are the most serious for infants less than 6 months of age (Why?)

There is a rapid and severe response of the infant and young child to respiratory problems

Respiratory Contributing Factors

Microbiological – virus or bacterial

• Epiglottitis

• Tonsillitis

• Bronchiolitis

• Respiratory Syncytial Virus (RSV)

Physical

• Croup

• Asthma

Developmental

• Cystic Fibrosis

• Sudden Infant Death Syndrome (SIDS)

Respiratory Clinical Manifestations

Altered respiratory rhythm/rate

Symmetry of movement

Depth of respirations

Retractions

Nasal flaring

Skin color changes

Cough

Change in behavior and/or activity

Nasal discharge/secretions

Chest pain

Adventitious lung sounds

• Absence

• Rhonchi

• Crackles (rales)

• Stridor

• Wheezing

• Grunting

Retractions

Sinking in of soft tissues relative to the cartilaginous and bony thorax, may occur in some pulmonary disorders. In disease  states (particularly in severe airway obstruction), retractions become extreme.

Nasal Flaring

A sign of respiratory distress and a significant finding in an infant. The enlargement of the nostrils helps reduce nasal resistance and maintains airway patency. Nasal flaring may be intermittent or continuous and should be described as minimal or marked.

Stridor

A high-pitched, noisy respiration is usually an indication of narrowing of the upper airway, either as a result of edema and inflammation or in association with an upper airway obstruction, often from mucus secretions or possibly from a foreign object. May be inspiratory or expiratory. Common causes in children include croup, epiglottitis, foreign body, or tracheitis.

Grunting

Is frequently a sign of pain in older children, suggesting acute pneumonia or pleural involvement. It is also observed in pulmonary edema and is a characteristic of respiratory distress in newborns and infants. It is the body's attempt at more efficient respirations. Serves to increase end-respiratory pressure and thus prolong the period of oxygen and carbon dioxide exchange across the alveolocapillary membrane.

Respiratory Commonalities of Care

Facilitate respiratory efforts

• Positioning

• Elevate head of bed

Promote rest

• Quiet activities

Promote comfort

• Suctioning

• Saline nose drops

• Cool mist tent

• Humidifiers

Improve oxygenation

• Administer oxygen (NC, mist tent, blow by)

• Insure patient is receiving nebulizer treatments

Give Fluids

But not when tachypneic (over 60 BPM)

Respiratory Nursing Diagnoses/Problems

Ineffective Airway Clearance

Ineffective Breathing Pattern

Impaired Gas Exchange

Infection

Anxiety

Altered G&D

Activity Intolerance

Fluid volume imbalance

Altered nutrition

Upper Respiratory Disorders

Croup

Epiglottitis

Croup

Is applied to several conditions with common sign and symptoms:

Barking cough

Inspiratory stridor

Hoarseness

Respiratory distress

Barking Cough

Due to larygneal edema

Types of Croup

Laryngitis

Laryngotracheobronchitis (LTB)

Acute spasmodic croup

Laryngotracheobronchitis (LTB)

Most common type

Acute inflammation of the larynx, trachea and bronchi

Usually viral

Usually begins with an upper respiratory infection

Acute Spasmodic Croup

Characterized by sudden episodes of airway obstruction, typically at night. Similar to LTB, but without the fever or signs of infection. Children with acute spasmodic croup often have a history of repeated episodes, which resolve without treatment after a few hours.

Causes: Allergies, gastroesophageal reflux, not really viral

Symptoms: Barking cough that is seal-like, hoarseness, stridor, anxious appearance in child, but not ill-looking

Treatment: Can be treated at home with cool mist steam.

Croup Contributing Factors

Microbiological

• Most commonly a virus in infants and toddlers

• Most commonly bacterial in 3-7 year olds

Croup Clinical Manifestations

Inspiratory Stridor/dyspnea

Substernal and suprasternal retractions

Elevated temperature

Irritability

Restlessness

Expiratory difficulty

Substernal Retractions

Become more pronounced as the diaphragm works hard in an attempt to fill collapsed air sacs, below the sternum.

Suprasternal Retractions

Become more pronounced as the diaphragm works hard in an attempt to fill collapsed air sacs, above the sternum.

Croup Treatment and Nursing Interventions

Treatment is usually initiated at home

• Put child in bathroom with hot shower running

• Cold moist night air

• Cool mist humidifier

Croup Treatment if Hospitalized

Cool mist tent (decrease stridor)

Rest

Give fluids via IV

Monitor for S&S of increased respiratory distress

Increased respiratory rate

Increased apical pulse rate

Retractions

Dyspnea

Steriods

If conditions is severe give racemic epinephrine via nebulizer

Be prepared to intubate

Elevate the HOB

Educate parents

Epiglottitis

Severe, rapidly progressing infection of the epiglottis and surrounding area

Common in children ages 3-7

Usually caused by Haemophilus influenza type B

Epiglottitis Clinical Manifestations

Three classic S&S:

Absence of spontaneous cough

Agitation

Drooling

Abrupt onset

Sore throat

Dysphagia

Elevated temperature

Pallor

Restlessness

Anxious

Frightened

Sitting forward with mouth open

Croaking sound on inspiration

Epiglottis is enlarged, edematous and cherry-red

Child looks toxic

Drooling (Epiglottis)

Because of the difficulty or pain on swallowing and excessive secretions

Epiglottis Nursing Interventions

Never suction or examine throat with tongue blade unless prepared to trach

Emergency situation - besides IV, oxygen and humidity:

• Antibiotics for 7 days

• Trach or intubate

• Administer steroids

Teach prevention:

• HiB vaccination

Bronchiolitis

Acute infection of the fine bronchioles

• Bronchial mucosa becomes swollen

• The lumina fill with mucous and exudate

  • Results in hyperinflation of alveoli which causes areas of atelectasis

Bronchiolitis Contributing Factors

Microbiological

• Viral (RSV)

  • Occurs in 2-12 month age group]

  • Most common cause of Bronchiolitis

  • Most common cause of apnea in children less than 6 months old

Bronchiolitis Clinical Manifestations

History of URI

Fever

Deep and frequent cough

Dyspnea

Tachypnea

Shallow respirations

Crackles

Retractions

Nasal flaring

Wheezing

Decreased breath sounds

Irritability

Nursing Interventions

Provide oxygen with high humidity

• May need mist tent

• May need to use Blow by

NPO with- IV

Elevate the head of bed

Perform chest PT

• Educate parents on how to perform as well

Provide suctioning as needed

Administer bronchodilators

Monitor the Apnea monitor

Does this patient need antibiotics?

Prevention

Administer palivizumab (Synagis)

• FDA approved for high-risk children

• It inhibits the actions of RSV and helps to prevent it from occurring

• IM injection monthly for a maximum of 5 doses

RSV is transmitted by close contact with child. It is NOT transmitted thru the air.

HANDWASHING,CONTACT AND DROPLET PRECAUTIONS!!!

Asthma

Reversible obstructive process characterized by increased responsiveness and inflammation of the airways

Results in:

• Inflammation and edema of mucous membranes

• Increased tenacious secretions

• Spasm of the smooth muscles of the bronchi and bronchioles

Asthma Contributing Factors

Allergic reaction

Cold air

Infections

Smoking

Exercise

Familial tendency - = 75% of children

Anxiety

Stress

Asthma Clinical Manifestations

Hacking, non-productive cough

Productive cough as secretions increase

Shortness of breath

Chest tightness

Wheezing

Pallor

Cyanosis

Increased restlessness

As an asthma attack progresses:

• Nasal flaring

• Retractions

• Respiratory acidosis

• Respiratory failure

Treatment and Nursing Interventions for an Acute Attack

Relieve bronchial obstruction

• Epinephrine 1:1,000

  • 0.01mg/kg up to max dose 0.5mg

• Administer bronchodilators (short acting Beta 2 agonists)

  • Albuterol (Proventil)

  • Xopenex

• Magnesium sulfate IV

  • Muscle relaxant that decreases inflammation and improves pulmonary function and peak flow

Administer steroids (IV/PO)

Keep patient NPO if tachypneic

Give fluids via PO/IV

Administer oxygen

Perform chest PT

Assess and treat status asthmaticus

Long Term Management of Asthma

Goals:

• Determine cause

• Prevent and control attacks

• Educate the parents and child

Drug Therapy: Inhaled steriods daily (Pulmicort/Flovent-teach rinse mouth with every dose)

Key to control – recognize and treat early

Use of peak flow meter

Teach abdominal breathing exercises

Encourage moderate exercise

Refer to community agencies

Initiate an Asthma Action Plan (Maintenance vs Rescue)

Long-Term Management Drug Therapy

Preventative/Maintenance Medications

• Salmeterol (Serevent)-Bronchodilator

• Cromolyn Sodium

• Leukotrienes- e.g. Montelukast sodium (Singulair)

  • Blocks inflammatory and bronchospasm effects

  • Oral

Cystic Fibrosis

Dysfunction of the exocrine glands

Bronchioles are obstructed with an increased viscosity of mucous

Results in frequent infections and permanent lung damage

Long-term condition

Cystic Fibrosis Contributing Factor

• Genetic: Autosomal recessive trait

Cystic Fibrosis Clinical Manifestations

Cough

Dyspnea

Emphysema- Late

Atelectasis

Clubbing of the fingers- Late

Shortness of breath

Barrel chest- Late

Cyanosis

Cystic Fibrosis Nursing Interventions

Provide vigorous pulmonary therapy

• (1-3times/day before meals)

Teach breathing exercises

Administer aerosol therapy: nebulizer

Administer expectorants: NOT cough suppresants

Provide suctioning as needed

Implement an exercise program

Administer medications

• CFTR Modulators

  • Depending on gene mutation in the CFTR gene

• Bronchodilators

• Antibiotics

Provide referrals to the Cystic Fibrosis Foundation

Encourage family support

Provide education for the family

Prognosis depends on extent of pulmonary involvement

Conditions Affecting the Respiratory System

Tonsillectomy and Adenoidectomy

Foreign Body Aspiration

Sudden Infant Death

Tonsillectomy and Adenoidectomy

Surgical procedure to treat infections of the tonsils or OSA

Post-op care includes:

• Monitor for hemorrhage

• Insure proper hydration (start with PO Clears)

• Pain Management

• Provide discharge instructions- DIET!

Frequent Swallowing After Tonsillectomy/Adenoidectomy

Indicative of post-operative bleeding

Tonsillectomy and Adenoidectomy Diet

No ice cream/dairy- will cause you to cough and it coats the surgery site

No red foods because we need to be able to observe bleeding

No acidic foods

No spicy/citrus food

No gargling

Soft foods and cold water are good

Foreign Body Aspiration

Always the first consideration with respiratory distress

• Immediate adaptations are:

  • Choking

  • Coughing

  • Gagging

  • Wheezing

S&S will depend on where object is stuck

Aspiration Nursing Interveentions

Immediate intervention:

• Heimlich Maneuver

  • Turn infant on abdomen and give back blows

Prepare for bronchoscopy

Teach parents prevention

• No small objects

• No balloons

• Food – no peanut butter, nuts, raisins, hot dogs, grapes or raw carrots

Sudden Infant Death Syndrome (SIDS)

Is the leading cause of death in children between 1 month and 1 year of age

The cause is unknown

Always occurs during sleep

Teach parents:

• “Back to sleep” – place the infant on their back

• Learn CPR

• Use of apnea monitor

Evaluation for Respiratory Conditions

Respirations will be unlabored and within normal limits

Will exhibit no sign and symptoms of distress

Will maintain patent airway

Will be free from infection

Will be able to rest comfortably

Parents and child will experience a decrease in anxiety

Parents will encourage normal Growth and Development to the best of the child's ability

Parents will demonstrate an understanding of their child’s condition and what the treatments are