Pediatric: respiratory ilnesses

Why are children at risk for respiratory disease?

Faster escalation, fewer alveoli, shorter/smaller airways, weak intercostal muscles, nasal breathers(2-6 months), higher O2 demand, Immature immune system

Why does having less alveoli affect children?

less surface area for gas exchange

Why does having shorter/smaller airways affect children?

More significant obstruction with smaller amount of edema/mucus

Why does having weak intercostal muscles affect children?

faster respiratory muscular fatigue

How does nasal breathing in children impact their risk for respiratory illness?

Nasal congestion will impair their breathing/feeding

How is oxygen demand different in children versus adults?

2x consumption compared to adults

How does an immature immune system impact risk of respiratory illness?

Less immune = greater risk of infections

What behavioral cue in respiratory assessment may indicate respiratory distress/failure?

restlessness/change in behavior/positioning

What are the compensatory signs of distress?

Tachypnea, Retractions, Nasal flaring, Grunting

What are retractions and how to assess?

Accessory muscle use to breathe, assess/visualize chest before auscultating —> neck, ribs, sternum and abdomen

What is “grunting”

expiratory sound from sudden glottic closure, helps prevent alveolar collapse + maintains functional residual capacity(FRC)

What type of abnormal lung sound is: Prominent on expiration due to lower airway narrowing

Wheezing

What type of abnormal lung sound is: Heard on inspiration, upper airway obstruction

Stridor

What type of abnormal lung sound is: Lower airway, fluid/secretions in small airways and associated with pneumonia?

Crackles

What type of abnormal lung sound(level of lung sound) is: caused by Decreased air movement, pneumonia, atelactasis, pleural effusion

Diminished breath sounds

What type of abnormal lung sound(level of lung sound): No air movement in area; pneumothorax or possible atelectasis

ABSENT breath sounds

What is atelectasis?

Collapse of a portion of the lung

What are the late signs of Respiratory Failure?

Depressed respirations

Bradycardia

Lethargy/Drowsiness

Cyanosis

Hypotension

How does breathing rate change from early to late respiratory failure?

early —> Fast breathing(tachypnea)= Compensatory

late —> slower breathing/no breathing = failure

Nursing goals for Respiratory distress

Ease respiratory effort (cool mist humidifiers)

Fever management

Promote rest, comfort, hydration, nutrition

Family support + teaching

What age group is acetaminophen used for fever control?

Appropriate for children younger and older than 6 months

What age group is ibuprofen used for fever control?

Older than 6 months

younger @ risk for GI/Renal failure

Why is aspirin not used for fever control?

Risk of Reye’s syndrome

Exception: KAWASAKI DISEASE

Why are children with respiratory illness at risk for dehydration?

Tachypnea can cause increased fluid loss

Respiratory distress —> prevent oral intake of fluids

What is Croup?

Viral caused: Acute Laryngotracheobronchitis

INFLAMMATION/EDEMA of Subglottic area (larynx + upper trachea)

What is the subglottic area?

Most narrow part of the airway

Etiology of Croup?

Parainfluenza VIRUS

When and how are symptoms presented?

24-72 hours after URI

Hoarseness

Barking, Seal cough

Inspiratory Stridor

Retractions, Nasal flaring

decreased breath sounds at night

fever

Which respiratory illness worsens at night?

Croup

What illness matches these clinical manifestations:

• Hoarseness

• "Barking" (seal-like) cough

• Inspiratory stridor

• Fever

• Retractions (intercostal, substernal)

• Nasal flaring

• Decreased breath sounds on auscultation

• Worsens at night

Croup

If a Steeple sign is seen on a Neck X-ray, what would you suspect?

Croup

What is the Steeple sign?

Church/Steeple shape at the subglottic tracheal narrowing

How is Croup treated?

racemic epinepherine nebulizer (bronchodilation of upper airway)

oral steroids (reduces laryngeal edema)

cool mist vaporizer (decreases respiratory effort)

Oxygen if spO2 is lower than 92%

Keep child calm, on parent’s lap (crying worsens obstruction)

What are possible complications of croup?

Acute Respiratory failure

Hypoxia

What is Epiglottitis

LIFE THREATENING EMERGENCY:

Bacterial inflammation of the epiglottis —> edematous narrowing of airway causing obstruction

What is the cause of epiglottits?

Bacterial (Haemophilus Influenzae type B aka Hib)

How can Epiglottits be prevented?

Hib vaccine

How is Epiglottitis manifested?

Sudden onset HIGH fever

Severe sore throat

Drooling/dysphagia

HOT POTATO VOICE (muffled)

Stridor

Tripod position

Tachypnea

Retractions

Nursing Goals for epiglottitis?

ABCs —> Emergency airway equipment, prepare for surgery if worsens

Keep child calm, agitation will worsen

Continuous SpO2 monitoring

Broad spectrum antibiotics

What is an important action to NOT DO in epiglottitis?

DO NOT inspect with throat depressor —> triggers laryngospasm/COMPLETE OBSTRUCTIOn

What is RSV?

Respiratory Syncytial Virus

Inflammation + edema of BRONCHIOLES

Increased Mucus production —> mucus plugging

Airway narrowing —> alveolar collapse(atelectasis)

Hypoxia from continued impaired gas exchange

What is an important consideration of transmission in RSV

Droplet AND contact precautions

What other conditions can RSV lead to?

Leading cause of bronchiolitis + pneumonia (in infants <1 yr)

Associated with later development of asthma

How is RSV manifested?

Copious clear nasal secretions

Cough

Tachypnea

Wheezing

Nasal flaring, retractions

Fever

What patient population is at most risk against RSV?

Infants <6 months

Premature/low birth weight

Chronic lung diseases

Congenital Heart disease

Down syndrome

How is RSV diagnosed?

Nasopharyngeal secretions are tested for positive RSV antigen

What are the 2 preventative measures of RSV

Nirsevimab/Clesrovimab + Abrysvo

Nirsevimab/Clesrovimab vs. Abrysvo: administered to?

Nirsevimab/Clesrovimab- <8 month old infant(non-immune mom or born during 1st RSV season)

Abrysvo- Pregnant Mom

Nirsevimab/Clesrovimab vs. Abrysvo: Dosage timing

Nirsevimab/Clesrovimab: single dose

Abrysvo: given during 32-36 weeks during RSV season

When is RSV season?

September - January

Nirsevimab/Clesrovimab vs. Abrysvo: MOA

Nirsevimab/Clesrovimab: NON-VACCINE, monoclonal antibody(passive immunity)

Abrysvo: Maternal antibodies transferred to fetus (passive immunity for first months)

What is Pneumonia?

Viral or Bacterial Infection of Lower respiratory tract —> Alveoli/Interstital tissue —> inflammation, atelectasis and impaired gas exchange

What are the most common viruses responsible for pneumonia?

RSV + Influenza

What is the most common bacteria responsible for pneumonia?

Streptococcus pneumoniae

What vaccines reduce the risk of pneumonia?

Hib + PCV

Manifestations of pneumonia

fever, cough, tachypnea, retractions, crackles/decreased breath sounds

What are diagnostics to confirm pneumonia?

CXR, CBC, Blood culture

Nursing goals for pneumonia

O2 if SpO2 <92%, antibiotics for bacterial, antipyretics and continuous O2 monitoring

What is GABHS Pharyngitis

Group A B-hemolytic Streptococcal Pharyngitis

Bacterial infection of the pharynx

Manifestations of GABHS

Abrupt onset

Erythematous pharynx + petechiae on soft palate

Erythematous tonsils with white patches/exudate

Severe sore throat

Fever

Lymphadenopathy

How is GABHS diagnosed?

Throat culture

How is GABHS treated?

Amoxicillin or cephalosporin for penicillin allergies

Nursing goals for GABHS + other bacterial infections

FINISH ENTIRE ANTIBIOTIC COURSE; replace toothbrush to prevent reinfection

Complications of GABHS

Rheumatic Fever —> Cardiac valve damage

Acute Poststreptococcal Glomerulonephritis

Scarlet fever

Peritonsillar abscess

What is Asthma?

Chronic inflammatory disorder of lung airways (bronchial hyperresponsiveness + airflow obstruction)

Pathophysiology of Asthma

Bronchospasm

Inflammation

Mucous plugging

Risk factors of Asthma

genetics, allergies(environmental, food), smoke exposure, frequent respiratory infections, obesity

Manifestations of Asthma

Wheezing, dyspnea, chest tightness and persistent cough(worsens at night)

What is exercise-induced asthma

Asthma but exercise is the trigger (coughing, wheezing, chest tightness, SOB and fatigue)

How is exercise-induced asthma treated?

15-30 minute in advance albuterol

What is Peak Flow Meter?

Device that measures peak expiratory flow rater, monitors airway narrowing to identify asthma before symptoms become severe

Done 3 times, record the highest of the 3

What does RED indicate on peak flow zone system?

SEVERE airway narrowing possible, albuterol admin —> ED

What does Yellow indicate on peak flow zone system?

not well controlled, possible need for maintenance therapy, increase beta agonist use

What are RESCUE medications for asthma

SABAs(albuterol), Corticosteriods for inflammation(prednisolone)

What are adverse effects of Albuterol/SABAs

^HR, tremors, hypokalemia

What are Maintenance medications for Asthma?

Inhaled corticosteroids, LABAs + corticosteriod combo, leukotriene modifiers

What is Budesonide/Pulmicort

Inhaled corticosteroid

What is Fluticasone + Salmeterol used for?

What is Montelukast (singulair)

How are asthma medications administered?

MDI w/ spacer(assisted coordination of inhalation)

Nebulizer (breathing mask)

Plain MDI (similar to nebulizer but attached to the medication)

What is Status Asthmaticus

SEVERE, LIFE THREATENING Exacerbation (immune to rescue inhalers)

Can progress to respiratory failure

Nursing priorities in Respiratory Failure:

1. Airway + Breathing

2. Supp. O2

3. Repeat/continuous nebulized albuterol

4. IV corticosteroid

5. Continuous pulse ox monitoring

6. PREP FOR INTUBATION (just in case)

Nursing Education goals for status asthmaticus / asthma

Use spacer for kids who struggle with inhaling technique

RINSE MOUTH after using inhaled corticosteroids (prevent thrush)

Always carry inhaler

account for hospitalization impact on child’s social life/sense of normalcy

What is SDOH- driven poor control?

Rather than medication non-adherence out of carelesseness, nurse must account for barriers(insurance access, housing, transportation) and help the patient access resources, peer/community education and housing referrals.

What is Cystic Fibrosis?

Autosomal recessive mutation of CFTR gene (chromosome 7)

What CFTR classes are associated with a milder phenotype?

IV to VI (these classes have more CFTR function comparatively)

PATHO of Cystic Fibrosis?

abnormal CFTR protein —> failure of chloride channel to transport ions —> salt/water imbalance of epithelial surfaces —> abnormally thick, sticky mucus —> mucuous obstruction/inflammation and scarring

Why is Cystic Fibrosis not considered just a lung disease?

Effects many systems: pulmonary, sinus, GI, Hepatic, endocrine, MSK, Skin, urinary and reproductive

What sinus issues appear with Cystic Fibrosis?

Nasal Polyps

What issues with the lungs are caused by cystic fibrosis

Drop in FEV1: forced expiratory volume in 1 second

Bronchiectasis: chronic permanant widening/damaging of bronchi

What infectious organisms are patients with CF at risk for?

PA: Pseudomonas Aeruginosa

SA: Staphylococcus Aureus

MRSA

Mycobacterium

How can Respiratory symptoms be treated in CF?

Increase Airway Clearance

Mucolytic (Dornase Alfa)

Hypertonic Saline (7%)

Antibiotic (oral, inhaled or IV) (Tobramycin for PA)

What are Pulmonary Airway Clearance Techniques?

CPT(physiotherapy)

Vest(vibration)

Acapella(mobile, hand held oscillating device)

Huff Cough(forced expiratory technique to mobilize secretions)

What is a culture?

A test to identify whether the bacteria is present

What is culture sensitivity?

Identifying which antibiotics will be effective based off the culture.

What are complications of CF?

Pneumothorax + Hemoptysis

What is Pneumothorax? (in relation to CF)

SPONTANEOUS collapse of lung, caused by pleural surface weakening from inflammation —> rupture of blebs/bullae

What are symptoms of pneumothorax?

Sudden(spontaneous): SOB, chest pain, tracheal deviation, respiratory distress

What is Hemoptysis (in relation to CF)

Spitting up blood from the BRONCHIAL ARTERIES

Improves after treating underlying infection

STOP AIRWAY CLEARANCE/AEROSOLS IF HEMOPTYSIS IS MODERATE-SEVERE!

If a patient with Hemoptysis spits up 100ml of blood how is categorized?

Mild to Moderate

If a patient with Hemoptysis spits up 2ml of blood how is categorized?

Scant