Chronic Resp. Disorders

Chronic Respiratory Disorders

• Allergic rhinitis

• Asthma

• Cystic fibrosis

Allergic Rhinitis

• Commonly associated with:

  • Atopic dermatitis

  • Asthma

  • Recurrent sinusitis

  • Acute otitis media

Allergic Rhinitis (Patho.)

• IgE mediated response to the allergen

• Allergen binds to IgE on surface of mast cell

• Histamine & leukotrienes are released

• Swelling & mucous production

Allergic Rhinitis (Sx)

• Rhinorrhea

• Itching/ sneezing

• “Allergic shiners"“/”Allergic salute”

• Swollen, blue/ gray turbinates

  • Clear nasal drainage

Allergic Rhinitis (Tx)

• Nasal saline washes

• Corticosteroid nasal sprays

• Oral antihistamines

  • First line of defense

  • Preferably non-drowsy

• Oral leukotriene modifiers

Allergic Rhinitis (Prevention)

• Control exposure to allergens

Asthma

• Most common chronic childhood illness

• Chronic inflammatory disorder

  • Structural changes (“Remodeling”)

  • Each exacerbation can cause permanent damage

Asthma (Risk Factors)

• One or both parents have asthma

• Signs of allergies

  • Including reaction to pollens or other airborne allergens or foods

• Area of high pollution

• Exposure to tobacco smoke

Asthma (Nursing Assessment)

• Health Hx

  • Hx of bronchiolitis

  • Cough (Particularly at night)

  • Chest tightness w/ play

  • Freq. resp. infections

• Inspection

  • Color

  • WOB

  • LOC

• Auscultation

  • Wheezing (Expiratory)

  • Diminished breath sounds (Ominous sign)

Asthma (Patho.)

• Trigger

• Inflammatory mediators released

• Inflammation

• Bronchoconstriction

  • Tx bronchoconstriction first

  • Bronchodilators (Short-acting in an acute case)

  • Long-acting to maintain & prevent them having a severe case

Asthma Attack (S/S)

• Active signs:

  • Chest tightness

  • Dyspnea (Especially exhaling)

  • Increased WOB

  • Coughing

  • Tachypnea

  • Expiratory wheezing

• Needs Medical Tx Fast!!!

  • Can’t speak

  • Cyanosis

  • Rescue inhaler NOT working

Asthma Treatment (Acute)

• VS/ Resp. assessment

• High Fowler’s position

• O2 to maintain sats 95%-100%

• Frequent resp. treatment & work w/ RT

• Short-acting Bronchodilators (SABA)

  • Short-acting for acute Tx of bronchoconstriction

  • Beta agonist:

    • Albuterol, levalbuterol (Xopenex)

    • Given by MDI or nebulizer

    • Relaxes airway smooth muscle

    • Side effects: Shakiness, tachycardia, palpitations, vomiting, headache

• Oral Corticosteroids or IV corticosteroids if severe

  • Reduce inflammation

• Status asthmaticus:

  • When we can’t break the acute attack

Asthma Management (Chronic)

• Prevention:

  • Take as directed, even if asymptomatic

  • NOT for acute attacks

• Long-Acting Bronchodilators (LABA)

• Inhaled corticosteroids

  • Use AFTER bronchodilators

• Leukotriene receptor antagonists

  • Adjuncts to therapy w/ LABAs & Corticosteroids

• Mast cell stabilizers

  • Adjuncts to therapy w/ LABAs & Corticosteroids

Asthma Management Chronic (LABA)

• For prevention of bronchospasm + inhaled steroid

• Formoterol, salmeterol (Nebulizer)

  • Maintenance Tx of bronchoconstriction

• Prevents inflammation & relaxes airway

• Given w/ steroids to decrease risk of asthma-related death

Asthma Management Chronic (Inhaled Corticosteroids)

• Use AFTER bronchodilators

• Fluticasone, beclomethasone (Budesonide inhaler)

  • Reduces frequency/ severity of exacerbations by decreasing inflammation

• Risk for oral thrush infection

  • Use spacer, gargle & rinse mouth afterwards

• MDI or nebulizer

  • Clean after use

Asthma Management Chronic (Leukotriene Receptor Antagonists)

• Adjuncts to therapy w/ LABAs & Corticosteroids

• Montelukast (Oral)

  • Gummies

  • Chewable tablets

  • Granules

• Decrease inflammation caused by leukotrienes

  • Relaxes smooth muscles

Asthma Management Chronic (Mast Cell Stabilizers)

• Adjuncts to therapy w/ LABAs & Corticosteroids

• Cromolyn, nedocromil (oral or intranasal)

  • Prevent release of histamine from sensitized mast cells to decrease allergic reactions

Asthma Testing & Monitoring

• Pulmonary Function Testing

• Peak Expiratory Flow Rate (PEFR)

Asthma Testing & Monitoring (Pulmonary Function Testing)

• Help determine severity

• Most effective if at least 5 years old

Asthma Testing & Monitoring (Peak Expiratory Flow Rate)

• PEFR

• Objective measurement of lung function

• Speed at which air moves out of lungs at the beginning of expiration

• Can provide early identification of subtle Sx changes

  • Signals when an exacerbation is imminent!!!

  • Decrease = asthma attack might be happening

• Early Tx can help decrease risk of permanent lung changes (remodeling)

Asthma Severity

• Intermittent

• Mild Persistent

• Moderate Persistent

• Severe Persistent

Asthma Severity (Intermittent)

• Symptoms under 2x/week

• Nocturnal symptoms under 2x/month

• Pulmonary function > 80% normal

• Rare activity restrictions

Asthma Severity (Mild Persistent)

• Symptoms more than 2x/week but NOT daily

• Nocturnal symptoms more than 2x/month

• Pulmonary function > 80% normal

• May affect activity

Asthma Severity (Moderate Persistent)

• Symptoms and bronchodilator use daily

• Nocturnal symptoms more than 1x/week

• Pulmonary function 60-80% normal

• Some activity limitations

Asthma Severity (Severe Persistent)

• Symptoms continuous throughout the day

• Frequently nocturnal symptoms

• Pulmonary function < 60% normal

• Severely limited activities

Asthma Action Plan

• Guides home mngmnt

• Green

  • 80% & above of expected peak flow

  • We want them to be at 80% or above

• Yellow

  • 50%-79% of expected peak flow

  • May add medications to prevent worsening

• Red

  • Less than 50% of expected peak flow

  • Medical alert

Asthma Maintenance

• How to use peak flow meter

  • Set arrow to zero

  • Stand up straight

  • Deep breath w/ lips tightly around meter

  • Blow out hard & fast

  • Repeat 3 times & record highest

  • Keep daily records

  • Perform test at the same time each day

• Personal best = Highest number reached over a 2-week period when feeling well

• Peak flow scores guides Asthma Action Plan

Asthma Management (Goals)

• Avoid asthma triggers

• Reduce or control exacerbations

Asthma Management (Medication Mngmnt)

• Increase meds. when worsening

• Decrease medication when improving

Asthma Management (Education)

• Rescue inhaler available at all times

• Have & follow an Asthma Action Plan

• Exercise w/ longer warm up period

• Promoting child’s self-esteem

  • Different from others

  • Increase self-efficacy

• Promote family coping

  • Education & encouragement

Cystic Fibrosis (CF)

• Autosomal recessive

  • They need both recessive genes

• Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) chromosome abnormality

  • Chromosome 7

• Chronic, progressive, inherited, incurable genetic disease

  • Affects the Exocrine (mucous-secreting) glands

• ACOG recommends testing women presenting for preconception or prenatal care

  • If positive screening, test partner

  • Chorionic villus sampling or amniocentesis if pregnant

  • IVF for preimplantation genetic testing or adoption if not pregnant

• Newborn screening

  • Typically diagnosed within first 2 years

• Increased survivability w/ new medicines

Cystic Fibrosis (CF) (Patho.)

• Genetic defect

• Abnormally thick secretions

• Obstruction

• Inflammation, bronchospasm, hyperinflation, chronic infection

• Impaired gas exchange (Hypoxia)

• Atelectasis

• Pulmonary complications

  • Failure

  • Death

• Pulmonary vasoconstriction

  • Congestive HF

Cystic Fibrosis (CF) (GI Clin. Manifest.)

• Blocked pancreatic enzyme (protease, amylase, lipase)

• Poor absorption of fat-soluble vitamins (D, E, K, A)

  • Malabsorption of fats → poor growth, steatorrhea, constipation, fecal impaction, prolapse or bowel obstruction → need to take pancreatic enzymes → may need feeding tube

  • NEEDS to take pancreatic enzymes

    • Every meal & snack (Maintain weight)

• Can lead to fibrosis to the pancreas causing diabetes

• Liver bile duct block → gallstones

• Meconium ileus in newborns

  • Might be the first sign

• Constipation or blockage → prevent constipation

Cystic Fibrosis (CF) (Reproductive Infertility Clin. Manifest.)

• Males:

  • Born without vas deferens or it is blocked w/ mucus

• Females:

  • Cervical secretions limit sperm penetration to ovum

  • Females should still use birth control

  • Can still be pregnant, just difficult

Cystic Fibrosis (CF) (Assessment Health Hx)

• Meconium ileus

• Steatorrhea

• Chronic cough

• Activity intolerance

• Significant constipation

• Poor weight gain despite adequate intake

Cystic Fibrosis (CF) (Assessment Inspection)

• Barrel chest

• Underweight

• Increased WOB

• Clubbing

• Bloody sputum

• Nasal polyps

Cystic Fibrosis (CF) (Assessment Auscultation)

• Crackles

• Wheezing

• Diminished lung sounds

• Tachycardia

• Possible gallop

Cystic Fibrosis (CF) (Assessment Complications)

• Cardiac failure

• Liver failure

• Cor pulmonale

Cystic Fibrosis (CF) (Sweat Chloride Testing for Diagnosis)

• Parents will note a salty taste to their skin

• Newborn screening can result in false positive

• Sweat chloride test if positive screening

  • Suspicious > 50 mEq/dL

  • Diagnostic > 60 mEq/dL

Cystic Fibrosis (CF) (Management Goals)

• Maximize lung function

• Minimize pulmonary complications & preventing infection

• Chest Physiotherapy (CPT)

  • 2-4x/day when well, more often when sick

• Postural drainage

• Flutter valve device

• Timing

  • Not right after/ before a meal

• Medications:

  • Bronchodilators

  • Inhaled corticosteroids

  • Inhaled antibiotics

  • Inhaled mucolytics

Cystic Fibrosis (CF) (Management Goals Maintain Growth)

• Pancreatic enzyme supplements

  • Varies based on size & content of meal

  • NEVER crushed

  • ALWAYS before food

• High-calorie, high-protein diet

• Supplemental vitamins

Cystic Fibrosis (CF) (Management Goals Exercise)

• Strengthens bones

• Improves lung function

  • Airway clearance technique

• Manages diabetes

• Improves mood, sleep

• Helps normalize lives of CF patients

• Need to maintain hydration & sat levels

  • May need to take salt supplements due to extra sweating

  • Watch for confusion, nausea, hypotension

Cystic Fibrosis (CF) (Management Goals) (Multidisciplinary approach)

• CF clinic every 2-3 months

• Monitoring growth & development

• Assess lung function w/ PFTs

• Assess GI tract for malabsorption Sx

  • Pancreatic enzyme administration

• Monitoring for complications of Tx

• Assess psychosocial issues

Cystic Fibrosis (CF) (Management Goals) (Education)

• Therapies

• Nutritional needs

• Early signs of infection

  • When to seek medical care

Pediatric Considerations (Tracheostomy)

• Same purpose as in adults

• Tube size & type varies depending on airway size

• Humidified air

• Often do NOT have an inner cannula to remove & clean

  • So replace the entire tube per protocol

Pediatric Considerations (Tracheostomy Emergency Equipment)

• Two spare trach

  • One the same size, one a size smaller

• Bag valve mask

• Suction equipment

• Call bell in a reach