Respiratory

Newborn noses

very small nasal passages, making them more prone to obstruction; sinuses are not developed so less prone to sinus infection.

Infants

preferential nose breathers (only mouth breath when in distress), produce very little mucus, which starts to make them more susceptible to infections.​

Infant throats

• Infant tongues are larger (relative to oropharynx) than than adults​

• Placement of tongue (posterior) can lead to airway obstruction.​

• Children have enlarged tonsillar and adenoid tissue, which can lead to airway obstruction.​

Pediatric trachea

• Smaller width in infants & children than adults​

• Edema, mucus, bronchospasms – greatly diminish airway​

• Leads to increase in​

  • Resistance to airflow​

  • Work of breathing/metabolic rate​

• Leads to quicker decline

Pediatric larynx and glottis

• Located higher in neck ​

  • Prone to aspiration of foreign bodies​

• Airway highly compliant/pliable​

  • Prone to collapse in presence of obstruction​

Pediatric lower airway structures

• The bronchi and bronchioles of infants and children are narrower in diameter than the adult’s.​

  • Increased risk for lower airway obstruction.​

• Fewer numbers of alveoli (major sites of gas exchange)​

  • Higher risk of hypoxemia.​

  • Continue to develop through age 7-8 years (numbers double from term infant )​

• Infant chest walls more compliant (pliable)​

• Can’t support lungs as well

Risk factors of respiratory issues

• Prematurity​

• Chronic illness (diabetes, sickle cell anemia, cystic fibrosis, congenital heart disease, chronic lung disease)​

• Mobility disorders (cerebral palsy, muscular dystrophy)​

• Immune deficiency ​

• Passive exposure to cigarette smoke​

• Crowded living conditions ​

• Air pollution​

• Daycare attendance​

• Travel

Normal respirations across pediatric ages

• Newborn (birth-4 weeks): 30 to 60/min

• Infant (1-12 months): 25-30/min

• Toddler (1-2 years): 25-30/min

• Preschooler (3-5 years): 20-25/min

• School aged (6-12 years): 20-25/min

• Adolescent (13-18 years): 16-20/min

Respiratory assessment

• Skin Color: pallor, cyanosis, acrocyanosis ​

• Rate and depth of respirations: tachypnea​

• Nose and oral cavity (obstruction, drainage, etc.)​

• Cough: productive vs non –productive, what does it sound like?​

• Upper airway noises: stridor, croup​

• Respiratory effort: nasal flaring, head bobbing, retractions, grunting​

• Anxiety and restlessness/fussiness signs of air hunger (if late you can see lethargy)​

• Clubbing (chronic sign of pulmonary or cardiac dysfunction)​

• Hydration status (dehydration)

Retractions

• Sign of respiratory distress (not normal!) ​

• Note the location:​

  • Supraclavicular​

  • Clavicular​

  • Suprasternal​

  • Substernal ​

  • Subcostal​

  • intercostal ​

• Identify if they are mild, moderate or severe

Palpation and percussion during assessment

• Palpate​

  • sinuses for tenderness in older child​

  • Enlargement/tenderness of lymph nodes of head/neck ​

  • Is tactile fremitus present? (pneumonia)​

• Percuss​

  • Flat or dull sounds over consolidated lung tissue (pneumonia) ​

  • Tympanic sounds (over pneumothorax)​

  • Hyperresonance with asthma-related air trapping

Auscultation

• Listen to Anterior (Front) & Posterior (Back)​

• Bilaterally – should be equal ​

• Different sounds on each side is concerning​

• Note Pitch, quality, volume ​

• Inspiratory phase usually softer/longer than expiration​

• Smaller fields/thinner chest walls so determine if sounds are truly in lung fields or being transmitted ​

• Also listen with the stethoscope against bare skin ​

• Listen when the child is sleeping/calm if possible

Abnormal auscultation findings

• Wheezing (inspiratory or expiratory)

• atelectasis

• diminished or absent lung sounds

• crackles

• coarse sounds

• stridor ​

Signs of respiratory distress in children

• Retractions​

• Tracheal tug​

• Nasal Flaring ​

• Head bobbing​

• Tachypnea​

• Grunting​

• Wheezing ​

• Stridor ​

• Low oxygen saturation (hypoxia)​

• Positioning (tripod)​

• Not “fighting” with caregiver or HCP (ominous sign)

Lab tests for respiratory disorder

• Arterial blood gases

• complete blood count​

• sputum cultures ​

• Nasal-pharyngeal Swabs: positive identification of RSV or other viral illness ​

• Rapid strep testing via throat swab culture (oropharyngeal)

Other diagnostics for respiratory disorders

• Pulse oximetry: oxygen saturation might be decreased significantly (continuous or intermittent monitoring) ​

• Imaging/X-rays: ​

  • Might reveal hyperinflation and patchy areas of atelectasis or infiltration or pneumothorax​

  • Chest x-ray, CT and MRI scans

Common medical treatments for respiratory disorders

• Supplemental Oxygen (many different devices) ​

• Suctioning​

  • Oral ​

  • Nasopharyngeal ​

  • Tracheal/ETT/Tracheostomy​

• High humidity​

• Chest physiotherapy and postural drainage​

• Saline rinses, gargles or lavage​

• Mucolytic agents​

• Chest tubes – removal of air/fluid from pleural space​

• Bronchoscopy – tube w/ camera and light. Assess the airway, identify/remove foreign body + other interventions

Oxygen delivery devices

• Nasal cannula – up to 4L/min, low oxygen concentration, risk for drying​

• Simple mask – 6-10L/min, can provide higher concentration than cannula, mouth breathers​

• Oxymask – wide range 1-15L/min – can deliver high oxygen concentration​

• High Flow Nasal Cannula – heated & humidified, wide range of flow, noninvasive/nonrestrictive​

  • Very popular​

• Oxygen tent/hood – can provide more humidity (covers the head or the upper body) – losing favor ​

• Non-rebreather mask - can provide high (95%) concentration, minimum 10-15L/min

Considerations for supplemental oxygen

• Oxygen is Considered a drug – need order to administer (unless protocol for emergency situations) ​

• Consult with respiratory therapists to determine best delivery method if questions​

• Select proper size mask if needed​

• Select delivery method based on flow of oxygen needed​

• With higher flows, use supplemental humidification

Tonsillitis

• Inflammation and redness of the tonsils​

• Often occurs with pharyngitis ​

• Infection: Viral or bacterial in nature​

  • Group A Beta-Hemolytic Strep (common offender) but it is not limited to strep! ​

• Can be Acute leading to Chronic

Tonsillitis risk factors

• exposure to bacterial or viral illness

• immature immune system

Tonsil grading

0 = no tonsils (due to past tonsillectomy) ​

1 = hidden behinds the pillars, barely visible​

2 = extend to the pillars, visible and normal size ​

3 = extends beyond the pillars but they are not midline yet (enlarged, may partially obstruct airway) ​

4= midline, touching the uvula or each other (likely to cause airway obstruction, breathing and swallowing issues)

Tonsillitis nursing assessment

• Ask: ​

  • History of pharyngitis or tonsillitis?​

  • Fever?​

  • Child’s voice hoarse or muffled?​

  • Any difficulty/pain with swallowing?​

• Inspect mouth for redness, enlargement of tonsils​

• If Enlarged – child may experience difficulty breathing & swallowing​

  • If touch at midline – airway can become obstructed​

  • If adenoids enlarged as well – posterior nares become obstructed​

• Child may mouth breathe and/or snore​

• Mouth odor (bad breath)

Acute tonsillitis treatment

• Viral – rest, warm fluids, salt-water gargles​

• Bacterial – same as viral PLUS Treat infection with antibiotics​

  • Medications for symptom management: ​

    • Antipyretics to treat fever and manage pain ​

    • Antibiotics – make sure that caregivers are aware that they must complete the full course

Tonsillectomy

• Surgical intervention is required for chronic, severe tonsillitis.​

• Tonsillectomy – for recurrent streptococcal tonsillitis or tonsillar hypertrophy​

• Adenoidectomy – for hypertrophied adenoids obstructing breathing​

• T&A = both of the above

Promoting airway clearance after tonsillectomy

• Place side-lying or prone – promotes drainage of secretions​

• Elevate head when awake ​

• Monitor for difficulty breathing related to oral secretions, edema or bleeding​

• Careful Suctioning – avoid trauma to surgical site

Risk for bleeding with tonsillectomy

• High risk for hemorrhage in the post-op period. ​

• Signs of Hemorrhage: frequent swallowing, clearing throat, restlessness, bright red emesis, tachycardia, pallor​

• Asses vital signs​

• Assess for continuing swallowing small amounts of blood – this could be early bleeding?​

• Dried blood may be present, spit may be blood tinged (but not frank blood)this is expected​

• Patient may re-bleed 4-10 days post-op when scabs come off (higher concern with fresh bleeding)​

• Prevention: Avoid straws, Discourage coughing, clearing throat, blowing nose​

Comfort/pain relief after tonsillectomy

• With or without narcotics​

  • Liquid meds, ​

  • Tetracaine (numbing) lollipops ​

  • Popsicles with pain medication added ​

  • Ice chips/Ice collar ​

• Round the clock for first 24 hours – even at night (wake up for meds!)

Fluid intake after tonsillectomy

• Encourage fluids intake – popsicles, ice chips​

  • Main purpose maintain fluid stats/hydration & keep throat moist​

  • Having a moist environment will help with comfort and healing ​

• Avoid acidic juices – may irritate the throat, painful​

• Avoid red/brown liquids – may be confused with blood if vomiting occurs​

Family education post tonsillectomy

• Care during recovery period (full recovery takes about 14 days): ​

• Importance of pain control ​

  • On first night after surgery it is important to wake the child up for two reasons ​

    • 1) to give pain medication ​

    • 2) to check for any bleeding (child could be swallowing blood in their sleep)​

• Complications to be aware of– bleeding and infection​

• Importance of maintaining hydration during recovery ​

• Activity / rest – limit activity

Reasons to contact provider after tonsillectomy discharge

• Signs of hemorrhage (frequent swallowing, clearing throat, pallor, restlessness, bright red emesis or bleeding) ​

• Signs of infection ​

• Difficulty breathing ​

• Lack of oral intake or signs of dehydration​

• Uncontrolled pain

Bronchiolitis

• Bronchiolitis = Acute inflammation of bronchioles and small bronchi​

• Small airways become obstructed which allows adequate inspiration but not full expiration ​

• leads to hyperinflation/atelectasis​

• Causes alterations in gas exchange – hypoxemia & CO2 retention, hypoventilation

• #1 cause is respiratory syncytial virus (RSV)

At risk groups for bronchiolitis

• infants & toddlers (usually seen in ages 0-2 years) ​

  • Severity inverse to age (younger = sicker, can be deadly) ​

  • Older kids and adults get RSV and it is like a cold -not too severe unless risk factors present

S/S of bronchiolitis at onset of illness

• Rhinorrhea - clear runny nose (often profuse)​

• Pharyngitis.​

• Low-grade fever.

S/S of bronchiolitis progression

• Development of cough 1 to 3 days into the illness, followed by a wheeze shortly thereafter.​

• Tachypnea & Retractions ​

• Copious secretions ​

• Poor feeding → dehydration

S/S of severe bronchiolitis illness

• Worsening Tachypnea RR>70​

• Apnea​

• Quiet chest (wheezes disappear, hyper expansion and poor air exchange) ​

Bronchiolitis nursing assessment

HISTORY:​

• Ask about onset of respiratory symptoms – did the child initially have a profuse runny nose? ​

• Any exposure to other sick people? Siblings with colds?​

• Day care attendance?​

• Has the child been eating normally?​

OBSERVATION: ​

• Does the child appear air hungry?​

FOCUSED RESPIRATORY ASSESSMENTS:

• Assess work of breathing – retractions, nasal flaring, tachypnea, etc.​

• Auscultation ​

• Varying degrees of cyanosis & respiratory distress (see symptoms) ​

• May have periods of apnea ​

VITAL SIGNS & MONITORING

• evaluate effect of treatment, progression of illness ​

• Full set of vitals​

• Expect to see tachypnea, tachycardia and fever, oxygen saturation may be low ​

• Arterial Blood Gas – determine severity of respiratory acidosis ​

DIAGNOSTICS:

• nasal swabs (detection of RSV antibodies/antigens)

• Lethargy & Uninterested in feeds, surroundings or parents

Bronchiolitis nursing management

• Course of illness is usually self-limited ​

  • If severe → Hospitalization for supportive care ​

  • Infants are the most likely to be hospitalized if they present with tachypnea, retractions, poor intake, lethargy​

• Treatment: focus on supportive treatments/care​

  • Supplemental oxygen to maintain SpO2 >90%​

  • Nasal/nasopharyngeal suctioning – maintain clear airway ​

    • Suctioning is a priority, provide as needed ​

    • Infants cannot blow their noses! ​

  • Oral/IV hydration ​

    • If the child is tachypneic or disinterested in feeding use IV fluids ​

    • High risk for aspiration with tachypnea – always assess respiratory system BEFORE feeding​

  • Inhaled bronchodilator therapy (not recommended) ​

  • Ribavirin – antiviral, given via aerosol (no pregnant caregivers due to teratogenic effects), for only severe cases in immunocompromised children

Objectives of bronchiolitis management

#1 Maintain patent airway – elevate head of bed, suction PRN​

#2 Promote adequate gas exchange – adjust O2 % as necessary, calm environment, avoid agitation/overstimulation​

• Reduce risk of infection – highly contagious (use isolation precautions), hand hygiene, PPE​

• Provide family education – recognize worsening symptoms if home, younger kids with increased risk, other chronic conditions?

RSV prevention

• The RSV monoclonal antibodies, Beyfortus (nirsevimab) and Synagis (palivizumab), help protect infants from RSV disease by giving the infant antibodies. ​

  • Beyfortus available to all babies under 8mo, given once, more accessible (costs less than Synagis) ​

• Synagis (Palivizumab) is available for at-risk populations (<2yo w/ prematurity, lung disease, immunocompromised), given monthly, VERY expensive ​

• They are not vaccines, but Both of these injections makes the infection less severe and reduces the risk for hospitalization​

• RSV Vaccination is available for pregnant women who expect to deliever their child during RSV season​

• Education – hand washing, respiratory etiquette, avoiding crowds or individuals who are have respiratory s/s

Croup

• Viral infection causing inflammation of larynx, trachea & bronchi (parainfluenza)​

  • Edema results in airway obstruction​

  • Mucus production​

  • Narrowing of trachea results in audible inspiratory stridor (heard on auscultation or even without stethoscope) ​

  • Harsh ”barking” cough ​

  • Mild or no fever​

  • Observe for suprasternal retractions​

• Most commonly affects children between 3 months & 3 years​

  • Croup rarely occurs age 6​

• Symptoms appear suddenly + most often occur at night or become worse at night​

• Self-limiting : typically resolves within 3 to 5 days

Croup complications

• Worsening respiratory distress​

• Hypoxia​

• Bacterial superinfection could develop (bacterial tracheitis) ​

• Hospitalization if significant stridor at rest or severe retractions

Croup nursing management

• Medications: ​

  • Corticosteroids – single dose to decrease inflammation​

  • Racemic epinephrine – aerosol (inhaled), mucosal vasoconstriction​

• Education on medications if any are used​

• Educate parents on symptoms of respiratory distress​

• Expose child to humidified air​

• If seen in ED, treated and sent home be sure to explain child may worsen again.

Epiglottitis

• Common Cause = Haemophilus influenzae type b ​

  • HIB vaccine has significantly reduced incidence​

• MEDICAL EMERGENCY

• Occurs most frequently in 2-7 year olds​

• Signs & Symptoms: ​

  • Rapid onset of symptoms​

  • High fever​

  • Child appearance – appears “toxic”​

  • Anxious, frightened appearance​

  • Refusal to speak or speak softly​

  • Refusal to lie down​

  • Cough usually absent

Epiglottitis on XRay

• Careful positioning for x-rays ​

  • Lateral position is used ​

  • Not supine because airway occlusion could occur​

• Thumb Sign

Epiglottitis nursing management

• Needs immediate attention and ICU monitoring​

• IV antibiotics to treat the infection​

• Provide 100% oxygen + respiratory support​

• Do Not try to visualize airway or stick anything in the child’s mouth! ​

  • You could compromise your airway! ​

    • Reflex laryngospasm may occur, precipitating immediate airway occlusion ​

    • If occlusion occurs- emergent tracheostomy required (better to proactively intubate with sedation before condition worsens)

Epiglottitis support & safety

• Child should not be left unattended​

• Help child/parents remain calm ​

• Position to provide maximum comfort to child (agitation can further increase the risk of airway occlusion​

​

Foreign body aspiration

• Younger children (infants and toddlers) at greatest risk ​

• Unintended death related to suffocation (most common in children under 1 year old)​

• Causes: ​

  • Large food pieces​

  • Small toys (legos, beads) ​

  • Found objects (coins, rocks) ​

  • Playing and running with objects or food in mouth

• Object can lodge in upper or lower airways:​

  • Upper – can often cough/blow it out​

  • Lower – may need bronchoscopy to remove

Foreign body aspiration complications

• Pneumonia, abscess formation, tissue damage ​

• Hypoxia → respiratory failure → death

Foreign body aspiration nursing assessment

• Sudden onset of cough, wheeze, stridor? Onset can also be gradual if it is not a complete obstruction​

• Universal choking sign in older children ​

• Cyanosis, difficulty breathing, loss of consciousness

Foreign body aspiration nursing management

• Key nursing intervention = prevention​

  • Educate!!! ​

  • Anticipatory guidance for parents, at each health care visit through age 5​

  • Avoid toys with small pieces, coins​

  • Table food – Cut into small pieces in case child does not chew​

  • Often recommend avoidance of foods, such as grapes/hot dogs/popcorn, completely until over age 3​

• If a child aspirates on your watch… ​

  • Follow AHA guidelines for a choking child or infant ​

  • Avoid blind sweeps of mouth ​

  • Infants = Alternating Back Blows and Chest Thrusts ​

  • Children and Adolescents = abdominal thrusts (Heimlich) ​

• Teach family how to address choking and CPR

Apparent Life Threatening Event (ALTE)

• A sudden event where an infant exhibits a combination of apnea or change in breathing, change in color, change in muscle tone and/or coughing, choking or gagging. May also include altered level of consciousness. ​

• Serious event – needs evaluation even it if resolved without intervention

Brief, resolved, unexplained event (BRUE)

term that is being used more frequently in practice and is recommended as a replacement for ALTE by the AAP

Apnea

• Absence of breathing for longer than 20 seconds (may or may not be accompanied by bradycardia) ​

• Can be chronic or acute ​

• Seen often when a patient presents with ALTE/BRUE​

• Other Potential Causes: ​

  • Central (unrelated to other cause – due to lack of signals from the brain to tell body to breathe while asleep) ​

  • Secondary to other illnesses/conditions (prematurity, sepsis, respiratory infection, hypothermia, metabolic disorders, neuro disorders, severe GERD etc.)​

• Administer caffeine or theophylline (respiratory stimulants) if a chronic problem (ex. Apnea of prematurity)

ALTE/BRUE Nursing assessment

• Ask parents and document findings of infant’s position & activities prior to event​

• Obtain detailed description of the event​

• How long was the event?​

• Did the infant start breathing on their own again? ​

  • If yes, Were any interventions (stimulation, CPR) needed to regain breathing? ​

• Assessment of Risk factors;​

  • prematurity, anemia, metabolic disorders​

  • Family history of seizures? ​

  • Sleep environment ​

  • Exposures (illness, toxins, smoke)

ALTE/BRUE nursing management

• If you are present for the event: ​

  • 1. Provide Stimulation to trigger infant to take breath​

  • 2. Rescue breathing & Bag-valve-mask ventilation if child has a pulse​ (most cases of a child going into cardiac arrest are due to a respiratory problem) ​

  • 3. CPR if pulseless ​

• Monitor for recurrent events ​

• Provide thermal neutral environment​

• Prepare family for Laboratory & Diagnostic testing per provider orders​

  • Identify or Rule out causes of the event ​

  • ECG, EEG, MRI, Sleep Study ​

• Family Education:​

  • Infant/Child CPR training​

  • Use & education of home apnea monitoring in hospital/at home

Sudden infant death syndrome (SIDS)

• The sudden – unpredictable – death of an infant without an identified cause, even after investigation & autopsy​

  • More than 90% of all SIDS deaths occur before 6 months of age.​

• Often occurs during sleep ​

  • A baby can die during sleep from causes other than SIDS. ​

  • Sleep itself does not cause SIDS or other sleep-related deaths.​

• Preventative measures are key: ​

  • education to families about risk factors & interventions​

  • Safe sleep!

SIDS risk factors

• Co-sleeping​

• Soft/non-standard bedding​

• Prone or side-lying position while sleeping​

• Overheating during sleep

• Maternal smoking during pregnancy​

• Exposure to second-hand smoke after birth​

• Parental substance use/abuse​

• Poverty (consider resources, education, environment)

• Prematurity/low-birth weight​

• Low Apgar scores​

• Limited prenatal care ​

• Family History of SIDS​

• Viral Illness​

• Twin/Multiple Birth​

Reducing risk of SIDS

• ABC’s of safe sleep: alone, on back, in a crib​

  • ALONE – avoid co-sleeping, no extra “stuff” in the crib ​

  • on BACK – supine positioning for sleep ​

  • CRIB – avoid other sleeping locations. Use a firm mattress. No loose/thick/fluffy blankets​

• Avoid exposure to smoke (cigarette and other)​

• Prevent overheating: adjust room temperature, don’t add extra layers of clothing or extra blankets​

• Use pacifier during naps & at night– associated with reduced risk for SIDS ​

• Keep immunizations up-to-date​

• Encourage Breastfeeding