Chapter 40: Respiratory Disfunction in Children

Respiratory Infections 

•The respiratory tract is susceptible to a wide variety of infective organisms

•Viruses cause most infections

•Infection rate increases from 3-6 months of age, remains high during the toddler and preschool years

•Occur most commonly during winter and spring months

•In children older than 5 years, there is an increase in GABHS and Mycoplasma pneumoniae infections

•Increased immunity develops with age

Anatomical Differences

–Peripheral airways narrowly branch and cause easier airway obstruction

–Less alveolar area is available for gas exchange

–Right bronchi is straighter

–Eustachian tubes lie more horizontally and are shorter, wider, and straighter in infants, increasing the risk of infection

Age-Related Illness

•Infants

Seasonal Variations

•Respiratory illness is most common during winter and spring

•Mycoplasma infections more common in fall and winter

•Asthmatic bronchitis more frequent in cold weather

•RSV season considered winter and spring

Clinical Manifestations of Respiratory Infections

–Fever

–Anorexia, vomiting, diarrhea, abdominal pain

–Cough, sore throat, nasal blockage or discharge

–Respiratory sounds

Respiratory Assessments: Subjective

–Home environment, activity level, meds

–PMH (LBW, pulmonary disease, passive smoke exposure, family history)

– any coughing, SOB, chest tightness, nasal congestion, apnea, etc.

Respiratory Assessments: Objective

–Breathing pattern and effort

–RR and depth

–Use of accessory muscles

–Auscultation

–Palpate the chest for thoracic expansion, tactile fremitus, and pain

–Nasal passage

–Diagnostic procedures (CBC, ABGs, sputum c/s, throat c/s, PFTs, Chest films, Sp02)

Viruses

–Respiratory syncytial virus (RSV)

–Parainfluenza

–Adenovirus

Other infectious agents

–Group A β-hemolytic streptococci

–Staphylococci

–Chlamydia trachomatis, mycoplasma organisms, pneumococci

–Haemophilus influenzae

What impedes resistance?

•Compromised Immune system

•Allergies, asthma

•Cardiac anomalies

•Cystic fibrosis

•Daycare

Upper respiratory tract: Nose & pharynx

–Acute Viral Nasopharyngitis

–Acute Streptococcal Pharyngitis

–Tonsillitis

–Influenza

–Otitis Media

–Croup Syndromes

–Acute Epiglottitis

–Acute Spasmodic Laryngitis

–Bacterial Tracheitis

Infections of Lower Respiratory tract: Bronchi & bronchioles

–Bronchitis

–Respiratory Syncytial Virus (RSV) and Bronchiolitis (most  cases caused by RSV)

–Pneumonia

Other Infections of Respiratory Tract

–Bronchitis

–Respiratory Syncytial Virus (RSV) and Bronchiolitis (most  cases caused by RSV)

–Pneumonia

Pulmonary Dysfunction Caused by Noninfectious Agents

–Irritants

–Foreign Body Aspiration (beads, paper clips, food items)

–Tobacco exposure

Long Term Respiratory Dysfunction

–Asthma

–Cystic Fibrosis

Respiratory Emergency

–Respiratory Failure

•CPR

Acute Upper Respiratory Infections

•Upper Respiratory Tract

•Involves any or all of the structures

•Viruses

•Self-Limiting

•Secondary Infections

Disorders of the Upper Respiratory Tract

•Acute Nasopharyngitis (Common Cold)

•Pharyngitis

•Tonsillitis

•Epistaxis

•Sinusitis

•Laryngitis

•Croup (Laryngotracheobronchitis)

•Epiglottis

Upper Respiratory Infections: Acute Nasopharyngitis

“Common Cold”

What are upper respiratory infection: Acute Nasopharyngitis caused by?

rhinovirus, RSV, adenovirus, influenza virus, and parainfluenza virus

What are the clinical manifestations of upper respiratory infection: Acute Nasopharyngitis?

It varies depending on the age of the child - more severe in younger children 

Most common clinical manifestations of URIs: Acute Nasopharyngitis

•Low grade fever (more common in younger children)

•Irritability

•Sneezing

• N/V, diarrhea

•Sore throat

•Muscle aches

•Cough

•Poor feeding

•Cervical lymph nodes swollen and palpable

Upper respiratory infections: Acute Nasopharyngitis etiology

–Period of infectivity – 1-2 hours before onset of symptoms to 1-2 days after illness apparent

–Group A streptococci: principle bacteria cause

Upper respiratory infections: Acute Nasopharyngitis epidemiology

–Susceptibility is universal

–Peaks of occurrence are September, late January and late April

–Children average 4-5 infections per year

–Frequency varies on the number of exposures

–Susceptibility may be increased with poor nutrition

Upper respiratory infection: Acute Nasopharyngitis pathology

–First changes are edema and vasodilatation

–Structural and functional changes in cilia

–Mucus Production

Upper respiratory infection: Acute Nasopharyngitis complications

–Otitis Media is most common

–Mastoiditis, Peritonsillar Cellulites

–Laryngotracheobronchitis, bronchiolitis, or pneumonia

–Viral nasopharyngitis can trigger asthma symptoms

Therapeutic management of URIs: Acute Nasopharyngitis

–Antipyretics for mild fever and discomfort

–Rest until child is fever-free for 1 day

–Humidified environment & increasing oral fluids

–Decongestants may be prescribed for children > 6 months to shrink swollen nasal passages

–Cough suppressants (with dextromethorphan) for dry, hacking cough in older children

Are URIs: Acute Nasopharyngitis preventable?

Prevention is Impossible

–Education: Importance of proper Hand Washing

Upper Respiratory Infections: \n Pharyngitis

•80-90% viral, 10 – 20 % bacterial

•Incidence > at 5-15 years old

•Peak incidence winter and spring

•Usually begins with droplet transmission

•Incubation period 2 to 5 days

Upper Respiratory Infections: \n Pharyngitis etiology

–Usually caused by viruses

–Group A beta-hemolytic streptococcus is the only common bacterial causative agent

Upper Respiratory Infections: \n Pharyngitis complications

–Viral – low incidence

–Bacterial – peri-tonsillar abscess, sinusitis, otitis media, rarely meningitis, acute glomerulonephritis & rheumatic fever

Viral Pharyngitis symptoms

–Sore throat

–Fever

–Rhinorrhea

–Cough

–General malaise

–Enlarged regional lymph nodes

–Erythema back of the pharynx and the palatine arch

–Exudate may or may not appear on the tonsils

Streptococcal Pharyngitis symptoms

–Bright red throat and palatine tonsils

–Tonsils are enlarged with white exudate

–Petechiae may be present on the palate

–Fever

–Sore throat

–Headache

–Stomach ache

–Difficulty swallowing

Viral Pharyngitis: Therapeutic Management

Symptomatic treatment

Bacterial Pharyngitis: Therapeutic Management

Streptococcal is treated with penicillin/cephalosporin for 10 days

Upper Respiratory Infections: \n Pharyngitis surgical treatment

•Tonsillectomy

•Adenoidectomy

Tonsils

masses of lymphoid tissue located in the pharyngeal cavity

What do tonsils do?

–Filter and protect the respiratory and alimentary tracts from invasion by pathogenic organisms

–Play a role in antibody formation

–Several pairs of tonsils are part of a mass of lymphoid tissue encircling the nasal and oral pharynx

–Palatine tonsils are visible during oral exam and are those removed during a tonsillectomy

–Pharyngeal tonsils, “adenoids”, are located above the palatine tonsils, cause difficulty with inflammation in the area of the nasopharynx

Inflammation of the tonsils

May be viral or bacterial (may be r/t strep)

Tonsillitis and Adenoiditis: Signs and symptoms

–sore throat

– fever

– enlarged tonsils

– purulent exudate

–difficulty breathing (“kissing tonsils”)

–dysphagia with inflammation of adenoids

What are the tonsils and adenoids made of?

Tonsils and adenoids are made of lymph tissue and are part of body’s defense against infection

Tonsillitis and Adenoiditis: Interventions

–Difficulty swallowing and breathing

–Provide cool mist vaporizer, salt-water gargles, throat lozenges (if age-appropriate), cool liquid diet, acetaminophen

–Removal of tonsils and adenoids not recommended if under 3 years of age

–Tonsillectomy done only if persistent airway obstruction or difficulty breathing occurs

Tonsillectomy: Indications

–For chronic problems within the upper respiratory airway

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–Should not be removed in children until they are 3 to 4 years old due to the excessive blood loss & possibility of re-growth or hypertrophy of lymphoid tissue.

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–Adenoidectomy is recommended for children that have recurrent otitis media (to prevent hearing loss) and for those wholes hypertrophied adenoids obstruct nasal breathing.

Tonsillectomy & Adenoidectomy: Pre-op

–Baseline vital signs, observe for signs of URI,

–Bleeding & clotting times with lab work, and

–Note loose teeth with physical assessment

Tonsillectomy & Adenoidectomy: Post-op

–Vital signs, observe for hemorrhage (immediately – up to 10 days post-op), assess for general response to surgery

–Frequent swallowing, flashlight checks

–Positioning

–No cough, gargle, clearing of throat, blowing of nose

–Nutrition

Nursing tips

•Frequent swallowing while the child is sleeping is an early sign of bleeding after a tonsillectomy

•Milk and milk products may coat the throat and cause the child to “clear” the throat, further irritating the operative site, therefore should be avoided in the immediate postop period

•Do not give red-colored fluids/popsicles

Epistaxis (Nosebleed)

•Common in children

•Usually occurs in trauma, such as picking at the nose or trauma

•Some families show a familiar disposition to them

Nosebleed interventions

–Keep child in upright position with the head tilted slightly forward to minimize the amount of blood pressure in nasal vessels and to keep blood moving forward, not back into the nasopharynx.

–Apply pressure to the cartilage on the sides of the nose for 10 minutes

–Prolonged or severe bleeding may need emergency intervention or packing.

Sinusitis

•Infection and inflammation of the sinus cavities

•Rarely occurs in children younger than 6 years of age because frontal sinuses do not develop fully until that age.

Sinusitis Symptoms

–Fever

–Nasal discharge

–Cough

–Last for over 10 days

Sinusitis Treatment

–Analgesic –pain

–Antibiotic – specific organism

Otitis Media

Inflammation of the middle ear is the most prevalent disease of childhood after a respiratory infection

Infants & Young Children are at high risk for otitis media

–Incidence is increased in children that are exposed to tobacco smoke

–Most susceptible are males, Alaskan and Native American children those with cleft palate and infants who are formula-fed rather than breastfed (infants are held in a more slanted position  while feeding allowing milk to enter the eustachian tube).

–Most often in children 6 to 36 months of age and again at 4 to 6 years

Highest in winter and spring

Otitis media clinical manifestations

–Chronic vs acute

–Feeling of “fullness in the ear”

–Any child with a fever of unknown origin should be evaluated for a middle ear infection

–Low grade fever for several days then suddenly fever peaks 102 F

–Cold

Otitis media is classified as:

–acute otitis media (AOM)

     or

–otitis media with effusion (OME)

•Half of all children experience OM by 1 year of age

Otitis media assessments

–Fever, could be as high as 106 (axillary)

–Bulging and bright-red Tympanic Membrane

–Pain (otalgia)

–Pulling at ear

–Irritability

–If OME: fullness feeling in ear, dull and retracted TM, serous fluid in middle ear

Factors predisposing young children to OM

–Anatomy of Eustachian tube

–Supine feeding position

–Bottle fed children

–Exposure to passive smoking

–Daycare

Examination with otoscope (Otitis Media)

reveals hyperemic, opaque, bulging tympanic membrane of poor mobility and purulent otorrhea may be present

Tympanometry (Otitis Media)

measures the change in air pressure in the external auditory canal from movement of the eardrum

Tympanocentesis (Otitis Media)

This is only for seriously ill, toxic patients developing supportive intra-temporal or intracranial complications; otitis in the newborn, very young infant or immunologically deficient patient

Otitis Media: Therapeutic management

–Current Literature states that it is safe to wait up to 72 hours for spontaneous resolution in healthy infants over 6 months & children

–Oral Amoxicillin for 10 to 14 days

–Supportive Care of fever & pain

Myringotomy

•With the patient asleep, the surgeon makes a small incision in the eardrum and removes the fluid. A small plastic or metal tube may then be placed in the incision so that air can enter the middle ear to help prevent the fluid from reforming.

•If tubes placed, they will remain in the ear drum for a variable length of time with an average of six months.

Swimming with Tubes

May swim with tubes: recommend ear plugs/swim cap.

After tubes fall out, f/u with Dr before swimming

Otitis Media: Nursing interventions

–Position child on affected side for comfort and to facilitate drainage

–Apply heat over the ear (warm compresses)

–Cleanse the external canal with antibiotic ointment or hydrogen peroxide if ordered

–Caution care-givers about allowing water to enter ear after a Myringotomy with tubes

•Especially when swimming!

–Notify MD if tube falls out (it is a normal occurrence)

CROUP SYNDROMES

•General term applied to conditions whose chief symptom is “barking” croupy cough

•Can also involve varying degrees of stridor-harsh high pitched sound and respiratory distress

•Can be BENIGN or ACUTE 

Croup Syndromes: Etiology

–Majority of patients that have viral croup are 6 months to 3 years

–3 to 7 years more commonly have H.Influenza or C. Diphtheria

–Incidence is higher in males

–Commonly occurs during cold season

–15% of patients have strong family history

–Croup & Laryngitis tend to recur in the same child

Croup Syndromes: Clinical Manifestations

•1st Brassy Cough with intermittent respiratory stridor

•1-2 days of mild upper respiratory symptoms

•Most patients with croup progress only as far as stridor & slight dyspnea

Acute laryngotracheobronchitis (LTB)

•Most common form of Croup

•Inflammation of mucosa lining the trachea, causing narrowing of airway

•Also referred to as __subglottic croup__ because edema occurs below the vocal cords

•Primarily viral

•Usually in young children (6mos – 3yrs)

•“Barking” cough

•Inspiratory stridor – harsh high pitched sound

Important things to know about (LTB)

–URI for days before the brassy cough, inspiratory stridor, & respiratory distress become noticeable.

–As extends downward involving the bronchi./bronchioles, the respiratory difficulty increases and the expiratory phase of breathing also become labored & prolonged. 

–Extremely restless and frightened

–Will have bilateral diminished breath sounds, rhonchi, scattered rales, temps may also be 102-104.

–Typically  worsen at night.

–Children are not usually seriously ill with LTB – they sometimes will have rhinitis and conjunctivitis or even both. 

–During physical exam a nurse will see, pharyngeal inflammation & respiratory distress with evidence of high respiratory obstruction, inflammatory edema of vocal cords & subglottic tissue may be seen when using a laryngoscope.

Epiglottitis

•Inflammation of the tissues above the vocal cords (the epiglottis is the flap of cartilage that covers the opening of the larynx to keep food and fluid out of airway when swallowing)

•Narrows airway inlet

Is epiglottitis bacterial or viral?

it can be bacterial or viral (Often caused by H. influenzae type B – vaccine @ 2mos)

When does epiglottitis usually occur?

•Most often seen in children 2 to 8 years of age

•Can occur in any season

•Course is rapid, progressive, and __**life-threatening!!!**__

Important things to know with epiglottitis

•Usually starts with fever, sore throat, dyspnea which rapidly progresses to respiratory obstruction

•Child insists on sitting up, leaning forward with mouth open, drools saliva because of difficulty in swallowing

•Cough is absent as airway narrows

•Examining the throat with a tongue blade could trigger laryngospasms; therefore, a tracheotomy set should be at the bedside before examination of the throat takes place

Epiglottitis diagnosis

•properly depressing the child’s tongue and seeing a large, swollen cherry red epiglottis

•BUT this should only be done if diagnosis is probable (based on other s/s) and complete cardiorespiratory support is available.

•BECAUSE some patients can have “reflex laryngospasm” that causes acute complete obstruction, aspiration of secretions & cardiorespiratory arrest.

Epiglottitis Treatment

•Treatment of choice is immediate __tracheotomy or endotracheal intubation__ and oxygen

–Prevents hypoxia, brain damage, and sudden death

•Parenteral antibiotics show dramatic improvements within a few days

•Prevention: HIB vaccine beginning at 2 months of age

Spasmodic laryngitis (spasmodic croup)

•Usually occurs in children 1-3 years of age

•Causes: viral (most cases), allergic, psychological, GERD

•Sudden onset, usually at night

•“Midnight Croup” – often gone in the AM

•Characterized by barking, brassy cough and respiratory distress; lasts a few hours

•Treatment: increasing humidity and providing fluids

Congenital laryngeal stridor

–Weakness in airway walls, __floppy epiglottis__ that causes __stridor on inspiration__

–__May exhibit inspiratory retractions__

–Symptoms lessen when prone or side lying

–Usually clears spontaneously as muscles strengthen.

General Treatment Croup Syndromes

–Cold water humidifier

–Helps relieve respiratory distress and laryngeal spasm

–If hospitalized, may be placed in a mist tent or croupette (Crying – remove and call MD)

–Cool air saturated in microdroplets enter small airway of child, cooling and vasoconstriction occurs, relieving the respiratory obstruction and distress

–Opiates are contraindicated, as are sedatives

–IV fluids-nutritional support due to vomiting

–Oxygen- monitor vital signs

–Nebulizers

–Corticosteroids

Lower Respiratory Infections: Respiratory Syncytial Virus (RSV)

•RSV is responsible for 80% of cases of bronchiolitis in infants (other causes: adenoviruses/parainfluenza) and most common cause of viral pneumonia

•Diagnosis:  nasopharygeal washing for RSV antigen

•An acute viral infection with maximum effect at the bronchiolar level

•Occurs often in the winter and spring

•Most common in children younger than 2 years of age, peaking incidence between 3 and 6 months of age

•Symptoms diminish with age and repeated infections:

–Rhinorrhea, low-grade fever, conjunctivitis, OM, wheezing, retractions, crackles, dyspnea

•Most common reason for hospitalization in infancy

RSV transmission

•Spread by direct contact with respiratory secretions-usually spread by contaminated hands.  It is not airborne.

•Survives more than 6 hours on countertops, tissues, and bars of soap

•Incubation approximately 4-7 days

•If hospitalized, place in contact isolation precautions

Personnel taking care of infants with RSV

Infant should be assigned to personnel who are not caring for patients at high risk for adverse response to RSV

It is important to know with RSV

•Adults who have RSV can shed the virus for up to 1 week after the infection; therefore, precautions should be taken if that adult is caring for infants

•Strict adherence to isolation precautions and hand hygiene are essential

RSV symptomatic care is provided and can include

–Supplemental oxygen

–Intravenous hydration

–Antiviral medication

–IV immune globulin (RespiGam) – plasma loaded with rsv antibodies

–Synagis- man made antibody to RSV

RSV Treatments

•Ribavirin = antiviral agent = controversial

•Costly, aerosol route, potential toxic effects among exposed health care personnel (teratogenic) & conflicting results of studies

RSV Prevention

–Used to prevent RSV infection

–Infants eligible are defined by specific criteria:

•Gestational age less than 29 weeks or less than 1 year of age with preexisting health conditions:

–Chronic lung disease of prematurity or congenital heart disease

–Injections are given monthly during RSV season   

Asthma

•Believed to be a condition resulting from complex interactions among inflammatory cells, mediators, and the cells and tissues present in the airways

•Chronic inflammatory disorder of the respiratory tract

Important things to know about asthma

•Reversible “reactive” airway disease

•Characterized by narrowing of the bronchi and bronchioles

•Results in airway obstruction and hyperinflation

•Most common chronic condition of childhood

•Primary cause of school absences

•Presents before 5 years of age

Asthma pathophysiology

–Inflammation and edema of the mucous membranes

–Accumulation of tenacious secretions from the mucous glands

–Smooth muscle spasm of the bronchi and bronchioles

–Triggered by allergens, irritants, chemical exposure, exercise, cold air, animals, foods, endocrine factors

Expiratory wheeze

an inspiratory wheeze places the pt. at higher risk of respiratory failure or coarse rhonchi

•The sudden cessation of wheezing can be an ominous sign the  airway is totally constricted, respiratory arrest is imminent!!

Asthma assessments

–Diaphoresis

–Cough

–Restlessness

–Dyspnea with prolonged expiration

–Nasal flaring

–Intercostal retractions

–Cyanosis

Asthma diagnosis

–ABGs, reveals decreased pH and Pa02

–Sputum culture -  presence of eosinophils

–CBC: reveals increased eosinophils

–PFTs

–Peak expiratory flow rate (PEFR) reveals severity of exacerbation

–Chest x-ray: reveals hyperinflation, infiltrates, and atelectasis

Short term asthma therapeutic management and treatment

•Inhaled short-acting beta2 agonists (Albuterol)

•Systemic (sub-q) beta2 agonists (epi, Terbutaline)

•Anticholinergics (Atrovent)

•Steroids

•Use of spacers

•0xygen

Long term asthma therapeutic management and treatment

•Allergen Control

•Drug Therapy

•Exercise

•Breathing exercises

•Hyposensitization

Medication Control for asthma (long-term control medications and quick relief medications)

–Corticosteroids

–Cromolyn sodium

–albuterol

–metaproterenol

–Terbutaline

–Xopenex

–Long-term bronchodilators (salmeterol \[Serevent\])

–Theophylline—monitor serum levels

–Leukotriene modifiers

Asthma Goals

–Avoid exacerbation

–Avoid allergens

–Relieve asthmatic episodes promptly

–Relieve bronchospasm

–Monitor function with peak flow meter

–Self-management of inhalers, devices, and activity regulation

Cystic Fibrosis

•Inherited autosomal recessive trait, with both parents carrying a gene for the disease (1:4 chance)

•Most common lethal genetic illness among Caucasian children

–Increased viscosity (thickness) of mucus gland secretions

–A loss of electrolytes in sweat because of an abnormal chloride movement

What is cystic fibrosis a major cause of?

Major cause of serious chronic lung disease

Cystic fibrosis and the endocrine system

Basic defect is an exocrine gland dysfunction that includes multiple systems

Cystic fibrosis and pregnancy

•Chorionic villi sampling or amniocentesis can be performed during pregnancy for early detection

•All newborns can be screened at birth.

•Affected males may be unable to reproduce secondary to persistent plugging and blocking of vas deferens by tenacious seminal fluid.

•Affected females may have thick cervical secretions that limit sperm motility.

•Alternative insemination and in vitro fertilization are options for patients who desire to become pregnant.

Respiratory system (Cystic Fibrosis)

Obstructed by secretions