RESPIRATORY

Anatomy and Physiology

Anatomy of Nose and Throat

  • Nose

    • Infants:

    • Obligate nose breathers.

    • Produce very little mucus, leading to increased susceptibility to infections.

    • Sinuses are not developed fully.

    • Newborns:

    • Very small nasal passages, increasing the risk of obstruction.

  • Throat

    • Increased risk for airway obstruction due to larger tongues relative to the oropharynx in infants.

    • Children may have enlarged tonsillar and adenoid tissue, contributing to obstruction risks.

Lower Respiratory Structures

  • Bifurcation of Trachea

    • Occurs at the level of the third thoracic vertebra, crucial for suctioning or intubating children.

  • Bronchi and Bronchioles

    • Infants and children have narrower bronchi and bronchioles, leading to a higher risk for airway obstruction.

  • Alveoli

    • Children have fewer alveoli, which increases their risk of hypoxemia.

Assessment Techniques

Inspection and Observation

  • Signs to monitor:

    • Anxiety and restlessness.

    • Color changes: pallor and cyanosis.

    • Hydration status assessment.

    • Clubbing of fingers.

    • Auscultation of breath sounds.

    • Respiratory rate and depth, noting tachypnea.

    • Effort of breathing.

    • Examination of the nose and oral cavity.

    • Cough and other airway noises, including stridor.

Adventitious Breath Sounds

  • Wheezing

    • High-pitched sounds during inspiration or expiration, often linked with obstruction in lower trachea or bronchioles, common in asthma or viral infections.

  • Rales

    • Crackling sounds indicating fluid filling in alveoli, often associated with pneumonia.

Laboratory and Diagnostic Tests

General Tests

  • Pulse Oximetry: Measures oxygen saturation, may show significant decreases.

  • Chest Radiograph: May reveal hyperinflation or patchy atelectasis/infiltration.

  • Blood Gases: Can indicate carbon dioxide retention and hypoxemia.

  • Nasal-Pharyngeal Washings: For identifying RSV or other viral illnesses using ELISA or IFA testing.

  • Rapid Strep Testing: Conducted via throat swab.

Specific Tests

Pneumonia

  • Chest X-ray: Variability depending on child’s age and causative agent.

  • Sputum Culture: Useful to determine causative bacteria in older children and adolescents.

  • White Blood Cell Count: Might be elevated in bacterial pneumonia.

Cystic Fibrosis

  • Sweat Chloride Test: Considered suspicious if chloride level is above 50 mEq/L and diagnostic if above 60 mEq/L.

  • Chest Radiograph: May show hyperinflation, bronchial wall thickening, and atelectasis.

  • Pulmonary Function Tests: May indicate decreased forced vital capacity and functional expiratory volume with increased residual volume.

Common Medical Treatments

  • Oxygen therapy.

  • High humidity treatments.

  • Suctioning of airways.

  • Chest physiotherapy and postural drainage.

  • Use of saline gargles or lavage.

  • Mucolytic agents to thin mucus.

  • Chest tubes for fluid drainage.

  • Bronchoscopy for direct intervention.

Risk Factors for Respiratory Disorders

  • General Risk Factors

    • Prematurity; chronic illnesses (e.g., diabetes, sickle cell anemia, congenital heart disease).

    • Developmental disorders such as cerebral palsy.

    • Passive exposure to cigarette smoke.

    • Immune deficiencies.

    • Socioeconomic factors, including crowded living conditions.

    • Attendance in daycare facilities.

  • Specific Risk Factors for Tuberculosis

    • HIV infection; incarceration; recent history of latent TB infection.

    • Immigration to endemic countries; exposure to vulnerable populations.

Pneumothorax

Risk Factors

  • Chest trauma or surgical history.

  • Intubation and mechanical ventilation assistance.

  • History of chronic lung diseases (e.g., cystic fibrosis).

Signs and Symptoms

  • Chest pain; signs of respiratory distress such as tachypnea, retractions, nasal flaring, and grunting.

Acute Infectious Disorders

  • Conditions include common cold, sinusitis, influenza, pharyngitis, tonsillitis, laryngitis, croup syndromes, RSV, pneumonia, and bronchitis.

Bronchiolitis (RSV) Symptoms

  • Onset may include:

    • Clear runny nose; pharyngitis; low-grade fever.

    • Development of cough within 1 to 3 days, progressing to wheeze and sign of poor feeding.

Pharyngitis

Symptoms

  • Associated with Streptococcus A infection include:

    • Petechiae on palate; fine, red, sandpaper-like rash; strawberry tongue.

Diagnosis

  • Utilizes rapid identification tests and throat cultures.

Nursing Care

  • Supportive measures focused on parent education, including:

    • Medication administration: Ensure full antibiotic dosage.

    • Fluid intake to prevent dehydration.

Tonsillitis

Description

  • Inflammation of the tonsils located in the pharynx.

Symptoms

  • Acute tonsillitis characterized by: fever, chills, foul breath, dry throat.

  • Other symptoms include dysphagia, referred otalgia, headache, malaise, and enlarged cervical nodes.

Diagnosis

  • Based on clinical presentation and throat inspection.

Nursing Care

  • Strategies to maintain hydration and comfort, including humidifiers, saline gargles, throat lozenges, and providing a soft diet.

  • Tonsillectomy may be indicated for recurrent cases.

Post-Operative Care for Tonsillectomy

Monitoring for Complications

  • Important to observe for:

    • Excessive swallowing; elevated heart rate with decreasing blood pressure.

    • Signs of fresh bleeding in the throat; vomiting bright red blood; restlessness not due to pain.

Education/Discharge Instructions

  • Avoid highly seasoned or “sharp” foods for 2 weeks.

  • Awareness of scab dislodgment timing (approximately 8-12 days post-surgery).

  • Guidelines against coughing or throat-clearing behaviors.

  • Limit activities that could provoke bleeding.

Croup

Overview

  • Croup is a term for various illnesses affecting the larynx, trachea, and bronchi characterized by inflammation and swelling.

Signs and Symptoms

  • Occurs predominantly in viral infections, with severe symptoms including:

    • Barky cough, sore throat, inspiratory stridor, hoarseness, use of accessory muscles, agitation, and signs of respiratory distress.

Nursing Care

  • Important to avoid visualizing the throat due to risk of laryngospasm.

  • Focus on maintaining airway, rest, humidity, fluid balance, and administering prescribed medications.

Epiglottitis

Signs and Symptoms

  • Cardinal signs include: drooling, dysphagia, and dysphonia, with evident respiratory distress.

Nursing Considerations

  • Safety precautions against airway obstruction, including having immediate access to emergency tracheostomy equipment.

Chronic Respiratory Disorders

Disorders Include

  • Allergic rhinitis, asthma, chronic lung disease (e.g., bronchopulmonary dysplasia), cystic fibrosis, and apnea.

Asthma Overview

Definition

  • Chronic inflammatory airway disorder leading to airway hyperresponsiveness, edema, and mucus production, potentially causing obstructive airflow problems.

Symptoms Include

  • Wheezing; cough, especially at night or early morning; increased respiratory rate; retractions; and nasal flaring.

Asthma Triggers

  • Irritants: smoke, cold air, air pollution, strong odors, respiratory infections, exercise, stress.

  • Allergens: mold, pollen, pet dander, dust mites, cockroaches.

Symptoms Indicating Emergency

  • Worsening respiratory symptoms or color changes requiring immediate treatment.

Asthma Management

  • Tiered Treatment Approach:

    • Rescue medication: Short-acting bronchodilators.

    • Maintenance medications: Include leukotriene modifiers, inhaled corticosteroids, and long-acting bronchodilators.

Asthma Action Plan

  • Clear instructions depending on symptom severity:

    • Green Zone: No symptoms; maintain medications.

    • Yellow Zone: Caution; adjust medications as per action plan if symptoms worsen.

    • Red Zone: Alert; seek emergency help immediately if experiencing severe symptoms.

Educational Aspects

  • Importance of medication adherence, recognizing triggers, and treatment management.

Cystic Fibrosis

Overview

  • Autosomal recessive disorder due to mutations in CFTR, leading to thick mucus production affecting the lungs and pancreas.

Diagnosis

  • Based on clinical evaluation and specific tests such as positive sweat tests, genetic testing, or nasal potential differences.

Treatment Strategies

  • Include chest physiotherapy, inhaled antibiotics, pancreatic enzyme supplementation, and a high-calorie, nutrient-rich diet.

Nursing Management Implications

  • Promote child self-esteem and coping strategies; ensure culturally sensitive education on disease management.

Conclusion

  • Effective nursing care for children with respiratory disorders relies on a thorough understanding of anatomy, pathophysiology, assessment techniques, treatment modalities, and family education to manage health conditions successfully and enhance quality of life.