Respiratory

Alterations in Respiratory Function

Respiratory Assessment

• Airway Components

  • Upper airway:

  • Comprises the nasopharynx and oropharynx, and the epiglottis.

  • Acts as a pathway for gas exchange and allows for ventilation.

  • Lower airway:

  • Facilitates oxygenation and gas exchange.

  • Includes bronchi, bronchioles, alveoli, and lungs.

  • Trachea is part of this airway.

Pediatric Upper Airway Variations

• Characteristics:

  • Shorter and narrower than adults.

  • Smaller oral cavities with larger tongues.

  • Longer, floppy epiglottises.

  • Larynx and glottis positioned higher in the neck.

  • More flexible cartilage in the neck.

  • Result: Increased airway resistance. Increases risk of obstruction if they are tired or during episodes of illness, particularly when the muscles relax further and the airway collapses more easily.

Pediatric Lower Airway Variations

• Features:

  • Mainstem bronchi separate at a higher level (T3 in infants vs. T6 in adults).

  • Children have fewer and immature alveoli.

  • Bronchioles are narrower.

  • Diaphragm is responsible for inspiration in children under 6.

  • Overall smaller lung volume.

  • Intercostal muscles are immature until they are 6 years old, which can affect the efficiency of their breathing and overall respiratory function.

Summary of Pediatric and Adult Airway Differences

Respiratory Assessment

• Key Components to Assess:

  • Respirations: Rate and rhythm, depth and symmetry, effort.

  • Cough: Analyze characteristics, effort, and timing.

  • Color: Note location and shade, the effect of crying, presence of cyanosis.

  • Pain: Consider location, origin, and severity.

Additional Observations

• Adventitious sounds:

  • Wheeze, Stridor, Crackles.

• Odors:

  • Breath and mucus odor analysis.

• Mucus:

  • Assess color and consistency.

• Positioning:

  • Note comfort and the effect of position on dyspnea.

Normal Respiratory Rates for Pediatric Age Groups

Respiratory Distress

• Compensatory Mechanisms:

  • Grunting (to keep alveoli open).

  • Retractions (to assist with ventilation).

  • Head bobbing (to assist ventilation).

  • Nasal flaring (to increase diameter of air passages).

  • Hyperextension of the head and neck (to open the airway).

• Common Signs:

  • Restlessness, Tachycardia, Tachypnea, Diaphoresis.

• Respiratory distress can lead to cardiac arrest if not addressed promptly, necessitating immediate medical intervention and possibly advanced airway management.

Respiratory Failure

• Definitions and Indicators:

  • Occurs suddenly when compensatory mechanisms fail, leading to potential respiratory arrest if untreated.

  • Preceded by hypoventilation in alveoli.

• Symptoms:

  • Cyanosis or gray color.

  • Tachypnea followed by bradypnea.

  • Severe retractions, apnea, altered mental status.

  • Extreme tachycardia followed by bradycardia.

  • Inability to maintain oxygen level.

  • Acidotic pH.

Comparing Respiratory Distress and Respiratory Failure

Oxygenation

• Breathing in Newborns:

  • Newborns are habitual nose breathers with mouth breathing beginning at 3-4 months of age.

  • Use nasal cannula due to the exclusive nasal breathing.

• Methods of Oxygen Delivery:

  • Device selection should be appropriate based on age, situation, and required flow rate.

  • Monitor O2 saturation while administering supplemental oxygen.

  • Strategies to increase oxygenation include patient positioning.

  • Various devices:

  • Nasal Cannula: 24%-35% oxygen, flow rate 0.25-6 L/min.

  • Simple Oxygen Mask: 35%-50% oxygen, flow rate 5-10 L/min.

  • Non-rebreather Mask: 70%-100% oxygen, flow rate 10-15 L/min.

  • Bilevel Positive Airway Pressure (BiPAP), Continuous Positive Airway Pressure (CPAP), or ventilator are needed if positive airway pressure is required.

Respiratory Disorders

Croup Disorders

• Laryngotracheobronchitis (LTB):

  • Most prevalent croup disorder; typically seen in children aged 6 months to 6 years.

  • Caused by viral infection in upper airway.

  • Gradual onset with slow progression.

  • Signs include a brassy cough (seal barking), dyspnea, stridor, and low-grade fever.

  • Treatment includes steroids - inflammation, fluids - dehydration, and racemic epinephrine - help with upper airway breathing.

  • Assess respiratory rate, SpO2, auscultate breath sounds, and monitor for any changes in respiratory distress or wheezing.

• Spasmodic Laryngitis:

  • Affects children aged 3 months to 3 years.

  • Sudden onset often occurring at night, with unknown cause (likely viral).

  • Symptoms: barking cough, afebrile, and mild respiratory distress, often self-limiting.

  • Treatment involves administering cool mist.

Epiglottitis

• Description:

  • Inflammation and swelling of the epiglottis, constitutes a medical emergency due to risk of airway constriction.

  • Typically, a bacterial infection with rapid onset.

  • Airway obstruction can occur within 2 to 6 hours post-onset.

• Clinical Presentation:

  • Toxic appearance, tripod positioning, drooling, stridor or characteristic croaking sound, high fever, cherry-red epiglottis, and may show the "steeple sign" on X-ray.

• Treatment:

  • Keep the patient calm to avoid anxiety and crying. The patient will be anxious about their condition , so it is crucial to provide reassurance and maintain a calm environment.

  • Immediate intubation (endotracheal tube) for airway clearance.

  • Administration of antibiotics.

Tracheitis

• Nature:

  • Commonly bacterial and more prevalent in fall and winter seasons, with higher incidence in males.

• Symptoms:

  • Signs of a toxic appearance, croupy cough, dysphonia, hoarseness, high fever without drooling, and stridor that doesn't improve with repositioning.

  • Presence of thick, purulent secretions.

• Treatment:

  • Administer antibiotics and fluids for rehydration, maintaining patent airway and oxygenation, and use of mucolytics as needed.

Pneumonia

• Definition:

  • Infection or inflammation affecting the lower airways, can be bacterial or viral, and may be community or hospital-acquired.

• Clinical Presentation:

  • Symptoms include fever, cough, tachypnea, nausea, vomiting, irritability, and lethargy.

• Treatment:

  • Mostly supportive and symptomatic management, monitoring for respiratory distress, encouraging coughing and deep breathing, administering antibiotics if bacterial, and ensuring adequate hydration.

Respiratory Syncytial Virus (RSV) Bronchiolitis and Bronchitis

• Bronchiolitis:

  • Caused by RSV; leads to cell death in bronchioles resulting in obstruction.

  • Symptoms include mild cough, rhinorrhea, and congestion, worsening after two days.

  • Treatment is symptomatic and self-limiting; palivizumab is available for high-risk infants.

  • Most greatest risk for kids under 2 years old and smaller airways which makes it easier for obstruction

• Bronchitis:

  • Inflammation of the trachea, bronchi, and bronchioles that can have viral causes or result from allergens/irritants.

  • Symptoms include coarse barking cough, chest pain, thick sputum, self-limiting with symptomatic treatment (humidification).

Pediatric Acute Respiratory Distress Syndrome (ARDS)

• Characteristics:

  • Acute, diffuse, and inflammatory lung injury leading to hypoxemia and non-compliant lungs.

  • Can occur from direct or indirect injury with bilaterally opaque findings on chest X-ray.

• Supportive Care:

  • Intensive care support including intubation, positive pressure mechanical ventilation, antibiotics, diuretics, vasodilators, decreasing pulmonary vascular resistance, and gastric ulcer prophylaxis (due to extra stress from condition).

Foreign Body Aspiration

• Overview:

  • Involves inhalation of an object, commonly food, into the respiratory tract.

• Manifestations:

  • Symptoms can include cough, dyspnea, stridor, and hoarseness with signs of severe respiratory distress.

• Management:

  • Foreign body removal through back blows, chest thrusts, bronchoscopy, or surgical intervention; prevention involves anticipatory guidance.

Pneumothorax

• Definition:

  • Refers to an accumulation of air in the pleural space, which may occur spontaneously, via trauma, or as tension pneumothorax.

• Manifestations:

  • Symptoms include tachypnea, dyspnea, respiratory distress, hypoxemia, and tracheal deviation.

• Treatment:

  • Chest tube placement, supplemental oxygen, and continuous monitoring of respiratory status. In cases of an open pneumothorax, cover with a gloved hand or dressing. For tension pneumothorax, emergent needle aspiration.

Asthma

• Overview:

  • Most prevalent chronic health condition in children characterized by chronic inflammation of the airways, intermittent bronchoconstriction, increased mucus production, and potential airway remodeling.

• Diagnosis:

  • Confirmed through pulmonary function testing.

• Treatment:

  • Utilize medications, control triggers, provide education; common triggers consist of pollen, mold, pet dander, tobacco smoke, exercise, anxiety, and dust mites.

• Management Approach:

  • A step-wise approach that includes interventions based on peak-flow meter results, developing asthma action plans.

Asthma Therapeutic Interventions

• Types:

  • Inhaled medications, corticosteroids, and oxygenation when required.

• Support Measures:

  • Ensure adequate hydration and nutrition alongside emotional and psychosocial support, compliance with medications, and avoidance of triggers.

• Patient Education:

  • Engage both patient and caregiver in understanding asthma management.

Cystic Fibrosis

• Overview:

  • An autosomal recessive genetic disorder leading to abnormalities in the body’s salt, water, and mucus-making cells. Carriers may be asymptomatic.

• Diagnosis:

  • Conducted through Sweat Chloride Testing which requires hydration of the child and stimulation of sweat production using electrical current. A positive result is indicated by a chloride level >40 mEq/L for infants <3 months and >60 mEq/L for others.

Cystic Fibrosis Manifestations

• Respiratory Symptoms:

  • Accumulation of mucus increases the risk of respiratory infections, symptoms include wheezing, rhonchi, dry cough, dyspnea, paroxysmal cough, obstructive emphysema, and atelectasis.

• Gastrointestinal Symptoms:

  • Steatorrhea, failure to thrive, deficiency in Vitamins A, D, E, and K.

• Integumentary Symptoms:

  • High sodium and chloride content in sweat, tears, and saliva.

• Endocrine Symptoms:

  • Decreased insulin and pancreatic enzyme production.

Management Strategies for Cystic Fibrosis

• Respiratory Management:

  • Interventions like percussion, drainage, mucolytics, and antibiotics for infections.

• Gastrointestinal and Endocrine Management:

  • Replacement of pancreatic enzymes, provision of high protein, high-calorie, high-fat diets, along with supplements for Vitamins A, D, E, and K.

Bronchopulmonary Dysplasia (BPD)

• Definition:

  • A chronic obstructive pulmonary disease arising from the prolonged use of supplemental oxygen and positive pressure ventilation, particularly following premature birth.

• Characteristics:

  • Reduced surface area for gas exchange, with symptoms including tachypnea, tachycardia, nasal flaring, grunting, retractions, wheezing, crackles, and failure to thrive.

• Treatment Objective:

  • Treatments include positioning, humidified supplemental oxygen, chest physiotherapy, bronchodilators, and suction.

  • Care organization should be clustered to mitigate fluid overload and may require tracheostomy.

COVID-19

• Overview:

  • Clinical manifestations vary from asymptomatic conditions to severe acute respiratory distress syndrome (SARS-CoV-2).

  • Symptoms can be respiratory or gastrointestinal in nature, often long-lasting in some patients, referred to as “Long COVID” (lasting longer than 28 days post-infection).

• Complications:

  • Potential development of pneumonia, Pediatric Acute Respiratory Distress Syndrome (PARDS), and multisystem inflammatory syndrome in children (MIS-C).

• Treatment:

  • Primarily supportive interventions; antiviral agents and monoclonal antibodies may also be utilized.