Respiratory Dysfunction

General aspects of respiratory infections

• upper respiratory tract

  • Oronasopharynx, pharynx, larynx, and trachea

  • Lower respiratory tract

  • Bronchi, bronchioles, and alveoli

  • Croup syndromes

  • Infections of epiglottis, larynx

• Infectious Agents

  • Viruses

    • RSV

    • parainfluenza

  • Others

    • Group A ß-hemolytic streptococcus

    • Staphylococci

    • Chlamydia trachomatis, mycoplasma, pneumococci

    • Haemophilus influenzae

• Age

  • Infants <6 months: maternal antibodies

  • 3-6 months: infection rate increases

  • Toddler and preschool ages: high rate of viral infection

  • >5 yrs: increase in mycoplasma pneumonia and ß-strep infections

  • Increased immunity with age

• Size differences in children

  • Diameter of airways

  • Distance between structures is shorter, allowing organisms to rapidly move down

  • Short Eustachian tubes

Differences in adults and pediatric airways

• Give description, detailed, easy to study

Seasonal variations

• Most common during winter and spring

• Mycoplasmal infections more common in fall and winter

• Asthmatic bronchitis more frequent in cold weather

• RSV season considered winter and spring

• Clinical manifestations

  • Vary with age

  • Generalized signs and symptoms and local manifestations differ in young children

  • Fever

    • Absent in newborns, peak 3 months to 3 years

  • Anorexia, vomiting, diarrhea, abdominal pain

  • Cough, sore throat, nasal blockage or discharge

  • Respiratory sounds (explain and examples)

  • Nasal flaring

  • Color changes

  • Chest pain

  • Restlessness, irritability, unexplained sudden confusion

  • ↑HR & RR

  • clubbing

  • Retractions—location significant

    • Suprasternal

    • Clavicular

    • Intercostal

    • Substernal

    • Subcoastal

• Nursing considerations

  • Assessment

  • Nursing diagnosis

  • PlanninG

  • Implementation

  • Evaluation

Assessment guideline for child in respiratory distress

• Quality of respirations

• Quality of pulse

• Color

• Cough

• Behavior change

• Signs of dehydration

• *Be alert! Children can crash quickly!!

• Nursing interventions

  • Ease respiratory effort

  • Fever management

  • Promote rest and comfort

  • Infection control

  • Promote hydration and nutrition

  • Family support and teaching

  • Prevent spread of infection

  • Provide support and plan for home care

Upper respiratory tract infections (URI)

• Nasopharyngitis—“common cold”

• Caused by numerous viruses

  • RSV, rhinovirus, adenovirus, influenza and parainfluenza viruses

  • Clinical manifestations

    • fever—varies with child irritability, restlessness decreased appetite and fluid intake nasal inflammation vomiting and diarrhea

  • Home management—varies with age

• Pharmacological tx for URI

  • OTC pediatric cold remedies are NOTrecommended for treating “common cold”

  • Antihistamines ineffective in most cases

  • Antipyretics for comfort from fever

  • Cough suppressants for dry cough (caution alcohol content

  • Decongestant to shrink swollen nasal passages (nose drops more effective than oral administration

Acute streptococcal pharyngitis

• GABHS infection of upper airway

• At risk for sequelae

  • Acute rheumatic heart fever

  • Acute glomerulonephritis

• Clinical manifestations

• Diagnostics: rapid strep test and/or throat culture

• Therapeutic management

• Nursing considerations

• Pharmacological interventions - strep

  • Penicillin

    • Oral

    • Needs 10 day treatment to decrease risk of rheumatic fever and glomerulonephritis post strep

    • Issues with medication compliance

  • IM: Penicillin G Resolves compliance issue (one injection)

    • Painful injection

    • Penicillin G Procaine is less painful injection

    • CANNOT give Penicillin G by IV route

  • Erythromycin if penicillin allergy

Tonsillitis

• Pathophysiology and etiology

• Clinical manifestations

  • Tonsilar edemaobstructs passage of air and food

  • Difficulty swallowing & breathing

  • If adenoids swollen, blocks post. nares mouth breather

• Therapeutic management

  • Remove if ≥3 infections/year despite appropriate tx

• Nursing considerations

  • General

  • postop

• Nursing concerns

  • Airway

  • Positioning

  • Bleeding

  • Observation—frequent swallowing?

  • Prevention of recurrent bleeding

  • Maintain quiet environment

  • Minimize agitation/crying

  • NO suctioning

  • Comfort

Influenza = “flu”

• 3 types: A, B, C

• Spread by direct contact or by articles contaminated with NP secretions

• More common in winter

• People are infectious 24 hrs before and after onset of symptoms

• Meds: Zanamivir (A & B) & Rimantadine (A)

• Pharmacological intervention for influenza in children

  • Antivirals for children

  • Oseltamivir (Tamiflu)

  • Zanamivir (RELENZA)

  • Must start within 48 hrs of symptom onset

  • Avoid aspirin—possible link with Reye syndrome

Otitis Media (OM) - Ear infection

• Pathophysiology and etiology

• Diagnostics

• Therapeutic management

  • Pharmacologic

    • Not for initial tx; wait 72 hrs in uncomplicated OM

  • Surgical: M & T

• Nursing considerations

  • Pain relief, facilitate drainage, prevent complications & recurrence, educate family, emotional support

• Prevention of recurrence

• Acute otitis media is characterized by abrupt onset, pain, middle ear effusion, and inflammation. Note the injected vessels and altered shape of cone of light.

• Otitis media with effusion is noted on otoscopy by fluid line or air bubbles. Pneumatic otoscopy or tympanometry shows a nonmobile tympanic membrane. Note that the light reflex is not in the expected position due to a change in tympanic membrane shape from air bubbles.

• Otitis Media—Antibiotic Therapy?

  • If over age 6 months—”watchful waiting” up to 72 hours for spontaneous resolution

  • Antibiotics if <2 years with persistent acute symptoms of fever and severe ear pain

  • Antibiotics if <6 months

  • Topical relief—heat or cold or benzocaine drops (Rx)

• Pharmacologic interventions

  • First line antibiotics

    • Amoxicillin PO divided twice daily x 10days

  • Second-line antibiotics

    • Amoxicilliln-clavulanate (Augmentin),

      • Azithromycin

        • Cephalosporins IM—if highly resistant organism or noncompliant with oral doses

  • Analgesic-antipyretic drugs

    • Acetaminophen

    • Ibuprofen (only if >6 months of age

  • No steroids, antihistamines, decongestants, antibiotic ear drops

Croup Syndrome

• Characterized by hoarseness, “barking” cough, inspiratory stridor, and varying degrees of respiratory distress

• Croup syndromes affect larynx, trachea, and bronchi

• Epiglottitis, laryngitis, laryngotracheobronchitis (LTB), tracheitis

Acute epiglottitis - a medical emergency

• Clinical manifestations

  • Sore throat, pain, tripod positioning, retractions

  • Inspiratory stridor, mild hypoxia, distress, drooling, no spontaneous cough

• Therapeutic management

  • Potential for respiratory obstruction

• Nursing considerations

• Never examine throat without emergency equipment handy

• Prevention: Hib vaccine

Signs of increasing respiratory distress in children

• RESTLESSNESS

• Tachycardia

• Tachypnea

• Retractions

  • Substernal

  • Suprasternal

  • Intracostal

Acute LTB

• LTB = Laryngotracheobronchitis

• Most common of the croup syndromes

• Generally affects children <5 yrs

• Organisms responsible

  • RSV, parainfluenza virus, Mycoplasma pneumoniae, influenza A and B

• Manifestations

  • Inspiratory stridor

  • Suprasternal retractions

  • Barking or “seal-like” cough

  • Increasing respiratory distress and hypoxia

  • Can progress to respiratory acidosis, respiratory failure and death

• Therapeutic management

  • Airway management

  • Maintain hydration—PO or IV

  • High humidity with cool mist

  • Nebulizer treatments

    • Epinephrine

    • Steroids

Acute Spasmodic Laryngitis

• AKA spasmodic croup, midnight croup

• Paroxysmal attacks of laryngeal obstruction; viral

• Occur chiefly at night

• Inflammation: mild or absent

• Most often affects children ages 1-3

• Therapeutic management

Bacterial tracheitis

• Infection of the mucosa of the upper trachea

• Distinct entity with features of croup and epiglottitis

• Clinical manifestations similar to LTB

• May be complication of LTB

• Thick, purulent secretions result in respiratory distress

• Therapeutic management

  • Humidified oxygen

  • Antipyretics

  • Antibiotics

  • May require intubation—be prepared for respiratory failure

• Infections of the lower airways

  • Considered the “reactive” portion of the lower respiratory tract

  • Includes bronchi and bronchioles

  • Cartilaginous support not fully developed until adolescence

  • Constriction of airways

Bronchitis

• AKA tracheobronchitis

• Definitions

• Causative agents

  • Clinical manifestations: persistent dry, hacking cough becoming productive in 2-3 days, tachypnea, low-grade fever

• Supportive care

Bronchiolitis

• Begins as URI with serous nasal drainage

• Mild fever, gradually develops into resp. illness, dyspnea, paroxysmal non- productive cough, tachypnea, nasal flaring, retractions, wheezing

• Maybe caused by many viral agents, but RSV is primary agent seen in 80% of cases

RSV - respiratory syncytial virus

• Transmission through direct contact with secretions, can live hours on surfaces

• Pathophysiology: bronchiole mucosa swell and fills with mucous → obstruction

• Therapeutic management: supportive

• Prevention of RSV—RSV immune globulin to at risk infants

• Nursing considerations

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS- CoV-2): COVID-19

• Coronavirus

• Clinical Manifestations

• Diagnostic Evaluation

• Therapeutic Management

• COVID-19 vaccination

• Nursing Care Management

Multisystem Inflammatory Syndrome in Children (MIS -C)

• Post COVID syndrome

  • Hyper- inflammatory syndrome

• Clinical Manifestations

• Prognosis

PNEUMONIA

• Lobar pneumonia

• Bronchopneumonia

• Interstitial pneumonia

• Pneumonitis

• Etiology of Pneumonias

  • Bacterial Or Viral

  • Aspiration

  • Histomycosis, coccidiomycosis, other fungi

  • “Atypical pneumonias”-

  • Mycoplasma

  • May be asymptomatic or cause several symptoms

• Etiology and epidemiology

• Clinical manifestations

  • Fever, malaise, rapid respiration, and cough

  • Chest or abdomen pain, nausea

• Diagnostic evaluation

• Therapeutic management

  • Prevention: PCV vaccine

  • Therapies

  • Complications

• Nursing care management

Foreign body aspiration

• Risk for child with feeding difficulties

• Prevention of aspiration

• Feeding techniques, positioning

• Avoid aspiration risks

  • Oily nose drops

  • Solvents

  • Talcum powder

Inhalation injury: smoke and carbon monoxide

• Severity depends on nature of substance, environment, and duration of contact

• Local injury

• Systemic injury

• Therapeutic management

• Nursing considerations

Passive smoking

• Scope of the problem

• Impact on children

• Nursing considerations

Asthma

• Chronic inflammatory disorder of airways

• 60-80% caused by allergens

• Some genetic predisposition

• Inflammation causes bronchial hyper- responsiveness to variety of stimuli

• Episodic-wheezing, breathlessness, chest tightness, and cough

• Limited airflow or obstruction that reverses spontaneously or with treatment

• Risk factors of asthma

  • Age

  • Atopy

  • Heredity

  • Gender

  • Mother <age 20 years

  • Smoking (maternal and grandmaternal)

  • Ethnicity (African Americans at greatest risk)

  • Previous life-threatening attacks

  • Lack of access to medical care

  • Psychologic and psychosocial problems

• Pathophysiology

  • Bronchospasm and obstruction from:

    • edema and inflammation of mucous membranes

    • Tenacious secretions

    • Spasm of smooth muscle of bronchi & bronchioles

    • Leads to ↓caliber of airways and child

• Triggers

  • Allergy

  • Irritants

  • Exercise

  • Cold air

  • Changes in weather

  • Medications

  • Emotions

  • Medical conditions

  • Food additives

  • Foods

  • Endocrine factors

• Diagnosis

  • Based on clinical manifestations, history, PE, lab tests

• Asthma management

  • To prevent disability, minimize physical and psychological morbidity, and assist in leading a “normal” life

  • Allergen control

  • Stepwise approach

    • Long-term control medications (prevent)

    • Quick-relief medications (rescue)

• Common medications in asthma

  • Rescue medications

    • B-adrenergic

      • Albuterol

      • Metaproterenol

      • Terbutaline

      • Xopenex

        • Metabolite of albuterol with less side effects, nebulized only, q 6 hours, expensive

  • Controller medications

    • Corticosteroid

      • Oral or inhaled

    • Cromolyn

      • Inhaled NSAID

    • Leukotriene modifier

      • Singulair

      • Accolate

      • Zyflo

• Rarely used medications

  • Methylxanthines

    • Theophylline

  • Toxicity

    • Must check serum levels

  • Can be given IM, IV, PO

  • Anticholinergics

    • Atropine

• Asthma Severity Classification in Children 5 yrs and Older

  • Step I: mild, intermittent asthma

  • Step II: mild, persistent asthma

  • Step III or IV: moderate, persistent asthma

  • Daily symptoms 3-4 times a month

  • Step V or VI: severe, persistent asthm

  • Continual symptoms throughout the day

  • Frequent nighttime symptoms

  • Clinical features of each classification

• Mild intermittent - step 1

  • Symptoms: ≤ 2 days/week and ≤ 2 nights/month

  • No daily medication

  • Albuterol prn symptoms

    • Nebulizer

    • MDI with spacer

• Mild Persistent-step 2: sx >2/week, but < 1x/day; > 2 night/month

  • Daily anti-inflammatory (low-dose)

  • Leukotriene OR

  • Nebulizer

    • Pulmicort

    • Cromolyn

  • MDI

    • Pulmicort

    • Flovent

    • Others

  • Rescue as needed

• Moderate Persistent-step 3 or 4

  • Symptoms daily & > 1 night/week

  • Daily anti-inflammatory (medium dose)

    • Nebulizer

    • MDI

  • Long-acting bronchodilator

  • Serevent

  • Rescue as needed

• Severe Persistent-step 5 or 6

  • Symptoms continual during day and frequent at night

  • Anti-inflammatory (high-dose)

    • Nebulizer

    • MDI

  • Long-acting bronchodilator

  • Oral steroids

• Asthma interventions

  • Exercise

  • Exercised induced asthma-use short- acting bronchodilators (2-3 hours) and long-term bronchodilators (10-12 hours)

  • Hyposensitization

  • Prognosis

• Other management musts

  • Peak expiratory flow monitoring used daily

    • Has 3 zones like stop light

    • Establish child’s best and uses to compare at later times

  • Written Action Plan

• Signs of SEVERE Respiratory Distress in Children with Asthma

  • Remains sitting upright, refuses to lie down

  • Sudden agitation

  • Agitated child who suddenly becomes quiet

  • Diaphoresis

  • Pale

• Status asthmaticus

  • Respiratory distress continues despite vigorous therapeutic measures

  • Emergency treatment—epinephrine 0.01 mL/kg SQ (max dose 0.3 mL)

  • IV magnesium sulfate

  • IV ketamine

  • IV corticosteroids

  • Concurrent infection in some cases

  • Therapeutic intervention

• Goals of asthma management

  • 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 (CF)

• Avoid exacerbation

• Avoid allergens

• Relieve asthmatic episodes promptly

• Relieve bronchospasm

• Monitor function with peak flow meter

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

• Pathophysiology of CF

  • Characterized by several unrelated clinical features

  • Respiratory system

  • GI system

  • small intestine, pancreas, bile ducts

  • Growth patterns

  • Reproductive system & skin

  • Pulmonary complications

  • Increased viscosity of mucous gland secretion

  • Results in mechanical obstruction

  • Thick, inspissated mucoprotein accumulates, dilates, precipitates, coagulates to form concretions in glands & ducts

  • Respiratory tract & pancreas are predominantly affected

  • EFFECTS OF EXOCRINE GLAND IN CF: (dumb it down and simplify)

  • Increased Viscosity of Mucous Gland Secretion

  • Results in mechanical obstruction

  • Thick mucoprotein accumulates, dilates, precipitates, coagulates to form concretions in glands and ducts

  • Respiratory tract and pancreas are predominately affected

  • Increased sweat electrolytes

    • Basis of the most reliable diagnostic procedure—sweat chloride test

    • Sodium and chloride will be 2-5 times greater than the controls

• Respiratory manifestations

  • Present in almost all CF patients but onset/extent is variable

  • Stagnation of mucus and bacterial colonization result in destruction of lung tissue

  • Tenacious secretions are difficult to expectorate-obstruct

  • Decreased O2/CO2 exchange

  • Results in hypoxia, hypercapnea, acidosis

  • Air gets trapped in small airways → atelectasis

  • Hyperaeration of alveoli → barrel chest, cyanosis, clubbing

• Respiratory progression

  • Gradual progression follows chronic infection

  • Bronchial epithelium is destroyed when chronically weakened → pulmonary disease

  • Infection spreads to peribronchial tissues weakening bronchial walls

  • Peribronchial fibrosis

  • Decreased O2/CO2 exchange

• Further respiratory progression

  • Chronic hypoxemia causes contraction/hypertrophy of muscle fibers in pulmonary arteries/arterioles

  • Compression of pulmonary blood vessels and progressive lung dysfunction lead to pulmonary hypertension, cor pulmonale, respiratory failure, and death

  • Pneumothorax

  • Hemoptysis

• GI tract

  • Thick secretions block ducts—cystic dilation — degeneration — diffuse fibrosis

  • Prevents pancreatic enzymes from reaching duodenum

  • Impaired digestion/absorption of fat- steatorrhea

  • Impaired digestion/absorption of protein- azotorrhea

  • 4 F’s of stools: frothy, foul-smelling, fat-containing, float

• Endocrine function of pancreas initially stays unchanged

• Eventually pancreatic fibrosis occurs; may result in diabetes mellitus

• Focal biliary obstruction results in multilobular biliary cirrhosis

• Failure to thrive

• Increased weight loss despite increased appetite

• Clinical manifestations of CF

  • Pancreatic enzyme deficiency

  • Progressive COPD associated with infection

  • Sweat gland dysfunction

  • Failure to thrive

  • Increased weight loss despite increased appetite

  • Gradual respiratory deterioration

• Presentation

  • Wheezing respiration, dry nonproductive cough

  • Generalized obstructive emphysema

  • Patchy atelectasis

  • Cyanosis

  • Clubbing of fingers and toes

  • Repeated bronchitis and pneumonia

  • Meconium ileus

  • Distal intestinal obstruction syndrome

  • Excretion of undigested food in stool — increased bulk, frothy, and foul

  • Wasting of tissues

  • Prolapse of the rectum

  • Delayed puberty in females

  • Sterility in males

  • Parents report children taste “salty”

  • Dehydration

  • Hyponatremic/hypochloremic alkalosis

• Infectious agents for cf patients

  • Pseudomonas aeruginosa

  • Burkholderia cepacia

  • Staphylococcus aureus

  • Haemophilus influenzae

  • Escherichia coli

  • Klebsiella pneumoniae

• DIAGNOSTIC Evaluation

  • Quantitative sweat chloride test

  • Chest x-ray

  • PFT

  • Stool fat and/or enzyme analysis

  • Barium enema

  • 3 Major Presentations of DX:

    • Meconium ileus, FTT or malabsorption, chronic RESPIRATORY INFECTION

• GOALS

  • Prevent/minimize pulmonary complications

     Adequate nutrition for growth

     Assist in adapting to chronic illness

• Respiratory management

  • CPT: ThAIRapy vest

    • Medications

      • Bronchodilators

      • Pulmozyme (DNase)

      • Antibiotics

      • oxygen

    • Forced expiration

    • Burkholderia cepacia issues

    • Lung transplant

• GI management

  • Replacement of pancreatic enzymes

  • High protein high calorie diet as much as 150% RDA

  • Intestinal obstruction

  • Reduction of rectal prolapse

  • Salt supplementation

  • Oral glucose-lowering agents or insulin injections as needed

  • Replace fat soluble vitamins

• Prognosis of CF

  • Decreased life expectancy for child born with CF

  • Maximize health potential

    • Nutrition

    • Prevention/early aggressive treatment of infection

    • Pulmonary hygiene

  • New research → hope for the future

    • Transplantation

    • Gene therapy

    • Bilateral lung transplants

    • Improved pharmacologic agents

• Family support

  • Coping with emotional needs of child and family

  • Child requires treatments multiple times/ day

  • Frequent hospitalization

  • Implications of genetic transmission of disease

Cardiopulmonary resuscitation (CPR)

• Pediatric cardiac arrest frequently represents the terminal event following respiratory failure or progressive shock

• Pediatric cardiac arrest rarely results from sudden cardiac collapse, as in adult populations

• Why chain of survival is different

• Causes of cardiac arrest

  • Vary with age and underlying chronic medical conditions

  • Out of hospital causes include: trauma, SIDS, poisoning, choking, severe asthma attack, drowning

  • In-hospital causes typically due to underlying condition

• Standard care

  • CPR

  • Pediatric advanced life support (PALS)