RESPIRATORY DISORDERS

1. RESPIRATORY DISORDERS AND
INFECTIONS
Presented by:
Navjot Kaur
Asstt. Professor

2. INTRODUCTION
 The age- and growth-dependent changes in
physiology and anatomy of the respiratory
control mechanism, airway dynamics, and
lung parenchymal characteristics have a
profound influence on the pathophysiologic
manifestations of the disease process.
Smaller airways, a more compliant chest wall,
and poor hypoxic drive render a younger
infant more vulnerable compared to an older
child with similar severity of disease.

3. CONTD……
 The main function of the respiratory system
is to supply sufficient oxygen to meet
metabolic demands and remove carbon
dioxide. A variety of processes including
ventilation, perfusion, and diffusion are
involved in tissue oxygenation and carbon
dioxide removal. Abnormalities in any one of
these mechanisms can lead to respiratory
failure.

4. CONTD….
 A child may be identified as being in
respiratory distress because of the
presence of signs such as cyanosis, nasal
flaring, grunting, tachypnea, wheezing,
chest wall retractions, and stridor.
Respiratory failure can be present without
respiratory distress; a patient with
abnormalities of central nervous system
(CNS) or neuromuscular disease may not
be able to mount sufficient effort to appear
in respiratory distress.

5. CONTD……
 A child who appears in respiratory distress
may not have a respiratory illness; a patient
with primary metabolic acidosis (diabetic
ketoacidosis) or central nervous system
excitatory states (encephalitis) may present
in severe respiratory distress without
respiratory disease.

6. PHYSIOLOGY
The nose is responsible for olfaction
and initial warming and humidification
of inspired air. In the anterior nasal
cavity, turbulent airflow and coarse
hairs enhance the deposition of large
particulate matter; the remaining nasal
airways filter out particles as small as
6 μm in diameter.

7. CONTD…..
 In the turbinate region, the airflow becomes
laminar and the airstream is narrowed and
directed superiorly, enhancing particle
deposition, warming, and humidification.
Nasal passages contribute as much as 50%
of the total resistance of normal breathing.
Nasal flaring, a sign of respiratory distress,
reduces the resistance to inspiratory airflow
through the nose and may improve
ventilation.

8. CONTD……
 Although the nasal mucosa is more
vascular, especially in the turbinate region
than in the lower airways, the surface
epithelium is similar, with ciliated cells,
goblet cells, submucosal glands, and a
covering blanket of mucus. The nasal
secretions contain lysozyme and secretory
immunoglobulin A (IgA), both of which have
antimicrobial activity, and IgG, IgE, albumin,
histamine, bacteria, lactoferrin, and cellular
debris, as well as mucous glycoproteins,
which provide viscoelastic properties.

9. CONTD,….
 Aided by the ciliated cells, mucus flows
toward the nasopharynx, where the
airstream widens, the epithelium becomes
squamous, and secretions are wiped away
by swallowing. Replacement of the mucous
layers occurs about every 10–20 min.
Estimates of daily mucus production vary
from 0.1–0.3 mg/kg/24 hr, with most of the
mucus being produced by the submucosal
glands.

10. CONGENITAL DISORDERS.
Congenital structural nasal
malformations are uncommon
compared with acquired abnormalities.
The nasal bones can be congenitally
absent so that the bridge of the nose
fails to develop, resulting in nasal
hypoplasia.

11.  Congenital absence of the nose (arhinia),
complete or partial duplication, or a single
centrally placed nostril can occur in isolation
but is usually part of a malformation
syndrome.

12.  Nasal bones can be sufficiently malformed
to produce severe narrowing of the nasal
passages. Often, such narrowing is
associated with a high and narrow hard
palate. Children with these defects may
have significant obstruction to airflow during
infections of the upper airways and are
more susceptible to the development of
chronic or recurrent hypoventilation.

13. Rarely, the alae nasi are sufficiently
thin and poorly supported to result in
inspiratory obstruction, or there may
be congenital nasolacrimal duct
obstruction with cystic extension into
the nasopharynx, causing respiratory
distress.

14. CHOANAL ATRESIA
 This is the most common congenital
anomaly of the nose and has a frequency of
≈1/7,000 live births. It consists of a unilateral
or bilateral bony (90%) or membranous
(10%) septum between the nose and the
pharynx; most cases are a combination of
bony and membranous atresia. Nearly 50%
of affected infants have other congenital
anomalies, with the anomalies occurring
more frequently in bilateral cases.

15. CLINICAL MANIFESTATIONS
 Newborn infants have a variable ability to
breathe through their mouths, so nasal
obstruction does not produce the same
symptoms in every infant. When the
obstruction is unilateral, the infant may be
asymptomatic for a prolonged period, often
until the 1st respiratory infection, when
unilateral nasal discharge or persistent
nasal obstruction may suggest the
diagnosis.

16. CONTD…..
 Infants with bilateral choanal atresia who
have difficulty with mouth breathing make
vigorous attempts to inspire, often suck in
their lips, and develop cyanosis. Distressed
children then cry (which relieves the
cyanosis) and become calmer, with normal
skin color, only to repeat the cycle after
closing their mouths. Those who are able to
breathe through their mouths at once
experience difficulty when sucking and
swallowing, becoming cyanotic when they
attempt to feed.

17. DIAGNOSIS
 This is established by the inability to pass a
firm catheter through each nostril 3–4 cm
into the nasopharynx. The atretic plate may
be seen directly with fiberoptic rhinoscopy.
The anatomy is best evaluated by using
high-resolution CT

18. TREATMENT
 Initial treatment consists of prompt
placement of an oral airway, maintaining the
mouth in an open position, or intubation. A
standard oral airway (such as that used in
anesthesia) can be used, or a feeding
nipple can be fashioned with large holes at
the tip to facilitate air passage. Once an oral
airway is established, the infant can be fed
by gavage until breathing and eating without
the assisted airway is possible.

19. CONTD…..
 In bilateral cases, intubation or, less often,
tracheotomy may be indicated. If the child is
free of other serious medical problems,
operative intervention is considered in the
neonate; transnasal repair is the treatment
of choice with the introduction of small
magnifying endoscopes and smaller
surgical instruments and drills. Stents are
usually left in place for weeks after the
repair to prevent closure or stenosis.

20. CONTD…..
 Tracheotomy should be considered in cases
of bilateral atresia in which the child has
other potentially life-threatening problems
and in whom early surgical repair of the
choanal atresia may not be appropriate or
feasible. Operative correction of unilateral
obstruction may be deferred for several yr.

21. FEEDING PRECAUTIONS
 Infant must be fed with certain pauses to permit
breathing
 Upright position during feeding
 Spoon feeding, dropper or gavage.

22. TRACHEO -
EOSPHAGEAL
FISTULA

23. DEFINITION
 It is a failure of the
esophagus to develop
as a continuous
passage from the
throat to the stomach
resulting in obstruction
of the infants normal
swallowing route.

24. PATHOPHYSIOLOGY
 During the normal embryonic development gut
and respiratory tract originates as a single tube.
 During the 4th and 5th week of gestation this tube
lengthens and separates longitudinally.
 Two parallel tubes are formed which joins at the
level of pharynx.
 Malformation of tracheo-esophagus is formed by
defective separation , incomplete fusion or
abnormal cellular growth during the
development.

25. CLASSIFICATION
Type 1
This is a most common formed in which upper
esophagus ends in a blind pouch proximally, at the
level of bifurcation of trachea the lower esophagus
communicates with trachea.

26. Type 2
The upper esophagus ends in a blind pouch and the
lower segment does not communicate with trachea.

27. Type 3
The upper esophagus ends in a trachea and cord like
connection may or may not exist with lower esophagus.

28. Type4
Both upper and lower portion communicates with each
other with individual fistula.

30. CLINICAL MANIFESTATIONS
 Excessive salivation and
drooling.
 Neonates may have coughing,
sneezing and choking.
 If feed the baby may swallow
but the feed comes through
nose and mouth
 Cyanosis due to aspiration
 Abdominal distention occurs if
air enters into stomach.

31. ASSESSMENT
 At birth infant has excessive saliva and
mucus and may froth, drool, cough, sneeze.
 Coughing, gagging, choking and cyanosis
are present at the first feed.
 Aspiration and pneumonia may also occur
in these children.

32. DIAGNOSTIC EVALUATION
 The diagnosis is made by
gently passing well
lubricated moderately stiff
catheter through the nose
and into the esophagus. If
it passes down the
esophagus then the
esophagus lumen is
patent.
 Radiography

33. MANAGEMENT
 Keep the child in upright position to prevent
aspiration.
 Frequent and careful suction of pharynx and
upper esophageal pouch to relieve
excessive secretions.
 Infant is not given anything by mouth and
only I/V fluids to be administered.

34. SURGICAL MANAGEMENT
 End to end anastomosis with excision of fistula.
 When the baby is not fit for surgery due to
pneumonitis and low birth weight then gastrostomy
is done.

35. PRE-OPERATIVE CARE
 Early detection should be done when Childs gets
choking, drooling and cyanosis.
 Keep baby warm.
 Frequent suctioning.
 Administered humidified oxygen
 Vital signs to be monitored.
 Abdominal distention should be checked
 I/V flow rate and electrolytes to be monitored regularly.
 No oral feeds should be given.

36. POST OPERATIVE CARE
 Adequate respiration to be
maintained.
 Frequent suction to be done to
maintain patent airway.
 Administer humidified oxygen.
 Monitor the thoracic drainage.
 Care of operative site to prevent
infection.
 Monitor vital signs regularly.
 Hold feeds until operative site
becomes healthy.
-

37. Acute Nasopharyngitis
It is the most common type of URTI’S in infants and
children in addition to nasopharynx, the accessory
paranasal sinuses and middle ear are generally
involved.
It is a disorder characterised by inflammation and
irritation of the mucous membranes of the nose. It is
self-limiting and mainly caused by viruses.
The infection can spread quickly, and serious
complications can result especially if malnutrition is
present.

38. CAUSES:
Adenovirus, Rhinovirus (most common), influenza,
parainfluenza virus, RSV etc.

39. Clinical manifestations:
1.Rhinorrhea
2.Nasal congestion and discharge
3.Sore throat
4.Sneezing
5.Cough and low grade fever
6.Watery eyes
7. Muscle aches
8.Moderate respiratory difficulty
9.Breastfeeding become difficult
10.GI disturbances

40. PATHOPHYSIOLOGY
 The patho physiological changes that occur
in the nasopharyngx include edema and
vasodilation in the submucosa,
mononuclear cell infiltration that becomes
polymorphonuclear, separation and possible
sloughing of the superficial cells and the
production of mucous that is at first profuse
and thin and that later becomes thick and
purulent.

41.  The infant or child is infectious from a few hours
before to 1 to 2 days after the infection appears. As
the infection progress, complications may occur,
especially in infants, because potentially pathogenic
bacteria have invaded the ears as well as other
portions of the respiratory tract.
 In infants and young children the invading organism
are usually Hemophylis influenzae and
staphylococci, whereas in older children they are
generally group streptococci and pneumococci.

42. COMPLICATIONS
 Involvement or suppuration of cervical lymph
nodes.
 Otitis media
 Laryngitis
 Bronchitis
 Pneumonia

43. Medical management:
• Check allergic history of the patient
• Anti-histamines:for
sneezing,itching,rhinorrhoea.
• Intra-nasal corticosteroids
• Opthalmic agents
• NSAIDS & ibrufen for aches
• Topical decongesants
• Increased intake of vit.C
• Adequate rest
• Increased amt. of fluids

44. NURSING MANAGEMENT AND HOME CARE
 Adequate hydration
 Promote Rest and isolation
 Reduction of fever
 Relief of local clinical manifestations
 Administer nasal drops
 Change the position regularly
 Increase humidity to liquify secretions
 Observing for complications.

45. ACUTE
BRONCHIOLITIS

46. DEFINITION
 Common viral disease of the lower
respiratory tract of infants resulting from
inflammatory obstruction at the bronchiolar
level.
 It usually occurs between the ages of 2 and
12 months, with the peak incidence at about
6 months of age.
 This illness is rare after the age of 2 years.

47. INCIDENCE
 1 and 6 months
 Reach peak in winter and decrease in spring.
 Respiratory syncytial virus is responsible in most
cases
 Other organisms like Para influenza virus,
adenovirus, influenza virus and mycoplasma
pneumoniae.

48. PATHOPHYSIOLOGY
Direct contact with respiratory secretions or particles
contaminated with virus
Invade the nasopharynx ( where it replicates)
Spreads down to lower respiratory tract
Cause inflammation of bronchiolar bronchioles
Edema, thickening formation of mucus plug and
cellular debris

49. Narrow bronchial lumen in children is further
decreased
Slight narrowing causes marked increase in airway
resistance and reduction of airflow during
inspiration and expiration.
During expiration bronchioles are partially collapsed
Leads to trapping of air inside the alveoli
Causing emphysematous changes
When obstruction become complete
Trapped air in lung (lead to atelectasis)

50. Decreased ventilation (hypoxemia)
Retention of carbon dioxide
Respiratory acidosis
In mild cases compensation occurs due to
hyperventilation of normal alveoli

51. CLINICAL MANIFESTATIONS
INTIAL:-
 Rhinorrhea
 Pharyngitis
 Coughing /sneezing
 Wheezing
 Possible ear or eye drainage
 Intermittent fever
 Dyspnea
 Tachypnea/ respiratory distress
 Afbrile
 Shallow intercoastal retractions
 Fine rales

52. WITH PROGRESS OF ILLNESS:-
 Increased coughing and wheezing
 Air hunger
 Tachypnea and retractions
 cyanosis

53. SEVERE ILLNESS:-
 Tachypnea, greater than 70 breaths/ min
 Listlessness
 Apneic spells
 Poor air exchange/ poor breath sounds

54. DIAGNOSTIC EVALUATION
 X-ray chest- hyperinflation, diaphragm
 Complete blood count
 Rapid test of monoclonal antibodies against RSV
on nasopharyngeal aspirate can identify RSV
 Blood gases- increase carbon dioxide and
hypoxemia.

55. MANAGEMENT
 Treatment is symptomatic
 Child is nursed in humified atmosphere in sitting
position at an angle 30-40 degree with head and
neck elevated .
 Oxygen is continuously administered even if
cyanosis is absent (keep oxygen saturation≥ 95%
 Antibiotic has no role
 Ribavirin shortens the course of illness in infants
with underlying congenital disease, chronic lung
disease and immunodeficiency.

56. CONTD….
 Ribavirin is delivered by a nebulizer 16 hrs a day for
3-5 days in such cases.
 Continuous air pressure (CPAP) or assisted
ventilation may be required to control respiratory
failure.

57. NURSING MANAGEMENT
 High humidity atmosphere and oxygen
 Adequate hydration
 Rest
 Pulmonary hygiene
 Medications (antibiotics are not used unless
secondary bacterial pneumonia occurs.)
 Parental support

58. SINUSITIS
SINUSES:
These are the mucus lined cavities filled with air that drain
normally into nose.

59. There are 4 types of sinuses:-
•Ethmoid sinus
•Maxillary sinus
•Frontal sinus
•Sphenoid sinus
SINUSITIS:
If the drainage is obstructed then it causes infection known
as sinusitis.
It refers to the inflammatory conditions involving the four
paired structures surrounding the nasal cavities.
Most frequently maxillary sinus is involved followed by
ethmoid, frontal, and sphenoid sinuses.
It is usually precipitated by congestion from viral URI’s.

60. ACUTE SINUSITIS
It is defined as sinusitis of <4weeks duration. It
occurs primarily as a consequence of preeceding
viral infections. It occurs 3 to 5 days after acute
rhinitis.
CHRONIC SINUSITIS
It is characterised by symptoms of sinus
inflammation lasting >12weeks. Infection is
thought to be due to the impairment of
mucocilliary clearance from repeated bacterial
infections.

61. Etiology:
A no. of infectious and non-infectious causes can contribute
to acute sinusitis:-
Infectious: It can be caused by variety of organisms such as :
Viruses: rhinovirus,parainfluenza &influenza virus.
Bacteria: S.pneumonia and H.influenzae.
Fungi: rhizopus,mucor, rhizomucor.
Non-infectious: it include
 Allergic rhinitis
Chemical irritants
Nasal or sinus tumors

62. Pathophysiology: Etiology(other URTI’S)
Nasal congestion,inflammation,edema
Nasal congestion
Obstruction of sinus cavities
Prevent adequate drainage in nasal passages
Stagnant secretion & is media for
infection

63. Clinical manifestations:
•Pain: stabbing or aching over the infected sinus.
•Nasal congestion and discharge(thick purulent colored in
bact.)
• Anosmia(lack of smell)inspired or expired air cannot reach
the olfactory groove.
•Red and edematous nasal mucosa
•Fever (may or may not present)
•Tooth pain involving upper molars
Diagnostic tests:
Tenderness on palpation over affected sinus.
Sinus X-ray: show air-fluid level in acute sinusitis, thickening
of sinus mucous membranes, opacification, anatomic
obstruction.

64. Medical management:
Anti-histamines(used to decrease secretions &
congestion)
Topical decongestants
-Saline irrigation
Nasal sprays
Anti-microbial agents
-pencillin 250mg po 6H for 10 days
-erythromycin/azithromycin 250mg 6H for 10 days

65. Surgical management:
Endoscopic:
-excising and cauterising nasal polyps
-incising & draining sinuses.
-aerating the sinuses
For chronic cases:
•Ethmoid- Ethmoidectomy
•Maxillary- creation of nasal window
•Frontal- incision into the skull
•Sphenoid- sphenodectomy

66. NURSING MANAGEMENT
 Nose drops or sprays containing phenylephrine
0.25 to 0.125 are administered as prescribed after
cleaning the nasal passages.
 Humidifier may be used to increase the water
vapour in the air, liquify the scretions and facilitate
the drainage.
 Warm moist compresses may be applied to the
affected area.
 Temperature monitoring
 Cool sponge baths and prescribed antipyretics may
be given to reduce fever.

67. CONTD…..
 Increased fluid intake
 Observing for the complications such as cry, ear
ache
 Indications of neurological problems
 Systemic antibiotics are given as prescribed after
cultures are done.

68. CYSTIC FIBROSIS

69. INTRODUCTION
 Cystic fibrosis is an inherited autosomal recessive
trait due to mutation of the cystic fibrosis gene on
chromosome 7.
 The CF gene codes for a protein of 1,480 amino
acids called the CF transmembrane regulator
(CFTR). CFTR has ion channel and regulatory
functions.
 CFTR is expressed in epithelial cells of airways,
GIT, sweat gland and genitourinary system.
 The affected child inherits gene from both parents.

71. DEFINITION
 Cystic fibrosis is an inherited multisystem disorder of
children and adults, characterized by obstruction and
infection of airways.
 The disorder affects the exocrine glands causing the
production of viscous mucus leading to the obstruction of
small passages of bronchi, small intestine and,
pancreatic and bile ducts.

72.  The sweat sodium and chloride content are
increased. Symptoms usually appear in childhood
and include meconium ileus, poor growth despite
good appetite, malabsorption and foul bulky stools,
chronic bronchitis with cough, recurrent pneumonia,
bronchiectasis, emphysema, clubbing of the
fingers, and salt depletion in hot weather.

75. INCIDENCE AND ETIOLOGY
 It affects 1 in 2000 infants.
 It affects male and female individuals equally.
 Cystic fibrosis is an inherited autosomal recessive
trait due to mutation of the cystic fibrosis gene on
chromosome 7.
 Cystic fibrosis is due to gene mutation

76. PATHOLOGICAL CHANGES IN
VARIOUS ORGANS

77.  Gene mutation
 Exocrine dysfunction
 Abnormal mucous secretion and obstruction
 Bronchi Small intestine Pancreatic ducts bile ducts
Bronchial
obstruction
Inspissated
meconium
Secondary
degeneration
of pancreas
Focal
biliary
fibrosis
Chronic
bronchial
pneumonia
Intestinal
obstruction
Generalized
obstructive
emphysema
Pancreatic
achylia
Bilary cirrhosis
Malabsorpti
on
syndrome
Portal
hypertensio
n

79. CLINICAL MANIFESTATIONS
1. Gastro
Intestinal Large,
bulky, loose, frothy,
extremely foul
smelling stool.
2. Voracious appetite
(early disease)
3. Loss of appetite
(later in disease)
4. Weight loss
5. Marked tissue
wasting
1. Failure to grow
2. Distended abdomen
3. Thin extremities
4. Evidence of
deficiency of fat
soluble vitamins A, D,
E, K
5. Anemia

80. PULMONARY MANIFESTATIONS
Initial signs
-wheezy respirations
-dry, nonproductive cough
Eventually
-increased Dysnea
-paroxysmal cough
-Evidence of obstructive emphysema and patchy areas of
atelectasis
Progressive involvement
-over inflated, barrel shaped chest
-cyanosis
-Clubbing of fingers and toes
-repeated episodes of bronchitis and bronchopneumonia

81. Meconium ileus
1. Abdominal distension
2. Vomiting
3. Failure to pass stool
4. Rapid development of dehydration

82. DIAGNOSTIC EVALUATION
 Family history
 Sweat chloride test to measure concentration of Na
and Chloride
 Pulmonary function test
 Chest X ray

83. COMPLICATIONS
PULMONARY
 Emphysema
 Pneumothorax
 Pneumonia
 Respiratory failure

84. GASTROINTESTINAL
 Cirrhosis
 Portal hypertension
 Faecal impaction
 Enlarged spleen
 Intussusception
 Pancreatitis
 Intestinal obstruction
ENDOCRINE
 Diabetes mellitus

85. MANAGEMENT OF PULMONARY PROBLEMS
 Antimicrobial therapy
 Bronchodilators
 Oxygen administration
 Aerobic exercises
 Postural drainage

86. MANAGEMENT OF GASTROINTESTINAL PROBLEMS
 Replacement of pancreatic enzymes which is
administered with meals and snacks.
 High protein and high calorie diet.

87. COMMON NURSING DIAGNOSES
 Ineffective airway clearance r/t tracheobronchial
secretions and obstruction
 Imbalanced nutrition: less than body requirements
r/t inability to digest food or absorb nutrients
 Risk for infection r/t chronic pulmonary disease
 Interrupted family processes r/t chronic illness

88. PLANNING & INTERVENTIONS
 Provide respiratory therapy
 Administer medications
 Meet nutritional needs
 Provide psychosocial support
 Discharge planning and home teaching

89. TREATMENTS
 Aimed at relieving symptoms and
complications
 Antibiotics
 Mucus-thinning drugs
 Thins secretions
 Easier to cough up
 Bronchodilators
 Relaxes smooth muscles in the airways

90. TREATMENTS
 Bronchial airway drainage
 Postural drainage
 Oral enzymes and better nutrition
 High calorie diet
 Special vitamins & pancreatic enzymes
 Lung transplant
 Pain relievers
 Ibuprofen

91. EXPECTED OUTCOMES
 The expected outcomes of nursing care include
 Family and/or child demonstrate proficiency in
 Providing pulmonary care
 Reducing pulmonary infections
 Developing a schedule for pulmonary cares that fits into family
needs
 Adequate calories and pancreatic enzymes are consumed
to support growth of the child to stay within developmental
weight ranges

92. PARENT AND CHILD EDUCATION
 Respiratory infections
 Avoid exposure
 Chest percussion &
postural drainage
 Diet
 Genetic counseling
 Written information
 Home care

93. RETROPHARYNGEAL ABSCESS
 A retropharyngeal abscess is a suppurative lesion
involving one or several of the retropharyngeal
lymph nodes.
 This condition occurs secondary to a
nasopharyngeal infection, although it may occur
rarely after extension of infection from vertebral
osteomyelitis or a wound of the posterior pharynx.
 A retropharyngeal abscess following naso-
pharyngitis most commonly occur during the first 3
years of life and rare after this age because of the
normal atrophy of the retropharyngeal nodes.

94. PATHOPHYSIOLOGY
 Several small retropharyngeal lymph nodes
normally occupy the potential space between the
posterior pharyngeal wall and the prevertebral
fascia.
 Lymphatic drainage from portions of the
nasopharynx and the posterior nasal passages
drains into these lymph nodes.
 When purulent infections occur in these areas, the
nodes may also become infected and breakdown,
leading to suppuration.
 Although the prominent organism are beta-
hemolytic streptococci, staphylococci and
anaerobic organisms have also been isolated.

95. ASSESSMENT
 Rise in temperature
 Painful and difficult swallowing
 Drooling
 Mouth is held open
 Noisy respiration
 Gurgling sounds
 Obstruction to breathing leads to stridor and
dyspnea
 X-ray or CT scan can be done to localize the
abscess.

96. MANAGEMENT
 Appropriate broad spectrum antibiotics are used
 It can prevent or relieve the abscess and
suppuration.
 Analgesics are prescribed for pain
 If abscess has been formed it can be incised under
general anesthesia
 After incision drainage is carefully suctioned to
prevent aspiration and culture and sensitivity tests
are done
 Child is given prone position after surgery
 Child must be monitored for respiratory and
hemorrhage

97. CONTD…..
 Oral intake of fluids is encouraged
 Local applications of heat and warm saline
irrigations if the child co-operate

98. CROUP
SYNDROMES

99. INTRODUCTION
 Croup is a general term applied to a
symptom complex characterized by
hoarsness, resonant cough described as
“barking” or “brassy”(croupy), varying
degrees of inspiratory stridor and varying
degree of respiratory distress resulting from
swelling or obstruction in the region of the
larynx.
 Croup syndrome is viral infection of upper
airway that affect the larynx, trachea and
bronchi.

100. CONTD…
 Croup syndromes are described according
to the primary anatomic area affected:-
 Epiglottis
 Laryngitis
 Laryngotracheobronchitis
 Tracheitis
 LTB occurs in very young children and
epiglottis is common in older childrens.

101. ACUTE EPIGLOTTIS
 Acute epiglottis or acute
supraglottis is a serious
obstructive inflammatory
process that occurs in
age group of 2 to 5 years,
but can occur from
infancy to childhood.
 The responsible organism
is haemophilus
influenzae.

102. CLINICAL MANIFESTATIONS
 Dysphagia
 Stridor aggravated when supine
 Restlessness
 Drooling
 High fever
 Voice is thick, muffled with frog like croaking
sound on inspiration
 Suprasternal and substernal retractions may be
visible.
 Appearance is not proper
 Rapid pulse and respirations

103. DIAGNOSTIC EVALUATION
 History
 Throat examination
 X-ray
 laryngeoscopy

104. TREATMENT
 Endotracheal intubation or tracheostomy is usually
considered with severe respiratory distress.
 Start I/V infusion
 Antibiotics for 7-10 days. Ampicillin 100 mg/kg,
chloramphenicol 50 mg/kg
 Corticosteroids for reducing edema.

105. ACUTE
LARYNGOTRACHEOBRONCHITIS
 LTB is the most common
croup syndrome.
 It primarily affects children
younger than 5 years of
age.
 The causative organism
are the para influenza
virus, RSV, influenza A
and B and mycoplasma
pneumoniae.

106. PATHOPHYSIOLOGY
upper respiratory infection
Descends to adjacent structures (characterized by
gradual onset of low grade fever)
Inflammation of mucosa lining of the larynx and
trachea
Narrowing of airway
Obstruction of air to lungs
Produces inspiratory stridor or suprasternal
retractions

107.  The typical child with LTB is a toddler who develops
a classic barking or seal like cough and acute
stridor after several days of coryza.
 If obstruction is severe enough to prevent adequate
exhalation of carbon dioxide can cause respiratory
acidosis and respiratory failure.

108. SYMPTOMS IN LTB
STAGE 1
 Hoarsness
 Croupy cough
 Inspiratory stridor when
disturbed
STAGE 2
 Continuous respiratory stridor
 Lower rib retractions
 Retraction of soft tissue of neck
 Use of accessory muscles of
respiration
 Labored respiration

109. CONTD…
STAGE 3
 Signs of anoxia and carbon dioxide retention
 Restlessness
 Anxiety
 Pallor
 Sweating
 Rapid respiration
STAGE 4
 Intermittent cyanosis
 Permanent cyanosis
 Cessation of breathing

110. TREATMENT
 Objective: to maintain airway and
providing adequate respiratory
exchange.
 High humidity with cool mist vaporizer
provides relief.
 Nebulizer epinephrine (2.25%) is
used. dilute with water
 corticosteroids decrease edema.
 If unable to take fluids orally start I/V.

111. ACUTE SPASMODIC LARYNGITIS
 Acute spasmodic laryngitis
(spasmodic croup, “midnight croup” or
‘twilight croup”) is distinct from laryngitis and
LTB and is characterized by paroxymal
attacks of larngeal obstruction that occurs
chiefly at night.
 Signs of inflammation are absent or mild
and there is a history of previous attacks
lasting 2 to 5 days.
 It affects children ages 1 to 3 years

112. CLINICAL MANIFESTATIONS
 Upper repiratory tract
infections
 Croupy cough
 Stridor
 Hoarseness
 Dysnea
 Restlessness
 Symptoms Disappears
during day
 Tends to recur

113. MANAGEMENT
 Cool mist is recommended.
 Nebulizer epinephrine.
 Corticosteroid therapy.

114. BACTERIAL TRACHEITIS
 It is a infection of the
mucosa of the upper
trachea, with a features
of both croup and
epiglottis.
 It occurs in children 1
month to 6 years of age.
 Causative organism is
staphylococcus aureus.

115. CLINICAL MANIFESTATIONS
 Upper respiratory infection
 Croupy cough
 Stridor
 Purulent secretions
 High fever
 No response to LTB therapy

116. MANAGEMENT
 Humidified oxygen
 Antibiotics
 Antipyretics
 If needed endotracheal intubation and
tracheotomy and frequent suction to
prevent airway obstruction.

117. NURSING
MANAGEMENT

118. MONITOR AND FACILATE RESPIRATORY
INFECTIONS
 Monitor respiratory rate and depth.
 Observe the signs of distress (retractions, cyanosis,
pallor).
 Nurse the child in humid atmosphere to liquefy
secretions, hot steam and cold vapors may be
used.
 Give oxygen inhalation, artificial airway can be
inserted if child has airway obstruction.
 Change position 2 hourly to prevent pooling of
secretions.
 Encourage child to take deep breath.
 Give chest physiotherapy as advised and
suctioning as needed.

119. ADMINISTRATION OF
MEDICATIONS
 In case of bacterial infection ampicillin can be used,
viral infections do not respond to any antibiotics.
 Corticosteroids can be given as a means of
diminishing edema and spasms of croup.
 Epinephrine nebulizer is prescribed in progressive
stridor.

120. MENTANCE OF HYDRATION
 If the child is unable to take by mouth and is in
shock or the intake is less then the I/V fluid are
given to prevent dehydration.
 Clear and high caloric fluids are given orally as
tolerated by child
 Intake- output record is maintained to assess the
hydration status of child

121. PROMOTION OF REST
 If the child is apprehensive and crying then his
demand for oxygen will increase to conserve
energy.
 Provide rest in high fowlers position to facilitate
respiration, familiar toys should be used relieve
apprehension and tell parents to stay with the child.
A quiet restful environment is important to facilitate
rest.

122. BRONCHITIS
 Bronchitis is an acute
inflammation of the air
passages within the lungs
(tracheobronchitis).
 It occurs when the trachea
and large and small bronchi
within the lungs become
inflamed because of infection
or other causes.
 The mucous lining of these
airways can become irritated
and swollen. The cells that
make up this lining may leak
fluids in response to the
inflammation.

123. BRONCHITIS
 Especially occur in the children younger than 4
years.
 Bronchitis occurs most often during the cold and
flu season and usually with an upper respiratory
infection.
 Viruses – influenza, para influenza, adeno-virus,
RSV and rhino virus.
 Bacteria are also known to cause bronchitis, such
as mycoplasma pneumoniae
 Inhaled irritants fumes or dusts.
 Chemical solvents and smoke, including tobacco
smoke
 May occur with communicable diseases like
pertussis, measles, diphtheria, scarlet fever,
typhoid fever.

124. PATHOPHYSIOLOGY
Two factors are involved
Inflammation of cartilaginous support
Bronchi & trachea of lower resp. not
fully developed
Increased secretions result in constriction
of lower airways
bronchitis

125. SYMPTOMS
 Acute bronchitis most commonly occurs after an
upper respiratory infection such as the common
cold or a sinusitis infection.
 Symptoms such as fever with chills, muscle
aches, nasal congestion, and sore throat.
 Cough (dry, hacking, unproductive but frequent)
 Anterior chest pain.
 Shortness of breath.
 The coughing and gagging can cause vomiting.
 Wheezing may occur because of the
inflammation of the airways.

126. MEDICAL TREATMENT
 Medications to help suppress the cough or
loosen and clear secretions may be helpful.
 Bronchodilator inhalers will help to open airways
and decrease wheezing.
 Antibiotics are prescribed for bacterial infection.
 The patient may be hospitalized if they
experience breathing difficulty that doesn't
respond to treatment. This usually occurs
because of a complication of bronchitis, not
bronchitis itself.

127. NURSING MANAGEMENT
 Balanced diet and rest
 Expectorants as advised
 Parent counseling regarding home based care of
the child

128. ASTHMA
 Asthma is a reversible, episodic, obstructive airway
disease caused by hyperactivity of the bronchial
tree to a variety of stimuli.
 Onset of the disease usually occur during the first
five years of life. Boys are effected twice as often as
girls until adolescence.
 Morbidity associated with asthma can impair the
physical activity, intellectual and social growth and
development of the children.

129. CAUSATIVE FACTORS
 Asthma is basically characterized by
bronchospasm and airway obstruction
which result in dyspnea, wheezing and
excessive cough.
 The obstructive process are secondary to
increased responsiveness of the bronchi to
any one or a combination of a diverse group
of factors referred to as “triggers”

130. CONTD…….
 The term extrinsic asthma or allergic asthma
is used when the symptoms are induced by
a hyperimmune response to the inhalation
of a specific allergen.
 Pollens, house dust, feathers, molds and
animal dander are the most common
causative agents.
 Children with extrinsic asthma usually have
positive skin tests and positive family
history.

131. CONTD…
 “Intrinsic asthma” refers to the same clinical
manifestations of airway obstruction but in
response to unidentified or non-specific factors in
the environment.
 This type of asthma is not produced by a
hyperimmune response, however there may be a
family history of asthma.
 Children affected with intrinsic asthma have highly
irritable or hyperactive airways. Inhalation of
irritants such as cigarette smoke, strong odour of
soaps and perfumes or other pollutants may trigger
episodes of bronchospasm and wheezing.

132. CONTD……
 Exercise, drugs and changes in
temperature, pressure, viral respiratory tract
infections and emotional stress or
excitement are important triggers of asthma.

133. PATHOPHYSIOLOGY
 The major pathophysiological mechanism
responsible for the airway obstruction with
asthma are :
 Spasm of the smooth muscles of the
bronchi
 Edema of the bronchial mucosa
 Increased accumulation of thick, tenacious
mucous with in the lumen of the bronchi and
bronchioles.

134. BIO-CHEMICAL AND MECHANICAL EVENTS
 Immunopathology
 Mediator release
 Respiratory dysfunction

135. IMMUNOPATHOLOGY
 Immediate hypersensitivity to an allergen is the
basis for extrinsic asthma.
 Specific antibody of immunoglobulin E is produced
upon exposure to an antigen.
 IgE released from the plasma, recognize, attach
and remain fixed to mast cells.
 These mast cells become the contact point for
antigen-antibody reaction in respiratory tract.
 The child is now called as sensitive or allergic
 When the child is re-exposed to the antigen, the IgE
molecules bind with the antigen on the surface of
the mast cells.

136. CONTD…..
 The antigen-IgE reaction initiates several bio-
chemical events that result in the release of
chemical mediators histamine, slow reactive
substance of anaphylaxis (SRS-A), and eosinophilic
chemotactic factor of anaphylaxis (ECF-A)
 Histamine causes smooth muscle contraction,
increased vascular permeability, edema and
increased mucous secretion and muscle
contraction.
 These mediators initiate the abnormal changes that
occur in asthma: bronchospasm, edema of the
bronchial mucosa, increased secretion of mucous
and inflammation.

137. MEDIATOR RELEASE
 Although the antigen-IgE reaction can initiate the
release of mediators, the biochemical process is
also regulated by sympathetic and parasympathetic
receptors in the bronchial tree and by the
concentrations of two cyclic nucleotides in the mast
cells. These are (C-AMP) and (C-GMP).
 Stimulation of sympathetic receptors by
catecholamines, such as epinephrine, increases the
concentration of C-AMP in the mast cells.
 An increase in the C-AMP produces
bronchodilatation and suppresses the release of
mast cell mediators (histamine, SRS-A, ECF-A)

138. CONTD…..
 Stimulation of parasympathetic receptors by
acetylcholine increase intracellular C-GMP. An increase
in intracellular C-GMP promotes bronchospasm and the
release of mediators from mast cells.
 The intracellular concentrations of these two cyclic
nucleotides are determined by the action of enzymes
produced in response to receptor stimulation .
 Phosphodiesterase breaks down C-AMP, increasing
intracellular C-GMP and its adverse effects.
 Medications used in the treatment of asthma,
particularly theophylline, act to increase intracellular C-
AMP by inhibiting phosphodiesterase.

139. RESPIRATORY DYSFUNCTION
 Asthmatic episode
 Smooth muscle surrounding the bronchioles constrict
 Shortening and narrowing of air passages
 Decreased supply of oxygen to alveoli (hypoventilation)
 Mucosal edema and increased secretions further narrow the
bronchial lumen
 Increased airway resistance to flow of inspired and expired air

140.  The air is trapped in the alveoli distal to the obstruction
 Airflow become turbulent produces wheezing and stimulate cough
reflex
 Respiratory rate and depth increases to compensate for
hypoventilation
 Hyperinflation of the lungs
 The child become fatiqued
 Hypoxemia
 Respiratory failure

141. ASSESSMENT
 Dyspnea
 Wheezing
 Cough
 Nasal flaring
 Chest retractions
 Cyanosis
 Chest and abdominal pain
 Headache
 Muscle twitching
 Confusion
 Coma
 Acute respiratory failure
 Proper history
 Physical examination

142. DIAGNOSTIC TESTS
 Sputum examination
 TLC, DLC
 Immunoelectrophoresis (for IgE)
 Allergy skin test
 Chest X-ray
 Pulmonary function tests

143. MEDICAL MANAGEMENT
The goal of the therapy is to:
 Promote bronchodilation
 Reduce inflammation
 Remove secretions

144. METHYLXANTHINES
 Effective bronchodilators frequently used in
the management of asthma.
 Theophylline and its derivatives are used
 Act by suppressing the enzyme
phosphodiesterase, which prevent the
degradation of C-AMP.
 So, level of C-AMP increases resulting in
bronchodilation.
 Dose is 10-16mg/kg/day.

145. SYMPATHOMIMETICS
 These drugs produce an elevation in intra-
cellular C-AMP through stimulation of beta-
adrenergic receptors, which result in
bronchodilation.

146. CROMOLYN SODIUM
 Act by blocking the release of chemical
mediators from the mast cells. It is inhaled
as a powder through an inhaler.

147. CONTD….
 Corticosteroids
 Miscellaneous medication

148. NURSING MANAGEMENT
 Providing emotional support and education
 Positioning
 Evaluating respiratory status
 Administering oxygen therapy
 Monitoring intravenous medication
 Administering fluid therapy
 Providing rest
 Supporting family members.

149. ACUTE PHARYNGITIS
 It refers to infections primarily involving the
throat. However it may also include acute
conditions such as tonsillitis and
pharyngotonsillitis.
 The pharynx is involved in most respiratory
tract infections. Acute pharyngitis is not
common in infancy but increases in
incidence with age, peaking at four to seven
years of age.

150. PATHOPHYSIOLOGY
 Usually caused by viruses.
 Group A beta hemolytic streptococci can also cause
the disease.
 Early signs include:
fever
generalized malaise
anorexia
moderate throat pain
enlargement of cervical lymph nodes
WBC count is elevated

151. ASSESSMENT
 A throat culture can be taken to differentiate
between viral or bacterial infection
 Child’s pharynx must be observed for inflammation
and exudates.

152. NURSING MANAGEMENT
 Bed rest
 Mild analgesics as prescribed
 Hot or cold compresses to neck
 Warm saline gargles can be advised
 Hot steam inhalations
 Cool bland liquids
 Prescribed antibiotics, penicillin G is given orally for
10 days in GABH, erythromycin is given if the child
is allergic to penicillin.
 Home teaching regarding medication use.
 Good hand washing should be emphasized.

153. CHRONIC PHARYNGITIS
 It is a rare condition
 Result from chronic infection of the sinuses,
adenoids or tonsils.

154. ASSESSMENT
 Throat discomfort (dryness and irritation)
 Lymphoid hypertrophy
 Blood vessels become visible on the
inflamed mucous membrane.

155. NURSING MANAGEMENT
 Nutritious diet including additional fluids.
 Oral hygiene with tooth brushing.

156. PATHOPHYSIOLOGY
 As with pharyngitis, the cause may be viral or
bacterial. As a result of inflammation, the tonsils,
palatine or faucial, enlarge.
 They may meet in the midline and obstruct the
passage of food and air.
 If the adenoids are also involved, they may block
the posterior nares, resulting in mouth breathing.
 In addition, the eustachian tubes may be blocked,
resulting in otitis media.

157. ACUTE TONSILLITIS
 Acute infections of the tonsils usually occur as a
result of pharyngitis.

158. TONSILLECTOMY AND ADENOIDECTOMY
 Surgery is rarely done on children under 2 to 3
years of age unless there is airway obstruction
 Children with hemophilia may safely undergo
surgery when cryoprecipitate is administered
before, during after the surgical procedure.
 It is done on an inpatient basis in the hospital, in a
short term unit such as a day care unit, or in an
ambulatory surgical center outside a hospital.

159. CONTD…….
 There are several advantages of these new short
term units:
 Children do not have to be away from home than a
few hours, resulting in less trauma and family
disturbance
 They do not come in contact with seriously ill
children in the hospital and therefore less likely to
contract infections
 In patient facilities are freed for children with major
problems
 Procedures done in short term units are less
expensive than those done on an inpatient basis.

160. ASSESSMENT
 Level of preparation of both parents and child
 The child has been told that the surgery will be
done in the throat. About the operating room,
specially how the child will feel in general
anesthesia.
 Nurse must look for any loose teeth.
 Pre-operative screening tests include bleeding and
clotting times and other routine tests.

161. NURSING MANAGEMENT
 Prone position
 Constant observation of the child
 Pulse rate and quality must be monitored
 Observe for any kind of bleeding
 Chipped ice can be given
 Red or brown colored liquid should be with held
 Increased fluid intake
 Milk and soft food must be started as soon as the
nausea subsides.
 Parents participation and encouragement

162. Nursing diagnosis:
1. Acute pain r/t sore throat
Interventions:
a)Assess and document level of pain
b)apply warm compress q.i.d
c)provide analgesics to child as prescribed
d)provide calm and comfortable environment to
patient
2. Ineffective airway clearance r/t thick mucous secretions
Interventions:
a)assist child in performing coughing and breathing
maneuvers.
b)position with head elevated at 45degree.
c)provide humidified oxygen
d)suction out secretions and chest physiotherapy.

163. 3. Risk for fluid deficit r/t difficulty in swallowing
Interventions:
a)encourage patient to drink lots of fluids
b)provide frequent oral care to the patient
c)adm. parenteral fluids as prescribed
4. Altered nutrition r/t difficulty in eating
Interventions:
a)encourage patient to have soft diet
b)teach patient to take vit. C rich diet.
c)teach patient to take cold diet e.g ice-creams
5. Sleep pattern disturbance r/t headache and nasal stiffness
Interventions:
a)assess patient’s comfort and relaxation level
b)give analgesics to the patient during bed time as prescribed

164. EPISTAXIS
 It is very common through out the childhood,
especially during school age, but the
incidence decreases after puberty.

165. PATHOPHYSIOLOGY
 It is caused by external trauma, foreign
bodies, forcible blowing of the nose or
picking of the nose.
 Allergic rhinitis or sinusitis may also lead to
nose bleed.
 The strain of emotional excitement or
physical exercise may be enough to start
nasal bleed.
 Some times conditions which elevate the BP
can also lead to epistaxis.

166. ASSESSMENT
 The nurse should question the child or parents
about the frequency of epistaxis.
 The child should be asked to relate those activities
that occurred before the episode, since many nose-
bleeds occur without warning
 Questions should be asked specific to the color of
vomitus or stools, because bleeding may occur
during sleep.
 Both nares should be inspected, however bleeding
may occur from just one nostril.

167. NURSING MANAGEMENT
 Semi-erect position
 Head tilted forward to prevent blood trickling
posteriorly into pharynx.
 If they swallow blood, then appear nauseated.
 Clothing around the neck must be loosened
 An ice-bag over the bridge of the nose is helpful
 Alae are gently but firmly pressed against the
septum
 A solution of epinephrine must be applied over the
bleeding nasal mucous membrane.
 A room humidifier can be used if the environment is
dry

168. PNEUMONIA
 It is the leading cause of mortality and a common
cause of morbidity in children below five years of
age.
 In developing countries pneumonia kills 3 million
children every year.
 It is responsible for 19% of all deaths below five
years of age.

169. DEFINITION
 It is defined as inflammation and consolidation of
lung parenchyma.

170. RISK FACTORS
 Low birth weight
 Malnutrition
 Vitamin A deficiency
 Lack of breastfeeding
 Passive smoking
 Poor socio-economic status
 Large family size
 Family history of bronchitis
 Advanced birth order
 Overcrowding
 Young age
 Indoor and outdoor pollution

171. CLASSIFICATION
Anatomically
 Lobar or lobular pneumonia
 Bronchopneumonia
 Interstitial pneumonia

172. LOBAR PNEUMONIA
 A lobar pneumonia is an infection that only involves
a single lobe, or section, of a lung. Lobar
pneumonia is often due to Streptococcus
pneumoniae (though Klebsiella pneumoniae is also
possible.)
 Multilobar pneumonia involves more than one lobe,
and it often causes a more severe illness.

173. NORMAL X-RAY LEFT LOWER LOBE PNEUMONIA RIGHT LOWER LOBE PNEUMONIA

174. BRONCHOPNEUMONIA
 Bronchial pneumonia affects the lungs in patches
around the tubes (bronchi or bronchioles).

175. INTERSTITIAL PNEUMONIA
 Interstitial pneumonia involves the areas in between
the alveoli, and it may be called "interstitial
pneumonitis." It is more likely to be caused by
viruses or by atypical bacteria

176. FROM WHERE AQUIRED
 Hospital acquired pneumonia
 Community acquired pneumonia

177. HOSPITAL ACQUIRED PNEUMONIA
 Hospital-acquired pneumonia, also called
nosocomial pneumonia, is pneumonia acquired
during or after hospitalization for another illness or
procedure with onset at least 72 hrs after
admission. Up to 5% of patients admitted to a
hospital for other causes subsequently develop
pneumonia. Hospitalized patients may have many
risk factors for pneumonia, including mechanical
ventilation, prolonged malnutrition, underlying heart
and lung diseases and immune disturbances.

178. CONTD……
 Hospital-acquired microorganisms may include
resistant bacteria such as MRSA, Pseudomonas,
Enterobacter, and Serratia. Because individuals
with hospital-acquired pneumonia usually have
underlying illnesses and are exposed to more
dangerous bacteria, it tends to be more deadly than
community-acquired pneumonia. Ventilator-
associated pneumonia (VAP) is a subset of
hospital-acquired pneumonia. VAP is pneumonia
which occurs after at least 48 hours of intubation
and mechanical ventilation.

179. COMMUNITY ACQUIRED PNEUMONIA
 Community-acquired pneumonia (CAP) is infectious
pneumonia in a person who has not recently been
hospitalized. CAP is the most common type of
pneumonia. The most common causes of CAP vary
depending on a person's age, but they include
Streptococcus pneumoniae, viruses, the atypical
bacteria, and Haemophilus influenzae.

180. ETIOLOGY
 Viral : it is caused by RSV, influenza, parainfluenza
or adenovirus may be responsible for about 40% of
cases.
 Bacterial : the common bacteria causing
pneumonia are Klebsiella, E. coli, pnuemococci and
staphylococci
 Atypical organisms : Chlamydia and Mycoplasma in
community acquired pneumonia in adults and
children.
 Pneumocystis carinii : This organism causes
pneumonia in immunocompromised children

181. CONTD….
 Fungi : histoplasmosis and coccidiomycosis.
 Metazoa : Ascaris
 Aspiration : food, oily nose drops and liquid paraffin
 Kerosene : poisoning causes chemical pneumonitis
 Hypersensitivity pneumonitis: the etiology remains
unknown in one-third of the case of pneumonia.

182. PNEUMOCOCCAL PNEUMONIA
 Respiratory infections due to streptococcus
pneumoniae are transmitted by droplets and are
more common in the winter months.
 Overcrowding and diminished host resistance
predisposes children to pneumococcal infection.

183. PATHOLOGY
Bacteria multiply in the alveoli and an inflammatory exudate is
formed. Scattered areas of consolidation occur, which
coalesce around the bronchi and later becomes lobar in
distribution
There is no tissue nacrosis and stage of congestion
Stage of red hepatization
Grey hepatization
Resolution.

184.  Congestion in the first 24 hours: This stage is
characterized histologically by vascular
engorgement, intra-alveolar fluid, small numbers of
neutrophils, often numerous bacteria. Grossly, the
lung is heavy and hyperemic

185.  Red hepatization or consolidation : Vascular
congestion persists, with extravasation of red cells
into alveolar spaces, along with increased numbers
of neutrophils and fibrin. The filling of airspaces by
the exudate leads to a gross appearance of
solidification, or consolidation, of the alveolar
parenchyma. This appearance has been likened to
that of the liver, hence the term "hepatization".

186.  Grey hepatization : Red cells disintegrate, with
persistence of the neutrophils and fibrin. The alveoli
still appear consolidated, but grossly the color is
paler.
 Resolution (complete recovery):The exudate is
digested by enzymatic activity, and cleared by
macrophages or by cough mechanism.

187. CLINICAL FEATURES
 Head ache
 Chills
 Cough
 Pain
 Chest indrawing
 Difficulty in feeding
 Cyanosis
 Air entry diminished
 Crepts

188. DIAGNOSTIC TESTS
 X-ray
 Gram staining and culture of sputum

189. TREATMENT
 Penicillin G 50,000 units/kg/day is given
intravenously or intramuscular in divided doses for
a week to ten days.
 Procaine penicillin 6,00,000 units intramuscular per
day or Penicillin V may be used orally instead.
 Oxygen should be given if cyanosis and respiratory
distress are present.
 Cephalosporins if allergic to penicillin.

190. STAPHYLOCOCCAL PNEUMONIA
 It occur in infancy and childhood. The pulmonary
lesion may be primary infection of parenchyma or
may be secondary to generalized staphylococcal
septicemia
 It may be the complication of measles, influenza
and cystic fibrosis.
 Certain conditions like malnutrition, DM,
macrophage dysfunction can predispose the child
to pnemonia

191. PATHOLOGY
 In infants pneumonic process is diffuse initially, but soon the lesion
suppurate, resulting in broncho-alveolar destruction.
 Multiple micro-abscesses are formed, which erode the bronchial wall
and discharge their content in bronchi.
 During inspiration, air enters the abscess cavity because the bronchi
are dilated in this phase.
 The bronchioles collapse during expiration and therefore the air
cannot easily move out.
 The abscess is progressively inflated, resulting in pneumatoceles

192. CONTD….
 These pneumatoceles fluctuate in size over time, ultimately resolving
and disappearing with in a period of few weeks to months.
 Epithelialization of the walls of the air cysts may occur.
 Staphylococcal abscesses in the lungs may errode the pericardium
causing purulent pericarditis.

193. CLINICAL MANIFESTATIONS
 Upper respiratory tract infection
 Grunting respiration
 Fever and anorexia
 Listless and irritable
 Abdominal distention
 Cynosis

194. DIAGNOSIS
 Pneumatoceles are present in X-ray films

195. TREATMENT
 Hospitalization and isolation
 Antipyretics for fever
 I-V fluids to maintain hydration status
 Oxygen administration
 Antibiotics

196. NURSING MANAGEMENT OF CHILD WITH
PNEUMONIA
Continuing assessment
Monitoring
Auscultation
Observation
Dyspnea

197.  Reduction of fever
 Facilitation of respiratory efforts
a) Maintenance of patent airway
b) Provision of high humidity atmosphere
c) Positioniong
d) Thoracentesis
 Administration of prescribed antibiotics
 Promotion of rest
 Provision of appropriate and adequate fluids and
rest.
 Support and education of parents.

198. ASPIRATION
 Aspiration syndromes include all conditions in
which foreign substances are inhaled into the lungs.
Most commonly, aspiration syndromes involve oral
or gastric contents associated
with gastroesophageal reflux (GER), swallowing
dysfunction, neurological disorders, and structural
abnormalities.

199.  The volume of refluxate may be significant, usually
causing acute symptoms associated with the
penetration of gastric contents into airways, or there
may be episodic incidents of small amounts of oral
or gastric reflux or saliva that enter the airways
causing intermittent or persistent symptoms.

200. PATHOPHYSIOLOGY
 Aspiration of acidic content (pH < 2.5) into the lungs
causes mucosal desquamation, damage to alveolar
lining cells and capillaries, and acute neutrophil
inflammation.

201. MEDICAL CARE
 Position infants in the prone or upright position.
Avoid placing infants younger than 6 months in a
seated position for approximately 90 minutes after a
feed.
 Do not feed the infant within 90 minutes before
bedtime. Elevation of the head of the bed
approximately 30° may help, although young infants
may slide down the bed during the night.

202.  Dietary modifications include thickening feeds for
infants; breastfeeding; decreasing volume of feeds
(10-20 mL/kg per feeding); and feeding small,
frequent meals. Patients with swallowing
dysfunction may benefit from certain food
consistencies, positioning, and adaptive feeding
equipment or utensils.

203.  The management of an acute aspiration event
consists of conservative management, observation,
and possible antibiotic therapy. Initially, the patient's
upper airway should be cleared and endotracheal
intubation should be considered if the patient is
unable to protect his airway.

204.  Close monitoring in an inpatient setting is
recommended for at least 48 hours. Initially, empiric
antibiotic therapy is not recommended, even if
fever, clinical, laboratory, or radiographic findings
are present.

205.  Selection of resistant organisms with the use of
empiric, broad-spectrum antibiotic therapy is always
a concern, especially in an uncomplicated chemical
pneumonitis picture. If the patient fails to improve
after 48 hours, the addition of broad-spectrum
antibiotics is recommended.

206.  A second or third generation cephalosporin is
appropriate to cover potential gram-positive flora
from the oropharynx and gram-negative organisms
from the GI tract. Anaerobic coverage is not
routinely required initially.

207. Effects of Aspirated Foreign
Bodies
ƒ Complete upper airway obstruction : death
ƒ Partial upper airway obstruction
–wheezing
–chest pain
–mucosal injuries : bleeding
ƒ Lower airway obstruction
–atelectasis
–pneumonia
–decreased breath sounds

208. ƒ buttons
ƒ toys
ƒ pins
ƒ hair clips
ƒ marbles
ƒ seeds, nuts
ƒ screws
ƒ nails
Objects Commonly Ingested
or Aspirated by Children
ƒ Peanuts ; most
common lower
airway object
ƒ coins
ƒ bones
ƒ balloons

209. Emergency Treatment for Aspirated
Foreign Bodies
ƒ Heimlich maneuver
ƒ Back blows
ƒ Chest thrusts
–note : none of these should be applied if
patient is able to speak or cough
ƒ Finger sweep / grasp
–should be done only if object is visible
and will not be wedged deeper

215. Chest thrusts for
pregnant victims

217. Symptoms of Foreign Body Aspiration into
the Tracheobronchial Tree
ƒ Respiratory arrest
ƒ Stridor
ƒ No symptons (up to 40 %)
ƒ Classic triad (in 40 %)
–wheezing
–coughing
–dyspnea

218. Types of Bronchial Obstruction
ƒ Bypass valve obstruction
–air passes in and out
–no radiographic changes
–may cause no symptoms
ƒ Check valve obstruction
–exhalation around object prevented
–obstructive emphysema results
ƒ Stop valve obstruction
–both inspiration and expiration blocked
–distal atelectosis results
–pneumonitis may occur

219. 14 month old who presented
with 4 day history of
dysphagia and fever ; 4
months later was found to
have an aortic
pseudoaneurism on chest X-
ray

220. Management After Diagnosis
of Aspirated Foreign Body
ƒ Bronchoscopy : 99 % success rate
–rigid : often preferred in kids
–flexible
ƒ ventilation more difficult
ƒ can extract more distal objects
ƒ Patient should be observed 12 to 24
hours post procedure (till CXR normal)

221. Precautions in Partial Airway
Obstruction in Children
ƒ Don't do chest physical therapy
–may dislodge object higher in airway
ƒ General anesthesia required for safe
object removal
ƒ May be more than one object aspirated