2. Physical Assessment
• Cough
• A cough reflex is initiated by stimulation of the nerves of the respiratory tract mucosa
by the presence of dust, chemicals, mucus, or inflammation. The sound of coughing
is caused by rapid expiratory air movement past the glottis. Coughing is a useful
procedure to clear excess mucus or foreign bodies from the respiratory tract or as a
response to gastric contents refluxed into the airway. Paroxysmal coughing refers
to a series of expiratory coughs after a deep inspiration. Commonly, this occurs in
children with pertussis (whooping cough) or in those who have aspirated a foreign
body or a liquid they attempted to drink. Coughing can also be a symptom of
underlying lung disease such as asthma or cystic fibrosis among others. Some
children vomit after coughing episodes (posttussive emesis), and this may be initially
attributed to a gastrointestinal illness.
3. • Rate and depth of respirations
• Tachypnea (an increased respiratory rate) often is the first indicator of respiratory distress in young
children. Assess not only the rate but also the depth and quality of respirations and other vital signs such
as saturations, heart rate, and temperature.
• Retractions
• When children must inspire more forcefully than normal to inflate their lungs because of an airway
obstruction or stiff, noncompliant lungs, intrapleural pressure is decreased to the point that the intercostal
spaces draw inward, creating retractions.
• Restlessness
• When children or infants have decreased oxygen in body cells (hypoxia), they can become anxious and
restless. Be careful not to interpret the excessive movements of infants with respiratory distress as a sign
that they are improving. Anxious or restless stirring may be a signal that respiratory obstruction is
becoming acute or it may be one of the first signs of airway obstruction.
• Cyanosis
• Cyanosis (a blue tinge to the skin) can indicate hypoxia. If children have a low unoxygenated red blood
cell count (below 5 g/100 ml), cyanosis may not be apparent because there are not enough
unoxygenated red blood cells to give the arterial blood its blue tinge. The degree of cyanosis present,
therefore, is not always an accurate indication of the degree of airway difficulty. Children increase
respiratory effort in an attempt to supply more oxygen to tissues.
4. • Restlessness
• When children or infants have decreased oxygen in body cells (hypoxia), they can become
anxious and restless. Be careful not to interpret the excessive movements of infants with
respiratory distress as a sign that they are improving. Anxious or restless stirring may be a signal
that respiratory obstruction is becoming acute or it may be one of the first signs of airway
obstruction.
• Cyanosis
• Cyanosis (a blue tinge to the skin) can indicate hypoxia. If children have a low unoxygenated red
blood cell count (below 5 g/100 ml), cyanosis may not be apparent because there are not enough
unoxygenated red blood cells to give the arterial blood its blue tinge. The degree of cyanosis
present, therefore, is not always an accurate indication of the degree of airway difficulty.
• Clubbing of fingers
• Children with chronic respiratory illnesses can develop clubbing of the fingers, a change in the
angle between the fingernail and nail bed because of increased capillary growth in the fingertips .
The increased capillary growth occurs as the body attempts to supply more oxygen routes (more
capillaries) to distal body cells.
5.
6. • Adventitious sounds
• Pathologic conditions cause adventitious breath sounds (extra or abnormal breathing
sounds), which can be heard on lung assessment in children with respiratory disorders.
The vibrations produced as air is forced past an obstruction, such as mucus in the nose
or pharynx, cause a snoring sound (rhonchi). If the obstruction is at the base of the
tongue or in the larynx, a harsher, strident sound on inspiration (stridor) occurs. If an
obstruction is in the lower trachea or bronchioles, an expiratory whistle sound (wheezing)
occurs. If alveoli become fluid filled, fine crackling sounds (rales) are heard. Diminished
or absent breath sounds occur when the alveoli are so fluid filled that little or no air can
enter them.
• Chest diameter
• With chronic obstructive lung disease, children may be unable to exhale completely, thus
allowing air to be chronically trapped in lung alveoli (hyperinflation). This produces an
elongated anteroposterior diameter of the chest, sometimes termed a “pigeon breast.”
There is an accompanying tympanic or hyperresonant (loud and hollow) sound heard on
percussion (see later discussion on chest physiotherapy) over lung spaces.
7. What is ABG?
• An arterial blood gas is a laboratory test to monitor the patient’s acid-
base balance. It is used to determine the extent of the compensation
by the buffer system and includes the measurements of the acidity
(pH), levels of oxygen, and carbon dioxide in arterial blood. Unlike
other blood samples obtained through a vein, a blood sample from an
arterial blood gas (ABG) is taken from an artery (commonly on radial or
brachial artery).
8. What are the components of ABG?
• pH
• The pH is the concentration of hydrogen ions and determines the acidity or alkalinity
of body fluids. A pH of 7.35 indicates acidosis and a pH greater than 7.45 indicates
alkalosis. The normal ABG level for pH is 7.35 to 7.45
9. • PaCO2 (Partial Pressure of Carbon Dioxide)
• PaCO2 or partial pressure of carbon dioxide shows the adequacy of the gas exchange
the gas exchange between the alveoli and the external environment (alveolar ventilation).
Carbon dioxide (CO2) cannot escape when there is damage in the alveoli, excess CO2
combines with water to form carbonic acid (H2CO3) causing an acidotic state. When there
is hypoventilation in the alveolar level (for example, in COPD), the PaCO2 is elevated, and
respiratory acidosis results. On the other hand, when there is alveolar hyperventilation
(e.g., hyperventilation), the PaCO2 is decreased causing respiratory alkalosis. For PaCO2,
the normal range is 35 to 45 mmHg (respiratory determinant)
10. • PaO2 (Partial Pressure of Oxygen)
• PaO2 or partial pressure of oxygen or PAO2 indicates the amount of oxygen available
oxygen available to bind with hemoglobin. The pH plays a role in the combining power of
oxygen with hemoglobin: a low pH means there is less oxygen in the hemoglobin. For
PaO2, the normal range is 75 to 100 mmHg
11. • BE (Base Excess)
• BE. Base excess or BE value is routinely checked with HCO3 value. A base excess of less
base excess of less than –2 is acidosis and greater than +2 is alkalosis. Base excess, the
normal range is –2 to +2 mmol/L
12. • SO2 (Oxygen Saturation)
• SO2 or oxygen saturation, measured in percentage, is the amount of oxygen in the blood
of oxygen in the blood that combines with hemoglobin. It can be measured indirectly by
calculating the PAO2 and pH Or measured directly by co-oximetry. Oxygen saturation, the
normal range is 94–100%
13. • HCO3 (Bicarbonate)
• HCO3 or bicarbonate ion is an alkaline substance that comprises over half of the total
over half of the total buffer base in the blood. A deficit of bicarbonate and other bases
indicates metabolic acidosis. Alternatively, when there is an increase in bicarbonates
present, then metabolic alkalosis results.
14. • For pH, the normal range is 7.35 to 7.45
• For PaCO2, the normal range is 35 to 45 mmHg (respiratory determinant)
• For PaO2, the normal range is 75 to 100 mmHg
• For HCO3, the normal range is 22 to 26 mEq/L (metabolic determinant)
• Oxygen saturation, the normal range is 94–100%
• Base excess, the normal range is –2 to +2 mmol/L
15.
16.
17. Blood gases interpretation
• 1. Evaluate the pH: Normally, pH falls between 7.35 and 7.45. A pH below 7.35 denotes
acidosis; one above 7.45 reflects alkalosis. If the patient has more than one acid–base
imbalance at work, the pH identifies the process in control.
• 2. Evaluate PCO2: The partial pressure of arterial CO2 (PCO2) normally ranges between
35 and 45 mmHg. A PCO2 greater than 45 mmHg indicates ventilatory failure and
respiratory acidosis from CO2 accumulation. A PCO2 less than 35 mmHg indicates
alveolar hyperventilation and respiratory alkalosis.
• 3. Evaluate HCO3: A bicarbonate (HCO3 −) less than 22 mEq/L or a base excess (BE)
less than −2 mEq/L denotes metabolic acidosis. A bicarbonate level greater than 26
mEq/L or a BE greater than 2 mEq/L reflects metabolic alkalosis. If the two
measurements conflict, the BE is the better indicator of metabolic status.
• 4. Determine which is the primary and which is the compensating disorder: Often, two
acid–base imbalances coincide; one is primary, the other is the body’s attempt to return
the pH to normal. When both the PCO2 and the HCO3 − are abnormal, one denotes the
primary acid–base disorder and the other denotes the compensating disorder.
18. acid–base imbalances coincide; one is primary, the other is the body’s attempt to return
the pH to normal. When both the PCO2 and the HCO3 − are abnormal, one denotes the
primary acid–base disorder and the other denotes the compensating disorder.
a)To decide which is which, check the pH. Only a process of acidosis can make the pH
acidic; only a process of alkalosis can make the pH alkaline. For example, if steps 2 and
3 indicate that the patient has respiratory acidosis and metabolic alkalosis and the pH is
7.25, the primary disorder must be respiratory acidosis. The remaining disorder is
compensating for the primary problem.
b) When pH rises (becomes alkalotic), PCO2 decreases in amount (will be below 35
mmHg). When pH decreases (becomes acidotic), PCO2 increases (will be above 45
mmHg). When an opposite problem exists this way (pH increased; PCO2 decreased),
the problem is respiratory in origin.
c) pH and HCO3 − normally move in the same direction (when pH is elevated, HCO3 − is
elevated). When these two measurements correspond this way (pH decreased, HCO3 −
decreased), then the cause of the problem is metabolic in origin.
d.) Three states of compensation are possible: noncompensation, reflected in an alteration
of only PCO2 or HCO3 −; partial compensation, in which both PCO2 and HCO3 − are
abnormal and, because compensation is incomplete, the pH is also abnormal; and complete
compensation, in which both PCO2 and HCO3 − are abnormal but, because compensation
is complete, the pH is normal. To identify the primary disorder when compensation is
complete, consider a pH between 7.35 and 7.40 indicative of primary acidosis and a pH
between 7.40 and 7.45 indicative of primary alkalosis.
19. 5) Evaluate oxygenation: Normally, PO2 remains between 80 and 100
mmHg. A PO2 between 60 and 80 mmHg reflects mild hypoxemia;
between 40 and 60 mmHg, moderate hypoxemia; and below 40 mmHg,
severe hypoxemia.
6) Interpret the findings: Your final analysis should include the degree of
compensation, the primary disorder, and the oxygenation status (e.g.,
“partially compensated respiratory acidosis with moderate hypoxemia”).
20. Pulse oximetry
• Pulse oximetry (SpO2) is a
noninvasive technique for estimating
arterial oxygen saturation (SaO2)
either as a single measurement or
via continuous monitoring. For the
measurement, a sensor and a
photodetector are placed around a
vascular bed, most often a finger for
a child or a foot for an infant .
Infrared light is directed through the
finger from the sensor to the
photodetector. Because hemoglobin
absorbs light waves differently when
it is bound to oxygen than when it is
not, the oximeter can estimate the
degree of oxygen saturation (SaO2)
in the hemoglobin.
• Pulse oximetry screening is
recommended for all newborns prior
to hospital discharge in order to
increase the early detection of
critical congenital heart disease.
21. • Nasopharyngeal cultures
• When done efficiently, nasopharyngeal cultures can provide valuable
information about the microorganisms causing a disease. However, most
children are terribly frightened by having something placed in their noses
or throats and so may resist accordingly. Firm, calm support during the
procedure is essential. Nose and throat cultures can reveal only the
organisms present in the upper respiratory tract. As a result, they may not
show organisms causing a lower respiratory tract infection. A throat culture
will miss pathogenic organisms if the culture tip is not touched to the
infected aspect of the pharynx.
• Sputum analysis
• Because they cannot raise sputum with a cough, sputum collection is
rarely feasible in children younger than school age, unless collected from
an artificial airway or tracheostomy tube. Older children, however, are able
to cough and expectorate sputum. Teach them exactly what you want (a
specimen of what they are coughing up, not just clearing from the back of
their throat). Then, ask them to breathe in and out several times, cough
deeply, and spit mucus they have raised into a sterile specimen container.
22. Diagnostic procedures
• Chest x-rays
• Pulmonary function studies-Spirometry is the most common test of lung
function in children and can be done in an office or specialty setting. It
measures the amount of air that can be forced out of the lungs (peak
expiratory flow) in a forceful breath. Peak flow is often measured using
a handheld device (peak flow meter) and is a common way to
measure respiratory impairment in the office and at home. It is
commonly used in children with asthma to assess impairment.
26. • Choanal atresia is congenital obstruction of the posterior nares by an obstructing
membrane or bony growth, which prevents a newborn from drawing air through the nose
and down into the nasopharynx . It may occur either unilaterally or bilaterally.
• Newborns up to approximately 3 months of age are naturally nose breathers, so infants
born with choanal atresia almost immediately develop signs of respiratory distress after
birth as they attempt to breathe through their nose for the first time. Passing a soft #8 or
#10 French catheter through the posterior nares to the stomach is a part of birthing room
procedure in many healthcare facilities and confirms immediately that no atresia is
present.
• Choanal atresia can also be assessed by holding the newborn’s mouth closed and then
gently compressing first one nostril and then the other. If atresia is present, infants will
struggle as they experience air hunger when their mouth is closed. Their color improves
when they open their mouth to cry. Atresia is also suggested if infants struggle and
become cyanotic at feedings because they cannot suck and breathe through the mouth
simultaneously.
• The treatment for choanal atresia is either local piercing of the obstructing membrane or
surgical removal of the bony growth. Because infants with choanal atresia have such
difficulty with feeding, they may receive intravenous (IV) fluid to maintain their glucose
and fluid level until surgery can be performed.
27. Acute Nasopharyngitis(common colds)
• Upper respiratory infections are caused by several viruses, most predominantly rhinovirus,
respiratory syncytial virus (RSV), adenovirus, parainfluenza viruses, and influenza viruses. Children
who are in ill health from some other cause, or who have a compromised immune system, are
more susceptible than others to viral infections.
• Symptoms begin with nasal congestion, a watery rhinitis, and a low-grade fever. The mucous
membrane of the nose becomes edematous and inflamed, constricting airway space and causing
difficulty breathing. Posterior rhinitis, plus local irritation, leads to pharyngitis (sore throat). As upper
airway secretions drain into the trachea, this leads to a cough. Cervical lymph nodes may be
swollen and palpable. Although fever typically lasts only a few days, respiratory symptoms
generally last for about a week. Previous viral upper respiratory infections can be a precursor to
development of a secondary bacterial infection in young children, such as ear infections.
• No specific treatment is available for a common cold. Antibiotics are not effective against viral
illnesses, unless a secondary bacterial infection is present. If a child has a fever that is causing
discomfort, it can be alleviated by an antipyretic such as acetaminophen or ibuprofen. Help parents
understand these drugs are effective only in controlling pain, discomfort, and fever symptoms; they
do not reduce congestion or “cure” the cold. Children younger than 18 years of age should not be
given acetylsalicylic acid (aspirin) because this is associated with the development of Reye
syndrome, a potentially fatal neurologic disorder.
28. Pharyngitis
• Viral Pharyngitis
• The causative agent of pharyngitis is usually a virus. The symptoms are
generally mild: a sore throat, fever, rhinorrhea, cough, and general
malaise. On a physical assessment, regional lymph nodes may be
enlarged. Erythema will be present in the back of the pharynx and the
palatine arch. Exudate may or may not appear on the tonsils. Laboratory
studies are generally not indicated.
• If the inflammation is mild, children rarely need more than an oral
analgesic such as acetaminophen or ibuprofen for comfort. By school age,
children are capable of gargling with a solution such as warm water to
help reduce the pain. Before this age, children tend to swallow the solution
unless the procedure is well explained and demonstrated to them.
• Because of throat pain, food intake may be diminished, so focus needs to
be on adequate oral hydration.
29. • Streptococcal Pharyngitis
• Group A β-hemolytic streptococcus is the organism most frequently involved in bacterial
pharyngitis in children, particularly those between the ages of 5 and 15 years.
• Streptococcal infections are generally more severe and present more suddenly than viral
infections. The back of the throat and palatine tonsils are usually markedly erythematous
(bright red); the tonsils are enlarged, and there may be a white exudate in the tonsillar
crypts. Petechiae may be present on the palate. A child typically appears ill, with a fever,
sore throat, headache, stomach ache, and difficulty swallowing. Other respiratory
symptoms are generally absent, such as cough, congestion, rhinorrhea, or conjunctivitis.
A rapid antigen test and/or throat culture should be done to confirm the presence of the
Streptococcus bacteria. These findings may vary depending on the child’s age and make
it difficult to distinguish it from a viral illness. Some children may develop a sandpaper-
like rash (scarlatiniform rash) on the body.
• Streptococcal pharyngitis is treated with antibiotics, such as a penicillin or cephalosporin,
along with supportive treatments such as those discussed for viral pharyngitis. Although
rare, streptococcal infections can lead to acute rheumatic fever and glomerulonephritis if
not treated. Antibiotic treatment may help decrease the occurrence of these diseases and
shorten the duration of symptoms.
30. Retropharyngeal abscess
• The retropharyngeal lymph nodes, which drain the nasopharynx, are located just behind
the posterior pharynx wall. Although uncommon, an abscess can form in these lymph
nodes and may constitute a medical emergency as it may impact the airway.
• The presentation may be a high fever, refusal to eat, and may drool because they cannot
swallow saliva past the obstruction in the back of their throat. They begin to “snore” with
respirations as the pharynx becomes further occluded. To allow themselves more
breathing space, they may hyperextend the head, which is a very unusual position for
infants.
• A physical assessment may reveal swelling on one side of the neck but may require
further evaluation with radiographs to further evaluate.
• Therapeutic Management. IV antibiotic treatment and hospitalization is needed for these
infants to monitor hydration and their respiratory status. Although some retropharyngeal
abscesses will resolve with antibiotic treatment, some will need surgical drainage.
• Tonsillectomy
• Tonsillectomy is removal of the palatine tonsils. Adenoidectomy is removal of th
pharyngeal tonsils. Frequent throat infections or tonsillar hypertrophy that cause
breathing problems are common reasons for removal of the tonsils. Adenoids may be
removed if they are so hypertrophied they cause obstruction or sleep apnea.
31. Epistaxis
• Epistaxis (nosebleed) is extremely common in children and usually occurs from trauma,
such as picking at the nose or trauma. Dry air can cause mucous membranes to become
dry and be susceptible to cracking and bleeding. Nosebleeds may also occur after
strenuous exercise, with hemolytic disorders, or may be associated with nasal polyps,
sinusitis, or allergic rhinitis. Some families appear to show a familial predisposition to
them.
• Nosebleeds can be frightening. The fear, however, and the amount of blood that can be
seen is generally out of proportion to the seriousness of the bleeding.
• Keep children with nosebleeds in an upright position with their head tilted slightly forward
to minimize the amount of blood pressure in nasal vessels and to keep blood moving
forward, not back into the nasopharynx. Apply pressure to the cartilage on the sides of
the nose with your fingers for about 10 minutes . Make every effort to quiet the child and
to help stop crying because crying increases pressure in the blood vessels of the head
and prolongs bleeding. Discourage putting tissue in the nose or blowing the nose, as this
may disrupt a clot that has formed. Prolonged or severe bleeding may need emergency
intervention and packing. Chronic nasal bleeding may need investigation to rule out a
systemic disease or blood disorder.
32.
33. Sinusitis
• Sinusitis is infection and inflammation of the sinus cavities. It rarely occurs
in children younger than 6 years of age because the frontal sinuses do not
develop fully until that age. It can occur either as a primary infection or as
a secondary bacterial infection from a viral upper respiratory illness.
Children with bacterial sinusitis often have a preceding upper respiratory
illness but have persistent or worsening symptoms of fever, nasal
discharge, and cough that generally last for over 10 days . Treatment for
acute bacterial sinusitis consists of an analgesic for pain and an antibiotic
for the specific organism involved.
34. Laryngitis
• Laryngitis is inflammation of the larynx, which results in brassy, hoarse
voice sounds or the inability to make audible voice sounds. It may
occur as a complication of pharyngitis or from excessive use of the
voice, as in shouting or loud cheering. Sips of fluid (either warm or
cold, whichever feels best) offer relief from the annoying tickling
sensation often present.
35. Congenital Laryngomalacia/Tracheolamacia
• Congenital laryngomalacia means that an infant’s laryngeal structure is weaker than normal and collapses
more than usual on inspiration . This produces laryngeal stridor (a high-pitched crowing sound on
inspiration) present from birth and possibly intensified when the infant is in a supine position or when
sucking.
• The infant’s sternum and intercostal spaces may retract on inspiration because of the increased effort
needed to pull air into the trachea past the collapsed cartilage rings. Many infants with this condition must
stop sucking frequently during a feeding to maintain adequate ventilation and to rest from their exhausting
respiratory effort.
• Therapeutic Management
• Most children with congenital laryngomalacia need no routine therapy other than to have parents feed
them slowly and provide rest periods as needed. The condition improves as infants mature and cartilage
in the larynx becomes stronger at about 1 year of age. When parents wake at night and listen in a quiet
house to the sound of stridor, it seems unbearably loud and can make it difficult for them to believe it is
safe for them to care for the infant at home.
36. Croup(LARYNGOTRACHEOBRONCHITIS
• Croup (inflammation of the larynx, trachea, and major bronchi) is a frightening illness in childhood,
although complications are rare for caregivers. In children between 6 months and 3 years of age,
the cause of croup is usually a viral infection such as parainfluenza virus.
• Assessment
• With croup, children typically have only minimal signs at bedtime. Temperature is normal or only
mildly elevated. They may develop a barking cough (croupy cough), inspiratory stridor, and marked
retractions from inflammation of the larynx, trachea, and major bronchi.
• Therapeutic Management
• Cool moist air combined with a corticosteroid, such as dexamethasone, or racemic epinephrine,
given by nebulizer, usually reduces inflammation and produces effective bronchodilation to open
the airway. The provider may prescribe dexamethasone for home administration but racemic
epinephrine needs to be administered in a healthcare setting.
37. Epiglottitis
• Epiglottitis is inflammation of the epiglottis, which is the flap of cartilage that covers the opening to the
larynx to keep out food and fluid during swallowing. Although it is rare, inflammation of the epiglottis is an
emergency because the swollen epiglottis cannot rise and allow the airway to open. It occurs most
frequently in children from 2 to about 8 years of age.
• Epiglottitis can be either bacterial or viral in origin. Haemophilus influenzae type B has been replaced as
the most common bacterial cause of the disorder followed by pneumococci, streptococci, or
staphylococci. Echovirus and RSV also can cause the disorder. The incidence of epiglottitis has greatly
decreased with the introduction of the H. influenzae type B vaccine.
• Assessment
• Symptoms begin as those of a mild upper respiratory tract infection. After 1 or 2 days, as inflammation
spreads to the epiglottis, the child suddenly develops severe inspiratory stridor, a high fever, hoarseness,
and a very sore throat. Children may have such difficulty swallowing that they drool saliva. They may
protrude their tongue to increase free movement in the pharynx.
• If a child’s gag reflex is stimulated with a tongue blade, the swollen and inflamed epiglottis can be seen
to rise in the back of the throat as a cherry-red structure. It can be so edematous, however, that the
gagging procedure causes complete obstruction of the glottis and shuts off the ability of the child to
inhale. Therefore, in children with symptoms of epiglottitis (e.g., dysphagia, inspiratory stridor, cough,
fever, and hoarseness), never attempt to visualize the epiglottis directly with a tongue blade or obtain a
throat culture unless a means of providing an artificial airway, such as tracheostomy or endotracheal
intubation, is immediately available. This is especially important for the nurse who functions in an
expanded role and performs physical assessments and routinely elicits gag reflexes.
38. Aspiration
• Aspiration (inhalation of a foreign
object into the airway) occurs most
frequently in infants and toddlers. When
a child aspirates a foreign object such
as a coin or a peanut, the immediate
reaction is choking and hard, forceful
coughing. Usually, this dislodges the
object. However, if the airway becomes
so obstructed and no coughing or
speech is possible, intervention is
essential. A series of back blows or
subdiaphragmatic abdominal thrusts
may be used with children.
39.
40. Bronchial obstruction
• The right main bronchus is straighter and has a larger lumen than the left bronchus in children older
than 2 years of age. For this reason, an aspirated foreign object that is not large enough to obstruct
the trachea may lodge in the right bronchus, obstructing a portion or all of the right lung. The alveoli
distal to the obstruction will collapse as the air remaining in them becomes absorbed (atelectasis),
or hyperinflation and pneumothorax may occur if the foreign body serves as a ball valve, allowing
air to enter but not leave the alveoli.
• Assessment
• After aspirating a small foreign body, the child generally coughs violently and may become
dyspneic. If the article is not expelled, hemoptysis, fever, purulent sputum, and leukocytosis will
generally result as infection develops. Localized wheezing (a high whistling sound on expiration
made by air passing through the narrowed lumen) may occur. Because this is localized, it is
different from the generalized wheezing of a child with asthma.
• A chest X-ray will reveal the presence of an object if it is radiopaque. Objects most frequently
aspirated include buttons, bones, popcorn, nuts, and coins. Because objects such as those made
of plastic, nuts, or popcorn cannot be visualized well on X-ray film, an X-ray study may be
inconclusive. Foreign bodies may also lodge in the esophagus and cause respiratory distress
because of compression on the trachea. Care must be taken when feeding young children to avoid
potential choking/aspiration hazards. Popcorn, grapes, nuts, etc., can pose hazards. Additionally,
children may aspirate on nonfood items such as toys, coins, etc.
41. • Therapeutic Management
• A bronchoscopy may be necessary to remove the foreign body in the
operating room. After a bronchoscopy, assess the child closely for
signs of bronchial edema and airway obstruction that occur from
mucus accumulation because of the bronchus manipulation. Obtain
frequent vital signs (increasing pulse and respiratory rates suggest
increased edema and obstruction).
• Keep a child nothing by mouth (NPO) for at least an hour. Once a gag
reflex is present, offer the first fluid cautiously to prevent additional
aspiration. Cool fluid may feel more soothing than warm fluid and also
can help reduce the soreness in the throat. Breathing cool, moist air or
having an ice collar applied may further reduce edema.
43. Influenza
• Influenza involves inflammation and infection of the major airways. It is caused by the
orthomyxovirus influenza type A, B, or C. It is marked by a cough and fever but may be
accompanied by fatigue, body aches, a sore throat, and gastrointestinal symptoms such
as vomiting or diarrhea. The disease spreads readily through a home or a classroom
because children are contagious on the day before symptoms appear and for about the
next 5 days. Young children are at highest risk of complications from the flu, in particular,
children with chronic health conditions.
• Oseltamivir (Tamiflu) may be prescribed for young children or children with risk factors
such as cardiac or respiratory disease. To prevent the infection, children over 6 months
of age should receive either the inactivated vaccine (given by injection) or the activated
vaccine (given by a nasal spray). Because the influenza virus mutates yearly, the
influenza vaccine is specific for only that year and must be readministered yearly.
44. Bronchitis
• Bronchitis (inflammation of the major bronchi and trachea) is one of the more common
illnesses affecting preschool- and school-age children. It is characterized by fever and
cough, usually in conjunction with nasal congestion. Causative agents include the
influenza viruses, adenovirus, and Mycoplasma pneumoniae, among others.
• Children usually have a mild upper respiratory tract infection for 1 or 2 days, after which
they develop a fever and a dry, hacking cough, which is hoarse and mildly productive and
serious enough to wake a child from sleep. These symptoms may last for a week,
although full recovery sometimes takes as long as 2 weeks. On auscultation, rhonchi and
coarse crackles (the sound of rales) can be heard. A chest X-ray will reveal diffuse
alveolar hyperinflation and some markings at the hilus of the lung.
• Therapeutic Management
• Therapy is aimed at relieving respiratory symptoms, reducing fever, and maintaining
adequate hydration. An antibiotic will be prescribed if bacterial infection is suspected.
45. Bronchiolitis
• Bronchiolitis is inflammation and edema of the fine bronchioles and small bronchi, usually due to a viral
illness. The most common cause of bronchiolitis is the RSV, although a number of other viruses may also
cause bronchiolitis . The infection occurs most often in the winter and spring and is the most common
lower respiratory illness in children younger than 2 years of age, peaking in incidence between 3 and 6
months of age. It is the most common reason for hospitalization in infancy.
• Assessment
• Typically, infants have several days of symptoms of a viral respiratory infection, such as congestion,
rhinorrhea, and fever. This can progress to lower respiratory symptoms, including a cough, wheezing,
and retractions. Infants can have variable presentation of respiratory distress. The diagnosis of
bronchiolitis is typically made by a provider based on the history and clinical symptoms. Routine testing
and radiographs are not indicated in typical cases.
• Therapeutic Management
• For children with less severe symptoms, antipyretics, adequate hydration, nasal suctioning, nasal saline,
avoidance of tobacco exposure, and home monitoring are adequate. Hospitalization is warranted for
children with severe illness, such as apnea, hypoxia, or dehydration, which may occur due to difficulty
feeding.
• Because RSV infection spreads readily from person to person and can survive on surfaces for extended
time periods (>6 hours), infection control and hand hygiene is important to reduce the risk of
transmission . Although fevers generally last for only the first several days of illness, respiratory
symptoms can last for about 2 weeks.
• Palivizumab, a monoclonal antibody, is recommended as prophylactic injection to prevent RSV during
RSV season. Infants eligible for palivizumab are defined by specific qualifying criteria, generally defined
by gestational age less than 29 weeks or less than 1 year of age with preexisting health conditions, such
46. Asthma
• Asthma is a chronic inflammatory disorder of the respiratory track and is the most common chronic
illness in children . Typically, asthma presents before 5 years of age, although it may be difficult to
make a definitive diagnosis in these early years. Many viral illnesses can present with symptoms
that are similar and asthma and viral illnesses can trigger asthma symptoms, adding to the
complexity of diagnosis. Asthma symptoms can be variable with each child with different triggers
and clinical presentations. The severity of asthma in a child is dependent on risk factors, which
include genetics as well as environmental exposures, such as allergens, stress, pollution, etc., that
affect the body’s immune responses.
• When an allergen invades, mast cells release histamine and leukotrienes that result in diffuse
obstructive and restrictive changes in the airway because of a triad of inflammation,
bronchoconstriction, and increased mucus production. Most children with asthma can be shown to
have allergy triggers. A primary irritant is environmental tobacco smoke. Other indoor allergens,
such as mice and cockroaches, are common irritants. Outdoor irritants can include pollens,
grasses, and pollution, among others. Viral respiratory illnesses are a common trigger for asthma
exacerbations in children.
47. Therapeutic Management
• The diagnosis and management of asthma involves four components: (a) measure of
asthma assessment and monitoring, which involves history and physical examination
and objective testing to determine asthma severity and control; (b) education for
home self-management; (c) control of environmental factors that contribute to
symptoms (i.e., allergens); and (d) pharmacologic therapy, defined as quick relief
and long acting medications.
• The primary goal in asthma management is the prevention of airway inflammation. A
child with mild intermittent asthma may be prescribed an inhaled short-acting β-
agonist, such as albuterol, to take as needed, whereas children with persistent or
severe symptoms will need an inhaled corticosteroid to take daily in order to prevent
exacerbations.
48. • FLUTICASONE PROPIONATE
• Classification: Fluticasone propionate is a corticosteroid used as an oral inhalation for
prevention of asthma symptoms.
• Action: anti-inflammatory (bronchodilator)
• Pregnancy Risk Category: C
• Dosage: Dosages are based on asthma severity and whether a child has had previous
bronchodilators or corticosteroid use; given via a metered dose inhaler with a valve
holding chamber (spacer), twice a day.
• Possible Adverse Effects: Dizziness, dysphonia, oral thrush, and dermatitis; potential
for decrease in linear growth, headache, nausea, dry and irritated throat, cough, nasal
congestion, epistaxis, sneezing
• Nursing Implications• Instruct parents and child that this drug is not effective in an acute
attack.
• Advise parent to have child rinse their mouth (or take a drink if too young to rinse)
after administration to prevent thrush.
• Caution child and parents to take the drug exactly as prescribed and to continue other
prescribed medications.
• Instruct child and parents in the use of metered-dose inhaler for administration.
49. Status Asthmaticus
• Status asthmaticus is a severe and prolonged asthma attack that is not responsive to
asthma therapy. It requires hospital evaluation and close cardiopulmonary monitoring.
• Assessment
• A child with status asthmaticus is in acute respiratory distress. By definition, a child in
status asthmaticus has failed to respond to first-line therapy. Both heart rate and
respiratory rate are elevated. The child’s level of alertness and responsiveness may be
altered, and they may appear anxious. Both oxygen saturation and PO2 are low; PCO2 is
elevated because the bronchi are so constricted the child cannot exhale, resulting in CO2
accumulation. The rising PCO2 rapidly leads to acidosis. In contrast to the loud wheezing
initially heard in an asthma attack, children with status asthmaticus may have so little air
passing in or out of their lungs that breath sounds may be limited.
• Therapeutic Management
• Continuous nebulization with an inhaled β2 agonist and IV corticosteroids may be
necessary to reduce symptoms, along with oral or IV steroids, smooth muscle relaxers,
and others. In severe attacks, endotracheal intubation and mechanical ventilation may be
necessary to maintain effective ventilation and perfusion.
50. Pneumonia
• Pneumonia is an infection and inflammation of alveoli. It often has a bacterial or viral origin
and is categorized as hospital- or community-acquired.
• Pneumococcal Pneumonia
• The onset of pneumococcal pneumonia is generally abrupt and follows an upper respiratory
tract infection. In infants, the infection tends to be bronchopneumonia with poor consolidation.
In older children, pneumonia often localizes in a single lobe with full consolidation. During the
initial 24 to 48 hours of infection, children may have blood-tinged sputum that transitions to a
thick, purulent sputum.
• Assessment
• Children may often appear acutely ill, with high fever, tachycardia, chest or abdominal pain,
chills, and signs of respiratory distress. Breath sounds are often diminished, and crackles
(rales) may be present. Dullness on percussion indicates total consolidation. Chest
radiography will often reveal consolidation, and laboratory studies will indicate leukocytosis.
• Therapeutic Management
• Pharmacologic management may include IV fluid therapy, antibiotics, and antipyretics.
Oxygen saturation levels should be assessed frequently. Humidified oxygen may help labored
breathing and prevent hypoxemia. CPT may be used to encourage the movement of mucus
and prevent obstruction. Repositioning the child will prevent pooling of secretions.
51. • Chlamydial Pneumonia
• Chlamydia trachomatis pneumonia, typically seen in newborns up to 12 weeks of age, is
often contracted from contact with the mother’s vagina during birth. Symptoms begin
gradually with nasal congestion, a sharp cough, and poor weight gain. These progress to
tachypnea and wheezing and rales on auscultation. A laboratory assessment will show
elevated levels of IgG and IgM antibodies, peripheral eosinophilia, and antibodies to C.
trachomatis. Antibiotics are often used for pharmacologic treatment.
• Viral pneumonia
• Viral pneumonia is generally caused by viral infections of the upper respiratory tract.
Symptoms begin as an upper respiratory tract infection and may progress to diminished
breath sounds and fine rales on auscultation. Antibiotic therapy is not effective against
viral infections. Rest and antipyretics are used for treatment. Similar to bacterial
pneumonia, fatigue often occurs following the acute phase of illness.
• Mycoplasmal Pnemonia
• Mycoplasmal pneumonia occurs more frequently in children over 5 years of age during
winter months. Fever, cough, cervical lymphadenopathy, and rhinitis are common
symptoms. Mycoplasmal organisms are generally sensitive to erythromycin or
tetracycline.
52. Atelectasis
• Atelectasis, the collapse of lung alveoli, may be a primary or secondary condition.
• Primary Atelectasis
• Primary atelectasis is seen in preterm newborns with limited surfactant and poor respiratory
strength or mucus or meconium plugs in the trachea . Respirations become irregular, with nasal
flaring and apnea. Respiratory grunting, caused by the glottis closing upon expiration, increases
pressure in the respiratory tract and keeps alveoli from collapsing. Grunting may also be tiring to
the newborn, resulting in hypoxemia, hypotonicity, and flaccidity. Therapy must be directed at the
cause of atelectasis. Crying and administration of oxygen may aerate the alveoli and may decrease
cyanosis.
• Secondary Atelectasis
• Secondary atelectasis often occurs from a respiratory tract obstruction that prevents air from
entering a portion of the alveoli . As residual air in the alveoli is absorbed, the alveoli collapse.
Causes of obstruction may include mucus plugs associated with chronic respiratory disease,
foreign object aspiration, or pressure on lung tissue from outside forces, such as compression from
a diaphragmatic hernia, scoliosis, or enlarged thoracic lymph nodes.
• Therapeutic Management
• Atelectasis caused by inspiration of a foreign object will not be relieved until the object is removed
by bronchoscopy. Atelectasis caused by a mucus plug will resolve when the plug clears up. The
chest of a child with atelectasis should be kept free from pressure for optimal lung expansion.
• A semi-Fowler’s position generally allows for the best lung expansion because it lowers abdominal
contents and increases chest space. Suction, CPT, and increased humidity may prevent further
bronchial plugging.
53. Pneumothorax
• Pneumothorax is the presence of atmospheric air in the pleural space, causing
atelectasis. It can occur when external puncture wounds allow air to enter the chest.
• Pneumothorax occurs in approximately 1% of newborns often because of rupture of the
alveoli from the extreme intrathoracic pressure needed to initiate a first inspiration. The
infant will develop signs of respiratory distress. Auscultation reveals absent or decreased
breath sounds on the affected side. Percussion may not be revealing. Despite the hollow
air space, the chest may be hyperresonant because of the presence of increased air. A
more revealing sign may be the shift of the apical pulse (mediastinal shift) away from the
site of the pneumothorax. Chest radiography will show a darkened area of the air-filled
pleural space.
• A child with a pneumothorax needs oxygen therapy to relieve respiratory distress. A
thoracotomy catheter or needle may be placed through the chest wall into the pleural
space to remove accumulated air. In most children with pneumothorax, symptoms are
relieved within 24 hours after suction initiation.
• If air in the pleural space is from a puncture wound such as a stab wound, cover the
chest wound immediately with an impervious material, such as petrolatum gauze, to
prevent further air from entering and to decrease the risk of atelectasis. The extent of
symptoms and the outcome will depend on the cause of entry of air into the pleural space
and its removal.
54. Bronchopulmonary dysplasia
• Bronchopulmonary dysplasia (BPD) is chronic lung condition that can
occur in infants. The condition, frequently found in preterm infants who
received mechanical ventilation for respiratory distress syndrome at birth,
is thought to occur from a combination of surfactant deficiency,
barotrauma, oxygen toxicity, and inflammation. Infants may develop
tachypnea, retractions, nasal flaring, tachycardia, and oxygen
dependence. Auscultation reveals decreased air movement. Chest
radiography may show areas of overinflation, inflammation, and
atelectasis. As inflamed surfaces heal, the infant is left with fibrotic
scarring.
• The clinical course ranges from a mild need for increased oxygen, which
gradually resolves over a few months, to a severe disease requiring
chronic tracheostomy and mechanical ventilation during the first few years
of life.
• Administration of a corticosteroid to reduce inflammation and a
bronchodilator by nebulizer can improve respiratory function. Infants need
to be monitored carefully for nutrition and fluid intake, especially if they are
55. Tuberculosis
• Tuberculosis, caused by the bacterium Mycobacterium tuberculosis, is a highly contagious pulmonary
disease that affects children worldwide. The mode of transmission is inhalation of infected droplets, and
the incubation period is 2 to 10 weeks.
• In initial stages of infection, primary inflammation occurs and a slight cough develops. As the disease
progresses, anorexia, weight loss, night sweats, and a low-grade fever may be present. Leukocytes and
lymphocytes invade the lung area to attack the tuberculosis organism and wall off the primary infection.
The wall surrounding the bacteria then calcifies and confines the organism permanently. If the infection is
unable to be contained, tuberculosis may spread to other parts of the body (miliary tuberculosis), such as
bones, lymph nodes, kidneys, and the subarachnoid space (tuberculous meningitis).
• Assessment
• All children living in high-risk areas should have a tuberculin test as part of basic preventive healthcare
screening at 9 to 12 months of age and yearly thereafter. A Mantoux test, also known as a purified
protein derivative (PPD) test, is administered by injecting 5 units of protein derivative vaccine
intradermally, usually in the left lower arm. Assessment of the area 72 hours after administration is
necessary to evaluate the level of reaction. A positive reaction, the formation of a 5- to 15-mm reddened
induration, indicates the child has been exposed to tuberculosis or has developed antibodies to the
foreign products of the tuberculosis organism. Children with positive reactions need a follow-up chest
radiograph. Skin testing should not be done on children who have a history of tuberculosis diagnosis
because of the risk of intense reaction at the testing site. Additionally, a tuberculosis screening test
should not be done immediately after administration of the measles, mumps, and rubella (MMR) vaccine
because of the possibility of a false-negative result.
• Sputum analysis, typically done for 3 consecutive days, is needed to confirm a diagnosis of active
disease. Mucus should be expectorated from the lungs. Infants and children younger than 5 years of age
do not expectorate sputum but swallow it; therefore, a gastric lavage may be necessary to obtain the
specimen. Therapeutic playand support are helpful throughout the procedure.
56. Therapeutic Management
• Antituberculosis drugs include isoniazid, rifampin, pyrazinamide, and
ethambutol. Dosage and frequency of pharmacologic therapy vary with
history and clinical presentation and are often determined in consultation with
an infectious disease specialist. In addition to drug therapy, children should
ingest a diet high in protein and calcium. Children should have periodic chest
radiographs to ensure the disease does not reactivate. Up-to-date
vaccination is encouraged. Children may return to regular activities, including
school, when drug therapy has been initiated and treatment compliance has
been established.
57. Cystic fibrosis
• Cystic fibrosis (CF) is an inherited disease of the secretory glands. The
disease is characterized by a thick mucus secretions, particularly in the
pancreas and the lungs, as well as electrolyte abnormalities in sweat
gland secretions. An abnormality of the long arm of chromosome 7 results
in the inability to transport small molecules across cell membranes,
leading to dehydration of epithelial cells in the airway and pancreas. CF is
inherited from an autosomal recessive trait. Chorionic villi sampling or
amniocentesis can be performed during pregnancy for ea.ly detection.
Additionally, all newborns can be screened at birth .
• Affected males may be unable to reproduce secondary to persistent
plugging and blocking of the vas deferens by tenacious seminal fluid.
Affected females may have thick cervical secretions that limit sperm
motility. Alternative insemination and in vitro fertilization are options for
patients who desire to become pregnant.
58. • Pancreas involvement
• The acinar cells of the pancreas normally produce lipase, trypsin, and amylase—
enzymes that flow into the duodenum to digest fat, protein, and carbohydrate. In patients
with CF, these enzyme secretions may be so thick that they plug ducts, resulting in
atrophy of the acinar cells and an inability to produce enzymes. The islets of Langerhans
and insulin production are influenced much later because of their endocrine (ductless)
activity.
• An absence of pancreatic enzymes in the duodenum results in an inability to digest fat,
protein, and some sugars. Bowel movements become large, bulky, and greasy
(steatorrhea). An increase in intestinal flora and fat results in an extremely foul odor, and
the increased bulk of feces often leads to a protuberant abdomen. Malnutrition occurs
without therapy and may include emaciated extremities and loose skin folds on the
buttocks. Fat-soluble vitamins, particularly vitamins A, D, and E, cannot be absorbed in
the absence of fat absorption, resulting in vitamin deficiency.
• Meconium in a newborn is normally thick and tenacious. In approximately 10% of children
with CF, it may be so thick that it obstructs the intestine, known as meconium ileus. A
newborn who develops abdominal distention with no passage of stool within 24 hours of
birth should be evaluated further.
59. • Lung involvement
• The anteroposterior diameter of the chest becomes enlarged in CF. Thickened mucus
pools in bronchioles and often results in frequent infections. Organisms most frequently
cultured are Staphylococcus aureus, Pseudomonas aeruginosa, and H. influenzae.
Atelectasis may occur as a result of absorption of air from alveoli behind blocked
bronchioles. Clubbed fingers may occur because of inadequate peripheral tissue
perfusion.
• Sweat gland involvement
• Assessment CF is typically detected at birth through screening tests. It may also be
detected by documentation of chromosomal abnormality, abnormal chloride concentration
in perspiration, absence of pancreatic enzymes in the duodenum, the presence of
immunoreactive trypsinogen in the blood secondary to pancreatic obstruction, and
pulmonary involvement.
• CF may be suspected in a newborn who fails to regain normal birth weight within 7 to 10
days after birth. This occurs secondary to the infant’s inability to absorb milk fat. Nurses
should be concerned with poor weight gain or meconium ileus in a newborn. Children
undiagnosed at birth may present with complaints of increased hunger and steatorrheic
stools because these stool changes are inconsistent with simple colic.
• Respiratory infections develop around 4 to 6 months of age, and wheezing and rhonchi
are often heard on chest auscultation. The chest may be hyperresonant with percussion.
Cough is a prominent finding by preschool, and clubbing of fingers may also be present
60. • Sweat Testing
• Sweat testing detects abnormal salt concentrations. In this procedure, the paper is analyzed
for sodium chloride content. A normal concentration of sodium chloride in sweat is 20 mEq/L;
more than 60 mEq/L of sodium chloride is diagnostic of CF. Sweat tests are often not
necessary because of advanced chromosomal testing.
• Duodenal Analysis
• Duodenal secretions may be used to detect pancreatic enzymes and reveal the extent of
pancreatic involvement. This is done by passing a nasogastric tube into the duodenum;
secretions are then aspirated for analysis. The tube placement can be determined by pH
levels. Secretions from the duodenum are sent to the laboratory for analysis of trypsin
content, the easiest pancreatic enzyme to assay.
• Stool Analysis
• Stool may be collected and analyzed for fat content and lack of trypsin of the stool.
• Pulmonary Testing
• A chest X-ray generally confirms the extent of pulmonary involvement. Pulmonary function
may be tested to determine the extent of atelectasis and emphysema. Therapeutic
Management
• Therapeutic management is a collaborative process to reduce the involvement of the
pancreas, lungs, and sweat glands.
