Lower respiratory Disorders

1. Lower respiratory tract infection
(LRTI)
PRESENTED BY : Mrs. RANI JOSEPH(MSc NURSING)
CHILD HEALTH DEPARTMENT
SRM TRICHY COLLEGE OF NURSING

2. LOWER RESPIRATORY TRACT DISORDERS

3. LOWER RESPIRATORY TRACT DISORDERS
Lower respiratory Tract Disorders includes
Acute Bronchitis
Bronchiolitis
Pneumonia
Acute Bronchitis:
Definition : Acute Bronchitis is a febrile illness, that is
characterized by dry couth (which is worst at night) and wheezing.
It involves inflammation of one or more bronchi.

5. Acute Bronchitis
Definition :
Acute Bronchitis is a febrile illness, that is characterized by dry cough (which is worst at night)
and wheezing. It involves inflammation of one or more bronchi.
Incidence and Etiology:
 Acute bronchitis occurs specially in children less than 4 years of age. It is usually associated
with previous upper respiratory infection.
 Acute bronchitis may be bacterial or viral in origin. The viruses commonly associated with
bronchitis are Adenovirus, Respiratory syncytial virus and Rhinovirus. It may also occur with
communicable diseases like Pertussis, Measles, Diphtheria and Typhoid. The bacteria
Mycoplasma pneumoniae ma cause acute bronchitis especially in school age children. Bronchitis
may also be caused by physical or Chemical agent like dust, allergens, strong fumes, etc.

6. Clinical Features:
The following are the most common symptoms of acute bronchitis:
Runny nose(usually before cough starts)
Malaise
Chills
Fever
Back and muscle pain
Sore throat
Wheezing
In early stages of condition, the child may experience a dry non-productive
cough which progresses to excessive mucous filled cough.
The symptoms usually last for 7-14days

7. Diagnostic Evaluation:
Diagnosis is on the basis of history and physical examination. Following tests
may help in diagnosis:
Chest auscultation reveals widespread rhonchi and coarse crepitations.
X-ray chest shows increased bronchial markings
Management
It includes administration of
Antibiotics
Cough Experiment
Antipyretic Medicine
Steam inhalation

8. BRONCHIOLITIS
Definition
Bronchiolitis is a serious illness characterized by inflammation of bronchioles,
causing severe dyspnoea.
Incidence and Etiology
Bronchiolitis is common in infants under the age of six months. It is common in
winter and early spring. The exact etiology is not clear. Etiologic agent may be
viruses such as Respiratory Syncytial virus, Adenovirus and Influenza virus. Certain
bacteria's like Haemophilus influenzae, Pneumococcus and Streptococcus
hemolyticus may also cause bronchiolitis.

10. Clinical features:
 Following mild upper respiratory infection, the disease abruptly manifests with
dyspnea(rapid shallow breathing) mild to moderate fever, air hunger, nasal flaring and
cyanosis.
 Chest signs include intercostal, subcostal and suprasternal retractions, hyper resonant
percussion note, diminished breath sounds, widespread crepitations and wheezing.
Diagnostic Evaluation
Diagnosis is obvious from clinical presentation and Chest X-ray. X-ray of chest shows
emphysema, prominent broncho vascular markings and small areas of collapse. Lungs are
characteristically over inflated and intercostal spaces are wide.

11. Management
Bronchiolitis is an emergency. The management is mostly symptomatic.
General measures include oxygen administration, maintaining atmosphere well
saturated with water vapor, mild sedation and postural drainage. IV fluids are
given to combat dehydration.
Antibiotics are used in case of secondary bacterial infection.
Sever bronchiolitis resulting from Respiratory Syncytial Virus is best treated
with antiviral agent Ribavirin(Virazole) available as powder to be
reconstituted for aerosol therapy.

13. PNEUMONIA
Definition
Pneumonia is defined as acute inflammation and consolidation of lung parenchyma.
Incidence:
Pneumonia in children is a major concern in developing countries, because 1/3rd of all hospital
out patients comprise of acute respiratory infections of which nearly 30% have pneumonia. It is
the second leading cause of death in children under five years of age.
Classification:
Pneumonia can be classified on
 Anatomic Basis
 Etiologic basis

15. A.A Classification on anatomic basis
i. Lobar or lobular pneumonia : One or more lobes of lungs are involved.
ii. Interstitial Pneumonia : Interstitial tissues of lungs are affected
iii.Bronchopneumonia: Patchy consolidation of lungs is known as
bronchopneumonia
B.Classification on etiologic basis
Bacterial pneumonia : It may be caused by Pneumococcus, Streptococcus,
Staphylococcus, Haemophilus, Influenzae and H.Pertussis.
Viral Pneumonia : It is caused by viruses like influenza, Measles, Adenovirus and
Respiratory Syncytial Virus.
Fungal Pneumonia : It may be caused by histoplasmosis and Coccidiomycosis.
Protozoal Pneumonia: It is caused by Pneumocystis Carinii, Toxoplasma gondii and
Entamoeba Histolytica

16. C.Miscellaneous Types
Aspiration Pneumonia : It is caused by aspiration of food, nasal drops, amniotic
fluid by newborn, water(drowning) and chemicals like kerosene oil, etc.
Loffler’s Pneumonia : It is a disease in which eosinophils accumulate in lungs, in
response to parasitic infection. It may be caused by parasites like Ascaris
lumbricoides, Strongyloides, Stercoralis and Ancylostoma duodenale.
Hypersensitivity Pneumonitis : It is an inflammation of alveoli within the lungs
caused by hypersensitivity to inhaled dust
Hypostatic Pneumonia : It results from collection of fluid in dorsal region of
lungs and occurs especially in those confined to bed for long time ( like bedridden
or elderly persons)

19. Clinical Features:
Clinical features of pneumonia include
Sudden onset
High fever with chills
Cough with thick sputum
Increased respiratory rate
Grunting respiration
Nasal flaring
Running nose
Irritability
Malaise
Sore throat
Anorexia

20. Clinical Features
Late symptoms include
Convulsions
Drowsiness
Inability to drink from mouth
Chest in drowning
Wheezing
Hoarseness of voice
Cyanosis
Pleural pain which may be increased by deep breathing in
and is referred to shoulder or abdomen.

21. Pathogenesis:
Bacteria or virus reach the lungs through respiratory passage and multiply in the alveoli.
They disturb the defence mechanism of the lungs.
There will be gross alteration in properties of normal lung secretions.
The first stage of attack is called “engorgement”.
During this period, the lungs become dark bluish red and heavy.
During the next stage i.e., ‘red hepatization’, the affected lobe becomes solid with red cells and fibrin and air
is displaced.
In the last stage i.e., ‘grey hepatization’, the pleural surface becomes dull in colour and alveoli are filled with
leucocytes and fibrin.
The invading organism produces inflammation in mucosa with exudation in alveoli due to which it becomes
consolidated.

22. Diagnostic Evaluation :
Diagnosis of pneumonia can be made on the following basis.
i. History of the child reveals presence of cough with increased respiration
ii. Chest X-ray :X-ray findings suggesting bronchopneumonia include diffuse patchy
consolidation in lungs. Consolidation is seen as homogenous opacity occupying in the
anatomic area of ta lobe, usually in one lung.
iii. Diagnosis is confirmed by isolating the organism in blood or from pleural fluid or
bronchoalveolar lavage fluid.
iv. Isolation of organism from nasopharynx or throat by culture or PCR in viral pneumonia
v. Blood test reveals increased blood count with polymorphonuclear leucocytosis seen in
bacterial pneumonia.

23. Management
 Management of pneumonia depends on the causative agent detected. Antimicrobial therapy is
started on the basis of sensitivity test.
 Antibiotics often used in the treatment of bacterial pneumonia include Penicillin, Amoxicillin
and Clavulanic acid and Macrolides including Erythromycin, Azithromycin and Clarithromycin.
Penicillin was formerly the antibiotic of choice in treating pneumonia. Penicillin may still be
effective in treatment of pneumococcal pneumonia, but it should only be used after cultures
of the bacteria and confirmation of sensitivity to this antibiotic. In pneumonia caused by
Klebsiella pneumoniae and Haemophilus influenzae, useful antibiotics are second and third-
generation Cephalosporin, Amoxicillin and Clavulanic acid, Fluoroquinolones (levofloxacin) and
Sulfamethoxazol/trimethorpirm.

24. Mycoplasma Pneumonia is a type of bacteria that often causes a slowly
developing infection. This bacteria is the main cause of may pneumonias in
summer and fall months, and the condition often referred to as “Atypical
Pneumonia”. Macrolides(Erythromycin, Clarithromycin,Azithromycin and
Fluoroquinolones) are the antibiotics commonly prescribed to treat
Mycoplasma pneumonia.
Viral pneumonia does not typically respond to antibiotic treatment. It mat be
caused by Adenoviruses, Rhinovirus, Influenza Virus(flu)> Respiratory
Syncytial Virus(RSV) and Parainfluenza virus. These pneumonias usually
resolve over time with the body’s immune system fighting off the infection.
In some situations, antiviral theraphy is helpful in treating these conditions.
It is important to make sure that a bacterial pneumonia does not secondarily
develop. If it does then the bacterial pneumonia is treated with appropriate
antibiotics more recently, H1N1 , Swine-origin influenza, has been associated
with very severe pneumonia, often resulting in respiratory failure.

25. Fungal infection that can lead to pneumonia include
Histoplasmosis, Coccidiomycosis, Blastomycosis, Aspergillosis,
and Cryptococcosis. These are responsible for a relatively
small percentage of pneumonias. Each fungus responds to
specific antifungal drugs, among which are Amphotericin B,
Fluconazole (Diflucan), Penicillin and Sulphonamides.

26. Nursing Management
i. Make Continuing assessment
 Monitor the Child’s respiratory rate and pattern.
 Monitor breath sounds to note presence of rale, rhonchi and wheezing.
 Observe for signs of respiratory distress.
ii. Facilitate respiratory efforts
 Maintain patent airway and provide high humidity atmosphere.
 Administer oxygen to maintain the oxygen saturation in blood.
 Place the child in semi-fowlers position to help in breathing.
 In case of unilateral pneumonia, make the child lie on affected side, to
splint the chest wall and prevent painful pleural rubbing.

27. Position of the child should be changed frequently to prevent
pooling of secretions in lungs.
Keep the child warm and comfortable
Administer cough suppressants and bronchodilators, as prescribed.
Provide steam inhalation and chest physiotherapy to help in
drainage of secretions.
If the child is old enough, teach him effective coughing and deep
breathing
Give increased amount of fluids as this will help in liquefying the
thick tenacious secretions.

28. iii. Control fever
 Provide bed rest to the child.
 Administer the prescribed antibiotics
 Tepid sponging is done to reduce fever
 Increase the fluid intake to prevent hydration.
iv. Maintain fluid and electrolyte balance along with nutritional status of the child
 Provide adequate fluids to meet increased fluid demand of the body.
 If the child is having breathing difficulty, do not give anything orally as there is
greater risk of aspiration.
 When oral feedings are started, after the child’s condition permits, feed the
child slowly and carefully to prevent aspiration and aggravation of cough.
 Give high calorie liquid diet to the child.

29. v. Promote rest and sleep
Handle the child as little as possible to provide rest
Provide diversion therapy to the child to avoid boredom.
Administer mild sedatives when the child is restless or
irritable.
Make the baby lie on affected side, to splint the chest
wall and reduce pleural pain.
Administer cough suppressants before the bay sleeps.

30. Complications
Complications of pneumonia include
Pleural effusion
Emphysema
Pneumatocele
Bronchiectasis
Prevention
Two vaccines are available to prevent pneumococcal disease the Pneumococcal
Conjugate Vaccine and the pneumococcal polysaccharide Vaccine. The
pneumococcal conjugate vaccine is recommended for al l children <2 years of age.
This vaccination should be repeated every five to seven years, whereas the flu
vaccine is given annually.