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Respiratory disorders peds
- 1. Respiratory Disorders Nursing III Linda Speranza PhD, ARNP-C
- 2. Respiratory Assessment Count respiration for 1 full minute Infants– obligatory nose breathers Identify signs of respiratory distress Listen to breath sounds 1st! Stridor- thrill harsh sound Rhonchi Wheezing
- 3. Respiratory Assessment Quality of respirations Quality of pulse Color- pale, cyanotic, mottling Cough- croupy- loose, wet, dry Behavior change- tired of breathing fast?, restless?, lethargic?, change in LOC Signs of dehydration- low I&O, L skin turgor- check in abd or sternum, lack of tears in older children,
- 4. Respiratory Assessment Nasal Flaring Widening of the nares during inspiration Represents an increased effort by the infant to breathe
- 6. Retractions Depth and location of retractions indicate the severity of distress Intercostal retractions- mild Subcostal - moderate Suprasternal – moderate Supraclavicular- severe Use of accessory muscles- severe
- 7. Anatomy is Different! • Development • Airways – shorter and more narrower • Increase in airway resistance in children • Flexible larynx • Tongue is proportionally larger – can cause obstruction • Obligate nose breathers – plugging can cause respiratory distress
- 8. A Child’s Respiratory Anatomy
- 9. Respiratory Distress Syndrome Resultof a primary absence, deficiency, or alteration in the production of pulmonary surfactant Prematurity Surfactant deficiency disease
- 10. Signs & Symptoms of RDS Shortness of breath Grunting Nasal flaring Cyanosis Apneic spells Increased work of breathing – tachypnea 1st sign of respiratory distress Retractions
- 11. Management/Treatment of RDS Support adequate ventilation Surfactant replacement therapy Monitor for Complications
- 12. Nursing Interventions Risk for ineffective breathing pattern Check prenatal meds Monitor vitals and skin Clear airway prn with bulb syringe Give warm humidified O2 Ineffective thermoregulation Warm all inspired gases. Cold air= more need of O2 and high metabolic rate Respiratory distress can lead to metabolic acidosis. Check for acrocyanosis, bradycardia, apnea, etc
- 13. Altered nutrition: less If there is respiratory distress do not give oral fluids. Start parenteral nutrition per MD Give calories to prevent metabolic acidosis due to starvation. TPN is an alternative Risk for fluid vol deficit Record I& O hourly and daily weights. Circulatory overload= pulmonary edema Check signs of dehydration: poor skin turgor, pale mucous memb, sunken anterior fontanelle. Specific gravity, etc Check IV sites for infiltration, infection (edema, and erythema)
- 15. Croup Syndrome Broad classification of upper airway illnesses that result from swelling of the epiglottis and larynx Viral Spasmodic laryngitis Laryngotracheitis Laryngotracheobronchitis (LTB) Bacterial Bacterial trachitis Epiglottitis
- 16. Laryngotracheobronchitis (LTB) LTB,most common form of croup Usually caused by virus; Adenovirus, Respiratory Syncytial Virus (RSV) Influenza Virus Inflammation and narrowing of the laryngeal and tracheal areas.
- 17. Clinical Manifestations of LTB Upper respiratory infection (URI) symptoms that gradually progress to signs of distress. Hoarseness, barky cough Inspiratory stridor Retractions Restlessness and irritability Pallor and cyanosis Sometimes a low grade fever Potential complication: airway obstruction Difficulty swallowing or drooling= epiglotitis
- 18. Treatment/Management of LTB Lateral neck x-ray confirms diagnosis Maintain Airway Patency Supplemental oxygen with humidity Cool mist tent Meet fluid and nutritional needs
- 19. Treatment/Management of LTB Medication Racemic epinephrine Bronchodilators – Albuterol Side tachycardia Steroid therapy- IV or inhaled Keep calm and comfortable NO Throat cultures or visual inspections of the mouth Continue to monitor- Respiratory effort, responsiveness, signs of respiratory distress Constant attendance
- 21. Epiglottitis • An inflammation of the epiglottis, the long narrow structure that closes off the glottis during swallowing • A life-threatening condition!!! This is a Medical Emergency • Bacterial- Caused by strep, staph, and haemophilus influenzae type B • Hib vaccine reduces risk for epiglottitis
- 22. Clinical Manifestation of Epiglottitis Sudden onset CARDINAL SIGNS- intense sore throat/difficulty swallowing/ drooling Cherry red, edematous epiglottis High fever- 102 Dysphonia Dysphagia Inspiratory stridor Respiratory distress Tripod position
- 23. Diagnosis of Epiglottitis Diagnosis confirmed by lateral neck films High Oxygenation to reverse hypoxemia Cool mist oxygen Cools airway and lowers swelling! Antipyretics, ab, & steroids to decrease inflammation May use a tracheostomy to bypass the problem
- 24. Treatment/ Management Epiglottitis Closely Monitor Respiratory status. Do not attempt to examine the throat. Axillary temp only! Medications include antibiotics and steroids to decrease inflammation Minimize fear and anxiety to decrease oxygen consumption
- 26. Bronchitis Lower airway disorder Inflammation of the trachea and bronchi Cause- mainly viral Symptoms Fever, dry hacking cough non productive. Productive in a couple of days Management Cool, humid air, increase fluids, antipyretics, cough suppressants
- 28. Bronchiolitis Caused when a virus or bacterium causes inflammation and obstruction (mucus) of the small airways Occurrence- First 2 years Peak: 6 months Cause – Respiratory Syncytial Virus (RSV)
- 29. Bronchiolitis Pathophysiology Cell debris- death virus after bursting to invade Irritation= Swelling/mucus Bronchospasm Inhalation, poor exhalation Wheezing, hypoxemia, respiratory failure
- 30. Clinical Manifestation of Bronchiolitis Illness may have been occurring for a few days- upper respiratory Lower respiratory Severerespiratory distress. Thick mucus occludes bronchioles Initial: Rhinitis, cough, low fever, tachypnea, poor feeding, v & d, dehydration, less playful
- 31. Clinical Therapy For Bronchiolitis History and Physical Chest x-ray Hyperinflation, atelectasis and inflammation Nasal swab- to find bacteria Ribavirin – antiviral for RSV. Used for immunocompromised Bulb syringe & Saline Isolation Risk Factors – lung disease, low weight, siblings that go to school, passive smoke, premmie
- 32. Treatment/Management Bronchiolitis Rest& elevate HOB to 30 Clear fluids (NPO if resp rate >60) I& O x 8 h & daily weights, mucous memb Maintain respiratory functions. Use suctioning- Also before feeding Cool, humidified oxygen Albuterol updrafts Steroids Infants often hospitalized due to feeding difficulties, increased respirations Hand washing!- RSV is recurrent
- 34. Bronchopulmonary Dysplasia (BPD) Chronic Lung Disease Results from an acute respiratory disorder that begins during infancy Risk Factors Prematurity Lung immaturity High inspired oxygenation concentrations, Positive pressure ventilation Patent ductus arteriosus Vitamin A deficiency
- 35. Clinical Manifestation of BPD Persistent signs of respiratory distress Tachypnea Wheezing Crackles Irritability Nasal flaring Grunting Retractions Pulmonary edema FTT- Failure to Thrive- O2 demands ↑ + fatigue Intermittent bronchospasm & mucous plugs
- 36. Tracheostomy Keep small toys, dust away from child Careful when bathing! No showers Observe and clean skin daily Suction prn Only 5 sec, sterile gloves, intermittent suction when withdrawing cath Notifyif secretions increase or turn purulent, or fever Have an emergency bag w extra cath and tubes No smoking O2 away from heat
- 37. BPD Diagnoses Chest x-ray shows hyperexpansion, atelectasis, and interstitial thickening Air trapping can cause “Barrel Shape” Chest Treatment Support respiratory function- supplemental O2 w humidity. Chest physiotherapy + meds Medications Nutrition Prognosis
- 39. Otitis Media Inflammation of the middle ear Occurrence- 6-36 m (winter) Risk Factors Causative organisms Streptococcus pneumoniae H. flu. Moraxella catarrhalis
- 40. Otitis Media Etiology – Eustachian tube dysfunction Pathophysiology Preceding upper respiratory infection Edema Blocked air Air reabsorbed to bloodstream Fluid is pulled from mucosal lining Tympanic membrane becomes infected
- 41. Otitis Media S & Sx Pulling at the ear Diarrhea, vomiting, & fever Irritability, awakens at night crying Diagnosis Otoscopic examination- Shows a red, bulging, non-mobile tympanic membrane Treatment Antibiotics Myringotomy/Tympanostomy (PE tubes) Pain relief – Tylenol/Ibuprofen, anesthetic ear drops- verify integrity of tympanic membrane
- 43. Tonsillitis Infection or inflammation of the palatine tonsils Clinical Manifestations Frequent throat infection Breathing and swallowing difficulties Persistent redness Enlargement of cervical lymph nodes
- 44. Tonsillectomy Before surgery H&P Are tonsils simply large or inflamed w exudate? Past tonsillar infections and lengh of present discomfort Free from sore throat, fever, respiratory infection for week before surgery No aspirin or ibuprofen for 2 weeks Check other home medication
- 45. Tonsillectomy
- 46. Tonsillectomy After Surgery May have sore throat for 7-10 days Drink cool fluid and chew gum Give Acetaminophen elixir Apply ice collar around child’s neck Side-lying position- difficult to swallow
- 47. Sore throat: cool fluids, chew gum, ice collar, gargle ½ tsp. of each baking soda and salt in water, rinse w viscous lidocaine and swallow. No citrus liquids Report bright red blood or increased swallowing immediately Avoid red, purple or brown liquids= difficult to assess for bleeding Normal: white, and odor on back of throat in the first wk. Report fever 102 F
- 49. Asthma Chronicinflammatory disorder of the airway Airway obstruction Increased airway responsiveness Acute exacerbations or persistent symptoms Onset-before age 5 Causes of asthma & respiratory problems in children Smoking, pet dander
- 50. Pathophysiology of Asthma After exposure to various “triggers” Bronchospasm Inflammation and edema of the bronchial mucosa Production of thick mucus Asthma triggers- perfume
- 51. Pathophysiology of Asthma Reactive airway responses Antigen binds to the specific immunoglobulin E surface on the mucosal mast cell Histamine is released Intercellular chemical mediators are released- histamines, prostaglandins, leukotrienes Release cytokines that make permanent airway remodeling- thickening Result: bronchospasm, mucosal edema, & mucus secretion
- 53. Clinical Manifestations of Asthma Airway Inflammation Obstruction (narrowing) Hyperreactivity “Asthma Attack”- sudden cough, wheeze, or SOB “Silent” asthma- frequent coughing, especially at night (airway is very sensitive)
- 54. Clinical Manifestations of Asthma Respirations Appears tired Nasal flaring- 4 wks Intercostal retractions Productive cough Expiratory wheezing Decreased air movement Respiratory fatigue In severe obstruction
- 55. Diagnosis of Asthma 4 key elements Symptoms of episodic airflow obstruction Partial reversal of bronchospasm with bronchodilator treatment Exclusion of alternative Diagnosis confirmation by spirometry
- 56. Evaluation of Asthma Spirometry Shows how much a person can exhale- evidence of episodic airflow obstruction and airway hyper-responsiveness. Place mouth covering entire mouth piece… Breathe out as hard as possible and then breathe in deeply
- 57. Evaluation of Asthma Peak flow meter (expiratory flow meter) Blow into it every morning to see if you need treatment like a nebulizer to open up the airway. Warns of impending attack Green- ok Yellow Red- less than 50%= Warning! Skin testing- to id triggers Medications
- 58. Medications Used for Asthma Short-acting bronchodilators Albuterol/ventolin/proventil- drug of choice Terbutaline- not very common Long & short acting beta agonists Salmeterol- can use for exercise and night sx Mast cell inhibitor Intal/cromolyn- Can be used in nebulizer Ex Singulair- Minimizes allergies Corticosteroids Prednisone or solumedrol
- 59. Status Asthmaticus Severe respiratory distress & bronchospasm in an asthmatic Itpersists in spite of pharmacologic and supportive interventions Considered a medical emergency Without immediate intervention, it will progress to respiratory failure & death
- 60. Meds Continuous nebulized albuterol Inhaled inpratropium, iv corticosteroids, magnesium, aminophylline Check electrolytes Nonivasive positive pressure ventilation intubation
- 61. Cystic Fibrosis CysticFibrosis is an autosomal recessive multisystem disorder with dysfunction of the exocrine glands Genetic testing Expected lifespan- 30 years (terminal disease) Results in physiologic alterations in several systems
- 62. Cystic Fibrosis Abnormal secretion of thick, tenacious mucus causes obstruction and dysfunction of all body organs with mucous ducts. This includes the pancreas, lungs, salivary glands, sweat glands, and reproductive organs.
- 63. Clinical Manifestations Production of thick sticky mucus Meconium ileus Constipation Chronic moist productive cough Frequent respiratory infections Chronic sinus infections Difficulty gaining & maintaining weight Short stature Clubbing of finger tips & toes
- 65. Diagnostic & Evaluation of CF 3 presentations Meconium ileus Malabsorption- steatorrhea Chronic recurrent respiratory infections The Sweat test is the standard diagnostic test for CF Spirometer Sputum cultures
- 66. Treatment & Management Chest physiotherapy (CPT): Can use percussion to help move secretions downward so they can cough it up. Position: head of baby downward to use gravity 3-4 x day to prevent increase of hospitalizations and infections Do not perform immediately after eating Give bronchodilator to open bronchi for easier expectoration before therapy AM Exercise stimulates mucus expectoration Use forced expiratory technique to mobilize secretion- Huffing
- 67. Treatment & Management of CF Antibiotics (oral, IV, & inhalation) Pancreatic enzymes with meals, Pancrease or Creon. To help digest food Aerosol bronchiodilators Steroids Diet- high calorie & protein, extra salt in hot weather, ADEK vitamins Psychosocial concerns
- 68. Allergic Reactions Allergy- abnormal or altered reaction to an antigen Allergens – antigens that cause allergy
- 69. Allergic reaction - antigen-antibody reaction that can manifest as anaphylaxis, atopic dermatitis, serum sickness or contact dermatitis Hypersensitivity response
- 70. Allergy Assessment Physical exam- history of exposure to allergens, itching, tearing, burning of eyes and skin, rashes, nose twitching, stuffiness Lab X-ray Pulmonary function studies Nasal function Skin testing
- 71. Treatment of Allergies Avoidance Desensitization For skin allergies Allergy alert bracelet Teaching about allergens in the home
- 73. Question One: Which of the following respiratory conditions is always considered a medical emergency? A. Asthma B. Epiglottitis C. Cystic Fibrosis D. Laryngotracheobronchitis
- 74. Question Two: In a child with asthma, albuterol is administered primarily to do which of the following? A. Dilate the bronchioles B. Decrease postnasal drip C. Reduce airway inflammation D. Reduce secondary infections
- 75. Question Three: When developing a care plan for a child diagnosed with cystic fibrosis, which of the following must the nurse keep in mind? A. CF is an autosomal dominant hereditary disorder B. Pulmonary secretions are abnormally thick. C. Obstruction of the endocrine glands occur D. Elevated levels of K+
Editor's Notes
- Naris expand Retractions Stridor: Thrill harsh sound Ronchi: Once you cough, rhonchi goes away. It’s the only one that goes away after coughing Rales- fine crackling sound. Associated with pneumonia- ab will help it go away; and CHF- Lasix will help it go away Make sure to listen to the lung bases
- Check for this findings: Look for dyspnea, tachypnea, nasal flaring, retractions, child can’t pronounce P because of diminished expiratory effort, focus on breathing, anxious expression, upright position w neck extended, crying improves or worsens the color, low cap refill Quality of Respirations: 1. Depth 2. Clarity of breath sounds 3. Pain with breathing- dyspnea 4. Difficulty breathing – use of accessory muscles – sternocleidomastoid and intercostal muscles Quality of pulse: 0- absent pulse, -4-bounding Normal RR Newborn 30-35 1- 25-40 3- 20-30 6- 16-22 10- 16-20 17- 12-20 Cyanosis: check mucous membranes and tongue Valsalva maneuver or expiratory grunt: is a preventive mechanism to prevent atelectasis. Do not intubate Fixed heart rate indicates a decrease in vagal stimulation Displacement of point of maximal impulse could be due to hernia in diaphragm or pneumothorax Decreased muscle tone of unresponsiveness= deteriorating CNS
- Tachycardia and tachypnea go together
- Retractions- due to moving muscles to get more air in Intercostal- under the ribs. Seen in mild distress Substernal, and subcostal- severity increases Supraclavicular, and suprasternal- due to use of accessory muscles
- Airway resistance: effort needed to move oxygen through the trachea to the lungs. Can intubate to help child
- Atelectasis- bronchioles filled with fluid
- Surfactant: reduces surface tension throughout the lung, thereby contributing to its general compliance. It gives alveolar stability by decreasing the alveoli’s surface tension and tendency to collapse. It gives better lung compliance and permits breathing w less work Leads to: atelectasis, hypoxia, acidosis (lack of gas exchange), and respiratory failure Collapsed alveoli= harder & harder to breath Hypoxia leads to Low pulmonary blood flow= fetal circulation= blood flow is moved around lungs Impaired response to cold Anaerobic metabolism Low perfusion to other organs Respiratory acidosis: Alveolar hypoventilation Metabolic acidosis Due to the anaerobic metabolism Atelectasis is the collapse of part or (much less commonly) all of a lung. Endotracheal tube pic RDS is only found in preterm babies
- Grunting: abnormal, short, deep, hoarse sounds in exhalation that often accompany severe chest pain. Slow expiratory flow that prevents alveolar collapse during expiration Apneic- respirations lasting longer than 20 sec Respiratory failure: Early signs- restlessness, tachypnea, tachycardia Imminent RF: dyspnea, bradycardia, cyanosis Tachypnea: more than 60 respirations See-saw respirations: flat chest during inspiration and abd bulging out. Use ventilation bc there is more O2 need and more workload
- Treat RDS Surfactant replacement with endotracheal tube + gas checkups + fix acid-base imbalance + regulate temperature + good nutrition + protection from infection. Treatment modalities: Increased humidified oxygen Continuous positive airway pressure (CPAP) Ventilation from a respirator High frequency ventilation (HFV) Treat cause of Resp failure Reverse hypoxemia w O2 Mechanical ventilation & Positive end expiratory pressure If decreased LOC: Endotracheal tube (ET) intubation Monitor vitals, respiratory status, O2 sat, LOC & changes in behavior Keep in upright position- elevate HOB Give O2 and keep emergency equipment at hand Pneumothorax- collapsed lung Intraventicular hemorrhage- bleeding in the brain?
- Croup= barking of a seal
- Symptoms worse at night. Progresses to retractions, increasing stridor and cyanosis Airway obstruction= intubation and ICU
- Throat cultures and visual inspection of the inner mouth and throat= laryngospasm= complete airway obstruction. My note: Use XR instead! Cool, noncarbonated nonacidic drinks: rehydration fluids or fruit flavored drinks, gelatin, and popsicles
- Beta agonist and betaadrenergics: albuterol, racemic w face mask? Temp relief in half an hour, side: tachycardia, HTN Corticosteroids: dexamethasone: decrease edema & stridor resolves faster, side: HTN Bronchodialator- xanapex? Quiet parent= quiet kid Once on steroids, wheezing should minimize O2 Sats should be above 92% Start with a quarter of a liter when giving O2 to a baby
- Sudden illness that starts with sore throat and can’t swallow own spit Keep airway open + ab.
- Epiglottis becomes cherry red, swollen and extremely edematous Use tripod position to breath in- also used with COPD Can’t swallow, no voice sounds (before intubation), acute onset of drooling, quiet child= CONCERN!
- Remind parents that ET tube can be removed in 1- 2 days, and that child may be unable to make sounds temporarily
- Assess breath sounds, nasal flaring, accessory muscle use, retractions, stridor, Axillary temp (Not the oral route!), pulse ox Keep NPO IV ab and antipyretics, corticosteroids, nebulized epinephrine (racemic epi)- vasoconstriction =lowers edema, Hib vaccine Do not leave child unattended until he is intubated, keep NPO, never supine, have resuscitation equipment av, prepare for endotracheal intubation, or tracheostomy, keep a relaxed athmosphere (crying= laryngospasm) Can insert ET tube to maintain the airway. Then take a culture of the epiglottis
- Cough is worse at night. Some cracking & wheezing, sore chest & ribs
- Greater incidence in Winter & Spring- keep supplies to treat condition at hand Bronchitis- large airways involved, bronchiolitis- small airways involved
- Initial: rhinorrhea, ear drainage, coughing, sneezing, wheezing Progresses: More coughing and wheezing, air hunger, tachypnea, retractions, cyanosis Severe: tachypnea (more than 70), increased adventitious sounds, listlessness, apneic episodes
- Viral- resolves by itself
- Use cardiorespiratory monitor and place a pulse ox w alarm Small freq feedings. IV if risk of aspiration Encourage parents to hold child to reduce anx
- Barrel chest
- Wean off assisted ventilation
- Bad nutrition bc of high metabolic needs and fatigue when feeding Meds: diuretics, bronchodilators, antiinflammatory, mehylxantines, Palivizumab to prevent RSV
- Most common childhood disease RF: enlarged adenoids, allergic rhinitis, pacifiers alters function of eustachian tube, parents that smoke, day care centers
- Tube becomes blocked due to edema from upper resp. inf.
- Why is ab treatment delayed for 2-3 days in children of 6 m to 2 years? Pg 1291 Myringotomy- allow draninage, equalize pressure & allow ventillation Ab- amoxicillin, keflex, tetracycline, etc PE- pressure equalizing tube. Cover ear if going into water, careful if swimming. Drops for pain relief.
- Drug of choice- penicillin Strep- sand paper rash, fever. Use saline gargles, ibuprofen x 8 h and tylenol x 6h alternating for inflammation, popsicles. Prevention, change tooth brush frequently
- Mast cell releases histamine= pouring out of fluid
- Smaller airway for gas exchange= wheezing
- Tripod position used for breathing better Nasal flaring, H RR, intercostal retractions, productive cough, expiratory wheezing, respiratory fatigue, chest tightness. Wheezing might not be heard if lack of airflow!
- Use bronchodilator before exercising Cta- abbreviation used for “clear to auscultation” Ronchi- clears with coughing, wheezes and rales don’t
- Peak flow meter- the one I have
- Short acting: Use bf inhaled steroid and wait 15 min. Hold breath 10 sec after inspiring. Rinse mouth. Side- tachycardia, headache, nervousness, n&v Long acting: not for acute asthma attack!. Pre exercise 30-60 min bf Mast cell inh- Up to 4 x d. Therapeutic in 2 wks. Careful w anaphylaxis, bronchospasm… Corticosteroids- decreases inflammation and obstruction, enhances effect of bronchodialators. Used for short courses until 80% of peak expiratory flow is achieved or no sx. Give w food in the AM. Side- decreased growth, unstable blood sugar, immunosuppresion Methylxantines: theophylline relaxes muscle bundles that constrict airway Pediapred- PO steroid, liquid? Use albuterol first and then steroid- Dilate vessels so that med can go into body Rinse mouth after using steroids
- Sx: Accessory muscles, restlessness, anxiety, altered loc, diaphoresis, cyanosis, can’t talk too much, hypercarbia, hypoxemia
- Exocrine- glands that excrete mucus
- Tenacious- thick secretions. May need tracheostomy because of the secretions
- Males are usually sterile & women may not be able to carry out pregnancy Meconium ileus- Unable to pass first meconium stool Sweat test-salty skin (Na in sweat) Steatorrhea- malabsorption due to cloggled pancreatic ducts + small intestine can’t absorb properly fats and proteins (short stature)
- CPT- abbreviation means “child protection team” or “chest physiotherapy”
- Vitamins A, D, E, K Don’t sprinkle enzymes on warm meals because heat will destroy the enzyme. Don’t put it in the baby‘s bottle either, can put a little amount of milk separate w the med and make sure the baby takes all of the milk.
- Mold, pollen, house dust, pet dander Cow’s milk, eggs, wheat, chocolate, citrus fruits, peanuts, pepper, etc- document on chart Oral and injectables, animal serum/venom and insect stings Plants, dyes, chemicals
- Allergic rhinitis, asthma, serous otitis media, allergic croup, eczema, urticaria, diarrhea, constipation, colic, headache, fatigue, dysuria, enuresis, anaphylaxis
- Answer: B
- Answer: A
- Answer: B Autosomal recessive Exocrine glands