The document describes the anatomy and physiology of the pediatric respiratory system, key differences compared to adults, respiratory assessment in children, common acute respiratory conditions like otitis media, tonsillitis, and croup, signs of respiratory distress and failure, and nursing considerations for treatment and management of respiratory issues in children.

1. 1
Joy A. Shepard, PhD, RN-BC, CNE
Joyce Buck, PhD(c), MSN, RN-BC, CNE
Alterations in Respiratory
Function
1

2. Learning Outcomes
1.Describe unique characteristics of pediatric
respiratory system anatomy and physiology
2.Contrast respiratory conditions and injuries that
cause respiratory distress in children
3.Distinguish between mild, moderate, and severe
respiratory distress and plan nursing care for
each level of distress severity
4.Assess the child’s respiratory status and analyze
the need for oxygen supplementation
2

3. Learning Outcomes (cont’d)
5. Differentiate between signs and symptoms of
upper and lower airway conditions
6. Create nursing care plan for child with common
acute respiratory conditions
7. Plan nursing care for child with chronic respiratory
conditions
3

4. Review: A & P Respiratory System
4

5. Upper Airway
 The upper airway consists of:
nose, oral cavity, pharynx,
and larynx
 Function of upper airway:
To warm the air
To humidify the air
To filter the air
Speech and smell
5

6. Lower Airway
 The lower airway consists of:
trachea, bronchi, bronchioles,
and alveoli
 Function of lower airway:
 Ventilation (to and fro
movement of gas)
 Gas exchange (CO2 & O2
exchanged b/n pulmonary
capillaries and alveoli)
6
Diaphragm separates chest cavity from abdominal
cavity; regulates pressure within chest cavity

7. Children are not just small adults….
7

8. Pediatric Respiratory System
 Changes until age 12
 Child respiratory-illness risk greater
than adult
 Upper airway more prone to
obstruction
 Smaller airway = greater resistance
 Less alveolar surface area
 Reduced area for gas exchange
 More diaphragmatic breathing
 Flexible chest reduces air intake
8

9. Respiratory Development
 Respiratory structures grow in
size and distance from each
other
 Immature infant respiratory and
neurologic system offers less
efficient response to hypoxia
and elevated PCO2
 Chest wall stiffens with age
 Less retraction with distress
9

10. Differences between Children and Adults
 Chest/ Respiratory System
 Obligate nasal breathers until 6 wks
 Short neck
 Smaller, shorter, narrower airways
 = More susceptible to airway obstruction
and resp. distress
 Tongue is larger in proportion to the
mouth
 = More likely to obstruct airway in
unconscious child
 Pediatric trachea is much more pliable
10

11. Differences between Children and Adults
Bifurcation of trachea Change in chest wall shape
11

12. Differences between Children and Adults Cont’d…
 Chest/ Respiratory System
 Smaller lung capacity and
underdeveloped intercostal
muscles, poor chest musculature
 = Less pulmonary reserve,
increased risk for lung function
impairment
 Children rely on diaphragm for
breathing
 = High risk for respiratory failure if
the diaphragm unable to contract
12

13. Upper Airway More Prone to Obstruction
Smaller Airway = Increased Airway Resistance
13

14. Review Question
Abdominal breathing is usually
present in a child until what age?
A. 2
B. 4
C. 6
D. 8
14

15. 15

16. Respiratory Assessment (p. 120 [new], 135 [old])
 Inspection
 Chest
 Size, symmetry movement
 Infancy shape is almost circular
 < 6-7 years respiratory
movement primarily abdominal
or diaphragmatic
 Respirations
 Rate, rhythm, depth, quality,
effort
 > 60 /min in small children =
significant respiratory distress
16 See video “Pediatric Assessment” 22:03 – 23:18
•A consistent respiratory rate of less than
10 or more than 60 breaths/min in a child
of any age is abnormal and suggests the
presence of a potentially serious problem

17.  Auscultation
 Listen comparing one areas to
the other
 Equality of breath sounds
 Diminished
 Poor air exchange
 Abnormal breath sounds
 Fine crackles
 Wheezes (sibilant rhonchi)
 Rhonchi (sonorous, coarse
crackles)
 Stridor
 Cough
* Prolonged inspiratory phase = upper
airway obstruction (croup, foreign body)
* Prolonged expiratory phase = lower
airway obstruction (asthma)
17
Respiratory Assessment (p. 122 [new], 138 [old])

18. 18

19. 19

20. Adjunct Assessments
 Color
 Mucous membranes
 Nailbeds
 Skin
 Cyanosis
 Temperature
 Febrile state increases oxygen consumption
 Fluid Needs
 Vomiting/diarrhea are commonly associated with respiratory illness
 Increase respiratory efforts, increased fluid losses with decreased PO
intake requires an increase in fluid needs
20

21. Respiratory Nursing Diagnoses
 Impaired gas exchange
 Ineffective breathing pattern
 Ineffective airway clearance
 Risk for aspiration
 Risk for imbalanced fluid volume
 Risk for ineffective tissue perfusion
 Anxiety
 Fatigue
 Activity intolerance
 Imbalanced nutrition: less than body
requirements
 Delayed growth/development
 Deficient knowledge
21

22. Respiratory Distress
22

23. Respiratory Distress
 Can lead to Respiratory Failure, then
Cardiopulmonary Arrest
 Early recognition and intervention vital
 Mild
 Tachypnea, tachycardia, diaphoresis
 Paleness of skin, mucous membranes
 Moderate
 Flaring, retractions, grunting, wheezing
 Change in LOC: anxiety, agitation,
irritability, confusion, mood changes
 Headaches, hypertension
 Mottled, cool extremities
 Severe (Progressing to
respiratory failure)
 Tachypnea  Bradypnea
 Tachycardia  Bradycardia
 Pallor  Cyanosis
 Anxiety, agitation  Lethargy
 Increased effort  Decreased effort
 Decreased breath sounds
 Decreased oxygen saturations
23 See video “Assessment of Respiratory Distress in the Pediatric Patient”
Respiratory distress: increased rate, effort and
noise of breathing; requires much energy, but
still in a state of compensation

24. Respiratory Failure
 Bradypnea, periodic apnea,
falling heart rate/ bradycardia*,
poor to absent air movement,
low oxygen saturation, stupor,
coma, unresponsiveness, poor
muscle tone, cyanosis
 (*Most cardiac problems in children
are respiratory problems)
 Cardiopulmonary arrest -
agonal or “guppy” breathing,
apnea, leading to asystole24
Respiratory failure: slow or absent
rate, weak or no effort, decreased O2
sats, child is very quiet; failing to
compensate (decompensation)
*BRADYCARDIA in infants and
children usually means a
respiratory emergency!*

25. 25

26. Review Question
A 6-month-old infant is being evaluated for
bradycardia. Which is the most likely cause of the
bradycardia?
A. Hypovolemia.
B. Hypoxia.
C. Drug toxicity.
D. Hyperglycemia.
26

27. Depth and Location of Retractions
 Retractions
 Substernal
 Subcostal
 Intercostal
 Suprasternal
 Supraclavicular
 Effort
 Grunting
 Nasal flaring
 Seesaw respirations/
paradoxical breathing
 Head bobbing27

28. 28

29. Retractions: Which types indicate
the most distress?
29

30. 30

31. Respiratory Distress Treatment
Oxygenation
Positioning
Fluids
Medications
Bronchodilator
Anti-inflammatory
Corticosteroid
31

32. Cardiorespiratory Monitoring
Pulse oximetry
Want reading ≥ 95%
(Except with children with
repaired cyanotic heart
defects*)
* Using high levels of O2 could lead to
excessive pulmonary blood flow &
CHF in these children
32

33. Indications for Mechanical Ventilation
 Airway Compromise – airway patency is in doubt or patient may be at
risk of losing patency
 Ability to sneeze, gag, or cough compromised; aspiration is possible
 Respiratory Failure – 2 Types
 Hypoxemic Respiratory Failure
 PaO2 < 60 mmHg in an otherwise healthy individual
 Insufficient O2 transfer into the blood
 Hypercapnic Respiratory Failure
 PaCO2 > 50 mmHg in an otherwise healthy individual
 AKA “Ventilatory Failure” (insufficient CO2 removal)
 Increased WOB, ↓ventilatory drive, or muscle fatigue
33

34. Review Question
A child in respiratory distress requires intubation.
The nurse would estimate the endotracheal tube
size based on:
A. The child’s little finger.
B. Whether the child is mouth or nose breathing.
C. The height of the child.
D. Whether the child has nasal flaring or retractions.
34

35. Acute Respiratory Conditions
35

36. Acute Respiratory Conditions
 Otitis Media
 Tonsillitis & Adenoiditis
 Streptococcal Pharyngitis
 Aspirations
 Foreign body
 Croup Syndromes
 Laryngotracheobronchitis &
epiglottitis
 Bronchiole Inflammation
 Bronchiolitis
 Pertussis
36

37. Otitis Media (OM)
 Inflammation of middle ear, sometimes
accompanied by infection
 Common illness: 6 – 24 mos
 Eustachian tube – shorter, wider, more
horizontal
 At risk: boys, daycare, allergies,
second-hand smoke, cleft-lip/ palate,
enlarged adenoids, Down syndrome,
formula-fed
 Preceded by upper respiratory/ throat
infection
 Generally bacterial (causative
agents)
 Winter months
 Chronic OM: > 3 mos; associated
with hearing loss37

38. 38

39. Three Anatomical Differences in Eustachian Tubes (Adults
& Small Children): Shorter, Wider, More Horizontal
39

40. Otitis Media: Clinical Manifestations
• Sudden piercing pain; irritability
• Fever (as high as 104°F [40°C])
• Vomiting, diarrhea
• Rubbing or pulling at ear
• Rolling head from side to side
• Night awakenings
• Muffled hearing; permanent
hearing loss
• Speech development problems
• Reddened, bulging membrane
40

41. Otitis Media: Clinical Manifestations
What objective sign is
this child displaying?
What does it indicate?
41

42. Otitis Media: Diagnosis &
Collaborative Care
 Otoscopic exam
 Reddened, bulging membrane
 Culture: Streptococcus pneumoniae,
Haemophilus influenzae, & Moraxella catarrhalis
 Antibiotics: amoxicillin, Augmentin, ceftriaxone,
Zithromax
 Surgical: myringotomy, tympanostomy tubes
 Analgesics/ antipyretics: acetaminophen,
ibuprofen by mouth; Auralgan otic drops (not
after myringotomy!)
 Chronic infection: hearing & language testing
42

43. A Normal TM
pars flaccida
umbo
malleus
light reflex
pars tensa
eustachian
tube opening

44. Acute Otitis Media - Characterized by abrupt onset, pain,
middle ear effusion, and inflammation
Note the
injected
vessels and
altered
shape of
cone of light
44

45. Serous Otitis Media
Note effusion
on otoscopy by
fluid line and
air bubbles
Note that the
light reflex is
not in the
expected
position due
to a change
in tympanic
membrane
shape from
air bubbles
45

46. 46

47. Otitis Media: Nursing Interventions
 Prevention strategies (educate caregivers)
Recognize URI, encourage early treatment
Identify & treat allergies
Avoid second-hand smoke
Do not put the baby to bed with bottle
Immunizations up-to-date (especially PCV)
Valsalva maneuver: chew gum; blow on a pinwheel
See video Otitis Media & Nursing Interventions
47

48. 48

49. Otitis Media: Nursing Interventions
 General education:
 Explain all diagnostic tests & procedures
 Take full course of antibiotics
 Warm compress, analgesics/ antipyretics
 Positioning
 Skin care
 No cotton swabs
 Comfort: relieve pain; facilitate drainage when possible; provide emotional
support to child & family
 After surgery: “Care of the Child with Tympanostomy Tube” (p. 458 [new], 500 [old])
49

50. 50

51. 51

52. Streptococcal Pharyngitis
 Inflammation of structures in throat
 School-aged children & teens
 Symptoms strep throat: abrupt onset;
severe sore throat; painful cervical lymph
nodes; fever > 101° F (38.3° C); tonsillar
exudate; anorexia, nausea, vomiting,
abdominal pain; headache, malaise;
petechial mottling of soft palate; possible
scarlet rash (p. 469 [new], 512 [old])
 Contrast: viral pharyngitis (p. 469 [new],
512 [old])
 Dx: Rapid strep test, throat culture
 Tx: 10-day course penicillin; may return
to school after 24 hrs of Tx
 Complications: rheumatic fever,
rheumatic heart disease, and post-
streptococcal glomerulonephritis
 Nursing interventions: plenty of rest &
fluids; sore throat symptom
management, prevent spread of
infection (same as for tonsillitis)
52

53. Viral Pharyngitis vs Strep Throat
53

54. Nurse Alert!
The nurse should remind the
child with a positive throat
culture for strep to discard their
toothbrush and replace it with a
new one after they have been
taking antibiotics for 24 hrs
54

55. 55

56. Tonsillitis & Adenoiditis
 Tonsils & adenoids: Important part of
body’s defense against infection
 Definition: Infection or inflammation
(enlargement)
 Pharyngitis (most often)
 Enlarged tonsils and adenoids: mouth
breathing, obstructive sleep apnea, ear
infections
 Preschool to mid-teenage years
 Caused by virus or bacterium
 Group A Beta-hemolytic streptococcal
infection – particularly dangerous
56

57. Tonsillitis & Adenoiditis:
Assessment Findings
• Red swollen tonsils
• White or yellow patches
• Swollen lymph nodes
• Sore throat
• Decreased food or fluid intake
• Difficulty swallowing
• Difficulty breathing
• Disrupted breathing during sleep
• Fever & chills
 Diagnostic Criteria:
 Rapid strep, throat culture
 Inspection, clinical manifestations, X-
rays, check for rash & spleen
enlargement, CBC
57

58. Tonsillitis
“Kissing tonsils” occur when the tonsils are so
enlarged they touch each other.58

59. Tonsillitis & Adenoiditis: Collaborative &
Supportive Care
 PCN (full 10-day course) for Group
A beta-hemolytic streptococcus
infection
 Viral infection – supportive care:
rest, fluids, comforting foods,
saltwater gargles, cool-air
humidifier, lozenges, treat pain &
fever
 Surgery: removal of tonsils &
adenoids (T & A)
 Respiratory/ swallowing status
compromised or for difficult-to-treat
conditions
59

60. Tonsillitis & Adenoiditis: Nursing
Interventions (Preoperative)
• Education vitally important!
• Routine preoperative care
• Reinforce food & fluid restrictions
• No medications that can cause
bleeding starting10 days before
surgery
• Age-appropriate explanations
• Encourage parents to stay with child
• Prepare child for sights & sounds of
surgery
• Allow child to play with equipment
• Provide reassurance
• Put transitional object in recovery
room
• Prepare child for post-operative
experience (sore throat)
60

61. Tonsillitis & Adenoiditis: Nursing
Interventions (Postoperative)
 Place child in tonsillar position (semi-
prone with head to side)
 Monitor airway, cardiopulmonary status,
vital signs
 Cool humidified air via face mask
 Once the child is awake: semi-Fowler’s,
head turned to side
 Check for signs of hemorrhage (such as
frequent swallowing)
 Provide ice collar
 Avoid oral fluids until fully awake; then clear,
cool, non-citrus fluids (nothing red)
 Administer acetaminophen PRN
 “Care After Tonsillectomy,” p.470(new),513(old)
 Avoid throat clearing & coughing
 Sore throat interventions
 Acetaminophen elixir
 Soft diet, push fluids
 Bleeding: 1st 24 hrs; 7 – 10 days post
surgery; frequent swallowing sign
 Report temps > 38.8°C (102°F)
61

62. Nurse Alert for Post-Op T & A
Surgery
Most obvious sign of early
bleeding is the child’s continuous
swallowing of trickling blood
 Note the frequency of
swallowing and notify the
surgeon immediately
62

63. Complications to “Routine” T & A
Surgeries Can Occur!
63

64. Nursing Care for the T & A Patient
64

65. Foreign Body Aspiration
 Inhalation of any object into
respiratory tract
 7% of deaths (children < 4)
 Manifestations: Coughing, choking,
gagging, hoarse or muffled voice sounds,
difficulty breathing, severe inspiratory
stridor, wheezing, tachypnea, nasal flaring,
retractions, irritability, decreased
responsiveness
 Nursing Management: Assessment,
cardiopulmonary monitoring, remove
foreign body
65

66. Figure 20-5 An aspirated foreign body (coin) is clearly visible in the child’s trachea on this chest radiograph. Courtesy of Rockwood Clinic,
Spokane, WA.
66

67. Foreign Body Aspiration: Teaching &
Prevention
 No small hard candies, hot
dogs, raisins, popcorn or nuts
until age 3 or 4 yrs
 No latex balloons
 Cut food into small pieces
 No running, jumping, or talking
with food in mouth
 Inspect toys for small parts
 Keep coins, earrings, marbles
out of reach
 Choking Hazard Foods Need
Warning Labels
67

68. Croup Syndromes -
Laryngotracheobronchitis
 Croup – severe inflammation &
obstruction of upper airway
 Laryngotracheobronchitis –Viral
croup syndrome
 Viral invasion of upper airway: causes
swelling (constriction) around the
larynx, trachea, & bronchial
passageways
 Inflammation of larynx
 Hoarseness, inspiratory stridor, barking
cough, often worse at night, low-grade
fever, respiratory distress, orthopnea
68

69. Figure 20-7 There are two important changes in the upper airway in croup: The epiglottis swells, thereby occluding the airway, and the
trachea swells against the cricoid cartilage, causing restriction and narrowing the airway.
69

70. Steeple Sign on X-Ray
70

71. Croup Syndromes -
Laryngotracheobronchitis
 Treatment & Nursing Care:
 Cluster care, keep child calm
 Cool mist humidification
 Cardiopulmonary/ vital signs
monitoring
 Oxygen, if SpO2 < 92%
 Sedatives contraindicated
 Antipyretics, racemic
epinephrine, corticosteroids
 Intravenous fluids
71

72. Review Question
An 18-month-old child is seen in the emergency department with a
“seal bark” cough, loud, raspy breathing, and chest wall retractions with
use of accessory muscles. He is admitted with a diagnosis of
laryngotracheobronchitis. Following the initial workup, the toddler is still
short of breath but is rubbing his eyes as if he is sleepy. The mother
wants to lay the toddler down for his nap. The child refuses to lie down.
The nurse should suggest:
A. Rocking the child until he is asleep and then lay him down.
B. The mother swaddle the child and lay him in her lap.
C. The mother allow the child to sleep in an upright position.
D. A sleeping pill to help the child rest.
72

73. 73

74. Croup Syndromes –
Epiglottitis
True Pediatric Emergency!
 Inflammation & edema of the epiglottis
 Bacterial, high fever
 Rapidly progressive course
 Classic symptoms: tripod position;
dysphagia; drooling; dysphonia;
distressed inspiratory efforts; stridor/
froglike croaking sound;
 Antibiotics needed
74

75. Croup Syndromes – Epiglottitis
Tripod position75

76. Croup Syndromes - Epiglottitis
 Don’t inspect the throat with
tongue blade!
 May require immediate tracheotomy/
endotracheal intubation
 Nursing interventions: reduce
anxiety, cardiopulmonary monitoring,
O2, no oral fluids, IV, antibiotics
 Prevention: H. influenzae type B
conjugate vaccine
76

77. 77

78. Critical Thinking Exercise
 Kim, a 4 year old, is admitted to the emergency
department with a sore throat, pain on swallowing,
drooling, and a fever of 102.2°. She looks ill, agitated
and prefers to sit up and lean over.
 What nursing interventions should the nurse
implement in this situation?
78

79. 79

80. Review Question
A child is brought to the emergency department with
suspected epiglottitis. Which nursing intervention
would be considered unsafe?
A. Allowing the child to remain in the position of choice.
B. Placing intubation equipment at the bedside.
C. Encouraging parents to comfort the child.
D. Examining the throat.
80

81. Bronchiolitis (RSV): Etiology, Pathophysiology, &
Complications
 Lower respiratory infection: acute
obstruction & inflammation of the
bronchioles
 Can cause viral pneumonia
 Leading cause of hospital admission
(infants <12 mos)
 Preterm, chronic disease states,
immunocompromised
 Obstructed airways, impaired gas
exchange, hypoxemia, hypercarbia,
atelectasis, respiratory failure
 Long-term effects: wheezing, asthma,
COPD
Bronchioles become narrowed or
occluded as a result of inflammatory
process; edema, mucous, and cellular
debris clog bronchioles and alveoli
81

82. Bronchiolitis (RSV): Epidemiology,
Transmission, & Diagnosis
 RSV (a virus) most common cause
 Most children infected; 2% require
hospitalization
 October – April
 Transmission: contact & droplet
 Sx: 4 – 6 days; most recover in 1 –
2 weeks
 Dx: Rapid RSV antigen, viral
culture, chest X-ray
82

83. Bronchiolitis (RSV): Clinical
Manifestations
• Tachypnea
• Thick nasal discharge
• Respiratory distress: grunting,
wheezing, crackles, retractions,
nasal flaring
• Irritability & lethargy
• Air trapping & atelectasis
• Distended abdomen
• Poor fluid/ food intake
• Severe coughing
• Vomiting
83

84. Bronchiolitis (RSV): Medical
Management
 Supportive tx
 Medical Management:
 Humidified oxygen
 IV fluids
 Contact & droplet isolation
 NG tube feeding
 Nasal suctioning
 Chest percussion
 Mechanical ventilation
 Medications:
 Nebulizer solutions
 Antipyretics
 Ribavirin (Virazole)
 Palivizumab (Synagis)84

85. Bronchiolitis (RSV): Nursing Care
• Cardiopulmonary monitoring
• Monitor respiratory/ cardiovascular
status
• Cluster care
• ↑ HOB/ crib
• Contact/ droplet isolation; meticulous
hand hygiene
• Chest percussion
• Promote hydration
• Support family
• Discharge planning
85

86. Review Question
The mother of an infant diagnosed with bronchiolitis asks
the nurse what causes this disease. The nurse’s response
would be based on the knowledge that the majority of
infections that cause bronchiolitis are a result of:
A. Ribavirin.
B. Mycoplasma pneumoniae (MP).
C. Respiratory syncytial virus (RSV).
D. Hemophilus influenzae.
86

87. Pertussis (Whooping Cough)
 Also known as whooping cough, highly
contagious and preventable with
the immunization DTaP
 Major cause of mortality/ morbidity
in children throughout the world
 Signs and symptoms
 Initially presents like URI then progresses to paroxysmal cough
and ends in a "whooping" sound when the person breathes in
 Hear the Sound of Pertussis

88. Pertussis: Nursing Care
 Limit paroxysms (observe severity of cough, nutrition, rest,
and recovery)
 Give antibiotic therapy
 Promote adequate nutrition
 Discuss vaccination (DTaP)
 Teach parents about hospitalization
 Droplet precaution
 Vital signs and oxygen saturation
 Hydration, nutrition, and fluids
88

89. Chronic Respiratory Conditions
89

90. Chronic Respiratory Conditions
Asthma
Cystic Fibrosis
Systemic exocrine disorder
90

91. Asthma: Introduction
 Most common chronic disease of childhood
 Chronic inflammatory condition of lower airways
 Recurrent, reversible airway obstruction
 Inflammation, bronchospasm, & mucous
 Air trapped in alveoli, hyperinflation
 Complex interplay of genetic (predisposition) &
environmental factors (triggers)
 Triggers: tobacco smoke, dust mites, pets, mold, allergens,
strong odors, food additives, physical exercise, weather
changes, strong emotions, certain medications
 At risk: family hx, allergies, eczema, black race
 Poor control: permanent airway remodeling
91

92. How asthma obstructs airflow through constriction
and narrowing of the airway, along with increased
production of mucus
92

93. Review Question
An adolescent with asthma says she heard her doctor say
smoking was her trigger. The adolescent asks the nurse
what that means. The nurse explains to the adolescent that a
trigger is:
A. A substance or condition that brings on an asthmatic episode.
B. The term for narrowing of the airways during an asthmatic episode.
C. Another way to describe asthma.
D. The rapid breathing associated with an asthma attack.
93

94. 94

95. 95

96. Review Question
Which of the following might a child with
asthma be advised to avoid?
A. Swimming.
B. Gymnastics.
C. Snow skiing.
D. Playgrounds.
96

97.  Frequent coughing (especially at night)
 Coughing that gets worse after active play or changes in the weather
 Prolonged expiration
 Expiratory wheezing
 Shortness of breath (short panting phrases)
 Increased work of breathing (tachypnea, nasal flaring, retractions,
use of accessory muscles)
 Chest tightness
 Poor exercise tolerance
Asthma: Clinical Manifestations
97

98. Figure 20-8 Children with severe respiratory distress and a narrowed airway often sit in a tripod position with arms on the legs leaning
forward. The head and neck are extended with the jaw thrust forward to help keep the airway open. This position may also be seen in a child
with a severe asthma flare.
98

99. Asthma Attack
99

100. Review Question
 A teenager with chronic asthma asks the nurse, “How
come I make so much noise when I breathe?”
The nurse’s best reply is:
 A. “It is the sound of air passing through fluid in your alveoli.”
 B. It is the sound of air passing through fluid in your bronchus.”
 C. “It is the sound of air being pushed through narrowed
bronchi on expiration.”
 D. “It is the sound of air being pushed past a narrowed larynx
on expiration.”
100

101. Asthma: Diagnostic Testing
 Clinical diagnosis: H & P,
symptoms, symptom patterns,
severity, observations
 Recurrent coughing spells
(especially at night)
 Family hx of asthma/
allergies
 Difficulty breathing
 Frequent respiratory infections
 Spirometry
 Pulse oximetry
 ABG: ↓ PaO2, ↑ PaCO2
 Elevated eosinophils
 Chest radiograph
 Allergy skin testing
101

102. Asthma: Collaborative Care
 Clinical therapy: medications, hydration, education, support of family/ child
 Main goal: Maintain good long-term asthma control using the least amount
of medications; reduce risk of adverse effects
 Stepwise approach to medication management
 Status asthmaticus: acute exacerbation of asthma, unresponsive to
rescue medications; medical emergency!
 Position upright; O2; cardiopulmonary monitoring; continuous
nebulizers; establish IV access; IV meds/ fluids (corticosteroids,
magnesium, theophylline, normal saline); monitor electrolytes
(especially K+ & Mg++)
102

103. Asthma: Rescue (Short-Term) Asthma
Control Medications (p. 499 [new], 544 [old])
 Rescue medications
 Short-acting beta agonists
(SABA) (bronchodilation, clear
mucous): albuterol (Ventolin);
levalbuterol (Xopenex); pirbuterol
(Maxair)
 Anticholinergic (bronchodilation,
clear mucous): Ipratropium
(Atrovent)
 Corticosteroids (anti-
inflammatory): prednisone;
prednisolone;
methylprednisolone
103

104. Asthma Rescue Medications
104

105. Asthma: Long-term Asthma Control
Medications (pp.499-500 [new], 545 [old])
 Long-acting beta-agonists (LABA) (bronchodilation): salmeterol (Serevent); formoterol
(Foradil, Perforomist)
 Inhaled corticosteroids (ICS) (anti-inflammatory): beclomethasone (Qvar); budesonide
(Pulmicort); flunisolide (Aerobid); fluticasone (Flovent); mometasone (Asmanex);
triamcinolone (Azmacort)
 Leukotriene receptor antagonist (LTRA) (bronchodilation, anti-inflammatory): montelukast
(Singulair); zafirlukast (Accolate); zileuton (Zyflo)
 Mast-cell inhibitors (anti-inflammatory): cromolyn sodium (Intal); nedocromil (Tilade)
 Theophylline (bronchodilation)
 Combination inhalers (bronchodilation, anti-inflammatory): fluticasone-salmeterol (Advair
Diskus), budesonide-formoterol (Symbicort) and mometasone-formoterol (Dulera)
105 See video Respiratory Meds

106. Asthma Control Medications
106

107. Asthma Control Medications
107

108. Asthma Control Medications
108

109. Review Question
 A child presents to the emergency department in acute
respiratory distress caused by an asthmatic episode.
Which of the following drugs would the nurse plan to
administer first?
A. Prednisone.
B. Albuterol.
C. Theophylline.
D. Cromolyn sodium.
109

110. Review Question
 A child with chronic asthma develops Cushing’s
syndrome. Development of the complication can
most likely be attributed to long-term use of:
A. Prednisone.
B. Theophylline.
C. Ipratropium (Atrovent)
D. Cromolyn sodium.
110

111. Stepwise approach to managing asthma in
children 0 to 4 years of age
111

112. Medications to Treat Asthma:
How to Use a Spray Inhaler
The health-care
provider should
evaluate inhaler
technique at each visit
112

113. Medications to Treat Asthma:
Inhalers and Spacers
Spacers can help
patients who have
difficulty with inhaler
use and can reduce
potential for adverse
effects from
medication
113

114. Medications to Treat Asthma:
Nebulizer
 Machine produces a mist of the
medication
 Used for young children or for
severe asthma episodes
 Adding moisture to respiratory
system helps clear secretions
from the lungs
 Patients unable to hold the
nebulizer mouthpiece in their
mouth should use aerosol mask
114

115. C h i l d R e c e i v i n g N e b u l i z e r Tr e a t m e n t
What is important patient teaching?
115

116. Managing Asthma:
Asthma Action Plan
 Develop with primary care provider
 Tailor to meet individual needs
 Educate patients and families about all aspects of plan
 Recognizing symptoms
 Medication benefits and side effects
 Proper use of inhalers and Peak Expiratory Flow (PEF) meters
116

117. Managing Asthma:
Sample Asthma Action Plan
Describes medicines
to use & actions to
take
National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and
Management of Asthma. NIH Publication no. 08-4051, 2007.
117

118. 118

119. Managing Asthma:
Peak Expiratory Flow (PEF) Meters
 Allows patient to assess status of his/ her asthma
 Recommended standard of care for management of asthma
119

120. Interpreting Peak Expiratory Flow
Rates
Green (80-100% of personal best) signals all clear and
asthma is under reasonably good control
Yellow (50-80% of personal best) signals caution;
asthma not well controlled; call provider if child stays in
this zone
Red (below 50% of personal best) signals a medical
alert. Severe airway narrowing is occurring; short acting
bronchodilator is indicated
120

121. How to use a peak flow meter
 Slide indicator tab to bottom (zero)
 Stand up straight
 Take a deep breath
 Close your lips tightly around mouthpiece
 Blow out as hard as you can
 Write down number where stopped
 Repeat 2 more times
 Record highest of 3 numbers
 Measure peak flow rate twice a day
(morning & evening)
121

122. 122

123. Managing Asthma:
Peak Flow Chart
People with moderate
or severe asthma
should take readings:
 Every morning
 Every evening
 After an exacerbation
 Before inhaling certain
medications
Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and
funded by NIH/NHLBI
123

124. Review Question
Which statement by an 8-year-old child with asthma indicates that
she understands the use of a peak expiratory flow meter?
A. “My peak flow meter can tell me if an asthma episode might be coming, even
though I might still be feeling okay.”
B. “When I do my peak flow, it works best if I do three breaths without pausing in
between breaths.”
C. “I always start with the meter reading about halfway up. That way I don’t waste
any breath.”
D. “If I use my peak flow meter every day, I will not have an asthma attack.”
124

125. Asthma: Nursing Management
 High Fowler’s, O2
 Monitor: respiratory &
cardiovascular status; cough;
vital signs; effectiveness of
drug therapy; peak flow rates
 Chest percussion
 Push fluids
 Cluster care
 Support family
125

126. Treatment and Nursing Care
Pulse
Oximetry
High Fowlers
position
Humidified
Oxygen via
mask
126

127. Asthma: Nursing Management
 Educate family & child:
Allergen & irritant exposure control
Avoid secondhand smoke
Signs of early respiratory distress
 Review asthma action plan
Maximum participation
Communicate plan to school nurse
 Discharge planning
127

128. Review Question
The nurse is giving discharge instructions to the parents of a
toddler with asthma. What information is essential to
include?
A. Take prescribed medications weekly to control asthma symptoms.
B. Remove mold, animal dander, dust, and cockroach particles from the child’s
surroundings.
C. Use commercial air fresheners to neutralize the smell of cigarette smoke in the
home.
D. For adequate nutrition, include cow’s milk, eggs, peanuts, and wheat products
in the diet.
128

129. 129

130. 130

131. Cystic Fibrosis
 Genetic illness, dysfunction of
exocrine glands
 Obstruction caused by thick,
viscous mucous
 Leads to irreversible lung damage
 Autosomal recessive trait: more
common in Caucasians
 One of the most common causes of
childhood death
 Complex disorder: affects multiple
organ systems, especially
respiratory & GI
Factor responsible for manifestations
of the disease is mechanical
obstruction caused by increased
viscosity of mucous gland secretions
131

132. 132
• Mucous throughout body
is thick, like tar resin
• Plugs up vital organs
Pancreas Lungs

133. Autosomal Recessive Inheritance: 1 in 4
Chance of Cystic Fibrosis
133

134. Defective CFTR leads to an imbalance between fluid absorption
and secretion in the lungs of cystic fibrosis patients, resulting
in dehydrated mucus on the airways
134

135. 135

136. Cystic Fibrosis: Complications
 Cardiorespiratory System
 Respiratory: Chronic sinusitis; chronic
moist productive cough; frequent
respiratory infections; dyspnea; tachypnea;
wheezing, decreased breath sounds, fine
crackles on auscultation; clubbing of
fingers and toes; barrel chest; cyanosis
 Pulmonary hypertension, over inflation of
the lungs
 Cardiovascular: Rt-sided heart
enlargement (cor pulmonale); heart failure;
hyponatremia; circulatory collapse
136

137. Clubbing of Fingers
137

138. Review Question
The highest priority nursing intervention for a child
hospitalized with respiratory infection and cystic
fibrosis would be:
A. Maintaining strict intake and output.
B. Administering intravenous antibiotics.
C. Recording vital signs every four hours.
D. Arranging for sweat chloride testing.
138

139. Cystic Fibrosis: Complications
 Gastrointestinal System
 Clinical manifestations may appear at birth
or may take years; vary in severity
 Blocked pancreatic ducts; no secretion
of digestive enzymes
 Meconium ileus in a neonate (1st
manifestation); large, frothy, bulky,
greasy, foul-smelling stools; distended
abdomen; abdominal cramping; weight
loss; FTT, malnourishment, vitamin
deficiency; liver cirrhosis
 Pot belly with wasted buttocks
139

140. 140

141. Review Question
When taking the nursing history of a child with cystic
fibrosis, what piece of information about the child’s newborn
period would the nurse expect the mother to report?
A. The child required resuscitation in the delivery room.
B. Labor was longer than 24 hours.
C. The child had a meconium ileus.
D. Labor was less than 4 hours.
141

142. Review Question
A 6-year-old client with cystic fibrosis (CF) is preparing to
eat breakfast. What is the most important piece of
information the nurse would want before the child eats?
A. Whether the meal is exactly what he ordered.
B. If he plans to eat all of it.
C. When he ate last.
D. If he has taken his enzymes.
142

143. Review Question
A child with cystic fibrosis is hospitalized for a respiratory
infection. Which documentation in the chart would indicate
the need for counseling regarding nutrition and
gastrointestinal complications?
A. Frothy, foul-smelling stools.
B. Weight unchanged from yesterday.
C. Consumption of high-sodium foods.
D. Eats three snacks every day.
143

144. Cystic Fibrosis: Complications
 Skin:
 Salty taste to the skin
 Secretions excessive salt
 Basis for the “sweat test”
 Loss of electrolytes: electrolyte
imbalances
 Reproductive system:
 In males: ↓ sperm motility
 Blocked vas deferens
 In females:
 Thick cervical mucous
• Difficulty conceiving
 Pregnancy complications
144

145. Review Question
An adolescent was diagnosed with cystic fibrosis as
an infant. At this time, the adolescent will need
additional teaching related to:
A. Obtaining a sweat chloride test.
B. The effect of pancreatic enzymes on the sex hormones.
C. Weight reduction diet.
D. Reproductive ability.
145

146. 146

147. Cystic Fibrosis: Diagnosis
 Presentation: meconium ileus; FTT;
respiratory infections; intussusception
 Newborn screening, genetic marker
 Positive sweat test – Gold standard
 Chloride – Normal < 40 mEq/L
 Highly suggestive of CF 50-60 mEq/L
 Diagnostic > 60 mEq/L
 Pancreatic enzymes
 Collection of stool specimen to assess trypsin &
lipase
 Trypsin absent in 80% of children with CF
147 Newborn Screening in North Carolina

148. Review Question
A child with a respiratory infection is scheduled to
have a sweat test. The mother asks the purpose of
this diagnostic test. The nurse’s response would be
based on the knowledge that the test:
A. Determines if the child is dehydrated.
B. Assesses if the sweat glands are functioning.
C. Identifies the infectious organism.
D. Establishes a diagnosis of cystic fibrosis.
148

149. Cystic Fibrosis: Maintaining Respiratory
Function
 Aerosol treatments – thin secretions, keep them mobile
 Bronchodilators
 Dornase alfa (DNase)
 Hypertonic saline
 Never give cough syrups or codeine (why?)
 Aggressive chest physiotherapy/ oscillating vest 3-4 times/day
(before meals & at bedtime) to increase sputum expectoration
 Breathing exercises
 Physical exercise important adjunct
 Lung transplantation
149

150. Cystic Fibrosis: Managing Infection
Meticulous hand hygiene
Immunizations
Good pulmonary hygiene
Prevention and treatment of pulmonary infections
with antibiotics
TOBI Podhaler
150

151. Cystic Fibrosis: Promoting Optimal
Nutrition
 I & O, daily weights
 High: protein, fat, calorie diet
 Medium-chain triglycerides (MCT) oil
 Vitamin replacement – A, D, E, K
 Push fluids
 Salty foods
 Pancreatic enzymes with meals and snacks
 Goal: achieve near-normal, well-formed stools & adequate
weight gain
151

152. Cystic Fibrosis: Preventing
Gastrointestinal Blockage
 Distal intestinal obstruction syndrome (DIOS) – ileum/ colon in right
lower quadrant
 Abdominal pain, distention, vomiting, failure to pass stools; right lower
quadrant mass
 Chronic constipation
 Rectal prolapse
 Prevention/ Treatment:
 Fiber and fluid
 Early aggressive laxative treatment with polyethylene glycol (Miralax) –
either oral or intestinal lavage
 Prokinetic agents (Reglan) – enhance gastrointestinal motility
 Enemas
152

153. Chest Physiotherapy: Cupping &
Clapping
153

154. Chest Physiotherapy
154

155. 155

156. Postural Drainage – Six Manual Chest
Physiotherapy Positions
156

157. Figure 20-16 (continued) A, Postural drainage can be achieved by clapping with a cupped hand on the chest wall over the segment to be
drained to create vibrations that are transmitted to the bronchi to dislodge secretions. B, Oscillating vibration vest that this child can
independently set up to perform chest physiotherapy.
B
157

158. Cystic Fibrosis: Medications (p.509 [new], 558 [old])
 Aerosol bronchodilators to open airways
 Mucolytic enzyme (Dornase alfa [Pulmozyne]) – to thin mucous to cough it
out easier
 Mist of hypertonic saline – to clear thick mucous from lungs
 Ibuprofen – slows lung function decline
 Inhaled antibiotics (tobramycin) – antimicrobial for chronic lung infections
(Pseudomonas aeruginosa)
 Oral and IV antibiotics – treat and suppress infections
 Pancreatic enzymes to help digest food
 Vitamins A, D, E, K / fat soluble vitamins
158

159. Cystic Fibrosis: Nursing
Interventions
 Pulmonary hygiene
 Nutrition
 Medications
 Conserve energy
 Organize care
 Monitor respiratory status,
vital signs, infection
 Teaching/ support
159

160. Review Question
An appropriate nursing recommendation for
parents to assist in preventing recurrent
respiratory infection would be to:
A. Keep child away from other children.
B. See the pediatrician weekly.
C. Maintain strict handwashing.
D. Avoid all animals.
160

161. Review Question
The parents of a child with cystic fibrosis inform the nurse that they will
be unable to perform postural drainage at home because their bed
does not recline like the hospital bed. The nurse’s response is based on
an understanding that:
A. Postural drainage is essential to mobilize secretions in the airways so they can be
coughed out.
B. Postural drainage is not necessary as long as the child takes his pulmozyme to
decrease the viscosity of the mucus.
C. Postural drainage does not influence the pulmonary status of a child with cystic
fibrosis.
D. The parents can be referred to The Cystic Fibrosis Foundation for a flexible bed.
161

162. Review Question
The mother has been taught to perform chest
physiotherapy on her child. Which observation by the nurse
indicates the need for additional teaching?
A. The child has on only a T-shirt.
B. The mother delayed the treatment until the child had finished
breakfast.
C. The mother is making a popping sound when doing
percussion.
D. The child is positioned in various head-down positions.
162

163. 163

164. Cystic Fibrosis “A Day in the Life”
https://www.youtube.com/watch?v=RyfsSJaMzn8
164

165. 165