SlideShare a Scribd company logo

THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf

•
•
K
KarolienFayeDonga1

This document discusses respiratory infections in children. It describes infections of the upper and lower respiratory tract, including common cold, acute nasopharyngitis, and acute pharyngitis. Symptoms vary based on age but may include fever, nasal congestion, sore throat, cough, and irritability. Management focuses on relieving symptoms through rest, fluids, nasal suction and saline drops. Complications are rare but parents should monitor for worsening symptoms.

Health & Medicine
1 of 200
Download to read offline
• Infections of the respiratory tract • Upper respiratory tract or upper airway • Oronasopharynx • Pharynx • Larynx • Upper part of the trachea • Lowe respiratory tract infection • Lower trachea • Bronchi • Bronchioles • Alveoli • Croup syndromes- infections of epiglottis and larynx that can lead to inspiratory stridor and barking cough. RESPIRATORY INFECTION
• Caused by viruses • Respiratory syncytial virus (RSV) • Rhinovirus • Nonpolio enterovirus (coxsackievirus A and B) • Adenovirus • Parainfluenza virus • Influenza virus • Human metapneumovirus • Other agents (primary or secondary invasion • Group A betahemolytic streptococci (GABHS) • Staphylococci • Haemophilus influenzae • Bordetella pertussis • Chlamydia trachomatis • Mycoplasma organisms • Pneumococci RESPIRATORY INFECTION
• Full term, and healthy (<3 months) • low infection rate due to protective function of maternal antibodies (colostrum). • susceptible to pertussis • 3-6 months • Infection rate increase due to decrease of maternal antibodies and infant’s own antibody production • Toddles and preschool year • Viral infection remains high • 5 years old • Mycoplasma pneumoniae and GABHS infections incident increases. • **repeat exposure to organisms confers increasing immunity as children grow older RESPIRATORY INFECTION
• Organisms move rapidly down the shorter respiratory tract of younger children. • Allows pathogens easy access to the middle ear because of short and open eustachian tube in infants. RESPIRATORY INFECTION
• Deficiencies of the immune system – risk for infection • Decrease resistance/weaken defenses • Malnutrition • Anemia • Fatigue • Allergies (e.g., allergic rhinitis) • Preterm birth • Bronchopulmonary congestion (BPD) • Asthma • History of RSV infection • Cardiac anomalies that cause pulmonary congestion • Cystic Fibrosis (CF) • Daycare attendance and secondhand smoke – risk for infection RESPIRATORY INFECTION
• Mycoplasmal infections • Often in autumn and early winter • Infection-related asthma/RVS • During cold weather, winter and early spring RESPIRATORY INFECTION
• Fever • May be absent in neonates (<28 days) • Greatest at 6 months old to 3 years old • May reach 39.5° to 40.5° C (103° to 105° F) even with mild infections • Often appears as first sign of infection • May lead to listlessness and irritability, with altered activity pattern (usually decreased) • Tendency to develop high temperatures with infection in certain families • May precipitate febrile seizure • Poor Feeding and Anorexia • Common with most childhood illnesses • Frequently the initial evidence of illness • Persists to a greater or lesser degree throughout febrile stage of illness; often extends into convalescence RESPIRATORY INFECTION
• Vomiting • Common in small children with illness • A clue to onset of infection • May precede other signs by several hours • Usually short lived but may persist during the illness Is frequent cause of dehydration • Diarrhea • Usually mild, transient diarrhea but may become severe • Often accompanies viral respiratory infections • Frequent cause of dehydration • Abdominal Pain • Common complaint • Sometimes indistinguishable from pain of appendicitis • May represent referred pain (e.g., chest pain associated with pneumonia) • May be caused by mesenteric lymphadenitis • May be linked to muscle spasms from vomiting, especially in nervous, tense child RESPIRATORY INFECTION
• Nasal Blockage • Small nasal passages of infants easily blocked by mucosal swelling and exudation • Can interfere with respiration and feeding in infants • May contribute to the development of otitis media (OM) and sinusitis • Nasal Discharge • Frequent occurrence • May be thin and watery (rhinorrhea) or thick and purulent • Depends on the type or stage of infection • Associated with itching • May irritate upper lip and skin surrounding the nose • Cough • Common feature • May be evident only during acute phase • May persist several months after a disease RESPIRATORY INFECTION
• Respiratory Sounds • Sounds associated with respiratory disease: • • Cough • • Hoarseness • • Grunting • • Stridor • • Wheezing • Findings on auscultation: • • Wheezing • • Crackles • • Absence of breath sounds (movement of air) • Sore Throat • Frequent complaint of older children • Young children (unable to describe symptoms) may not complain even when highly inflamed • Often accompanied by refusal to take oral fluids or solids RESPIRATORY INFECTION
• Meningismus • Meningeal signs without infection of the meninges • Occurs with abrupt onset of fever • Accompanied by: • • Headache • • Pain and stiffness in the back and neck • • Presence of Kernig and Brudzinski signs • Subsides as body temperature decreases RESPIRATORY INFECTION
• The assessment should include: • respiratory rate • depth and rhythm • heart rate, oxygenation • hydration status • body temperature • level of consciousness • activity level • level of comfort • A noninvasive pulse oximeter (oxygen saturation [SaO2]) measurement. RESPIRATORY INFECTION
• Pattern of Respirations • Rate: Rapid (tachypnea), normal, or slow for the particular child • Depth: Normal depth, too shallow (hypopnea), too deep (hyperpnea); usually estimated from theamplitude of thoracic and abdominal excursion • Ease: Effortless, labored (dyspnea), orthopnea (difficult breathing except in upright position), associated with intercostal or substernal retractions (inspiratory “sinking in” of soft tissues in relation to the cartilaginous and bony thorax), pulsus paradoxus (blood pressure falling with inspiration and rising with expiration), nasal flaring, head bobbing (head of sleeping child with suboccipital area supported on caregiver's forearm bobbing forward in synchrony with each inspiration), grunting, wheezing, or stridor • Labored breathing: Continuous, intermittent, becoming steadily worse, sudden onset, at rest or on exertion, associated with wheezing, grunting, or chest pain • Rhythm: Variation in rate and depth of respirations RESPIRATORY INFECTION
• Other Observations • In addition to respirations, particular attention is addressed to: • Evidence of infection: Check for elevated temperature; enlarged cervical lymph nodes; inflamed mucous membranes; and purulent discharges from the nose, ears, or lungs (sputum). • Cough: Observe the characteristics of the cough (if present), when the cough is heard (e.g., night only, on arising), the nature of the cough (paroxysmal with or without wheeze, “croupy” or “brassy”), frequency of the cough, association with swallowing or other activity, character of the cough (moist or dry), productivity. • Wheeze: Note whether it occurs with expiration or inspiration, high pitched or musical, prolonged, slowly progressive or sudden, association with labored breathing. • Cyanosis: Note distribution (peripheral, perioral, facial, trunk, and face), degree, duration, association with activity. • Chest pain: This may be a complaint of older children. Note location and circumstances: localized or generalized; referral to base of neck or abdomen; dull or sharp; deep or superficial; association with rapid, shallow respirations or grunting. • Sputum: Older children may provide sample by blowing nose or provide sputum sample by coughing, young children may need use of bulb suction, wall suction, DeLee mucus trap, or baby nasal aspirator (attaches to wall suction tubing and fits on small nose) to provide a sample. Note volume, color, viscosity, and odor. • Bad breath (halitosis): May be associated with some throat and lung infections. RESPIRATORY INFECTION
• Warm or cool mist • Common therapeutic measure for symptomatic relief of respiratory discomfort. RESPIRATORY INFECTION
• Infant nasal aspirator or bulb syringe • Helpful in removing nasal secretions • Instillation of saline nose drops to clear nasal passage and promote feeding. • Dissolving ½-1tsp of salt in 1 cup of warm water. Two to three drops of saline can be put into the nostril and a bulb syringe can be used to suction it out. • 2-12 y.o • Use of vasoconstrictive nose drops may be adminster every 4 hours as needed • Oxymetazoline 0.05% /Phenylephrine 0.25% • Prescribed children older that 6 y.o • Pseudoephedrine • Prescribed by mouth as decongestant every 6hours in children older than 4 years old • Topical vapor rubs • could be considered for children older than 2 years old to ease nasal congestion. RESPIRATORY INFECTION
• Hand washing • Cover nose and mouth when cough or sneeze and dispose it properly. RESPIRATORY INFECTION
• If the child has a significantly elevated body temperature, controlling the fever is important for comfort. • Cool liquids are encouraged to reduce the temperature and minimize the chances of dehydration RESPIRATORY INFECTION
• Infants are especially prone to fluid and electrolyte deficits when they have a respiratory illness because a rapid respiratory rate that accompanies such illnesses precludes adequate oral fluid intake. • Adequate fluid intake is encouraged by offering small amounts of favorite fluids (clear liquids if vomiting) at frequent intervals. • Infants who are breastfeeding should continue to be breastfed, because human milk confers some degree of protection from infection. • Diapers are weighed to assess output, which should be approximately 1 ml/kg/hr in a child who weighs less than 30 kg. It should be at least 30 ml per hour in patients weighing more than 30 kg. The practitioner should be notified if the urine output is low. RESPIRATORY INFECTION
• Signs of clinical deterioration include increasing respiratory distress, increasing respiratory rate, increasing heart rate, worsening hypoxia, poor perfusion, reduced level of consciousness, and lethargy. • Any deterioration is notified to the primary service. RESPIRATORY INFECTION
• Loss of appetite is characteristic of children with acute infections. • Many children show no decrease in appetite, and others respond well to foods such as gelatin, popsicles, and soup • Urging foods for children who are sick may precipitate nausea and vomiting and cause an aversion to feeding that may extend into the convalescent period and beyond. RESPIRATORY INFECTION
• Young children with respiratory tract infections may be irritable and difficult to comfort; therefore, the family needs support, encouragement, and practical suggestions concerning comfort measures and administration of medication. RESPIRATORY INFECTION
• “Common cold” • Caused by: • Rhinoviruses • RSV • Adenoviruses • Enteroviruses • Influenza virus • Parainfluenza virus RESPIRATORY INFECTION Upper Respiratory Tract Infections
• ACUTE Nasopharyngitis •Younger Children Fever Irritability Restlessness Poor feeding and decreased fluid intake Sneezing Nasal mucus (abundant) causing mouth breathing Vomiting or diarrhea Upper Respiratory Tract Infections
• ACUTE Nasopharyngitis •Older Children Dryness and irritation of nose and throat initially Nasal discharge causing mouth breathing Sneezing, chilling Muscle aches Cough (sometimes) Upper Respiratory Tract Infections
• ACUTE Nasopharyngitis •Physical Assessment Signs Edema and vasodilation of mucosa Upper Respiratory Tract Infections
• ACUTE Pharyngitis •Younger Children Fever General malaise Anorexia Moderate sore throat Headache Upper Respiratory Tract Infections
• ACUTE Pharyngitis •Older Children Fever (may reach 40° C [104° F]) Headache Anorexia Dysphagia Abdominal pain Vomiting Upper Respiratory Tract Infections
• ACUTE Pharyngitis •Physical Assessment Signs • Younger Children • Mild to moderate hyperemia • Older Children • Mild to bright red, edematous pharynx • Hyperemia of tonsils and pharynx; may extend to soft palate and uvula • Often abundant follicular exudate that spreads and coalesces to form pseudomembrane on tonsils • Cervical glands enlarged and tender Upper Respiratory Tract Infections
• Children with nasopharyngitis are managed at home. • Antipyretics may be indicated for fever and discomfort • Fluids and rest are recommended. •Prevention • The best methods for preventing transmission of these viruses are frequent hand washing and avoiding touching one's eyes, nose, and mouth. Upper Respiratory Tract Infections
• Nasopharyngitis is related to the nasal obstruction • Elevating the head of the bed or crib mattress assists with drainage of secretions. • Suctioning and vaporization. • Saline nose drops and gentle suction with a bulb syringe before feeding and sleep time. • Nasopharyngitis is spread from secretions • prevention is avoiding contact with affected persons • Family members with a cold should carefully dispose of tissues, not share towels, glasses, or eating utensils, cover the mouth and nose with tissues when coughing or sneezing, and wash hands thoroughly after nose blowing or sneezing. • Children should wash their hands thoroughly or use hand sanitizer and avoid touching their eyes, noses, and mouths. •Family Support • The best methods for preventing transmission of these viruses are frequent hand washing and avoiding touching one's eyes, nose, and mouth. Upper Respiratory Tract Infections
•Family Support • Early Evidence of Respiratory Complications • Parents are instructed to notify the health professional if any of the following are noted: • Refusal to eat • Evidence of earache • Respirations faster than 50 to 60 breaths/min • Fever over 38.3° C (101° F) • Listlessness • Confusion • Increasing irritability with or without fever • Persistent cough for 2 days or more • Wheezing • Restlessness and poor sleep patterns Upper Respiratory Tract Infections
• Acute infectious pharyngitis can be caused by many bacteria or viruses. • Group A beta- hemolytic Streptococcus (GABHS) infection is the most common causative organism for this infection. • Children with GABHS infection of the upper airway (strep throat) are at risk for rheumatic fever (RF), an inflammatory disease of the heart, joints, and central nervous system (CNS), and acute glomerulonephritis (AGN), an acute kidney infection. • Permanent damage can result from these sequelae— especially RF. • GABHS may also cause skin manifestations, including impetigo and pyoderma. Upper Respiratory Tract Infections
Upper Respiratory Tract Infections
• Onset • Pharyngitis • Headache • Fever • Abdominal pain • The tonsils and pharynx may be inflamed and covered with exudate, which usually appear by the second day of illness • The tongue may appear edematous and red (strawberry tongue) • The child may have a fine sandpaper rash on the trunk, axillae, elbows, and groin seen in scarlet fever (caused by a strain of group A streptococcus) • The uvula is edematous and red • Anterior cervical lymphadenopathy usually occurs early, and the nodes are often tender. • Pain can be relatively mild to severe enough to make swallowing difficult. • Clinical manifestations usually subside in 3 to 5 days unless complicated by sinusitis or parapharyngeal, peritonsillar, or retropharyngeal abscess. Upper Respiratory Tract Infections
• Throat swab requires vigorous swabbing of the tonsils and pharynx for accurate detection. • Rapid identification of GABHS with diagnostic test kits (rapid antigen detection test) is possible in the office or clinic setting. • Throat culture is recommended for negative test results. Upper Respiratory Tract Infections
• If streptococcal sore throat infection is present, oral penicillin V or amoxicillin is prescribed for 10 days to control the acute local manifestations and to maintain an adequate level for at least 10 days to eliminate any organisms that might remain to initiate RF symptoms. • Penicillin usually produces a prompt response within 24 hours. • Patients who have a history of RF or who remain symptomatic after a full course of antibiotics may require a follow-up throat swab.Intramuscular (IM) benzathine penicillin G is an appropriate therapy, but it is painful and is not the first choice for children. • An oral macrolide (erythromycin, azithromycin, clarithromycin) is indicated for children who are allergic to penicillin. • Other antibiotics used to treat GABHS are oral cephalosporins, clindamycin, and amoxicillin with clavulanic acid . Upper Respiratory Tract Infections
• The nurse often obtains a throat swab for culture or rapid antigen testing and instructs the parents about administering oral antibiotics and analgesics as prescribed. • If an injection of penicillin is required, it must be administered deep into a large muscle mass (e.g., vastus lateralis or ventrogluteal muscle). To prevent pain, application of a topical anesthetic cream, such as LMX4 (4% lidocaine) or eutectic mixture of local anesthetics (EMLA; lidocaine and prilocaine) over the injection site before the injection is helpful. • Children are considered infectious to others at the onset of symptoms and up to 24 hours after initiation of antibiotic therapy, but they should not return to school or daycare until they have been taking antibiotics for a full 24-hour period. • If the child continues to have a high fever that does not respond to antipyretics, has an extremely sore throat, refuses liquids, and appears toxic 24 to 48 hours after starting antibiotics, further evaluation by the practitioner is recommended. Upper Respiratory Tract Infections
• The tonsils are masses of lymphoid tissue located in the pharyngeal cavity. • They filter and protect the respiratory and alimentary tracts from invasion by pathogenic organisms and play a role in antibody formation. • Although their size varies, children generally have much larger tonsils than adolescents or adults. This difference is thought to be a protective mechanism because young children are especially susceptible to URIs. Upper Respiratory Tract Infections
• Several pairs of tonsils are part of a mass of lymphoid tissue encircling the nasal and oral pharynx, known as the Waldeyer tonsillar ring (Fig. 21-3). • A surface of the palatine tonsils is usually visible during oral examination. The palatine tonsils are those removed during tonsillectomy. • The pharyngeal tonsils, also known as the adenoids, are located above the palatine tonsils on the posterior wall of the nasopharynx. • Their proximity to the nares and eustachian tubes causes difficulties in instances of inflammation. Upper Respiratory Tract Infections
• Tonsillitis often occurs with pharyngitis. • Because of the abundant lymphoid tissue and the frequency of URIs, tonsillitis is a common cause of illness in young children. • The causative agent may be viral or bacterial. Upper Respiratory Tract Infections
• The manifestations of tonsillitis are caused by inflammation. • As the palatine tonsils enlarge from edema, they may meet in the midline (kissing tonsils), obstructing the passage of air or food. • The child has difficulty swallowing and breathing. • When enlargement of the adenoids occurs, the space behind the posterior nares becomes blocked, making it difficult or impossible for air to pass from the nose to the throat. As a result, the child breathes through the mouth. Upper Respiratory Tract Infections
• Throat cultures positive for GABHS infection warrant antibiotic treatment. • Tonsillectomy is the surgical removal of the palatine tonsils. • Adenoidectomy (the surgical removal of the adenoids) is recommended for children who have a history of four or greater episodes of recurrent purulent rhinorrhea in the previous 12 months in a child younger than 12 years old. Upper Respiratory Tract Infections
• Nursing care involves providing comfort and minimizing activities or interventions that precipitate bleeding. • Patients with sleep-disordered breathing require close monitoring of airway and breathing postoperatively. • A soft to liquid diet is preferred. • Warm saltwater gargles, warm fluids, throat lozenges, and analgesic/antipyretic drugs (such as acetaminophen) are used to promote comfort. • If surgery is required, the child requires the same psychological preparation and physical care as for any other surgical procedure Upper Respiratory Tract Infections
• Family Support and Home Care • Discharge instructions include • (1) avoiding irritating and highly seasoned foods, • (2) avoiding gargles or vigorous toothbrushing, • (3) avoiding coughing or clearing of the throat or putting objects in the mouth (e.g., a straw), • (4) using analgesics or an ice collar for pain, and • (5) limiting activity to decrease the potential for bleeding. • Hemorrhage may occur after surgery as a result of tissue sloughing from the healing process. • Any sign of bleeding warrants immediate medical attention. • Objectionable mouth odor and slight ear pain with a low- grade fever are common for 5 to 10 days postoperatively. • The child's voice may sound different postoperative, especially if the tonsils were large. Upper Respiratory Tract Infections
• Influenza, or the “flu,” is classified into three groups of orthomyxoviruses, which are antigenically distinct: types A and B, which cause epidemic disease, and type C, which is antigenically stable and causes milder disease. • Influenza is spread from one individual to another by direct contact (large- droplet infection) or by articles recently contaminated by nasopharyngeal secretions. • Influenza is frequently most severe in infants. • Affected persons are most infectious for 24 hours before and after the onset of symptoms. • The viruses can be isolated from nasopharyngeal secretions early after the onset of infection, and serologic tests identify the type by complement fixation or the subgroups by hemagglutination inhibition. Upper Respiratory Tract Infections
• Most patients have a dry throat and nasal mucosa, a dry cough, and a tendency toward hoarseness. • A flushed face, photophobia, myalgia, hyperesthesia, and sometimes exhaustion and lack of energy accompany a sudden onset of fever and chills. • The symptoms of influenza last for 4 or 5 days. Complications include severe viral pneumonia (often hemorrhagic); encephalitis; and secondary bacterial infections such as otitis media (OM), sinusitis, or pneumonia. Upper Respiratory Tract Infections
• Uncomplicated influenza in children usually requires only symptomatic treatment, including acetaminophen or ibuprofen for fever and sufficient fluids to maintain hydration. • Oseltamivir is a neuraminidase inhibitor that may be administered orally for 5 days to children older than 1 year of age (and adults) to decrease the flu symptoms; this drug must be taken within 2 days of the onset of symptoms. • Zanamivir can be used for treatment of influenza in patients 7 years old and older and for prophylaxis of influenza in patients 5 years old and older. • Bronchospasm and a decline in lung function can occur when zanamivir is used in patients with underlying airway disease, such as asthma or chronic obstructive pulmonary disease (COPD). Upper Respiratory Tract Infections
• Prevention • The influenza vaccine is now recommended annually for children over 6 months old. • Influenza vaccine (trivalent inactivated influenza vaccine [TIV]) may be given to healthy children 6 months old and older via IM injection. • The TIV vaccines are safe and effective provided the antigens in the vaccine correlate with the circulating influenza viruses. • Patients who have had anaphylactic reactions to egg protein should not receive either influenza vaccine. Upper Respiratory Tract Infections
• Influenza, or the “flu,” is classified into three groups of orthomyxoviruses, which are antigenically distinct: types A and B, which cause epidemic disease, and type C, which is antigenically stable and causes milder disease. • Influenza is spread from one individual to another by direct contact (large- droplet infection) or by articles recently contaminated by nasopharyngeal secretions. • Influenza is frequently most severe in infants. • Affected persons are most infectious for 24 hours before and after the onset of symptoms. • The viruses can be isolated from nasopharyngeal secretions early after the onset of infection, and serologic tests identify the type by complement fixation or the subgroups by hemagglutination inhibition. Upper Respiratory Tract Infections
• Otitis media (OM): An inflammation of the middle ear without reference to etiology or pathogenesis • Acute otitis media (AOM): An inflammation of the middle ear space with a rapid onset of the signs and symptoms of acute infection—namely, fever and otalgia (ear pain) • Otitis media with effusion (OME): Fluid in the middle ear space without symptoms of acute infection • Most episodes of acute otitis media (AOM) occur in the first 24 months of life, but the incidence decreases with age except for a small increase at 5 or 6 years old when children enter school. • Family socioeconomic status and extent of exposure to other children are the two most important identifiable risk factors for the occurrence of OM. Upper Respiratory Tract Infections
• Streptococcus pneumoniae, H. influenzae, and Moraxella catarrhalis are the three most common bacteria causing AOM. • The etiology of noninfectious OM is unknown, but OM may occur because of blocked eustachian tubes, which results in negative ear pressure. Fluid is pulled from the mucosal lining, which accumulates and becomes colonized by infectious organisms. • Predisposing factors include URIs, allergic rhinitis, Down syndrome, cleft palate, daycare attendance, exposure to secondhand smoke, and bottle propping during feeding. • Infants fed breast milk have a lower incidence of OM than formula-fed infants. Upper Respiratory Tract Infections
• OM is primarily a result of malfunctioning eustachian tubes. • Mechanical or functional obstruction of the eustachian tube causes accumulation of secretions in the middle ear. • Intrinsic obstruction can be caused by infection or allergy; extrinsic obstruction is usually a result of enlarged adenoids or nasopharyngeal tumors. • When the passage is not totally obstructed, contamination of the middle ear can take place by reflux, aspiration, or insufflation during crying, sneezing, nose blowing, and swallowing when the nose is obstructed. Upper Respiratory Tract Infections
• Careful assessment of tympanic membrane mobility with a pneumatic otoscope is essential to differentiate AOM from OME • An immobile tympanic membrane or an orange, discolored membrane indicates OME. Upper Respiratory Tract Infections
• Acute Otitis Media • Follows an upper respiratory tract infection • Otalgia (earache)Fever—may or may not be present • Purulent discharge (otorrhea)—may or may not be present • Infants and Very Young Children • Crying, fussiness, restlessness, irritability, especially on lying down • Tendency to rub, hold, or pull affected ear • Rolling head from side to side • Difficulty comforting child • Loss of appetite, refusal to feed Upper Respiratory Tract Infections
• Older Children • Crying or verbalizing feelings of discomfort • Irritability • Lethargy • Loss of appetite • Chronic Otitis Media • Hearing loss • Difficulty communicating • Feeling of fullness, tinnitus, or vertigo may be present Upper Respiratory Tract Infections
• Oral amoxicillin in high doses (80 to 90 mg/kg/day divided twice daily) is the treatment of choice for initial episodes of AOM in children who have not received antibiotics within the past month. • Second-line antibiotics used to treat OM include amoxicillin/clavulanate and cephalosporins (such as cefdinir, cefuroxime, and cefpodoxime). IM ceftriaxone is used if the causative organism is a highly resistant pneumococcus or if the parents are noncompliant with the therapy. • Myringotomy, a surgical incision of the eardrum, may be necessary to alleviate the severe pain of AOM or OME. • Tympanostomy tube placement and adenoidectomy are surgical procedures that may be done to treat recurrent chronic OM (defined as three bouts in 6 months, six in 12 months, or six by 6 years of age). • Adenoidectomy is not recommended for treatment of AOM and is performed only in children with recurrent AOM or chronic OME with postnasal obstruction, adenoiditis, or chronic sinusitis. Upper Respiratory Tract Infections
• Prevention • Routine immunization with the pneumococcal conjugate vaccine PCV7 (Prevnar 7) has reduced the incidence of AOM in some infants and children • The vaccine is administered as a four-dose series beginning at 2 months old. • The Advisory Committee on Immunization Practices recommends routine vaccination with PCV13 of all children 2 to 59 months old, children 60 to 71 months old with underlying medical conditions that increase their risk for pneumococcal disease or complications, and children who previously received one or more doses of PCV7. Upper Respiratory Tract Infections
• Nursing objectives for children with AOM include • (1) relieving pain, • (2) facilitating drainage when possible, • (3) preventing complications or recurrence, • (4) educating the family in care of the child • (5) providing emotional support to the child and family. • Analgesic drugs such as acetaminophen (all ages) and ibuprofen (6 months of age and older) are used to treat mild pain. • If the ear is draining, the external canal may be cleaned with sterile cotton swabs or pledgets coupled with topical antibiotic treatment. • Reducing the chances of OM is possible with measures such as sitting or holding an infant upright for feedings, maintaining routine childhood immunizations, and exclusively breastfeeding until at least 6 months old. • Eliminating tobacco smoke and known allergens is also recommended. Upper Respiratory Tract Infections
• Infectious mononucleosis is an acute, self-limiting infectious disease that is common among young people under 25 years old. • Symptoms include fever, exudative pharyngitis, lymphadenopathy, hepatosplenomegaly, and an increase in atypical lymphocytes. • The course is usually mild but occasionally can be severe or, rarely, accompanied by serious complications. Upper Respiratory Tract Infections
• The herpes-like Epstein-Barr virus (EBV) is the principal cause of infectious mononucleosis. • It appears in both sporadic and epidemic forms, but the sporadic cases are more common. • The virus is believed to be transmitted in saliva by direct intimate contact, blood transfusion, or transplantation. • The incubation period after exposure is approximately 30 to 50 days. Upper Respiratory Tract Infections
• The onset of symptoms may be acute or insidious and may appear anywhere from 10 days to 6 weeks after exposure. Heterophil antibody tests (Paul-Bunnell or Monospot) determine the extent to which the patient's serum will agglutinate sheep red blood cells; the response in these tests is primarily to immunoglobulin M (IgM), which is present in the first 2 weeks of the illness and may last up to a year. • The spot test (Monospot) is a slide test of venous blood that has high specificity for the diagnosis of infectious mononucleosis. Blood is usually obtained for the test by finger puncture or venous sampling and is placed on special paper. If the blood agglutinates, forming fragments or clumps, the test result is positive for the infection. Upper Respiratory Tract Infections
• Early Signs • Headache • Epistaxis • Malaise • Fatigue • ChillsLow-grade fever • Loss of appetite • Puffy eyes • Acute Disease • Cardinal Features • FeverSore throat • Cervical adenopathy Upper Respiratory Tract Infections
• Common Features • Splenomegaly (may persist for several months) • Palatine petechiae • Macular eruption (especially on trunk) • Exudative pharyngitis or tonsillitis • Hepatic involvement to some degree, often associated with jaundice Upper Respiratory Tract Infections
• A mild analgesic is often sufficient to relieve the headache, fever, and malaise. • Rest is encouraged for fatigue but is not imposed for any specific period. • If sore throat is severe, effective therapies include gargles, warm drinks, anesthetic troches, or analgesics, including opioids. • Corticosteroids have been used to treat respiratory distress from significant tonsillar inflammation, myocarditis, hemolytic anemia, thrombocytopenia, and neurologic complications • Prognosis • Acute symptoms often disappear within 7 to 10 days, and persistent fatigue subsides within 2 to 4 weeks. • Some adolescents may need to restrict their activities for 2 to 3 months, but the disease rarely extends for longer periods. • The child is encouraged to maintain limited exercise to prevent deconditioning. Upper Respiratory Tract Infections
• Direct nursing responsibilities toward providing comfort measures to relieve symptoms. • The child is advised to limit exposure to persons outside the family, especially during the acute phase of illness. • Throat pain may be severe enough to require an analgesic, such as acetaminophen or ibuprofen. • Careful nursing assessment of swallowing ability is essential to detect serious airway edema and airway compromise. Upper Respiratory Tract Infections
• Croup is a general term applied to a symptom complex characterized by hoarseness, a resonant cough described as “barking” or “brassy” (croupy), varying degrees of inspiratory stridor, and varying degrees of respiratory distress resulting from swelling or obstruction in the region of the larynx and subglottic airway. • Croup syndromes can affect the larynx, trachea, and bronchi. • Causes: parainfluenza virus, human metapneumovirus, influenza types A and B, adenovirus, and measles. Croup Syndromes
Upper Respiratory Tract Infections Croup Syndromes
• Acute epiglottitis, or acute supraglottitis, is a medical emergency. • It is a serious obstructive inflammatory process that occurs predominantly in children 2 to 5 years old but can occur from infancy to adulthood. • The obstruction is supraglottic as opposed to the subglottic obstruction of laryngitis. • The responsible organism is usually H. influenzae. Croup Syndromes
Croup Syndromes • Three clinical observations that are predictive of epiglottitis are absence of spontaneous cough, presence of drooling, and agitation. • The child is irritable, extremely restless, and has an anxious, apprehensive, and frightened expression. • The voice is thick and muffled, with a froglike croaking sound on inspiration, but the child is not hoarse. • Suprasternal and substernal retractions may be evident. • The child seldom struggles to breathe, and slow, quiet breathing provides better air exchange. • The sallow color of mild hypoxia may progress to frank cyanosis if treatment is delayed. • The throat is red and inflamed, and a distinctive large, cherry red, edematous epiglottis is visible on careful throat inspection.
• The child who is suspected of having epiglottitis should be examined in a setting where emergency airway equipment is readily available. • Examination of the throat with a tongue depressor is contraindicated until experienced personnel and equipment are available to proceed with immediate intubation or tracheostomy in the event that the examination precipitates further or complete obstruction. • A lateral neck radiograph of the soft tissues is indicated for diagnosis. • Nasotracheal intubation or on occasion, tracheostomy, is considered for the child with epiglottitis with severe respiratory distress. • Humidified oxygen is administered as necessary either via mask in older children or blow-by in younger children to avoid further agitation. • Children with suspected bacterial epiglottitis are given antibiotics intravenously followed by oral administration to complete a 7- to 10- day course. Croup Syndromes
• It is important to act quickly but calmly and to provide support without increasing anxiety. • When epiglottitis is suspected, the nurse should not attempt to visualize the epiglottis directly with a tongue depressor or take a throat culture but should refer the child for medical evaluation immediately. • Continuous monitoring of respiratory status, including pulse oximetry (and blood gases if the patient is intubated), is an important part of nursing observations, and the IV infusion is maintained. Croup Syndromes
• Acute LTB is the most common croup syndrome. • It primarily affects children 6 months to 3 years old, and the causative organisms are viral agents, particularly the parainfluenza virus types 1, 2 and 3, adenovirus, enterovirus, RSV, rhinovirus, and influenza A and B. • Bacterial organisms are rarely a causative organism but can include M. pneumonia and diphtheria. • Inflammation of the mucosal lining the larynx and trachea causes a narrowing of the airway. • Other classic manifestations include cough and hoarseness. • Respiratory distress in infants and toddlers may be manifested by nasal flaring, intercostal retractions, tachypnea, and continuous stridor. • Obstruction that is severe enough to prevent adequate ventilation and exhalation of carbon dioxide can cause respiratory acidosis and eventually respiratory failure. Croup Syndromes
• The major objective in medical management is maintaining the airway and providing adequate respiratory exchange. • The application of humidity with cool mist provides some relief for most children with mildcroup. • Nebulized epinephrine (racemic epinephrine) is often used in children with severe disease, stridor at rest, retractions, or difficulty breathing. • Oral steroids (dexamethasone) have proven effective in the treatment of croup (often as a single dose) • Nebulized budesonide may be administered in conjunction with IM dexamethasone. • Antibiotics are only used to treat specific bacterial complications of croup. Croup Syndromes
• The most important nursing function in the care of children with LTB is continuous, vigilant observation and accurate assessment of respiratory status. • Cardiac, respiratory, and pulse oximetry monitoring supplement visual observation. • The trend away from early intubation of children with LTB emphasizes the importance of nursing observations and the ability to recognize impending respiratory failure so that intubation can be implemented without delay. • Parents need frequent reassurance (provided in a calm, quiet manner) and education regarding what they can do to make their child more comfortable. • Home care after discharge includes monitoring for worsening symptoms, continued humidity, adequate hydration, and nourishment. Croup Syndromes
• Acute spasmodic laryngitis (spasmodic croup) is distinct from laryngitis and LTB, and it is characterized by recurrent paroxysmal attacks of laryngeal obstruction that occur chiefly at night. • Signs of inflammation are absent or mild, and it is followed by an uneventful recovery. • The child feels well the next day. Some children appear to be predisposed to the condition; allergies or hypersensitivities may be implicated in some cases. Croup Syndromes
• Bacterial tracheitis, an infection of the mucosa and soft tissues of the upper trachea, is a distinct entity with features of both croup and epiglottitis. • The disease occurs in typically at a mean age between 5 and 7 years old and may cause severe airway obstruction. • Staphylococcus aureus is the most frequent organism responsible, M. catarrhalis, S. pneumoniae, and H. influenzae have also been implicated. • The child has a history of previous URI with croupy cough, stridor unaffected by position, toxicity, absence of drooling, and high fever. • Thick, purulent tracheal secretions are common, and respiratory difficulties are secondary to these copious secretions. • The child's white cell count will be elevated. Croup Syndromes
• Bacterial tracheitis requires vigorous management with oxygen therapy, antipyretics, and antibiotics. • Early recognition to prevent life-threatening airway obstruction is essential. • Many children with bacterial tracheitis need endotracheal intubation and mechanical ventilation for airway obstruction. Croup Syndromes
• The reactive portion of the lower respiratory tract includes the bronchi and bronchioles in children. • The smooth muscle in these structures represents a major factor in the constriction of the airway, particularly in the bronchioles, the portion that extends from the bronchi to the alveoli. Infections of the Lower Airways
Infections of the Lower Airways
• Bronchitis (sometimes referred to as tracheobronchitis) is inflammation of the large airways (trachea and bronchi), which is frequently associated with URIs. • Viral agents are the primary cause of the disease, although M. pneumoniae is a common cause in children older than 6 years of age. • A dry, hacking, nonproductive cough that worsens at night and becomes productive in 2 or 3 days characterizes this condition. • Bronchitis is a mild, self-limiting disease that requires only symptomatic treatment, including analgesics, antipyretics, and humidity. Cough suppressants may be useful to allow rest but can interfere with clearance of secretions. Most patients recover uneventfully in 5 to 10 days. • Adolescents with chronic bronchitis (>3 months) should be screened for tobacco or marijuana use. Infections of the Lower Airways
• Bronchiolitis is a common, acute viral infection with upper respiratory and lower respiratory infection of the bronchioles due to inflammation. • Cause: • Adenoviruses • parainfluenza viruses • Human merapneumovirus Infections of the Lower Airways
• RSV affects the epithelial cells of the respiratory tract. • The ciliated cells swell, protrude into the lumen, and lose their cilia. • The walls of the bronchi and bronchioles are infiltrated with inflammatory cells, and varying degrees of intraluminal obstruction lead to hyperinflation, obstructive emphysema resulting from partial obstruction, and patchy areas of atelectasis. • Dilation of bronchial passages on inspiration allows sufficient space for intake of air, but narrowing of the passages on expiration prevents air from leaving the lungs. Thus, air is trapped distal to the obstruction and causes progressive overinflation (emphysema). Infections of the Lower Airways
• Initial • Rhinorrhea • Pharyngitis • Coughing, sneezing • Wheezing • Possible ear or eye drainage • Intermittent fever • With Progression of Illness • Increased coughing and wheezing • Tachypnea and retractions • Cyanosis • Severe Illness • Tachypnea, >70 breaths/min • Listlessness • Apneic spells • Poor air exchange; poor breath sounds Infections of the Lower Airways
• Identification on nasopharyngeal secretions, • rapid immunofluorescent antibody/direct fluorescent antibody (DFA) staining • enzyme-linked immunosorbent assay (ELISA) for RSV antigen detection • Hyperinflation of the lungs is generally seen on the chest radiograph. Infections of the Lower Airways
• Children with bronchiolitis are cared for home if they are maintaining hydration, do not have respiratory distress, and do not need oxygen therapy. • Humidified oxygen is administered in concentrations sufficient to maintain adequate oxygenation (SpO2) at or above 90% as measured by pulse oximetry. • An infant who is tachypneic or apneic, has marked retractions, seems listless, has a history of poor fluid intake, or is dehydrated should be closely observed for respiratory failure. • Children with thickened secretions may benefit from extra humidity blended with oxygen administration and continuous positive airway pressure (CPAP) via a high flow nasal cannula (HFNC). A prescriber order is required to indicate the flow rate and percentage of the oxygen therapy. The HFNC improves functional residual capacity, reducing the work of breathing. Infections of the Lower Airways
• Infants with abundant nasal secretions benefit from regular suctioning, especially before feeding. • Nasal aspiration of the external nares using an aspirator may be sufficient to remove most secretions • Fluids by mouth may be contraindicated because of tachypnea, weakness, and fatigue • Nasogastric (NG) fluids may be required if the infant is unable to tolerate oral fluids and a peripheral IV is difficult to establish. • Ribavirin, an antiviral agent (synthetic nucleoside analog), is the only specific therapy approved for hospitalized children. • Palivizumab (Synagis), a monoclonal antibody, which is given monthly in an IM injection for a maximum of five doses to prevent hospitalization associated with RSV. Infections of the Lower Airways
• Droplet and standard precautions are used, including hand washing, not touching the nasal mucosa or conjunctiva, and using gloves and gowns when entering the patient's room; contact precautions are also recommended. • If a nasal cannula is being used, the skin around the child's ears must be observed for signs of irritation and pressure related injuries. • If a nasal cannula is being used, the skin around the child's ears must be observed for signs of irritation and pressure related injuries. Pulse oximetry probes must be rotated at least every 4 to 8 hours to prevent pressure-related injuries to the skin. • Breastfeeding mothers are encouraged to continue feeding the infant or, if feedings are contraindicated because of the acuity of the illness, mothers should pump their milk and store it appropriately for later use. • Nursing care is aimed at monitoring oxygenation with pulse oximetry, ensuring any bronchodilator therapy is optimized by using a small mask for delivery, monitoring IV fluids and NG fluids administered, monitoring temperature, and providing information for the parent and family regarding the infant's status. Infections of the Lower Airways
• Pneumonia, inflammation of the pulmonary parenchyma, is common in childhood but occurs more frequently in early childhood. The causative agent is either inhaled into the lungs directly or comes from the bloodstream. • The most useful classification of pneumonia is based on the etiologic agent (e.g., viral, bacterial, mycoplasmal, or aspiration of foreign substances). • • Neonates: Group B streptococci, gram-negative enteric bacteria, cytomegalovirus, Ureaplasma urealyticum, Listeria monocytogenes, C. trachomatis • • Infants: RSV, parainfluenza virus, influenza virus, adenovirus, metapneumovirus, S. pneumoniae, H. influenzae, M. pneumoniae, Mycobacterium tuberculosis • • Preschool children: RSV, parainfluenza virus, influenza virus, adenovirus, metapneumovirus, S. pneumoniae, H. influenzae, M. pneumoniae, M. tuberculosis • • School-age children: M. pneumoniae, Chlamydia pneumoniae, M. tuberculosis, and respiratory virusesHistomycosis, coccidioidomycosis, and other fungi also cause pneumonia. Infections of the Lower Airways
• Pneumonitis is a localized acute inflammation of the lung without the toxemia associated with lobar pneumonia. • The causative agent is identified from the clinical history, the child's age, the general health history, the physical examination, radiography, and the laboratory examination. Infections of the Lower Airways
• Viruses that cause pneumonia include RSV in infants and parainfluenza, influenza, human metapneumovirus, enterovirus, and adenovirus in older children. Differentiation among viruses is usually made by clinical features, such as child's age, medical history, season of the year, and radiographic and laboratory examination. • Treatment is symptomatic and includes measures to promote oxygenation and comfort, such as oxygen administration with cool mist, postural drainage, antipyretics for fever management, monitoring fluid intake, and family support. Infections of the Lower Airways
• General Signs of Pneumonia • Fever: Usually high • Respiratory Cough: Unproductive to productive with whitish sputum Tachypnea Breath sounds: Crackles, decreased breath sounds Dullness with percussion Chest pain Retractions Nasal flaring Pallor to cyanosis (depends on severity) • Chest radiography: Diffuse or patchy infiltration with peribronchial distribution • Behavior: Irritability, restlessness, malaise, lethargy • Gastrointestinal: Anorexia, vomiting, diarrhea, abdominal pain Infections of the Lower Airways
• Atypical pneumonia refers to pneumonia that is caused by pathogens other than the traditionally most common and readily cultured bacteria (e.g., S. pneumoniae). • In the category of atypical pneumonias, M. pneumoniae is the most common cause of community-acquired pneumonia in children 5 to 15 years old • Chlamydial pneumonia, caused by C. trachomatis, can occur in infants and generally appears between 2 and 19 weeks after delivery • Chlamydial pneumonia is characterized by a persistent cough, tachypnea, and sometimes rales. • Oral azithromycin is the treatment of choice; alternatively, erythromycin or ethylsuccinate can be give. Infections of the Lower Airways
• S. pneumoniae is the most common bacterial pathogen responsible for community-acquired pneumonia in both children and adults • Other bacteria that cause pneumonia in children are group A streptococcus, S. aureus, M. catarrhalis, M. pneumonia, and C. pneumoniae. Infections of the Lower Airways
• S. pneumoniae is the most common bacterial pathogen responsible for community-acquired pneumonia in both children and adults • Other bacteria that cause pneumonia in children are group A streptococcus, S. aureus, M. catarrhalis, M. pneumonia, and C. pneumoniae. • Symptoms include fever, malaise, rapid and shallow respirations, cough, and chest pain. The associated cough may persist for several weeks or months. The pain of pneumonia may be referred to the abdomen in young children. Chills and meningeal symptoms (meningism) without meningitis are common. • Antibiotic therapy, rest, liberal oral intake of fluid, and administration of an antipyretic for fever are the principal therapeutic measures. Infections of the Lower Airways
• Hospitalization is indicated when pleural effusion or empyema accompanies the disease, when moderate or severe respiratory distress or deoxygenation occurs, in situations in which compliance with therapy is estimated to be poor, in infants younger than 6 months old, and when there are chronic illnesses such as congenital heart disease or BPD . • Complications • Infants, with staphylococcal pneumonia develop empyema, pyopneumothorax, or tension pneumothorax. • AOM and pleural effusion are common in children with pneumococcal pneumonia • vaccination with pneumococcal vaccines is an important part of preventing pneumococcal pneumonia Infections of the Lower Airways
• Pneumothorax occurs when there is an accumulation of air in the pleural space; this air increases intrapleural pressure, making it more difficult to expand the affected lung. • This leads to the clinical manifestations of dyspnea, chest pain and often back pain, labored respirations, tachycardia, and decreased oxygen saturation (SaO2). • In neonates and infants on mechanical ventilation, the first clinical signs of a pneumothorax are oxygen desaturation and hypotension. • The three major types of pneumothorax are tension, spontaneous, and traumatic. • The definitive diagnosis of pneumothorax is a chest radiograph. • The emergent treatment involves needle aspiration of the air within the pleural space; subsequently a chest tube to closed drainage is usually inserted to prevent the reaccumulation of air. • Pleural effusion occurs when there is an excessive accumulation of fluid in the pleural space. • The diagnosis is made by chest radiography, and the treatment involves evacuation of the fluid by needle aspiration followed by insertion of a chest tube to closed drainage. Infections of the Lower Airways
• Nursing Care Management • Supportive and symptomatic, thorough respiratory assessment and administration of supplemental oxygen (as required), fluids, and antibiotic • Child with a chest tube requires close attention to respiratory status • The chest tube and drainage device used are monitored for proper function (i.e., drainage is not impeded, vacuum setting is correct, tubing is free of kinks, dressing covering chest tube insertion site is intact, water seal is maintained [if used], and chest tube remains in place). • A simple bulb suction syringe is usually sufficient for clearing the nares and nasopharynx of infants. • Chest percussion, postural drainage, and nebulize bronchodilator treatments may be prescribed. • For the child being cared for at home, the nurse educates the parent regarding observation for worsening symptoms, antibiotic and antipyretic administration, and encouragement of oral fluid intake. Infections of the Lower Airways
• Pertussis, or whooping cough, is an acute respiratory tract infection caused by B. Pertussis, which in the past primarily occurred in children younger than 4 years old who were not immunized. • Complications in adolescents can include syncope, rib fractures, and pneumonia; whereas on younger children, seizures, pnemonia, intracranial bleeding, conjunctival bleeding and death can occur. • Diagnosis is obtained via culture or B. pertussis polymrase chain reaction (PCR) test on specimens obtained with nasal swab. • Treatment with antibiotics (erythromycin, clarithromycin, or azithromycin) in the catarrhal stage may result in a milder form of the infection. Other Infections of the Respiratory Tract
• Tuberculosis (TB) along with human immunodeficiency virus is the leading cause of death from a single infectious disease. • TB is caused by M. tuberculosis, an acid-fast bacillus. Children are susceptible to the human (M. tuberculosis) and the bovine (Mycobacterium bovis) organisms. • The source of TB infection in children is usually an infected member of the household or a frequent visitor to the home, such as a babysitter or domestic worker. • In the lungs, a proliferation of epithelial cells surrounds and encapsulates the multiplying bacilli in an attempt to wall it off, thus forming the typical tubercle. • Erosion of blood vessels by the primary lesion can cause widespread dissemination of the tubercle bacillus to near and distant sites (miliary TB). • Extrapulmonary (miliary) TB may be manifested as malaise, fever, weight loss, superior lymphadenitis, meningitis, hepatomegaly, splenomegaly, and osteoarthritis. Other Infections of the Respiratory Tract
• May be asymptomatic or produce a broad range of symptoms: • • Fever • • Malaise • • Anorexia • • Weight loss • • Cough (may or may not be present; progresses slowly over weeks to months) • • Aching pain and tightness in the chest • • Hemoptysis (rare) • With progression: • • Increasing respiratory rate • • Poor expansion of lung on the affected side • • Diminished breath sounds and crackles • • Dullness to percussion • • Persistent fever • • Generalized symptoms • • Pallor, anemia, weakness, and weight loss Other Infections of the Respiratory Tract
• Diagnosis is based on information derived from physical examination, history, tuberculin skin testing, radiographic examinations, and cultures of the organism. • The tuberculin skin test (TST) is the most important indicator of whether a child has been infected with the tubercle bacillus. • A targeted testing method is employed wherein only children and adolescents at high risk for contracting the disease, in addition to patients at risk for progression to TB disease, are screened. Other Infections of the Respiratory Tract
• The standard dose of purified protein derivative (PPD) is 5 tuberculin unit, which is administered using a 27-gauge needle and a 1-ml syringe intradermally into the volar aspect of the forearm. • The tuberculin is injected ID with bevel of the needle pointing upward. • A 6-10mm in diameter should form between the layers of the skin when the solution is injected properfly. • The reaction to the skin test is determined in 48 to 72 hours by a health professionals. • A positive reaction indicates that the individual has been infected and has developed sensitivity to the protein of the tubercle bacillus. Other Infections of the Respiratory Tract
Other Infections of the Respiratory Tract
• The term latent tuberculosis infection (LTBI) is used to indicate infection in a person who has a positive TST, no physical findings of disease, and normal chest radiograph findings. • Children younger than 5 years old who have LTBI often progress rapidly to disease and complications (such as TB meningitis and miliary TB) are more common in this age group. • The term TB disease or clinically active TB is used when a child has clinical symptoms or radiographic manifestations caused by the M. tuberculosis organism. • Sputum specimens are difficult or impossible to obtain from infants and young children, because they swallow any mucus coughed from the lower respiratory tract. Early morning aspiration of gastric contents with a NG tube may be performed to capture sputum swallowed overnight and should ideally occur daily for 3 days before the child eats. In some cases, an induced sputum specimen may be obtained by administering aerosolized normal saline for 10 to 15 minutes followed by chest percussion and postural drainage and suctioning of the nasopharynx. • The Xpert MTB/RIF is a diagnostic test that can be used on gastric lavage and nasopharyngeal secretions to identify M. tuberculosis and to detect resistance to rifampin. Other Infections of the Respiratory Tract
• Tuberculin Skin Test Recommendations for Infants, Children, and Adolescents* • Children for Whom Immediate Tuberculin Skin Test Is Indicated • Contacts of persons with confirmed or suspected contagious tuberculosis (TB; contact investigation) • Children with radiographic or clinical findings suggesting TB disease • Children immigrating from endemic countries (e.g., Asia, Middle East, Africa, Latin America) • Children with travel histories to endemic countries or significant contact with indigenous persons from such countries† • Children Who Should Have Annual Tuberculin Skin Test‡ • Children infected with human immunodeficiency virus (HIV) • Incarcerated adolescents Other Infections of the Respiratory Tract
• Tuberculin Skin Test Recommendations for Infants, Children, and Adolescents* • Children for Whom Immediate Tuberculin Skin Test Is Indicated • Contacts of persons with confirmed or suspected contagious tuberculosis (TB; contact investigation) • Children with radiographic or clinical findings suggesting TB disease • Children immigrating from endemic countries (e.g., Asia, Middle East, Africa, Latin America) • Children with travel histories to endemic countries or significant contact with indigenous persons from such countries† • Children Who Should Have Annual Tuberculin Skin Test‡ • Children infected with human immunodeficiency virus (HIV) • Incarcerated adolescents Other Infections of the Respiratory Tract
• Medical management of TB disease in children consists of adequate nutrition, pharmacotherapy, general supportive measures, prevention of unnecessary exposure to other infections that further compromise the body's defenses, prevention of reinfection, and sometimes surgical procedures. • Ethambutol, isoniazid, pyrazinamide (PZA), and rifampin are common medications used to treat TB in children. • If the child is suspected of having multidrug-resistant TB, a fourth medication such as streptomycin (IM injection only), kanamycin, amikacin, or capreomycin may be added for 4 to 8 weeks. Other Infections of the Respiratory Tract
• Prognosis • Most children recover from primary TB infection and are often unaware of its presence. • TB is a serious disease during the first 2 years of life, during adolescence, and in children who are HIV positive. • Antibiotic therapy has decreased the death rate and the hematogenous spread from primary lesions. • Prevention • The only definite means to prevent TB is to avoid contact with the tubercle bacillus. • Limited immunity can be produced by administration of bacillus Calmette-Guérin (BCG), a live vaccine containing bovine bacilli with reduced virulence (attenuated). • BCG vaccination may be recommended for long-term protection of infants and children with negative TST results who are not infected with HIV and who • (1) are at high risk for continuing exposure to persons with infectious pulmonary TB or • (2) are continuously exposed to persons with TB who have bacilli resistant to both INH and rifampin. Other Infections of the Respiratory Tract
• Children with no cough and negative sputum smears can be hospitalized in a regular patient room. • Airborne precautions and a negative-pressure room are required for children who are contagious and hospitalized with active TB disease. • Asymptomatic children with TB can attend school or daycare facilities if they are receiving pharmacotherapy. • They can return to regular activities as soon as effective therapy has been instituted, adherence to therapy has been documented, and clinical symptoms have diminished. • Because the success of therapy depends on compliance with the drug regimen, parents are instructed about the importance and rationale for Directly Observed Therapy (DOT). Other Infections of the Respiratory Tract
• Small children characteristically explore matter with their mouths and are prone to aspirate foreign bodies (FBs). • Small children also place objects such as beads, toys, paper clips, small magnets, or food items in the nose, which can easily be aspirated into the trachea. FB aspiration can occur at any age but is most common in children 1 to 3 years old. • “Fun foods” such as hard candy and hot dogs are the worst offenders in terms of potential for choking. • Offending foods in the order of frequency of choking are hot dogs, round candies, peanuts or other types of nuts, grapes, cookies or biscuits, pieces of meats, caramels, carrots, apples, peas, celery, popcorn, fruit and vegetable seeds, cherry pits, gum, and peanut butter. Pulmonary Dysfunction Caused by Noninfectious Irritants
• The diagnosis of FB aspiration is suspected on the basis of the history and physical signs. FB in the air passages can cause choking, gagging, wheezing, or coughing. Laryngotracheal obstruction most commonly causes dyspnea, cough, stridor, and hoarseness because of decreased air entry. • Cyanosis may occur if the obstruction becomes worse. • Bronchial obstruction usually produces cough (frequently paroxysmal), wheezing, asymmetric breath sounds, decreased airway entry, and dyspnea. • When an object is lodged in the larynx, the child is unable to speak or breathe. • Secondary symptoms are related to the anatomic area in which the object is lodged and are usually caused by a persistent respiratory tract infection distal to the obstruction. • Nasal FBs often manifest by unilateral purulent drainage that does not improve with time. • Radiographic examination reveals opaque • Bronchoscopy is required for a definitive diagnosis of objects in the larynx and trachea. • Fluoroscopic examination is valuable in detecting FBs in the bronchi. The mainstay of diagnosis and management of FBs is endoscopy and bronchoscopy. Pulmonary Dysfunction Caused by Noninfectious Irritants
• FB aspiration may result in life-threatening airway obstruction, especially in infants because of the small diameters of their airways. • Current recommendations for the emergency treatment of the choking child include the use of abdominal thrusts for children older than 1 year of age and back blows and chest thrusts for children younger than 1 year old. • Most frequently, it must be removed instrumentally by bronchoscopy. • After removal of the FB, the child is usually observed for any complications such as laryngeal edema and then discharged home within a matter of hours if vital signs are stable and recovery is satisfactory. Pulmonary Dysfunction Caused by Noninfectious Irritants
• A major role of nurses caring for a child who has aspirated an FB is to recognize the signs of FB aspiration, observe for worsening of respiratory symptoms, and implement immediate measures to relieve an emergency obstruction. • To aid a child who is choking, nurses must recognize the signs of distress. A blind sweep of the child's mouth should never be performed, because it may lodge the agent farther into the airway. • Prevention • Nurses can educate parents singly or in groups about hazards of aspiration in relation to the developmental level of their children and encourage them to teach their children safety. • Parents should be cautioned about behaviors that their children might imitate (e.g., holding foreign objects, such as pins, nails, and toothpicks, in their lips or mouth). • Parents should be educated on access to age-appropriate toys and how older sibling toys could be hazardous for younger siblings. • Magnets must be kept away from younger children. Pulmonary Dysfunction Caused by Noninfectious Irritants
• Aspiration pneumonia occurs when food, secretions, inert materials, volatile compounds, or liquids enter the lung and cause inflammation and a chemical pneumonitis. • Aspiration of fluid or foods is a particular hazard in the child who has difficulty with swallowing or is unable to swallow because of paralysis, weakness, debility, congenital anomalies, or absent cough reflex or in the child who is force-fed, especially while crying or breathing rapidly. • Classic symptoms include an increasing cough or fever with foul-smelling sputum, deteriorating oxygenation, evidence of infiltrates on chest radiographs, and other signs of lower airway involvement. • Other substances that may cause pneumonia are hydrocarbons, lipids, powder, and contrast dye or barium. The severity of the lung injury depends on the pH of the aspirated material. Pulmonary Dysfunction Caused by Noninfectious Irritants
• The major focus of nursing care is on prevention of aspiration. • Proper feeding techniques should be carried out, and preventive measures should be used to prevent aspiration of any material that might enter the nasopharynx. • Other risk factors include decreased gastrointestinal motility, ineffective cough, poor gag reflex, impaired swallow, high gastric residual, and trauma or surgery to the neck, face, or mouth.Children who are at risk for swallowing difficulties as a result of illness, physical debilitation, anesthesia, or sedation are kept NPO (nothing by mouth) until they can properly swallow fluids effectively. • The child who is at risk for vomiting and incapable of protecting the airway should be positioned in a side-lying recovery position. Pulmonary Dysfunction Caused by Noninfectious Irritants
• Pulmonary edema (PE) is the movement of fluid into the alveoli and interstitium of the lungs caused by extravasation of fluid from the pulmonary vasculature. • There are two main types of PE: cardiogenic and noncardiogenic. • Cardiogenic (hydrostatic, hemodynamic) PE is caused by an increase in pulmonary capillary pressure because of an increase in pulmonary venous pressure. • Noncardiogenic PE is caused by various conditions that result in increased pulmonary capillary permeability. • Other causes include aspiration, traumatic injury, organ dysfunction caused by sepsis, multiorgan failure, alcoholism or substance abuse, pregnancy (eclampsia), chronic renal impairment, malnutrition, hypertension, or a blood transfusion (transfusion-related ALI). Pulmonary Dysfunction Caused by Noninfectious Irritants
• Fluid flows from the pulmonary vasculature into the alveolar interstitial space and then returns to the systemic circulation in a normal lung. • Movement of this fluid is controlled by the net difference between hydrostatic and osmotic pressures and the permeability of the capillary membrane. • Increased pulmonary hydrostatic pressure or increased permeability of the vascular membrane results in movement of fluid into the alveoli and interstitium of the lung. • The pulmonary lymph system normally drains away any fluid from the alveoli, but when the amount of fluid present in the alveoli exceeds lymph drainage, PE occurs. • Symptoms include extreme shortness of breath, cyanosis, tachypnea, diminished breath sounds, anxiety, agitation, confusion, diaphoresis, orthopnea, respiratory crackles, expiratory wheezing (in young infants), heart murmur, S3 gallop, cool peripheries, jugular venous distension, nocturnal dyspnea, cough, pink frothy sputum (if severe), tachycardia, hypertension, and hypotension (if caused by left ventricle dysfunction). Pulmonary Dysfunction Caused by Noninfectious Irritants
• Management of PE depends on the cause but can include oxygen therapy, positive end-expiratory pressure (PEEP) via CPAP, and intubation with ventilatory support if respiratory failure occurs. • If ventricular failure is the cause, medications such as diuretics, digoxin, positive inotropes, and vasodilators (nitroglycerin) may be started, and the child may be placed on a fluid and sodium restriction. • Morphine may be prescribed to relieve dyspnea. • The primary goal of management is to determine why PE occurred and treat the underlying condition. Pulmonary Dysfunction Caused by Noninfectious Irritants
• Pulse oximetry is monitored, and vital signs are observed closely for any deterioration. • The nurse should note changes in SaO2, end-tidal carbon dioxide (ETCO2), and arterial blood gas (ABG) values. • Oxygen, medications, and other respiratory treatments are administered as prescribed. • Close monitoring of intake and output, electrolytes, and comfort are important. • The child should be monitored for restlessness, anxiety, and air hunger. • Placing the child in a high Fowler position may help with lung expansion. Pulmonary Dysfunction Caused by Noninfectious Irritants
• ARDS is a potentially life-threatening inflammatory lung condition that may occur in both children and adults. • Sepsis, trauma, viral pneumonia, aspiration, fat emboli, drug overdose, reperfusion injury after lung transplantation, smoke inhalation, and near-drowning, among others, have been associated with ARDS. • Mechanical ventilation is often required. • Hypoxemia is expressed in terms of the ratio of partial pressure of oxygen (PaO2) to the fraction of inspired oxygen (FiO2) or P/F ratio. In the setting of a PEEP or CPAP ≥5 cm H2O, mild, moderate and severe ARDS are defined by P/F ratios between 200 and 300, between 100 and 200, and ≤100 mm Hg. Pulmonary Dysfunction Caused by Noninfectious Irritants
• ARDS is increased permeability of the alveolar-capillary membrane. • During the acute phase of ARDS, inflammatory mediators cause damage to the alveolocapillary membrane, with an increasing pulmonary capillary permeability with resulting interstitial edema. • Later stages are characterized by pneumocyte and fibrin infiltration of the alveoli, with the start of either the healing process or fibrosis. • In ARDS, the lungs become stiff as a result of surfactant inactivation; gas diffusion is impaired; and eventually, bronchiolar mucosal swelling and congestive atelectasis occur. • Surfactant secretion is reduced, and the atelectasis and fluid-filled alveoli provide an excellent medium for bacterial growth. • Hypoxemia or increased work of breathing may require ventilatory support. • The child with ARDS may first demonstrate only symptoms caused by an injury or infection, but as the condition deteriorates, hyperventilation, tachypnea, increasing respiratory effort, cyanosis, and decreasing SaO2 occur. Pulmonary Dysfunction Caused by Noninfectious Irritants
• Treatment involves supportive measures to maintain adequate oxygenation and pulmonary perfusion, treatment of infection (or the precipitating cause), and maintenance of adequate cardiac output and vascular volume. After the underlying cause has been identified, specific treatment (e.g., antibiotics for infection) is initiated. • Many patients require mechanical ventilatory support. • Fluid administration to maintain adequate intravascular volume and end-organ perfusion must be balanced against the desire to decrease lung fluid to improve oxygenation. Psychological support of the patient and family is also important. • Protective ventilatory strategies using low tidal volumes (6 ml/kg ideal body weight) have been demonstrated to improve outcomes in adults and theoretically are also appropriate in children. Pulmonary Dysfunction Caused by Noninfectious Irritants
• Prognosis • The prognosis for patients with ARDS is improving. • The precipitating disorder influences the outcome; the worst prognosis is associated with profound hypoxemia, uncontrolled sepsis, bone marrow transplantation, cancer, and multisystem involvement with hepatic failure. • Children who recover may have persistent cough and exertional dyspnea. Pulmonary Dysfunction Caused by Noninfectious Irritants
• The child with ARDS is cared for in the ICU during the acute stages of illness. • Nursing care involves close monitoring of oxygenation and respiratory status, cardiac output, perfusion, fluid and electrolyte balance, and renal function (urinary output). • Blood gas analysis, acid-base status, and pulse oximetry are important evaluation tools. • Diuretics may be administered to reduce pulmonary fluid, and vasodilators may be administered to decrease pulmonary vascular pressure. • Nutritional support is often required because of the prolonged acute phase of the illness. • The nursing care of the child with ARDS also involves close observance of skin condition, prevention of skin breakdown by pressure area relief, and passive range of motion for prevention of muscle atrophy and contractures. Pulmonary Dysfunction Caused by Noninfectious Irritants
• Three distinct syndromes of pulmonary complications may occur in children with inhalation injury: • (1) early carbon monoxide (CO) poisoning, airway obstruction, and PE; • (2) ARDS occurring at 24 to 48 hours or later in some cases; and • (3) late complications of pneumonia and pulmonary emboli. • Smoke inhalation results in three types of injury: heat, chemical, and systemic. • Heat injury involves thermal injury to the upper airway. Air has low specific heat; therefore, the injury goes no farther than the upper airway. Reflex closure of the glottis prevents injury to the lower airway. • Chemical injury involves gases that may be generated during the combustion of materials, such as clothing, furniture, and floor coverings. Acids, alkalis, and their precursors in smoke can produce chemical burns. Pulmonary Dysfunction Caused by Noninfectious Irritants
• Systemic injury occurs from gases that are nontoxic to the airways (e.g., CO, hydrogen cyanide). However, these gases cause injury and death by interfering with or inhibiting cellular respiration. • When CO enters the bloodstream, it binds readily with hemoglobin to form carboxyhemoglobin (COHb). Because it is released less readily than oxygen, tissue hypoxia reaches dangerous levels before oxygen is available to meet tissue needs. • Mild manifestations include headache, visual disturbances, irritability, and nausea; more severe intoxication causes confusion, hallucinations, ataxia, and coma. Pulmonary Dysfunction Caused by Noninfectious Irritants
• The most widely accepted treatment is placing the child on humidified 100% oxygen as quickly as possible to rapidly reverse tissue hypoxia and to displace CO and cyanide from protein-binding sites. • The child is monitored for signs of respiratory distress and impending failure and intubation may be required. • A laryngoscopy or bronchoscopy evaluation may be done to assess for airway damage. • Baseline ABGs and COHb levels are obtained. P • Hyperbaric oxygen therapy may be useful in the treatment of neurologic complications related to CO poisoning. • Pulmonary care may be facilitated by bronchodilators, humidification, chest percussion, and postural drainage to enhance the removal of necrotic material, minimize bronchoconstriction, and avoid atelectasis. • Bronchoscopy may be needed to clear heavy secretions. Pulmonary Dysfunction Caused by Noninfectious Irritants
• Assessment and localization of the obstruction should be accomplished before severe swelling of the head, neck, or oropharynx occurs. • Intubation is often necessary when (1) severe burns in the area of the nose, mouth, and face increase the likelihood of developing oropharyngeal edema and obstruction; (2) vocal cord edema causes obstruction; (3) the patient has difficulty handling secretions; and (4) progressive respiratory distress requires artificial ventilation. Pulmonary Dysfunction Caused by Noninfectious Irritants
• The initial goal is to maintain a patent airway and effective ventilation status. • Vital signs and other respiratory assessments (oxygenation, work of breathing, acid-base status) are performed frequently, and the pulmonary status is carefully observed and maintained. • The administration of nebulized bronchodilators, humidified oxygen, and inhaled corticosteroids is often part of the nursing care. • Chest percussion and postural drainage may be part of the therapy, as well as mechanical ventilation if needed. • Parents need support, reassurance, and information regarding the child's condition, treatment, and progress. The nurse can provide anticipatory guidance and education families on prevention of inhalation injuries and the importance of CO detectors in the home. Pulmonary Dysfunction Caused by Noninfectious Irritants
• Children exposed to (second-hand) passive or environmental tobacco smoke have an increased number of respiratory illnesses, increased respiratory symptoms (i.e., cough, sputum, and wheezing), and reduced performance on pulmonary function tests (PFTs). • A Indoor exposure to tobacco smoke has been linked to asthma in children. • Maternal cigarette smoking is associated with increased respiratory symptoms and illnesses in children; decreased fetal growth; increased deliveries of low birth weight, preterm, and stillborn infants; and a greater incidence of sudden infant death syndrome (SIDS). • The risk for diagnosis of early-onset asthma in the first 6 years of life is associated with in utero exposure to maternal smoking. • Exposure to tobacco smoke during childhood may also contribute to the development of chronic lung disease in the adult. Pulmonary Dysfunction Caused by Noninfectious Irritants
• Nurses must provide information about the hazards of environmental smoke exposure in all of their interactions with children and their family members. • In families in which smokers are unwilling to quit, appropriate guidance is provided for reducing smoke in the child's environment. • Nurses have an important role in providing parents with affordable smoking cessation education resources, including the appropriate use of smoking cessation pharmacologic aids. Nurses also have a role in educating adolescents about avoiding using tobacco products or smoking marijuana. Pulmonary Dysfunction Caused by Noninfectious Irritants
• Asthma is a chronic inflammatory disorder of the airways characterized by recurring symptoms, airway obstruction, bronchial hyperresponsiveness, and an underlying inflammation process. • Inflammation causes an increase in bronchial hyperresponsiveness to a variety of stimuli. • Asthma is the most common chronic disease of childhood, the primary cause of school absences, and the third leading cause of hospitalizations in children younger than 15 years old. Long-Term Respiratory Dysfunction
• Asthma Severity Classification in Children Long-Term Respiratory Dysfunction Step 5 or 6: Severe Asthma  Continual symptoms throughout the day  Frequent nighttime symptoms (>1 time/week ages 0 to 4 and 7 nights/week, ages 5 and older)  Pulmonary expiratory flow (PEF): <60%  Forced expiratory volume in 1 second (FEV1): <75% of predicted value  Interference with normal activity: Extremely limited  Use of short-acting β-agonist for symptom control: Several times a day
• Asthma Severity Classification in Children Long-Term Respiratory Dysfunction Step 3 or 4: Moderate Asthma  Daily symptoms  Nighttime symptoms: Three to four times a month (0 to 4 years old), >1/week but not nightly (5 to 11 years old)  PEF: 60% to 80% of predicted value (ages 5 and older)  FEV1: 75% to 80% (ages 5 and older)  PEF variability: >30%  Interference with normal activity: Some limitation  Use of short-acting β-agonist for symptom control: Daily
• Asthma Severity Classification in Children Long-Term Respiratory Dysfunction Step 2: Mild Asthma  Symptoms >2 times/week but <1 time/day  Nighttime symptoms: One to two times a month (0 to 4 years old), three or four times a month (5 to 11 years old)  PEF or FEV1: ≥80% of predicted value  PEF variability: 20% to 30%  Interference with normal activity: Minor limitation  Use of short-acting β-agonist for symptom control: >2 days/wk but not daily
• Asthma Severity Classification in Children Long-Term Respiratory Dysfunction Step 1: Intermittent Asthma Symptoms ≤2 days/wk Nighttime symptoms (awakenings): None (0 to 4 years old); ≤2 nights per month (5 to 11 years old) PEF or FEV1: ≥80% of predicted value PEF variability: <20% Interference with normal activity: None Use of short-acting β-agonist for symptom control: <2 days/wk
• Triggers Tending to Precipitate or Aggravate Asthma Exacerbations Long-Term Respiratory Dysfunction • Allergens • Outdoor: Trees, shrubs, weeds, grasses, molds, pollens, air pollution, spores • Indoor: Dust or dust mites, mold, cockroach antigen • Irritants: Tobacco smoke, wood smoke, odors, sprays • Exposure to occupational chemicals • Exercise • Cold air • Changes in weather or temperature• Environmental change: Moving to new home, starting new school, and so on
• Triggers Tending to Precipitate or Aggravate Asthma Exacerbations Long-Term Respiratory Dysfunction • Colds and infections • Animals: Cats, dogs, rodents, horses • Medications: Aspirin, NSAIDs, antibiotics, beta-blockers • Strong emotions: Fear, anger, laughing, crying • Conditions: Gastroesophageal reflux, tracheoesophageal fistula • Food additives: Sulfite preservatives • Foods: Nuts, milk or other dairy products • Endocrine factors: Menses, pregnancy, thyroid disease
• Asthma is the results from complex interactions among inflammatory cells, mediators, and the cells and tissues present in the airways . • Asthma can cause is bronchospasm and airflow obstruction. • The mechanisms responsible for the obstructive symptoms in asthma include • (1) inflammatory response to stimuli; • (2) airway edema and accumulation and secretion of mucus; • (3) spasm of the smooth muscle of the bronchi and bronchioles, which decreases the caliber of the bronchioles; and • (4) airway remodeling, which causes permanent cellular changes • Chronic inflammation may also cause permanent damage (airway remodeling) to airway structures, which cannot be prevented by and is not responsive to current treatments. Long-Term Respiratory Dysfunction
• Cough • Hacking, paroxysmal, irritative, and nonproductive • Becomes rattling and productive of frothy, clear, gelatinous sputum • Respiratory-Related Signs • Shortness of breath • Prolonged expiratory phase • Audible wheeze • May have a malar flush and red ears • Lips deep, dark red color • May progress to cyanosis of nail beds or circumoral cyanosis • Restlessness • Apprehension • Prominent sweating as the attack progresses • Older children sitting upright with shoulders in a hunched-over position, hands on the bed or chair, and arms braced (tripod) • Speaking with short, panting, broken phrases Long-Term Respiratory Dysfunction
• Chest • Hyperresonance on percussion • Coarse, loud breath sounds • Wheezes throughout the lung fields • Prolonged expiration • Crackles • Generalized inspiratory and expiratory wheezing; increasingly high pitched • With Repeated Episodes • Barrel chest • Elevated shoulders • Use of accessory muscles of respiration • Facial appearance—flattened malar bones, dark circles beneath the eyes, narrow nose, prominent upper teeth Long-Term Respiratory Dysfunction
• The diagnosis is determined primarily on the basis of clinical manifestations, history, physical examination, and, to a lesser extent, laboratory tests. • Pulmonary function tests (PFTs) provide an objective method of evaluating the presence and degree of lung disease, as well as the response to therapy. Spirometry can generally be performed reliably on children by 5 or 6 years old. • Peak expiratory flow rate (PEFR), which measures the maximum flow of air (in liters per minute) that can be forcefully exhaled in 1 second using a peak expiratory flow meter (PEFM). • Bronchoprovocation testing, direct exposure of the mucous membranes to a suspected antigen in increasing concentrations helps to identify inhaled allergens. Exposure to methacholine (methacholine challenge), histamine, or cold or dry air may be performed to assess airway responsiveness or reactivity. • Skin prick testing (SPT) and serological testing (with quantification of sIgE) for allergen-specific immunoglobulin E (sIgE) may be used to identify environmental allergens that trigger asthma. • The presence of eosinophilia of greater than 500/mm3 suggests the presence of an allergic or inflammatory disorder. Long-Term Respiratory Dysfunction
• Allergen control • Nonpharmacologic therapy is aimed at the prevention and reduction of exposure to airborne allergens and irritants. • Drug Therapy • Pharmacologic therapy is used to prevent and control asthma symptoms, reduce the frequency and severity of asthma exacerbations, and reverse airflow obstruction. • Asthma medications are categorized into two general classes: • long-term control medications (preventive medications) to achieve and maintain control of inflammation, and • quick-relief medications (rescue medications) to treat symptoms and exacerbations. • Inhaled corticosteroids, cromolyn sodium, long-acting β2-agonists (LABAs), methylxanthines, and leukotriene modifiers are used as long-term control medications. • Short-acting β2-agonists, anticholinergics, and systemic corticosteroids are used as quick-relief medications. Long-Term Respiratory Dysfunction
• Many asthma medications are given by inhalation with a nebulizer or a metered-dose inhaler (MDI). • Corticosteroids are antiinflammatory drugs used to treat reversible airflow obstruction, control symptoms, and reduce bronchial hyperresponsiveness in chronic asthma. • β-Adrenergic agonists (short acting) (primarily albuterol, levalbuterol [Xopenex], and terbutaline) are used for treatment of acute exacerbations and for the prevention of EIB. • Salmeterol (Serevent) is a LABA (bronchodilator). This drug is added to antiinflammatory therapy and used for long-term prevention of symptoms, especially nighttime symptoms, and EIB. • Theophylline is a methylxanthine drug used for decades to relieve symptoms and prevent asthma attacks. • Cromolyn sodium stabilizes mast cell membranes; inhibits activation and release of mediators from eosinophil and epithelial cells; and inhibits the acute airway narrowing after exposure to exercise, cold dry air, and sulfur dioxide. • Leukotrienes are mediators of inflammation that cause increases in airway hyperresponsiveness. Leukotriene modifiers (e.g., zafirlukast [Accolate], zileuton [Zyflo], and montelukast sodium [Singulair]) block inflammatory and bronchospasm effects. • Anticholinergics (atropine and ipratropium [Atrovent]) help relieve acute bronchospasm. Long-Term Respiratory Dysfunction
• Exercise • Exercise-induced bronchospasm (EIB) is an acute, reversible, usually self-terminating airway obstruction that develops during or after vigorous activity, reaches its peak 5 to 10 minutes after stopping the activity, and usually stops in another 20 to 30 minutes. • Swimming is well tolerated by children with EIB because they are breathing air fully saturated with moisture and because of the type of breathing required in swimming. • Breathing Exercises • Breathing exercises and physical training help produce physical and mental relaxation, improve posture, strengthen respiratory musculature, and develop more efficient patterns of breathing. Long-Term Respiratory Dysfunction
• Hyposensitization • Immunotherapy is considered for asthma patients in the following situations • • Patient's preference • • Poor adherence to therapy • • Incomplete response to allergen avoidance • • Significant medication side effects or adverse effect • • Multiple and/or high dose medication requirements • Hyposensitization injections should be administered only with emergency equipment and medications readily available in the event of an anaphylactic reaction.. Long-Term Respiratory Dysfunction
• Status Asthmaticus • Status asthmaticus is a medical emergency that can result in respiratory failure and death if untreated. • Status asthmaticus is a medical emergency that can result in respiratory failure and death if untreated. • O2 sat should maintain above 90% • Systemic corticosteroid (oral, IV or IM) is given to decrease the effects of inflammation. • Anticholinergic agent (ipratropium). Long-Term Respiratory Dysfunction
• Prognosis • Some children's asthma symptoms may improve at puberty, but up to two thirds of children with asthma continue to have symptoms through puberty and into adulthood. • The younger child and adolescent age group appear to be the most vulnerable, with the greatest increase occurring in children younger than 4 years old and 12 to 17 years . • Risk factors for asthma-related deaths include early onset, frequent attacks, difficult-to-manage disease, adolescence, history of respiratory failure, psychological problems (refusal to take medications), dependency on or misuse of asthma drugs (high use), presence of physical stigmata (barrel chest, intercostal retractions), and abnormal PFT results. Long-Term Respiratory Dysfunction
• Acute Asthma Care • When β2-agonists, supplemental oxygen, and corticosteroids are given, the child is monitored closely and continuously for relief of respiratory distress and signs of side effects. • When β2-agonists, supplemental oxygen, and corticosteroids are given, the child is monitored closely and continuously for relief of respiratory distress and signs of side effects. • The child in status asthmaticus should be placed on continuous cardiorespiratory (including blood pressure) and pulse oximetry monitoring. • The child in status asthmaticus should be placed on continuous cardiorespiratory (including blood pressure) and pulse oximetry monitoring. Long-Term Respiratory Dysfunction
• Provide Long-Term Asthma Care • These may include asthma education in the primary care setting and in schools and other community settings, care of the child with asthma in the acute care setting, ambulatory care, care coordination, and intensive care. • Nurses also obtain information on how asthma affects the child's everyday activities and self-concept, the child's and family's adherence to the prescribed therapy, and their personal treatment goals. • Parents are taught how to prevent exacerbations, to recognize and respond to symptoms of bronchospasm, to maintain health and prevent complications, and to promote normal activities. Long-Term Respiratory Dysfunction
• Avoid Allergens • Parents need to know how to avoid allergens that precipitate asthma episodes. • Parents are cautioned to avoid exposing a sensitive child to excessive cold, wind, and other extremes of weather; smoke (open fire or tobacco); sprays; scents; and other irritants. • Foods known to provoke symptoms should be eliminated from the diet. Long-Term Respiratory Dysfunction
• Relieve Bronchospasm • Teach parents and older children to recognize early signs and symptoms of an impending attack. • Objective signs that parents may observe include rhinorrhea, cough, low-grade fever, irritability, itching (especially in front of the neck and chest), apathy, anxiety, sleep disturbance, abdominal discomfort, and loss of appetite. • Children who use a nebulizer, MDI, Diskus, or Turbuhaler to deliver drugs need to learn how to use the device correctly. • A spacer or AeroChamber device should be used with MDI inhalers. • A spacer or AeroChamber device should be used with MDI inhalers. • Teach breathing exercises and controlled breathing for motivated children, and the nurse should provide information concerning activities that promote diaphragmatic breathing, side expansion, and improved mobility of the chest wall. Long-Term Respiratory Dysfunction
Long-Term Respiratory Dysfunction
• CF is a life-shortening disease, inherited as an autosomal recessive trait. The affected child inherits the defective gene from both parents, with an overall risk of one in four if both parents carry the gene. Long-Term Respiratory Dysfunction
• CF is characterized by several clinical features, which are increased viscosity of mucous gland secretions, a striking elevation of sweat electrolytes, an increase in several organic and enzymatic constituents of saliva, and abnormalities in autonomic nervous system function. • Children with CF demonstrate an increase in sodium and chloride in both saliva and sweat. • The primary factor, and the one that is responsible for many of the clinical manifestations of the disease, is mechanical obstruction caused by the increased viscosity of mucous gland secretions. Long-Term Respiratory Dysfunction
Long-Term Respiratory Dysfunction
• Meconium Ileus* • Abdominal distention • Vomiting • Failure to pass stools • Rapid development of dehydration • Gastrointestinal Manifestations • Large, bulky, loose, frothy, extremely foul-smelling stools • Voracious appetite (early in disease) • Loss of appetite (later in disease) • Weight loss • Marked tissue wasting • Failure to grow • Distended abdomen • Thin extremities • Sallow skinEvidence of deficiency of fat-soluble vitamins A, D, E, and K • Anemia Long-Term Respiratory Dysfunction
• Pulmonary Manifestations • Initial signs: • Wheezy respirations • Dry, nonproductive cough • Eventually: • Increased dyspnea • Paroxysmal cough • Evidence of obstructive emphysema and patchy areas of atelectasis • Progressive involvement: • Overinflated, barrel-shaped chest • Cyanosis • Clubbing of fingers and toes • Repeated episodes of bronchitis and bronchopneumonia Long-Term Respiratory Dysfunction
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf
THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf

Recommended

Acute laryngotracheobronchitis bondi
Acute laryngotracheobronchitis bondiAcute laryngotracheobronchitis bondi
Acute laryngotracheobronchitis bondi
Sasha Bondi
 
Respiratory Diseases - Pediatrics
Respiratory Diseases - PediatricsRespiratory Diseases - Pediatrics
Respiratory Diseases - Pediatrics
Nihal Yuzbasheva
 
Introduction to Respiratory Peds.ppt
Introduction to Respiratory Peds.pptIntroduction to Respiratory Peds.ppt
Introduction to Respiratory Peds.ppt
Mahdi Hemmat
 
Acute respiratory infections in children
Acute respiratory infections in childrenAcute respiratory infections in children
Acute respiratory infections in children
Laith Ali
 
APPROACH TO COUGH IN CHILDREN
APPROACH TO COUGH IN CHILDRENAPPROACH TO COUGH IN CHILDREN
APPROACH TO COUGH IN CHILDREN
Dr. Manidipa Barman
 
Childhood Asthma.pptx
Childhood Asthma.pptxChildhood Asthma.pptx
Childhood Asthma.pptx
VijayakanthVijayakum
 
Respiratory system disorder
Respiratory system disorderRespiratory system disorder
Respiratory system disorder
Binand Moirangthem
 
Cough in children.pptx by dr sayed ismail
Cough in children.pptx by dr sayed ismailCough in children.pptx by dr sayed ismail
Cough in children.pptx by dr sayed ismail
Sayed Ahmed
 

Recommended

Acute laryngotracheobronchitis bondi
Acute laryngotracheobronchitis bondiAcute laryngotracheobronchitis bondi
Acute laryngotracheobronchitis bondi
Sasha Bondi
 
Respiratory Diseases - Pediatrics
Respiratory Diseases - PediatricsRespiratory Diseases - Pediatrics
Respiratory Diseases - Pediatrics
Nihal Yuzbasheva
 
Introduction to Respiratory Peds.ppt
Introduction to Respiratory Peds.pptIntroduction to Respiratory Peds.ppt
Introduction to Respiratory Peds.ppt
Mahdi Hemmat
 
Acute respiratory infections in children
Acute respiratory infections in childrenAcute respiratory infections in children
Acute respiratory infections in children
Laith Ali
 
APPROACH TO COUGH IN CHILDREN
APPROACH TO COUGH IN CHILDRENAPPROACH TO COUGH IN CHILDREN
APPROACH TO COUGH IN CHILDREN
Dr. Manidipa Barman
 
Childhood Asthma.pptx
Childhood Asthma.pptxChildhood Asthma.pptx
Childhood Asthma.pptx
VijayakanthVijayakum
 
Respiratory system disorder
Respiratory system disorderRespiratory system disorder
Respiratory system disorder
Binand Moirangthem
 
Cough in children.pptx by dr sayed ismail
Cough in children.pptx by dr sayed ismailCough in children.pptx by dr sayed ismail
Cough in children.pptx by dr sayed ismail
Sayed Ahmed
 
Acute inflammations-of-larynx
Acute inflammations-of-larynxAcute inflammations-of-larynx
Acute inflammations-of-larynx
sunitisingh6
 
Airborne Diseases
Airborne DiseasesAirborne Diseases
Airborne Diseases
Sweet Lyn Balleza
 
COMMON COLD.pptx
COMMON COLD.pptxCOMMON COLD.pptx
COMMON COLD.pptx
KawooyaAbdul
 
Air way emergencies.ppt
Air way emergencies.pptAir way emergencies.ppt
Air way emergencies.ppt
FayyeeraaAbeetuu
 
Ari
AriAri
Ari
sana anum
 
UNIT 4.ppt
UNIT 4.pptUNIT 4.ppt
UNIT 4.ppt
EstibelMengist
 
EPIDEMIOLOGY OF ARI
EPIDEMIOLOGY OF ARIEPIDEMIOLOGY OF ARI
EPIDEMIOLOGY OF ARI
MAHESWARI JAIKUMAR
 
EPIDEMIOLOGY OF ARI
EPIDEMIOLOGY OF ARIEPIDEMIOLOGY OF ARI
EPIDEMIOLOGY OF ARI
MAHESWARI JAIKUMAR
 
Tonsillitis
TonsillitisTonsillitis
Tonsillitis
Rama Saragih
 
Diagnostic criteria and treatment of bronchiolitis.pptx
Diagnostic criteria and treatment of bronchiolitis.pptxDiagnostic criteria and treatment of bronchiolitis.pptx
Diagnostic criteria and treatment of bronchiolitis.pptx
Ugo161BB
 
upper & lower airway obstruction
upper & lower airway obstructionupper & lower airway obstruction
upper & lower airway obstruction
Ramya Deepthi P
 
Paediatric Infectious diseases
Paediatric Infectious diseasesPaediatric Infectious diseases
Paediatric Infectious diseases
Dr.Bharat Kalidindi
 
paediatricdiseases-150701030336-lva1-app6892.pdf
paediatricdiseases-150701030336-lva1-app6892.pdfpaediatricdiseases-150701030336-lva1-app6892.pdf
paediatricdiseases-150701030336-lva1-app6892.pdf
Rishabhtrivedi22
 
Lower respiratory tract infection: BRONCHITIS, BRONCHIOLITIS, PNEUMONIA IN CH...
Lower respiratory tract infection: BRONCHITIS, BRONCHIOLITIS, PNEUMONIA IN CH...Lower respiratory tract infection: BRONCHITIS, BRONCHIOLITIS, PNEUMONIA IN CH...
Lower respiratory tract infection: BRONCHITIS, BRONCHIOLITIS, PNEUMONIA IN CH...
Manisha Thakur
 
Croup
CroupCroup
Croup
Pediatrics
 
Upper Respiratory Tract Infections | Jindal Chest Clinic
Upper Respiratory Tract Infections | Jindal Chest ClinicUpper Respiratory Tract Infections | Jindal Chest Clinic
Upper Respiratory Tract Infections | Jindal Chest Clinic
Jindal Chest Clinic
 
Dd wheezy chest in infant for fm
Dd wheezy chest in infant for fmDd wheezy chest in infant for fm
Dd wheezy chest in infant for fm
Hussein Abdeldayem
 
Respiratory Disease - Pediatrics
Respiratory Disease - PediatricsRespiratory Disease - Pediatrics
Respiratory Disease - Pediatrics
RyanSanni1
 
Pertussis (Whooping cough)
Pertussis (Whooping cough)Pertussis (Whooping cough)
Pertussis (Whooping cough)
BrahmjotKaur11
 
Approach to a child with respiratory distress
Approach to a child with respiratory distressApproach to a child with respiratory distress
Approach to a child with respiratory distress
Maulana Azad Medical College
 
linearity concept of significance, standard deviation, chi square test, stude...
linearity concept of significance, standard deviation, chi square test, stude...linearity concept of significance, standard deviation, chi square test, stude...
linearity concept of significance, standard deviation, chi square test, stude...
KavyasriPuttamreddy
 
Introducing VarSeq Dx as a Medical Device in the European Union
Introducing VarSeq Dx as a Medical Device in the European UnionIntroducing VarSeq Dx as a Medical Device in the European Union
Introducing VarSeq Dx as a Medical Device in the European Union
Golden Helix
 

More Related Content

Similar to THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf

Diagnostic criteria and treatment of bronchiolitis.pptx
Diagnostic criteria and treatment of bronchiolitis.pptxDiagnostic criteria and treatment of bronchiolitis.pptx
Diagnostic criteria and treatment of bronchiolitis.pptx
Ugo161BB
 

Similar to THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf (20)

Acute inflammations-of-larynx
Acute inflammations-of-larynxAcute inflammations-of-larynx
Acute inflammations-of-larynx
 
Airborne Diseases
Airborne DiseasesAirborne Diseases
Airborne Diseases
 
COMMON COLD.pptx
COMMON COLD.pptxCOMMON COLD.pptx
COMMON COLD.pptx
 
Air way emergencies.ppt
Air way emergencies.pptAir way emergencies.ppt
Air way emergencies.ppt
 
Ari
AriAri
Ari
 
UNIT 4.ppt
UNIT 4.pptUNIT 4.ppt
UNIT 4.ppt
 
EPIDEMIOLOGY OF ARI
EPIDEMIOLOGY OF ARIEPIDEMIOLOGY OF ARI
EPIDEMIOLOGY OF ARI
 
EPIDEMIOLOGY OF ARI
EPIDEMIOLOGY OF ARIEPIDEMIOLOGY OF ARI
EPIDEMIOLOGY OF ARI
 
Tonsillitis
TonsillitisTonsillitis
Tonsillitis
 
Diagnostic criteria and treatment of bronchiolitis.pptx
Diagnostic criteria and treatment of bronchiolitis.pptxDiagnostic criteria and treatment of bronchiolitis.pptx
Diagnostic criteria and treatment of bronchiolitis.pptx
 
upper & lower airway obstruction
upper & lower airway obstructionupper & lower airway obstruction
upper & lower airway obstruction
 
Paediatric Infectious diseases
Paediatric Infectious diseasesPaediatric Infectious diseases
Paediatric Infectious diseases
 
paediatricdiseases-150701030336-lva1-app6892.pdf
paediatricdiseases-150701030336-lva1-app6892.pdfpaediatricdiseases-150701030336-lva1-app6892.pdf
paediatricdiseases-150701030336-lva1-app6892.pdf
 
Lower respiratory tract infection: BRONCHITIS, BRONCHIOLITIS, PNEUMONIA IN CH...
Lower respiratory tract infection: BRONCHITIS, BRONCHIOLITIS, PNEUMONIA IN CH...Lower respiratory tract infection: BRONCHITIS, BRONCHIOLITIS, PNEUMONIA IN CH...
Lower respiratory tract infection: BRONCHITIS, BRONCHIOLITIS, PNEUMONIA IN CH...
 
Croup
CroupCroup
Croup
 
Upper Respiratory Tract Infections | Jindal Chest Clinic
Upper Respiratory Tract Infections | Jindal Chest ClinicUpper Respiratory Tract Infections | Jindal Chest Clinic
Upper Respiratory Tract Infections | Jindal Chest Clinic
 
Dd wheezy chest in infant for fm
Dd wheezy chest in infant for fmDd wheezy chest in infant for fm
Dd wheezy chest in infant for fm
 
Respiratory Disease - Pediatrics
Respiratory Disease - PediatricsRespiratory Disease - Pediatrics
Respiratory Disease - Pediatrics
 
Pertussis (Whooping cough)
Pertussis (Whooping cough)Pertussis (Whooping cough)
Pertussis (Whooping cough)
 
Approach to a child with respiratory distress
Approach to a child with respiratory distressApproach to a child with respiratory distress
Approach to a child with respiratory distress
 

Recently uploaded

linearity concept of significance, standard deviation, chi square test, stude...
linearity concept of significance, standard deviation, chi square test, stude...linearity concept of significance, standard deviation, chi square test, stude...
linearity concept of significance, standard deviation, chi square test, stude...
KavyasriPuttamreddy
 
Introducing VarSeq Dx as a Medical Device in the European Union
Introducing VarSeq Dx as a Medical Device in the European UnionIntroducing VarSeq Dx as a Medical Device in the European Union
Introducing VarSeq Dx as a Medical Device in the European Union
Golden Helix
 
Cardiac Impulse: Rhythmical Excitation and Conduction in the Heart
Cardiac Impulse: Rhythmical Excitation and Conduction in the HeartCardiac Impulse: Rhythmical Excitation and Conduction in the Heart
Cardiac Impulse: Rhythmical Excitation and Conduction in the Heart
MedicoseAcademics
 

Recently uploaded (20)

linearity concept of significance, standard deviation, chi square test, stude...
linearity concept of significance, standard deviation, chi square test, stude...linearity concept of significance, standard deviation, chi square test, stude...
linearity concept of significance, standard deviation, chi square test, stude...
 
Introducing VarSeq Dx as a Medical Device in the European Union
Introducing VarSeq Dx as a Medical Device in the European UnionIntroducing VarSeq Dx as a Medical Device in the European Union
Introducing VarSeq Dx as a Medical Device in the European Union
 
Multiple sclerosis diet.230524.ppt3.pptx
Multiple sclerosis diet.230524.ppt3.pptxMultiple sclerosis diet.230524.ppt3.pptx
Multiple sclerosis diet.230524.ppt3.pptx
 
Factors Affecting child behavior in Pediatric Dentistry
Factors Affecting child behavior in Pediatric DentistryFactors Affecting child behavior in Pediatric Dentistry
Factors Affecting child behavior in Pediatric Dentistry
 
ANATOMY OF THE LOWER URINARY TRACT AND MALE [Autosaved] [Autosaved].pptx
ANATOMY OF THE LOWER URINARY TRACT AND MALE [Autosaved] [Autosaved].pptxANATOMY OF THE LOWER URINARY TRACT AND MALE [Autosaved] [Autosaved].pptx
ANATOMY OF THE LOWER URINARY TRACT AND MALE [Autosaved] [Autosaved].pptx
 
Hemodialysis: Chapter 2, Extracorporeal Blood Circuit - Dr.Gawad
Hemodialysis: Chapter 2, Extracorporeal Blood Circuit - Dr.GawadHemodialysis: Chapter 2, Extracorporeal Blood Circuit - Dr.Gawad
Hemodialysis: Chapter 2, Extracorporeal Blood Circuit - Dr.Gawad
 
Cardiac Impulse: Rhythmical Excitation and Conduction in the Heart
Cardiac Impulse: Rhythmical Excitation and Conduction in the HeartCardiac Impulse: Rhythmical Excitation and Conduction in the Heart
Cardiac Impulse: Rhythmical Excitation and Conduction in the Heart
 
Creating Accessible Public Health Communications
Creating Accessible Public Health CommunicationsCreating Accessible Public Health Communications
Creating Accessible Public Health Communications
 
The POPPY STUDY (Preconception to post-partum cardiovascular function in prim...
The POPPY STUDY (Preconception to post-partum cardiovascular function in prim...The POPPY STUDY (Preconception to post-partum cardiovascular function in prim...
The POPPY STUDY (Preconception to post-partum cardiovascular function in prim...
 
The hemodynamic and autonomic determinants of elevated blood pressure in obes...
The hemodynamic and autonomic determinants of elevated blood pressure in obes...The hemodynamic and autonomic determinants of elevated blood pressure in obes...
The hemodynamic and autonomic determinants of elevated blood pressure in obes...
 
Prix Galien International 2024 Forum Program
Prix Galien International 2024 Forum ProgramPrix Galien International 2024 Forum Program
Prix Galien International 2024 Forum Program
 
Relationship between vascular system disfunction, neurofluid flow and Alzheim...
Relationship between vascular system disfunction, neurofluid flow and Alzheim...Relationship between vascular system disfunction, neurofluid flow and Alzheim...
Relationship between vascular system disfunction, neurofluid flow and Alzheim...
 
Vaccines: A Powerful and Cost-Effective Tool Protecting Americans Against Dis...
Vaccines: A Powerful and Cost-Effective Tool Protecting Americans Against Dis...Vaccines: A Powerful and Cost-Effective Tool Protecting Americans Against Dis...
Vaccines: A Powerful and Cost-Effective Tool Protecting Americans Against Dis...
 
Non-Invasive assessment of arterial stiffness in advanced heart failure patie...
Non-Invasive assessment of arterial stiffness in advanced heart failure patie...Non-Invasive assessment of arterial stiffness in advanced heart failure patie...
Non-Invasive assessment of arterial stiffness in advanced heart failure patie...
 
In-service education (Nursing Mangement)
In-service education (Nursing Mangement)In-service education (Nursing Mangement)
In-service education (Nursing Mangement)
 
Compare home pulse pressure components collected directly from home
Compare home pulse pressure components collected directly from homeCompare home pulse pressure components collected directly from home
Compare home pulse pressure components collected directly from home
 
Antiplatelets in IHD, Dose Duration, DAPT vs SAPT
Antiplatelets in IHD, Dose Duration, DAPT vs SAPTAntiplatelets in IHD, Dose Duration, DAPT vs SAPT
Antiplatelets in IHD, Dose Duration, DAPT vs SAPT
 
Anuman- An inference for helpful in diagnosis and treatment
Anuman- An inference for helpful in diagnosis and treatmentAnuman- An inference for helpful in diagnosis and treatment
Anuman- An inference for helpful in diagnosis and treatment
 
PT MANAGEMENT OF URINARY INCONTINENCE.pptx
PT MANAGEMENT OF URINARY INCONTINENCE.pptxPT MANAGEMENT OF URINARY INCONTINENCE.pptx
PT MANAGEMENT OF URINARY INCONTINENCE.pptx
 
"Central Hypertension"‚ in China: Towards the nation-wide use of SphygmoCor t...
"Central Hypertension"‚ in China: Towards the nation-wide use of SphygmoCor t..."Central Hypertension"‚ in China: Towards the nation-wide use of SphygmoCor t...
"Central Hypertension"‚ in China: Towards the nation-wide use of SphygmoCor t...
 

THE CHILD WITH PROBLEMS RELATED TO THE TRANSFER OF OXYGEN AND NUTRIENTS.pdf

  • 1.
  • 2. • Infections of the respiratory tract • Upper respiratory tract or upper airway • Oronasopharynx • Pharynx • Larynx • Upper part of the trachea • Lowe respiratory tract infection • Lower trachea • Bronchi • Bronchioles • Alveoli • Croup syndromes- infections of epiglottis and larynx that can lead to inspiratory stridor and barking cough. RESPIRATORY INFECTION
  • 3. • Caused by viruses • Respiratory syncytial virus (RSV) • Rhinovirus • Nonpolio enterovirus (coxsackievirus A and B) • Adenovirus • Parainfluenza virus • Influenza virus • Human metapneumovirus • Other agents (primary or secondary invasion • Group A betahemolytic streptococci (GABHS) • Staphylococci • Haemophilus influenzae • Bordetella pertussis • Chlamydia trachomatis • Mycoplasma organisms • Pneumococci RESPIRATORY INFECTION
  • 4. • Full term, and healthy (<3 months) • low infection rate due to protective function of maternal antibodies (colostrum). • susceptible to pertussis • 3-6 months • Infection rate increase due to decrease of maternal antibodies and infant’s own antibody production • Toddles and preschool year • Viral infection remains high • 5 years old • Mycoplasma pneumoniae and GABHS infections incident increases. • **repeat exposure to organisms confers increasing immunity as children grow older RESPIRATORY INFECTION
  • 5. • Organisms move rapidly down the shorter respiratory tract of younger children. • Allows pathogens easy access to the middle ear because of short and open eustachian tube in infants. RESPIRATORY INFECTION
  • 6. • Deficiencies of the immune system – risk for infection • Decrease resistance/weaken defenses • Malnutrition • Anemia • Fatigue • Allergies (e.g., allergic rhinitis) • Preterm birth • Bronchopulmonary congestion (BPD) • Asthma • History of RSV infection • Cardiac anomalies that cause pulmonary congestion • Cystic Fibrosis (CF) • Daycare attendance and secondhand smoke – risk for infection RESPIRATORY INFECTION
  • 7. • Mycoplasmal infections • Often in autumn and early winter • Infection-related asthma/RVS • During cold weather, winter and early spring RESPIRATORY INFECTION
  • 8. • Fever • May be absent in neonates (<28 days) • Greatest at 6 months old to 3 years old • May reach 39.5° to 40.5° C (103° to 105° F) even with mild infections • Often appears as first sign of infection • May lead to listlessness and irritability, with altered activity pattern (usually decreased) • Tendency to develop high temperatures with infection in certain families • May precipitate febrile seizure • Poor Feeding and Anorexia • Common with most childhood illnesses • Frequently the initial evidence of illness • Persists to a greater or lesser degree throughout febrile stage of illness; often extends into convalescence RESPIRATORY INFECTION
  • 9. • Vomiting • Common in small children with illness • A clue to onset of infection • May precede other signs by several hours • Usually short lived but may persist during the illness Is frequent cause of dehydration • Diarrhea • Usually mild, transient diarrhea but may become severe • Often accompanies viral respiratory infections • Frequent cause of dehydration • Abdominal Pain • Common complaint • Sometimes indistinguishable from pain of appendicitis • May represent referred pain (e.g., chest pain associated with pneumonia) • May be caused by mesenteric lymphadenitis • May be linked to muscle spasms from vomiting, especially in nervous, tense child RESPIRATORY INFECTION
  • 10. • Nasal Blockage • Small nasal passages of infants easily blocked by mucosal swelling and exudation • Can interfere with respiration and feeding in infants • May contribute to the development of otitis media (OM) and sinusitis • Nasal Discharge • Frequent occurrence • May be thin and watery (rhinorrhea) or thick and purulent • Depends on the type or stage of infection • Associated with itching • May irritate upper lip and skin surrounding the nose • Cough • Common feature • May be evident only during acute phase • May persist several months after a disease RESPIRATORY INFECTION
  • 11. • Respiratory Sounds • Sounds associated with respiratory disease: • • Cough • • Hoarseness • • Grunting • • Stridor • • Wheezing • Findings on auscultation: • • Wheezing • • Crackles • • Absence of breath sounds (movement of air) • Sore Throat • Frequent complaint of older children • Young children (unable to describe symptoms) may not complain even when highly inflamed • Often accompanied by refusal to take oral fluids or solids RESPIRATORY INFECTION
  • 12. • Meningismus • Meningeal signs without infection of the meninges • Occurs with abrupt onset of fever • Accompanied by: • • Headache • • Pain and stiffness in the back and neck • • Presence of Kernig and Brudzinski signs • Subsides as body temperature decreases RESPIRATORY INFECTION
  • 13. • The assessment should include: • respiratory rate • depth and rhythm • heart rate, oxygenation • hydration status • body temperature • level of consciousness • activity level • level of comfort • A noninvasive pulse oximeter (oxygen saturation [SaO2]) measurement. RESPIRATORY INFECTION
  • 14. • Pattern of Respirations • Rate: Rapid (tachypnea), normal, or slow for the particular child • Depth: Normal depth, too shallow (hypopnea), too deep (hyperpnea); usually estimated from theamplitude of thoracic and abdominal excursion • Ease: Effortless, labored (dyspnea), orthopnea (difficult breathing except in upright position), associated with intercostal or substernal retractions (inspiratory “sinking in” of soft tissues in relation to the cartilaginous and bony thorax), pulsus paradoxus (blood pressure falling with inspiration and rising with expiration), nasal flaring, head bobbing (head of sleeping child with suboccipital area supported on caregiver's forearm bobbing forward in synchrony with each inspiration), grunting, wheezing, or stridor • Labored breathing: Continuous, intermittent, becoming steadily worse, sudden onset, at rest or on exertion, associated with wheezing, grunting, or chest pain • Rhythm: Variation in rate and depth of respirations RESPIRATORY INFECTION
  • 15. • Other Observations • In addition to respirations, particular attention is addressed to: • Evidence of infection: Check for elevated temperature; enlarged cervical lymph nodes; inflamed mucous membranes; and purulent discharges from the nose, ears, or lungs (sputum). • Cough: Observe the characteristics of the cough (if present), when the cough is heard (e.g., night only, on arising), the nature of the cough (paroxysmal with or without wheeze, “croupy” or “brassy”), frequency of the cough, association with swallowing or other activity, character of the cough (moist or dry), productivity. • Wheeze: Note whether it occurs with expiration or inspiration, high pitched or musical, prolonged, slowly progressive or sudden, association with labored breathing. • Cyanosis: Note distribution (peripheral, perioral, facial, trunk, and face), degree, duration, association with activity. • Chest pain: This may be a complaint of older children. Note location and circumstances: localized or generalized; referral to base of neck or abdomen; dull or sharp; deep or superficial; association with rapid, shallow respirations or grunting. • Sputum: Older children may provide sample by blowing nose or provide sputum sample by coughing, young children may need use of bulb suction, wall suction, DeLee mucus trap, or baby nasal aspirator (attaches to wall suction tubing and fits on small nose) to provide a sample. Note volume, color, viscosity, and odor. • Bad breath (halitosis): May be associated with some throat and lung infections. RESPIRATORY INFECTION
  • 16. • Warm or cool mist • Common therapeutic measure for symptomatic relief of respiratory discomfort. RESPIRATORY INFECTION
  • 17. • Infant nasal aspirator or bulb syringe • Helpful in removing nasal secretions • Instillation of saline nose drops to clear nasal passage and promote feeding. • Dissolving ½-1tsp of salt in 1 cup of warm water. Two to three drops of saline can be put into the nostril and a bulb syringe can be used to suction it out. • 2-12 y.o • Use of vasoconstrictive nose drops may be adminster every 4 hours as needed • Oxymetazoline 0.05% /Phenylephrine 0.25% • Prescribed children older that 6 y.o • Pseudoephedrine • Prescribed by mouth as decongestant every 6hours in children older than 4 years old • Topical vapor rubs • could be considered for children older than 2 years old to ease nasal congestion. RESPIRATORY INFECTION
  • 18. • Hand washing • Cover nose and mouth when cough or sneeze and dispose it properly. RESPIRATORY INFECTION
  • 19. • If the child has a significantly elevated body temperature, controlling the fever is important for comfort. • Cool liquids are encouraged to reduce the temperature and minimize the chances of dehydration RESPIRATORY INFECTION
  • 20. • Infants are especially prone to fluid and electrolyte deficits when they have a respiratory illness because a rapid respiratory rate that accompanies such illnesses precludes adequate oral fluid intake. • Adequate fluid intake is encouraged by offering small amounts of favorite fluids (clear liquids if vomiting) at frequent intervals. • Infants who are breastfeeding should continue to be breastfed, because human milk confers some degree of protection from infection. • Diapers are weighed to assess output, which should be approximately 1 ml/kg/hr in a child who weighs less than 30 kg. It should be at least 30 ml per hour in patients weighing more than 30 kg. The practitioner should be notified if the urine output is low. RESPIRATORY INFECTION
  • 21. • Signs of clinical deterioration include increasing respiratory distress, increasing respiratory rate, increasing heart rate, worsening hypoxia, poor perfusion, reduced level of consciousness, and lethargy. • Any deterioration is notified to the primary service. RESPIRATORY INFECTION
  • 22. • Loss of appetite is characteristic of children with acute infections. • Many children show no decrease in appetite, and others respond well to foods such as gelatin, popsicles, and soup • Urging foods for children who are sick may precipitate nausea and vomiting and cause an aversion to feeding that may extend into the convalescent period and beyond. RESPIRATORY INFECTION
  • 23. • Young children with respiratory tract infections may be irritable and difficult to comfort; therefore, the family needs support, encouragement, and practical suggestions concerning comfort measures and administration of medication. RESPIRATORY INFECTION
  • 24. • “Common cold” • Caused by: • Rhinoviruses • RSV • Adenoviruses • Enteroviruses • Influenza virus • Parainfluenza virus RESPIRATORY INFECTION Upper Respiratory Tract Infections
  • 25. • ACUTE Nasopharyngitis •Younger Children Fever Irritability Restlessness Poor feeding and decreased fluid intake Sneezing Nasal mucus (abundant) causing mouth breathing Vomiting or diarrhea Upper Respiratory Tract Infections
  • 26. • ACUTE Nasopharyngitis •Older Children Dryness and irritation of nose and throat initially Nasal discharge causing mouth breathing Sneezing, chilling Muscle aches Cough (sometimes) Upper Respiratory Tract Infections
  • 27. • ACUTE Nasopharyngitis •Physical Assessment Signs Edema and vasodilation of mucosa Upper Respiratory Tract Infections
  • 28. • ACUTE Pharyngitis •Younger Children Fever General malaise Anorexia Moderate sore throat Headache Upper Respiratory Tract Infections
  • 29. • ACUTE Pharyngitis •Older Children Fever (may reach 40° C [104° F]) Headache Anorexia Dysphagia Abdominal pain Vomiting Upper Respiratory Tract Infections
  • 30. • ACUTE Pharyngitis •Physical Assessment Signs • Younger Children • Mild to moderate hyperemia • Older Children • Mild to bright red, edematous pharynx • Hyperemia of tonsils and pharynx; may extend to soft palate and uvula • Often abundant follicular exudate that spreads and coalesces to form pseudomembrane on tonsils • Cervical glands enlarged and tender Upper Respiratory Tract Infections
  • 31. • Children with nasopharyngitis are managed at home. • Antipyretics may be indicated for fever and discomfort • Fluids and rest are recommended. •Prevention • The best methods for preventing transmission of these viruses are frequent hand washing and avoiding touching one's eyes, nose, and mouth. Upper Respiratory Tract Infections
  • 32. • Nasopharyngitis is related to the nasal obstruction • Elevating the head of the bed or crib mattress assists with drainage of secretions. • Suctioning and vaporization. • Saline nose drops and gentle suction with a bulb syringe before feeding and sleep time. • Nasopharyngitis is spread from secretions • prevention is avoiding contact with affected persons • Family members with a cold should carefully dispose of tissues, not share towels, glasses, or eating utensils, cover the mouth and nose with tissues when coughing or sneezing, and wash hands thoroughly after nose blowing or sneezing. • Children should wash their hands thoroughly or use hand sanitizer and avoid touching their eyes, noses, and mouths. •Family Support • The best methods for preventing transmission of these viruses are frequent hand washing and avoiding touching one's eyes, nose, and mouth. Upper Respiratory Tract Infections
  • 33. •Family Support • Early Evidence of Respiratory Complications • Parents are instructed to notify the health professional if any of the following are noted: • Refusal to eat • Evidence of earache • Respirations faster than 50 to 60 breaths/min • Fever over 38.3° C (101° F) • Listlessness • Confusion • Increasing irritability with or without fever • Persistent cough for 2 days or more • Wheezing • Restlessness and poor sleep patterns Upper Respiratory Tract Infections
  • 34. • Acute infectious pharyngitis can be caused by many bacteria or viruses. • Group A beta- hemolytic Streptococcus (GABHS) infection is the most common causative organism for this infection. • Children with GABHS infection of the upper airway (strep throat) are at risk for rheumatic fever (RF), an inflammatory disease of the heart, joints, and central nervous system (CNS), and acute glomerulonephritis (AGN), an acute kidney infection. • Permanent damage can result from these sequelae— especially RF. • GABHS may also cause skin manifestations, including impetigo and pyoderma. Upper Respiratory Tract Infections
  • 36. • Onset • Pharyngitis • Headache • Fever • Abdominal pain • The tonsils and pharynx may be inflamed and covered with exudate, which usually appear by the second day of illness • The tongue may appear edematous and red (strawberry tongue) • The child may have a fine sandpaper rash on the trunk, axillae, elbows, and groin seen in scarlet fever (caused by a strain of group A streptococcus) • The uvula is edematous and red • Anterior cervical lymphadenopathy usually occurs early, and the nodes are often tender. • Pain can be relatively mild to severe enough to make swallowing difficult. • Clinical manifestations usually subside in 3 to 5 days unless complicated by sinusitis or parapharyngeal, peritonsillar, or retropharyngeal abscess. Upper Respiratory Tract Infections
  • 37. • Throat swab requires vigorous swabbing of the tonsils and pharynx for accurate detection. • Rapid identification of GABHS with diagnostic test kits (rapid antigen detection test) is possible in the office or clinic setting. • Throat culture is recommended for negative test results. Upper Respiratory Tract Infections
  • 38. • If streptococcal sore throat infection is present, oral penicillin V or amoxicillin is prescribed for 10 days to control the acute local manifestations and to maintain an adequate level for at least 10 days to eliminate any organisms that might remain to initiate RF symptoms. • Penicillin usually produces a prompt response within 24 hours. • Patients who have a history of RF or who remain symptomatic after a full course of antibiotics may require a follow-up throat swab.Intramuscular (IM) benzathine penicillin G is an appropriate therapy, but it is painful and is not the first choice for children. • An oral macrolide (erythromycin, azithromycin, clarithromycin) is indicated for children who are allergic to penicillin. • Other antibiotics used to treat GABHS are oral cephalosporins, clindamycin, and amoxicillin with clavulanic acid . Upper Respiratory Tract Infections
  • 39. • The nurse often obtains a throat swab for culture or rapid antigen testing and instructs the parents about administering oral antibiotics and analgesics as prescribed. • If an injection of penicillin is required, it must be administered deep into a large muscle mass (e.g., vastus lateralis or ventrogluteal muscle). To prevent pain, application of a topical anesthetic cream, such as LMX4 (4% lidocaine) or eutectic mixture of local anesthetics (EMLA; lidocaine and prilocaine) over the injection site before the injection is helpful. • Children are considered infectious to others at the onset of symptoms and up to 24 hours after initiation of antibiotic therapy, but they should not return to school or daycare until they have been taking antibiotics for a full 24-hour period. • If the child continues to have a high fever that does not respond to antipyretics, has an extremely sore throat, refuses liquids, and appears toxic 24 to 48 hours after starting antibiotics, further evaluation by the practitioner is recommended. Upper Respiratory Tract Infections
  • 40. • The tonsils are masses of lymphoid tissue located in the pharyngeal cavity. • They filter and protect the respiratory and alimentary tracts from invasion by pathogenic organisms and play a role in antibody formation. • Although their size varies, children generally have much larger tonsils than adolescents or adults. This difference is thought to be a protective mechanism because young children are especially susceptible to URIs. Upper Respiratory Tract Infections
  • 41. • Several pairs of tonsils are part of a mass of lymphoid tissue encircling the nasal and oral pharynx, known as the Waldeyer tonsillar ring (Fig. 21-3). • A surface of the palatine tonsils is usually visible during oral examination. The palatine tonsils are those removed during tonsillectomy. • The pharyngeal tonsils, also known as the adenoids, are located above the palatine tonsils on the posterior wall of the nasopharynx. • Their proximity to the nares and eustachian tubes causes difficulties in instances of inflammation. Upper Respiratory Tract Infections
  • 42. • Tonsillitis often occurs with pharyngitis. • Because of the abundant lymphoid tissue and the frequency of URIs, tonsillitis is a common cause of illness in young children. • The causative agent may be viral or bacterial. Upper Respiratory Tract Infections
  • 43. • The manifestations of tonsillitis are caused by inflammation. • As the palatine tonsils enlarge from edema, they may meet in the midline (kissing tonsils), obstructing the passage of air or food. • The child has difficulty swallowing and breathing. • When enlargement of the adenoids occurs, the space behind the posterior nares becomes blocked, making it difficult or impossible for air to pass from the nose to the throat. As a result, the child breathes through the mouth. Upper Respiratory Tract Infections
  • 44. • Throat cultures positive for GABHS infection warrant antibiotic treatment. • Tonsillectomy is the surgical removal of the palatine tonsils. • Adenoidectomy (the surgical removal of the adenoids) is recommended for children who have a history of four or greater episodes of recurrent purulent rhinorrhea in the previous 12 months in a child younger than 12 years old. Upper Respiratory Tract Infections
  • 45. • Nursing care involves providing comfort and minimizing activities or interventions that precipitate bleeding. • Patients with sleep-disordered breathing require close monitoring of airway and breathing postoperatively. • A soft to liquid diet is preferred. • Warm saltwater gargles, warm fluids, throat lozenges, and analgesic/antipyretic drugs (such as acetaminophen) are used to promote comfort. • If surgery is required, the child requires the same psychological preparation and physical care as for any other surgical procedure Upper Respiratory Tract Infections
  • 46. • Family Support and Home Care • Discharge instructions include • (1) avoiding irritating and highly seasoned foods, • (2) avoiding gargles or vigorous toothbrushing, • (3) avoiding coughing or clearing of the throat or putting objects in the mouth (e.g., a straw), • (4) using analgesics or an ice collar for pain, and • (5) limiting activity to decrease the potential for bleeding. • Hemorrhage may occur after surgery as a result of tissue sloughing from the healing process. • Any sign of bleeding warrants immediate medical attention. • Objectionable mouth odor and slight ear pain with a low- grade fever are common for 5 to 10 days postoperatively. • The child's voice may sound different postoperative, especially if the tonsils were large. Upper Respiratory Tract Infections
  • 47. • Influenza, or the “flu,” is classified into three groups of orthomyxoviruses, which are antigenically distinct: types A and B, which cause epidemic disease, and type C, which is antigenically stable and causes milder disease. • Influenza is spread from one individual to another by direct contact (large- droplet infection) or by articles recently contaminated by nasopharyngeal secretions. • Influenza is frequently most severe in infants. • Affected persons are most infectious for 24 hours before and after the onset of symptoms. • The viruses can be isolated from nasopharyngeal secretions early after the onset of infection, and serologic tests identify the type by complement fixation or the subgroups by hemagglutination inhibition. Upper Respiratory Tract Infections
  • 48. • Most patients have a dry throat and nasal mucosa, a dry cough, and a tendency toward hoarseness. • A flushed face, photophobia, myalgia, hyperesthesia, and sometimes exhaustion and lack of energy accompany a sudden onset of fever and chills. • The symptoms of influenza last for 4 or 5 days. Complications include severe viral pneumonia (often hemorrhagic); encephalitis; and secondary bacterial infections such as otitis media (OM), sinusitis, or pneumonia. Upper Respiratory Tract Infections
  • 49. • Uncomplicated influenza in children usually requires only symptomatic treatment, including acetaminophen or ibuprofen for fever and sufficient fluids to maintain hydration. • Oseltamivir is a neuraminidase inhibitor that may be administered orally for 5 days to children older than 1 year of age (and adults) to decrease the flu symptoms; this drug must be taken within 2 days of the onset of symptoms. • Zanamivir can be used for treatment of influenza in patients 7 years old and older and for prophylaxis of influenza in patients 5 years old and older. • Bronchospasm and a decline in lung function can occur when zanamivir is used in patients with underlying airway disease, such as asthma or chronic obstructive pulmonary disease (COPD). Upper Respiratory Tract Infections
  • 50. • Prevention • The influenza vaccine is now recommended annually for children over 6 months old. • Influenza vaccine (trivalent inactivated influenza vaccine [TIV]) may be given to healthy children 6 months old and older via IM injection. • The TIV vaccines are safe and effective provided the antigens in the vaccine correlate with the circulating influenza viruses. • Patients who have had anaphylactic reactions to egg protein should not receive either influenza vaccine. Upper Respiratory Tract Infections
  • 51. • Influenza, or the “flu,” is classified into three groups of orthomyxoviruses, which are antigenically distinct: types A and B, which cause epidemic disease, and type C, which is antigenically stable and causes milder disease. • Influenza is spread from one individual to another by direct contact (large- droplet infection) or by articles recently contaminated by nasopharyngeal secretions. • Influenza is frequently most severe in infants. • Affected persons are most infectious for 24 hours before and after the onset of symptoms. • The viruses can be isolated from nasopharyngeal secretions early after the onset of infection, and serologic tests identify the type by complement fixation or the subgroups by hemagglutination inhibition. Upper Respiratory Tract Infections
  • 52. • Otitis media (OM): An inflammation of the middle ear without reference to etiology or pathogenesis • Acute otitis media (AOM): An inflammation of the middle ear space with a rapid onset of the signs and symptoms of acute infection—namely, fever and otalgia (ear pain) • Otitis media with effusion (OME): Fluid in the middle ear space without symptoms of acute infection • Most episodes of acute otitis media (AOM) occur in the first 24 months of life, but the incidence decreases with age except for a small increase at 5 or 6 years old when children enter school. • Family socioeconomic status and extent of exposure to other children are the two most important identifiable risk factors for the occurrence of OM. Upper Respiratory Tract Infections
  • 53. • Streptococcus pneumoniae, H. influenzae, and Moraxella catarrhalis are the three most common bacteria causing AOM. • The etiology of noninfectious OM is unknown, but OM may occur because of blocked eustachian tubes, which results in negative ear pressure. Fluid is pulled from the mucosal lining, which accumulates and becomes colonized by infectious organisms. • Predisposing factors include URIs, allergic rhinitis, Down syndrome, cleft palate, daycare attendance, exposure to secondhand smoke, and bottle propping during feeding. • Infants fed breast milk have a lower incidence of OM than formula-fed infants. Upper Respiratory Tract Infections
  • 54. • OM is primarily a result of malfunctioning eustachian tubes. • Mechanical or functional obstruction of the eustachian tube causes accumulation of secretions in the middle ear. • Intrinsic obstruction can be caused by infection or allergy; extrinsic obstruction is usually a result of enlarged adenoids or nasopharyngeal tumors. • When the passage is not totally obstructed, contamination of the middle ear can take place by reflux, aspiration, or insufflation during crying, sneezing, nose blowing, and swallowing when the nose is obstructed. Upper Respiratory Tract Infections
  • 55. • Careful assessment of tympanic membrane mobility with a pneumatic otoscope is essential to differentiate AOM from OME • An immobile tympanic membrane or an orange, discolored membrane indicates OME. Upper Respiratory Tract Infections
  • 56. • Acute Otitis Media • Follows an upper respiratory tract infection • Otalgia (earache)Fever—may or may not be present • Purulent discharge (otorrhea)—may or may not be present • Infants and Very Young Children • Crying, fussiness, restlessness, irritability, especially on lying down • Tendency to rub, hold, or pull affected ear • Rolling head from side to side • Difficulty comforting child • Loss of appetite, refusal to feed Upper Respiratory Tract Infections
  • 57. • Older Children • Crying or verbalizing feelings of discomfort • Irritability • Lethargy • Loss of appetite • Chronic Otitis Media • Hearing loss • Difficulty communicating • Feeling of fullness, tinnitus, or vertigo may be present Upper Respiratory Tract Infections
  • 58. • Oral amoxicillin in high doses (80 to 90 mg/kg/day divided twice daily) is the treatment of choice for initial episodes of AOM in children who have not received antibiotics within the past month. • Second-line antibiotics used to treat OM include amoxicillin/clavulanate and cephalosporins (such as cefdinir, cefuroxime, and cefpodoxime). IM ceftriaxone is used if the causative organism is a highly resistant pneumococcus or if the parents are noncompliant with the therapy. • Myringotomy, a surgical incision of the eardrum, may be necessary to alleviate the severe pain of AOM or OME. • Tympanostomy tube placement and adenoidectomy are surgical procedures that may be done to treat recurrent chronic OM (defined as three bouts in 6 months, six in 12 months, or six by 6 years of age). • Adenoidectomy is not recommended for treatment of AOM and is performed only in children with recurrent AOM or chronic OME with postnasal obstruction, adenoiditis, or chronic sinusitis. Upper Respiratory Tract Infections
  • 59. • Prevention • Routine immunization with the pneumococcal conjugate vaccine PCV7 (Prevnar 7) has reduced the incidence of AOM in some infants and children • The vaccine is administered as a four-dose series beginning at 2 months old. • The Advisory Committee on Immunization Practices recommends routine vaccination with PCV13 of all children 2 to 59 months old, children 60 to 71 months old with underlying medical conditions that increase their risk for pneumococcal disease or complications, and children who previously received one or more doses of PCV7. Upper Respiratory Tract Infections
  • 60. • Nursing objectives for children with AOM include • (1) relieving pain, • (2) facilitating drainage when possible, • (3) preventing complications or recurrence, • (4) educating the family in care of the child • (5) providing emotional support to the child and family. • Analgesic drugs such as acetaminophen (all ages) and ibuprofen (6 months of age and older) are used to treat mild pain. • If the ear is draining, the external canal may be cleaned with sterile cotton swabs or pledgets coupled with topical antibiotic treatment. • Reducing the chances of OM is possible with measures such as sitting or holding an infant upright for feedings, maintaining routine childhood immunizations, and exclusively breastfeeding until at least 6 months old. • Eliminating tobacco smoke and known allergens is also recommended. Upper Respiratory Tract Infections
  • 61. • Infectious mononucleosis is an acute, self-limiting infectious disease that is common among young people under 25 years old. • Symptoms include fever, exudative pharyngitis, lymphadenopathy, hepatosplenomegaly, and an increase in atypical lymphocytes. • The course is usually mild but occasionally can be severe or, rarely, accompanied by serious complications. Upper Respiratory Tract Infections
  • 62. • The herpes-like Epstein-Barr virus (EBV) is the principal cause of infectious mononucleosis. • It appears in both sporadic and epidemic forms, but the sporadic cases are more common. • The virus is believed to be transmitted in saliva by direct intimate contact, blood transfusion, or transplantation. • The incubation period after exposure is approximately 30 to 50 days. Upper Respiratory Tract Infections
  • 63. • The onset of symptoms may be acute or insidious and may appear anywhere from 10 days to 6 weeks after exposure. Heterophil antibody tests (Paul-Bunnell or Monospot) determine the extent to which the patient's serum will agglutinate sheep red blood cells; the response in these tests is primarily to immunoglobulin M (IgM), which is present in the first 2 weeks of the illness and may last up to a year. • The spot test (Monospot) is a slide test of venous blood that has high specificity for the diagnosis of infectious mononucleosis. Blood is usually obtained for the test by finger puncture or venous sampling and is placed on special paper. If the blood agglutinates, forming fragments or clumps, the test result is positive for the infection. Upper Respiratory Tract Infections
  • 64. • Early Signs • Headache • Epistaxis • Malaise • Fatigue • ChillsLow-grade fever • Loss of appetite • Puffy eyes • Acute Disease • Cardinal Features • FeverSore throat • Cervical adenopathy Upper Respiratory Tract Infections
  • 65. • Common Features • Splenomegaly (may persist for several months) • Palatine petechiae • Macular eruption (especially on trunk) • Exudative pharyngitis or tonsillitis • Hepatic involvement to some degree, often associated with jaundice Upper Respiratory Tract Infections
  • 66. • A mild analgesic is often sufficient to relieve the headache, fever, and malaise. • Rest is encouraged for fatigue but is not imposed for any specific period. • If sore throat is severe, effective therapies include gargles, warm drinks, anesthetic troches, or analgesics, including opioids. • Corticosteroids have been used to treat respiratory distress from significant tonsillar inflammation, myocarditis, hemolytic anemia, thrombocytopenia, and neurologic complications • Prognosis • Acute symptoms often disappear within 7 to 10 days, and persistent fatigue subsides within 2 to 4 weeks. • Some adolescents may need to restrict their activities for 2 to 3 months, but the disease rarely extends for longer periods. • The child is encouraged to maintain limited exercise to prevent deconditioning. Upper Respiratory Tract Infections
  • 67. • Direct nursing responsibilities toward providing comfort measures to relieve symptoms. • The child is advised to limit exposure to persons outside the family, especially during the acute phase of illness. • Throat pain may be severe enough to require an analgesic, such as acetaminophen or ibuprofen. • Careful nursing assessment of swallowing ability is essential to detect serious airway edema and airway compromise. Upper Respiratory Tract Infections
  • 68. • Croup is a general term applied to a symptom complex characterized by hoarseness, a resonant cough described as “barking” or “brassy” (croupy), varying degrees of inspiratory stridor, and varying degrees of respiratory distress resulting from swelling or obstruction in the region of the larynx and subglottic airway. • Croup syndromes can affect the larynx, trachea, and bronchi. • Causes: parainfluenza virus, human metapneumovirus, influenza types A and B, adenovirus, and measles. Croup Syndromes
  • 69. Upper Respiratory Tract Infections Croup Syndromes
  • 70. • Acute epiglottitis, or acute supraglottitis, is a medical emergency. • It is a serious obstructive inflammatory process that occurs predominantly in children 2 to 5 years old but can occur from infancy to adulthood. • The obstruction is supraglottic as opposed to the subglottic obstruction of laryngitis. • The responsible organism is usually H. influenzae. Croup Syndromes
  • 71. Croup Syndromes • Three clinical observations that are predictive of epiglottitis are absence of spontaneous cough, presence of drooling, and agitation. • The child is irritable, extremely restless, and has an anxious, apprehensive, and frightened expression. • The voice is thick and muffled, with a froglike croaking sound on inspiration, but the child is not hoarse. • Suprasternal and substernal retractions may be evident. • The child seldom struggles to breathe, and slow, quiet breathing provides better air exchange. • The sallow color of mild hypoxia may progress to frank cyanosis if treatment is delayed. • The throat is red and inflamed, and a distinctive large, cherry red, edematous epiglottis is visible on careful throat inspection.
  • 72. • The child who is suspected of having epiglottitis should be examined in a setting where emergency airway equipment is readily available. • Examination of the throat with a tongue depressor is contraindicated until experienced personnel and equipment are available to proceed with immediate intubation or tracheostomy in the event that the examination precipitates further or complete obstruction. • A lateral neck radiograph of the soft tissues is indicated for diagnosis. • Nasotracheal intubation or on occasion, tracheostomy, is considered for the child with epiglottitis with severe respiratory distress. • Humidified oxygen is administered as necessary either via mask in older children or blow-by in younger children to avoid further agitation. • Children with suspected bacterial epiglottitis are given antibiotics intravenously followed by oral administration to complete a 7- to 10- day course. Croup Syndromes
  • 73. • It is important to act quickly but calmly and to provide support without increasing anxiety. • When epiglottitis is suspected, the nurse should not attempt to visualize the epiglottis directly with a tongue depressor or take a throat culture but should refer the child for medical evaluation immediately. • Continuous monitoring of respiratory status, including pulse oximetry (and blood gases if the patient is intubated), is an important part of nursing observations, and the IV infusion is maintained. Croup Syndromes
  • 74. • Acute LTB is the most common croup syndrome. • It primarily affects children 6 months to 3 years old, and the causative organisms are viral agents, particularly the parainfluenza virus types 1, 2 and 3, adenovirus, enterovirus, RSV, rhinovirus, and influenza A and B. • Bacterial organisms are rarely a causative organism but can include M. pneumonia and diphtheria. • Inflammation of the mucosal lining the larynx and trachea causes a narrowing of the airway. • Other classic manifestations include cough and hoarseness. • Respiratory distress in infants and toddlers may be manifested by nasal flaring, intercostal retractions, tachypnea, and continuous stridor. • Obstruction that is severe enough to prevent adequate ventilation and exhalation of carbon dioxide can cause respiratory acidosis and eventually respiratory failure. Croup Syndromes
  • 75. • The major objective in medical management is maintaining the airway and providing adequate respiratory exchange. • The application of humidity with cool mist provides some relief for most children with mildcroup. • Nebulized epinephrine (racemic epinephrine) is often used in children with severe disease, stridor at rest, retractions, or difficulty breathing. • Oral steroids (dexamethasone) have proven effective in the treatment of croup (often as a single dose) • Nebulized budesonide may be administered in conjunction with IM dexamethasone. • Antibiotics are only used to treat specific bacterial complications of croup. Croup Syndromes
  • 76. • The most important nursing function in the care of children with LTB is continuous, vigilant observation and accurate assessment of respiratory status. • Cardiac, respiratory, and pulse oximetry monitoring supplement visual observation. • The trend away from early intubation of children with LTB emphasizes the importance of nursing observations and the ability to recognize impending respiratory failure so that intubation can be implemented without delay. • Parents need frequent reassurance (provided in a calm, quiet manner) and education regarding what they can do to make their child more comfortable. • Home care after discharge includes monitoring for worsening symptoms, continued humidity, adequate hydration, and nourishment. Croup Syndromes
  • 77. • Acute spasmodic laryngitis (spasmodic croup) is distinct from laryngitis and LTB, and it is characterized by recurrent paroxysmal attacks of laryngeal obstruction that occur chiefly at night. • Signs of inflammation are absent or mild, and it is followed by an uneventful recovery. • The child feels well the next day. Some children appear to be predisposed to the condition; allergies or hypersensitivities may be implicated in some cases. Croup Syndromes
  • 78. • Bacterial tracheitis, an infection of the mucosa and soft tissues of the upper trachea, is a distinct entity with features of both croup and epiglottitis. • The disease occurs in typically at a mean age between 5 and 7 years old and may cause severe airway obstruction. • Staphylococcus aureus is the most frequent organism responsible, M. catarrhalis, S. pneumoniae, and H. influenzae have also been implicated. • The child has a history of previous URI with croupy cough, stridor unaffected by position, toxicity, absence of drooling, and high fever. • Thick, purulent tracheal secretions are common, and respiratory difficulties are secondary to these copious secretions. • The child's white cell count will be elevated. Croup Syndromes
  • 79. • Bacterial tracheitis requires vigorous management with oxygen therapy, antipyretics, and antibiotics. • Early recognition to prevent life-threatening airway obstruction is essential. • Many children with bacterial tracheitis need endotracheal intubation and mechanical ventilation for airway obstruction. Croup Syndromes
  • 80. • The reactive portion of the lower respiratory tract includes the bronchi and bronchioles in children. • The smooth muscle in these structures represents a major factor in the constriction of the airway, particularly in the bronchioles, the portion that extends from the bronchi to the alveoli. Infections of the Lower Airways
  • 82. • Bronchitis (sometimes referred to as tracheobronchitis) is inflammation of the large airways (trachea and bronchi), which is frequently associated with URIs. • Viral agents are the primary cause of the disease, although M. pneumoniae is a common cause in children older than 6 years of age. • A dry, hacking, nonproductive cough that worsens at night and becomes productive in 2 or 3 days characterizes this condition. • Bronchitis is a mild, self-limiting disease that requires only symptomatic treatment, including analgesics, antipyretics, and humidity. Cough suppressants may be useful to allow rest but can interfere with clearance of secretions. Most patients recover uneventfully in 5 to 10 days. • Adolescents with chronic bronchitis (>3 months) should be screened for tobacco or marijuana use. Infections of the Lower Airways
  • 83. • Bronchiolitis is a common, acute viral infection with upper respiratory and lower respiratory infection of the bronchioles due to inflammation. • Cause: • Adenoviruses • parainfluenza viruses • Human merapneumovirus Infections of the Lower Airways
  • 84. • RSV affects the epithelial cells of the respiratory tract. • The ciliated cells swell, protrude into the lumen, and lose their cilia. • The walls of the bronchi and bronchioles are infiltrated with inflammatory cells, and varying degrees of intraluminal obstruction lead to hyperinflation, obstructive emphysema resulting from partial obstruction, and patchy areas of atelectasis. • Dilation of bronchial passages on inspiration allows sufficient space for intake of air, but narrowing of the passages on expiration prevents air from leaving the lungs. Thus, air is trapped distal to the obstruction and causes progressive overinflation (emphysema). Infections of the Lower Airways
  • 85. • Initial • Rhinorrhea • Pharyngitis • Coughing, sneezing • Wheezing • Possible ear or eye drainage • Intermittent fever • With Progression of Illness • Increased coughing and wheezing • Tachypnea and retractions • Cyanosis • Severe Illness • Tachypnea, >70 breaths/min • Listlessness • Apneic spells • Poor air exchange; poor breath sounds Infections of the Lower Airways
  • 86. • Identification on nasopharyngeal secretions, • rapid immunofluorescent antibody/direct fluorescent antibody (DFA) staining • enzyme-linked immunosorbent assay (ELISA) for RSV antigen detection • Hyperinflation of the lungs is generally seen on the chest radiograph. Infections of the Lower Airways
  • 87. • Children with bronchiolitis are cared for home if they are maintaining hydration, do not have respiratory distress, and do not need oxygen therapy. • Humidified oxygen is administered in concentrations sufficient to maintain adequate oxygenation (SpO2) at or above 90% as measured by pulse oximetry. • An infant who is tachypneic or apneic, has marked retractions, seems listless, has a history of poor fluid intake, or is dehydrated should be closely observed for respiratory failure. • Children with thickened secretions may benefit from extra humidity blended with oxygen administration and continuous positive airway pressure (CPAP) via a high flow nasal cannula (HFNC). A prescriber order is required to indicate the flow rate and percentage of the oxygen therapy. The HFNC improves functional residual capacity, reducing the work of breathing. Infections of the Lower Airways
  • 88. • Infants with abundant nasal secretions benefit from regular suctioning, especially before feeding. • Nasal aspiration of the external nares using an aspirator may be sufficient to remove most secretions • Fluids by mouth may be contraindicated because of tachypnea, weakness, and fatigue • Nasogastric (NG) fluids may be required if the infant is unable to tolerate oral fluids and a peripheral IV is difficult to establish. • Ribavirin, an antiviral agent (synthetic nucleoside analog), is the only specific therapy approved for hospitalized children. • Palivizumab (Synagis), a monoclonal antibody, which is given monthly in an IM injection for a maximum of five doses to prevent hospitalization associated with RSV. Infections of the Lower Airways
  • 89. • Droplet and standard precautions are used, including hand washing, not touching the nasal mucosa or conjunctiva, and using gloves and gowns when entering the patient's room; contact precautions are also recommended. • If a nasal cannula is being used, the skin around the child's ears must be observed for signs of irritation and pressure related injuries. • If a nasal cannula is being used, the skin around the child's ears must be observed for signs of irritation and pressure related injuries. Pulse oximetry probes must be rotated at least every 4 to 8 hours to prevent pressure-related injuries to the skin. • Breastfeeding mothers are encouraged to continue feeding the infant or, if feedings are contraindicated because of the acuity of the illness, mothers should pump their milk and store it appropriately for later use. • Nursing care is aimed at monitoring oxygenation with pulse oximetry, ensuring any bronchodilator therapy is optimized by using a small mask for delivery, monitoring IV fluids and NG fluids administered, monitoring temperature, and providing information for the parent and family regarding the infant's status. Infections of the Lower Airways
  • 90. • Pneumonia, inflammation of the pulmonary parenchyma, is common in childhood but occurs more frequently in early childhood. The causative agent is either inhaled into the lungs directly or comes from the bloodstream. • The most useful classification of pneumonia is based on the etiologic agent (e.g., viral, bacterial, mycoplasmal, or aspiration of foreign substances). • • Neonates: Group B streptococci, gram-negative enteric bacteria, cytomegalovirus, Ureaplasma urealyticum, Listeria monocytogenes, C. trachomatis • • Infants: RSV, parainfluenza virus, influenza virus, adenovirus, metapneumovirus, S. pneumoniae, H. influenzae, M. pneumoniae, Mycobacterium tuberculosis • • Preschool children: RSV, parainfluenza virus, influenza virus, adenovirus, metapneumovirus, S. pneumoniae, H. influenzae, M. pneumoniae, M. tuberculosis • • School-age children: M. pneumoniae, Chlamydia pneumoniae, M. tuberculosis, and respiratory virusesHistomycosis, coccidioidomycosis, and other fungi also cause pneumonia. Infections of the Lower Airways
  • 91. • Pneumonitis is a localized acute inflammation of the lung without the toxemia associated with lobar pneumonia. • The causative agent is identified from the clinical history, the child's age, the general health history, the physical examination, radiography, and the laboratory examination. Infections of the Lower Airways
  • 92. • Viruses that cause pneumonia include RSV in infants and parainfluenza, influenza, human metapneumovirus, enterovirus, and adenovirus in older children. Differentiation among viruses is usually made by clinical features, such as child's age, medical history, season of the year, and radiographic and laboratory examination. • Treatment is symptomatic and includes measures to promote oxygenation and comfort, such as oxygen administration with cool mist, postural drainage, antipyretics for fever management, monitoring fluid intake, and family support. Infections of the Lower Airways
  • 93. • General Signs of Pneumonia • Fever: Usually high • Respiratory Cough: Unproductive to productive with whitish sputum Tachypnea Breath sounds: Crackles, decreased breath sounds Dullness with percussion Chest pain Retractions Nasal flaring Pallor to cyanosis (depends on severity) • Chest radiography: Diffuse or patchy infiltration with peribronchial distribution • Behavior: Irritability, restlessness, malaise, lethargy • Gastrointestinal: Anorexia, vomiting, diarrhea, abdominal pain Infections of the Lower Airways
  • 94. • Atypical pneumonia refers to pneumonia that is caused by pathogens other than the traditionally most common and readily cultured bacteria (e.g., S. pneumoniae). • In the category of atypical pneumonias, M. pneumoniae is the most common cause of community-acquired pneumonia in children 5 to 15 years old • Chlamydial pneumonia, caused by C. trachomatis, can occur in infants and generally appears between 2 and 19 weeks after delivery • Chlamydial pneumonia is characterized by a persistent cough, tachypnea, and sometimes rales. • Oral azithromycin is the treatment of choice; alternatively, erythromycin or ethylsuccinate can be give. Infections of the Lower Airways
  • 95. • S. pneumoniae is the most common bacterial pathogen responsible for community-acquired pneumonia in both children and adults • Other bacteria that cause pneumonia in children are group A streptococcus, S. aureus, M. catarrhalis, M. pneumonia, and C. pneumoniae. Infections of the Lower Airways
  • 96. • S. pneumoniae is the most common bacterial pathogen responsible for community-acquired pneumonia in both children and adults • Other bacteria that cause pneumonia in children are group A streptococcus, S. aureus, M. catarrhalis, M. pneumonia, and C. pneumoniae. • Symptoms include fever, malaise, rapid and shallow respirations, cough, and chest pain. The associated cough may persist for several weeks or months. The pain of pneumonia may be referred to the abdomen in young children. Chills and meningeal symptoms (meningism) without meningitis are common. • Antibiotic therapy, rest, liberal oral intake of fluid, and administration of an antipyretic for fever are the principal therapeutic measures. Infections of the Lower Airways
  • 97. • Hospitalization is indicated when pleural effusion or empyema accompanies the disease, when moderate or severe respiratory distress or deoxygenation occurs, in situations in which compliance with therapy is estimated to be poor, in infants younger than 6 months old, and when there are chronic illnesses such as congenital heart disease or BPD . • Complications • Infants, with staphylococcal pneumonia develop empyema, pyopneumothorax, or tension pneumothorax. • AOM and pleural effusion are common in children with pneumococcal pneumonia • vaccination with pneumococcal vaccines is an important part of preventing pneumococcal pneumonia Infections of the Lower Airways
  • 98. • Pneumothorax occurs when there is an accumulation of air in the pleural space; this air increases intrapleural pressure, making it more difficult to expand the affected lung. • This leads to the clinical manifestations of dyspnea, chest pain and often back pain, labored respirations, tachycardia, and decreased oxygen saturation (SaO2). • In neonates and infants on mechanical ventilation, the first clinical signs of a pneumothorax are oxygen desaturation and hypotension. • The three major types of pneumothorax are tension, spontaneous, and traumatic. • The definitive diagnosis of pneumothorax is a chest radiograph. • The emergent treatment involves needle aspiration of the air within the pleural space; subsequently a chest tube to closed drainage is usually inserted to prevent the reaccumulation of air. • Pleural effusion occurs when there is an excessive accumulation of fluid in the pleural space. • The diagnosis is made by chest radiography, and the treatment involves evacuation of the fluid by needle aspiration followed by insertion of a chest tube to closed drainage. Infections of the Lower Airways
  • 99. • Nursing Care Management • Supportive and symptomatic, thorough respiratory assessment and administration of supplemental oxygen (as required), fluids, and antibiotic • Child with a chest tube requires close attention to respiratory status • The chest tube and drainage device used are monitored for proper function (i.e., drainage is not impeded, vacuum setting is correct, tubing is free of kinks, dressing covering chest tube insertion site is intact, water seal is maintained [if used], and chest tube remains in place). • A simple bulb suction syringe is usually sufficient for clearing the nares and nasopharynx of infants. • Chest percussion, postural drainage, and nebulize bronchodilator treatments may be prescribed. • For the child being cared for at home, the nurse educates the parent regarding observation for worsening symptoms, antibiotic and antipyretic administration, and encouragement of oral fluid intake. Infections of the Lower Airways
  • 100. • Pertussis, or whooping cough, is an acute respiratory tract infection caused by B. Pertussis, which in the past primarily occurred in children younger than 4 years old who were not immunized. • Complications in adolescents can include syncope, rib fractures, and pneumonia; whereas on younger children, seizures, pnemonia, intracranial bleeding, conjunctival bleeding and death can occur. • Diagnosis is obtained via culture or B. pertussis polymrase chain reaction (PCR) test on specimens obtained with nasal swab. • Treatment with antibiotics (erythromycin, clarithromycin, or azithromycin) in the catarrhal stage may result in a milder form of the infection. Other Infections of the Respiratory Tract
  • 101. • Tuberculosis (TB) along with human immunodeficiency virus is the leading cause of death from a single infectious disease. • TB is caused by M. tuberculosis, an acid-fast bacillus. Children are susceptible to the human (M. tuberculosis) and the bovine (Mycobacterium bovis) organisms. • The source of TB infection in children is usually an infected member of the household or a frequent visitor to the home, such as a babysitter or domestic worker. • In the lungs, a proliferation of epithelial cells surrounds and encapsulates the multiplying bacilli in an attempt to wall it off, thus forming the typical tubercle. • Erosion of blood vessels by the primary lesion can cause widespread dissemination of the tubercle bacillus to near and distant sites (miliary TB). • Extrapulmonary (miliary) TB may be manifested as malaise, fever, weight loss, superior lymphadenitis, meningitis, hepatomegaly, splenomegaly, and osteoarthritis. Other Infections of the Respiratory Tract
  • 102. • May be asymptomatic or produce a broad range of symptoms: • • Fever • • Malaise • • Anorexia • • Weight loss • • Cough (may or may not be present; progresses slowly over weeks to months) • • Aching pain and tightness in the chest • • Hemoptysis (rare) • With progression: • • Increasing respiratory rate • • Poor expansion of lung on the affected side • • Diminished breath sounds and crackles • • Dullness to percussion • • Persistent fever • • Generalized symptoms • • Pallor, anemia, weakness, and weight loss Other Infections of the Respiratory Tract
  • 103. • Diagnosis is based on information derived from physical examination, history, tuberculin skin testing, radiographic examinations, and cultures of the organism. • The tuberculin skin test (TST) is the most important indicator of whether a child has been infected with the tubercle bacillus. • A targeted testing method is employed wherein only children and adolescents at high risk for contracting the disease, in addition to patients at risk for progression to TB disease, are screened. Other Infections of the Respiratory Tract
  • 104. • The standard dose of purified protein derivative (PPD) is 5 tuberculin unit, which is administered using a 27-gauge needle and a 1-ml syringe intradermally into the volar aspect of the forearm. • The tuberculin is injected ID with bevel of the needle pointing upward. • A 6-10mm in diameter should form between the layers of the skin when the solution is injected properfly. • The reaction to the skin test is determined in 48 to 72 hours by a health professionals. • A positive reaction indicates that the individual has been infected and has developed sensitivity to the protein of the tubercle bacillus. Other Infections of the Respiratory Tract
  • 105. Other Infections of the Respiratory Tract
  • 106. • The term latent tuberculosis infection (LTBI) is used to indicate infection in a person who has a positive TST, no physical findings of disease, and normal chest radiograph findings. • Children younger than 5 years old who have LTBI often progress rapidly to disease and complications (such as TB meningitis and miliary TB) are more common in this age group. • The term TB disease or clinically active TB is used when a child has clinical symptoms or radiographic manifestations caused by the M. tuberculosis organism. • Sputum specimens are difficult or impossible to obtain from infants and young children, because they swallow any mucus coughed from the lower respiratory tract. Early morning aspiration of gastric contents with a NG tube may be performed to capture sputum swallowed overnight and should ideally occur daily for 3 days before the child eats. In some cases, an induced sputum specimen may be obtained by administering aerosolized normal saline for 10 to 15 minutes followed by chest percussion and postural drainage and suctioning of the nasopharynx. • The Xpert MTB/RIF is a diagnostic test that can be used on gastric lavage and nasopharyngeal secretions to identify M. tuberculosis and to detect resistance to rifampin. Other Infections of the Respiratory Tract
  • 107. • Tuberculin Skin Test Recommendations for Infants, Children, and Adolescents* • Children for Whom Immediate Tuberculin Skin Test Is Indicated • Contacts of persons with confirmed or suspected contagious tuberculosis (TB; contact investigation) • Children with radiographic or clinical findings suggesting TB disease • Children immigrating from endemic countries (e.g., Asia, Middle East, Africa, Latin America) • Children with travel histories to endemic countries or significant contact with indigenous persons from such countries† • Children Who Should Have Annual Tuberculin Skin Test‡ • Children infected with human immunodeficiency virus (HIV) • Incarcerated adolescents Other Infections of the Respiratory Tract
  • 108. • Tuberculin Skin Test Recommendations for Infants, Children, and Adolescents* • Children for Whom Immediate Tuberculin Skin Test Is Indicated • Contacts of persons with confirmed or suspected contagious tuberculosis (TB; contact investigation) • Children with radiographic or clinical findings suggesting TB disease • Children immigrating from endemic countries (e.g., Asia, Middle East, Africa, Latin America) • Children with travel histories to endemic countries or significant contact with indigenous persons from such countries† • Children Who Should Have Annual Tuberculin Skin Test‡ • Children infected with human immunodeficiency virus (HIV) • Incarcerated adolescents Other Infections of the Respiratory Tract
  • 109. • Medical management of TB disease in children consists of adequate nutrition, pharmacotherapy, general supportive measures, prevention of unnecessary exposure to other infections that further compromise the body's defenses, prevention of reinfection, and sometimes surgical procedures. • Ethambutol, isoniazid, pyrazinamide (PZA), and rifampin are common medications used to treat TB in children. • If the child is suspected of having multidrug-resistant TB, a fourth medication such as streptomycin (IM injection only), kanamycin, amikacin, or capreomycin may be added for 4 to 8 weeks. Other Infections of the Respiratory Tract
  • 110. • Prognosis • Most children recover from primary TB infection and are often unaware of its presence. • TB is a serious disease during the first 2 years of life, during adolescence, and in children who are HIV positive. • Antibiotic therapy has decreased the death rate and the hematogenous spread from primary lesions. • Prevention • The only definite means to prevent TB is to avoid contact with the tubercle bacillus. • Limited immunity can be produced by administration of bacillus Calmette-Guérin (BCG), a live vaccine containing bovine bacilli with reduced virulence (attenuated). • BCG vaccination may be recommended for long-term protection of infants and children with negative TST results who are not infected with HIV and who • (1) are at high risk for continuing exposure to persons with infectious pulmonary TB or • (2) are continuously exposed to persons with TB who have bacilli resistant to both INH and rifampin. Other Infections of the Respiratory Tract
  • 111. • Children with no cough and negative sputum smears can be hospitalized in a regular patient room. • Airborne precautions and a negative-pressure room are required for children who are contagious and hospitalized with active TB disease. • Asymptomatic children with TB can attend school or daycare facilities if they are receiving pharmacotherapy. • They can return to regular activities as soon as effective therapy has been instituted, adherence to therapy has been documented, and clinical symptoms have diminished. • Because the success of therapy depends on compliance with the drug regimen, parents are instructed about the importance and rationale for Directly Observed Therapy (DOT). Other Infections of the Respiratory Tract
  • 112. • Small children characteristically explore matter with their mouths and are prone to aspirate foreign bodies (FBs). • Small children also place objects such as beads, toys, paper clips, small magnets, or food items in the nose, which can easily be aspirated into the trachea. FB aspiration can occur at any age but is most common in children 1 to 3 years old. • “Fun foods” such as hard candy and hot dogs are the worst offenders in terms of potential for choking. • Offending foods in the order of frequency of choking are hot dogs, round candies, peanuts or other types of nuts, grapes, cookies or biscuits, pieces of meats, caramels, carrots, apples, peas, celery, popcorn, fruit and vegetable seeds, cherry pits, gum, and peanut butter. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 113. • The diagnosis of FB aspiration is suspected on the basis of the history and physical signs. FB in the air passages can cause choking, gagging, wheezing, or coughing. Laryngotracheal obstruction most commonly causes dyspnea, cough, stridor, and hoarseness because of decreased air entry. • Cyanosis may occur if the obstruction becomes worse. • Bronchial obstruction usually produces cough (frequently paroxysmal), wheezing, asymmetric breath sounds, decreased airway entry, and dyspnea. • When an object is lodged in the larynx, the child is unable to speak or breathe. • Secondary symptoms are related to the anatomic area in which the object is lodged and are usually caused by a persistent respiratory tract infection distal to the obstruction. • Nasal FBs often manifest by unilateral purulent drainage that does not improve with time. • Radiographic examination reveals opaque • Bronchoscopy is required for a definitive diagnosis of objects in the larynx and trachea. • Fluoroscopic examination is valuable in detecting FBs in the bronchi. The mainstay of diagnosis and management of FBs is endoscopy and bronchoscopy. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 114. • FB aspiration may result in life-threatening airway obstruction, especially in infants because of the small diameters of their airways. • Current recommendations for the emergency treatment of the choking child include the use of abdominal thrusts for children older than 1 year of age and back blows and chest thrusts for children younger than 1 year old. • Most frequently, it must be removed instrumentally by bronchoscopy. • After removal of the FB, the child is usually observed for any complications such as laryngeal edema and then discharged home within a matter of hours if vital signs are stable and recovery is satisfactory. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 115. • A major role of nurses caring for a child who has aspirated an FB is to recognize the signs of FB aspiration, observe for worsening of respiratory symptoms, and implement immediate measures to relieve an emergency obstruction. • To aid a child who is choking, nurses must recognize the signs of distress. A blind sweep of the child's mouth should never be performed, because it may lodge the agent farther into the airway. • Prevention • Nurses can educate parents singly or in groups about hazards of aspiration in relation to the developmental level of their children and encourage them to teach their children safety. • Parents should be cautioned about behaviors that their children might imitate (e.g., holding foreign objects, such as pins, nails, and toothpicks, in their lips or mouth). • Parents should be educated on access to age-appropriate toys and how older sibling toys could be hazardous for younger siblings. • Magnets must be kept away from younger children. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 116. • Aspiration pneumonia occurs when food, secretions, inert materials, volatile compounds, or liquids enter the lung and cause inflammation and a chemical pneumonitis. • Aspiration of fluid or foods is a particular hazard in the child who has difficulty with swallowing or is unable to swallow because of paralysis, weakness, debility, congenital anomalies, or absent cough reflex or in the child who is force-fed, especially while crying or breathing rapidly. • Classic symptoms include an increasing cough or fever with foul-smelling sputum, deteriorating oxygenation, evidence of infiltrates on chest radiographs, and other signs of lower airway involvement. • Other substances that may cause pneumonia are hydrocarbons, lipids, powder, and contrast dye or barium. The severity of the lung injury depends on the pH of the aspirated material. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 117. • The major focus of nursing care is on prevention of aspiration. • Proper feeding techniques should be carried out, and preventive measures should be used to prevent aspiration of any material that might enter the nasopharynx. • Other risk factors include decreased gastrointestinal motility, ineffective cough, poor gag reflex, impaired swallow, high gastric residual, and trauma or surgery to the neck, face, or mouth.Children who are at risk for swallowing difficulties as a result of illness, physical debilitation, anesthesia, or sedation are kept NPO (nothing by mouth) until they can properly swallow fluids effectively. • The child who is at risk for vomiting and incapable of protecting the airway should be positioned in a side-lying recovery position. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 118. • Pulmonary edema (PE) is the movement of fluid into the alveoli and interstitium of the lungs caused by extravasation of fluid from the pulmonary vasculature. • There are two main types of PE: cardiogenic and noncardiogenic. • Cardiogenic (hydrostatic, hemodynamic) PE is caused by an increase in pulmonary capillary pressure because of an increase in pulmonary venous pressure. • Noncardiogenic PE is caused by various conditions that result in increased pulmonary capillary permeability. • Other causes include aspiration, traumatic injury, organ dysfunction caused by sepsis, multiorgan failure, alcoholism or substance abuse, pregnancy (eclampsia), chronic renal impairment, malnutrition, hypertension, or a blood transfusion (transfusion-related ALI). Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 119. • Fluid flows from the pulmonary vasculature into the alveolar interstitial space and then returns to the systemic circulation in a normal lung. • Movement of this fluid is controlled by the net difference between hydrostatic and osmotic pressures and the permeability of the capillary membrane. • Increased pulmonary hydrostatic pressure or increased permeability of the vascular membrane results in movement of fluid into the alveoli and interstitium of the lung. • The pulmonary lymph system normally drains away any fluid from the alveoli, but when the amount of fluid present in the alveoli exceeds lymph drainage, PE occurs. • Symptoms include extreme shortness of breath, cyanosis, tachypnea, diminished breath sounds, anxiety, agitation, confusion, diaphoresis, orthopnea, respiratory crackles, expiratory wheezing (in young infants), heart murmur, S3 gallop, cool peripheries, jugular venous distension, nocturnal dyspnea, cough, pink frothy sputum (if severe), tachycardia, hypertension, and hypotension (if caused by left ventricle dysfunction). Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 120. • Management of PE depends on the cause but can include oxygen therapy, positive end-expiratory pressure (PEEP) via CPAP, and intubation with ventilatory support if respiratory failure occurs. • If ventricular failure is the cause, medications such as diuretics, digoxin, positive inotropes, and vasodilators (nitroglycerin) may be started, and the child may be placed on a fluid and sodium restriction. • Morphine may be prescribed to relieve dyspnea. • The primary goal of management is to determine why PE occurred and treat the underlying condition. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 121. • Pulse oximetry is monitored, and vital signs are observed closely for any deterioration. • The nurse should note changes in SaO2, end-tidal carbon dioxide (ETCO2), and arterial blood gas (ABG) values. • Oxygen, medications, and other respiratory treatments are administered as prescribed. • Close monitoring of intake and output, electrolytes, and comfort are important. • The child should be monitored for restlessness, anxiety, and air hunger. • Placing the child in a high Fowler position may help with lung expansion. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 122. • ARDS is a potentially life-threatening inflammatory lung condition that may occur in both children and adults. • Sepsis, trauma, viral pneumonia, aspiration, fat emboli, drug overdose, reperfusion injury after lung transplantation, smoke inhalation, and near-drowning, among others, have been associated with ARDS. • Mechanical ventilation is often required. • Hypoxemia is expressed in terms of the ratio of partial pressure of oxygen (PaO2) to the fraction of inspired oxygen (FiO2) or P/F ratio. In the setting of a PEEP or CPAP ≥5 cm H2O, mild, moderate and severe ARDS are defined by P/F ratios between 200 and 300, between 100 and 200, and ≤100 mm Hg. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 123. • ARDS is increased permeability of the alveolar-capillary membrane. • During the acute phase of ARDS, inflammatory mediators cause damage to the alveolocapillary membrane, with an increasing pulmonary capillary permeability with resulting interstitial edema. • Later stages are characterized by pneumocyte and fibrin infiltration of the alveoli, with the start of either the healing process or fibrosis. • In ARDS, the lungs become stiff as a result of surfactant inactivation; gas diffusion is impaired; and eventually, bronchiolar mucosal swelling and congestive atelectasis occur. • Surfactant secretion is reduced, and the atelectasis and fluid-filled alveoli provide an excellent medium for bacterial growth. • Hypoxemia or increased work of breathing may require ventilatory support. • The child with ARDS may first demonstrate only symptoms caused by an injury or infection, but as the condition deteriorates, hyperventilation, tachypnea, increasing respiratory effort, cyanosis, and decreasing SaO2 occur. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 124. • Treatment involves supportive measures to maintain adequate oxygenation and pulmonary perfusion, treatment of infection (or the precipitating cause), and maintenance of adequate cardiac output and vascular volume. After the underlying cause has been identified, specific treatment (e.g., antibiotics for infection) is initiated. • Many patients require mechanical ventilatory support. • Fluid administration to maintain adequate intravascular volume and end-organ perfusion must be balanced against the desire to decrease lung fluid to improve oxygenation. Psychological support of the patient and family is also important. • Protective ventilatory strategies using low tidal volumes (6 ml/kg ideal body weight) have been demonstrated to improve outcomes in adults and theoretically are also appropriate in children. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 125. • Prognosis • The prognosis for patients with ARDS is improving. • The precipitating disorder influences the outcome; the worst prognosis is associated with profound hypoxemia, uncontrolled sepsis, bone marrow transplantation, cancer, and multisystem involvement with hepatic failure. • Children who recover may have persistent cough and exertional dyspnea. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 126. • The child with ARDS is cared for in the ICU during the acute stages of illness. • Nursing care involves close monitoring of oxygenation and respiratory status, cardiac output, perfusion, fluid and electrolyte balance, and renal function (urinary output). • Blood gas analysis, acid-base status, and pulse oximetry are important evaluation tools. • Diuretics may be administered to reduce pulmonary fluid, and vasodilators may be administered to decrease pulmonary vascular pressure. • Nutritional support is often required because of the prolonged acute phase of the illness. • The nursing care of the child with ARDS also involves close observance of skin condition, prevention of skin breakdown by pressure area relief, and passive range of motion for prevention of muscle atrophy and contractures. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 127. • Three distinct syndromes of pulmonary complications may occur in children with inhalation injury: • (1) early carbon monoxide (CO) poisoning, airway obstruction, and PE; • (2) ARDS occurring at 24 to 48 hours or later in some cases; and • (3) late complications of pneumonia and pulmonary emboli. • Smoke inhalation results in three types of injury: heat, chemical, and systemic. • Heat injury involves thermal injury to the upper airway. Air has low specific heat; therefore, the injury goes no farther than the upper airway. Reflex closure of the glottis prevents injury to the lower airway. • Chemical injury involves gases that may be generated during the combustion of materials, such as clothing, furniture, and floor coverings. Acids, alkalis, and their precursors in smoke can produce chemical burns. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 128. • Systemic injury occurs from gases that are nontoxic to the airways (e.g., CO, hydrogen cyanide). However, these gases cause injury and death by interfering with or inhibiting cellular respiration. • When CO enters the bloodstream, it binds readily with hemoglobin to form carboxyhemoglobin (COHb). Because it is released less readily than oxygen, tissue hypoxia reaches dangerous levels before oxygen is available to meet tissue needs. • Mild manifestations include headache, visual disturbances, irritability, and nausea; more severe intoxication causes confusion, hallucinations, ataxia, and coma. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 129. • The most widely accepted treatment is placing the child on humidified 100% oxygen as quickly as possible to rapidly reverse tissue hypoxia and to displace CO and cyanide from protein-binding sites. • The child is monitored for signs of respiratory distress and impending failure and intubation may be required. • A laryngoscopy or bronchoscopy evaluation may be done to assess for airway damage. • Baseline ABGs and COHb levels are obtained. P • Hyperbaric oxygen therapy may be useful in the treatment of neurologic complications related to CO poisoning. • Pulmonary care may be facilitated by bronchodilators, humidification, chest percussion, and postural drainage to enhance the removal of necrotic material, minimize bronchoconstriction, and avoid atelectasis. • Bronchoscopy may be needed to clear heavy secretions. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 130. • Assessment and localization of the obstruction should be accomplished before severe swelling of the head, neck, or oropharynx occurs. • Intubation is often necessary when (1) severe burns in the area of the nose, mouth, and face increase the likelihood of developing oropharyngeal edema and obstruction; (2) vocal cord edema causes obstruction; (3) the patient has difficulty handling secretions; and (4) progressive respiratory distress requires artificial ventilation. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 131. • The initial goal is to maintain a patent airway and effective ventilation status. • Vital signs and other respiratory assessments (oxygenation, work of breathing, acid-base status) are performed frequently, and the pulmonary status is carefully observed and maintained. • The administration of nebulized bronchodilators, humidified oxygen, and inhaled corticosteroids is often part of the nursing care. • Chest percussion and postural drainage may be part of the therapy, as well as mechanical ventilation if needed. • Parents need support, reassurance, and information regarding the child's condition, treatment, and progress. The nurse can provide anticipatory guidance and education families on prevention of inhalation injuries and the importance of CO detectors in the home. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 132. • Children exposed to (second-hand) passive or environmental tobacco smoke have an increased number of respiratory illnesses, increased respiratory symptoms (i.e., cough, sputum, and wheezing), and reduced performance on pulmonary function tests (PFTs). • A Indoor exposure to tobacco smoke has been linked to asthma in children. • Maternal cigarette smoking is associated with increased respiratory symptoms and illnesses in children; decreased fetal growth; increased deliveries of low birth weight, preterm, and stillborn infants; and a greater incidence of sudden infant death syndrome (SIDS). • The risk for diagnosis of early-onset asthma in the first 6 years of life is associated with in utero exposure to maternal smoking. • Exposure to tobacco smoke during childhood may also contribute to the development of chronic lung disease in the adult. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 133. • Nurses must provide information about the hazards of environmental smoke exposure in all of their interactions with children and their family members. • In families in which smokers are unwilling to quit, appropriate guidance is provided for reducing smoke in the child's environment. • Nurses have an important role in providing parents with affordable smoking cessation education resources, including the appropriate use of smoking cessation pharmacologic aids. Nurses also have a role in educating adolescents about avoiding using tobacco products or smoking marijuana. Pulmonary Dysfunction Caused by Noninfectious Irritants
  • 134. • Asthma is a chronic inflammatory disorder of the airways characterized by recurring symptoms, airway obstruction, bronchial hyperresponsiveness, and an underlying inflammation process. • Inflammation causes an increase in bronchial hyperresponsiveness to a variety of stimuli. • Asthma is the most common chronic disease of childhood, the primary cause of school absences, and the third leading cause of hospitalizations in children younger than 15 years old. Long-Term Respiratory Dysfunction
  • 135. • Asthma Severity Classification in Children Long-Term Respiratory Dysfunction Step 5 or 6: Severe Asthma  Continual symptoms throughout the day  Frequent nighttime symptoms (>1 time/week ages 0 to 4 and 7 nights/week, ages 5 and older)  Pulmonary expiratory flow (PEF): <60%  Forced expiratory volume in 1 second (FEV1): <75% of predicted value  Interference with normal activity: Extremely limited  Use of short-acting β-agonist for symptom control: Several times a day
  • 136. • Asthma Severity Classification in Children Long-Term Respiratory Dysfunction Step 3 or 4: Moderate Asthma  Daily symptoms  Nighttime symptoms: Three to four times a month (0 to 4 years old), >1/week but not nightly (5 to 11 years old)  PEF: 60% to 80% of predicted value (ages 5 and older)  FEV1: 75% to 80% (ages 5 and older)  PEF variability: >30%  Interference with normal activity: Some limitation  Use of short-acting β-agonist for symptom control: Daily
  • 137. • Asthma Severity Classification in Children Long-Term Respiratory Dysfunction Step 2: Mild Asthma  Symptoms >2 times/week but <1 time/day  Nighttime symptoms: One to two times a month (0 to 4 years old), three or four times a month (5 to 11 years old)  PEF or FEV1: ≥80% of predicted value  PEF variability: 20% to 30%  Interference with normal activity: Minor limitation  Use of short-acting β-agonist for symptom control: >2 days/wk but not daily
  • 138. • Asthma Severity Classification in Children Long-Term Respiratory Dysfunction Step 1: Intermittent Asthma Symptoms ≤2 days/wk Nighttime symptoms (awakenings): None (0 to 4 years old); ≤2 nights per month (5 to 11 years old) PEF or FEV1: ≥80% of predicted value PEF variability: <20% Interference with normal activity: None Use of short-acting β-agonist for symptom control: <2 days/wk
  • 139. • Triggers Tending to Precipitate or Aggravate Asthma Exacerbations Long-Term Respiratory Dysfunction • Allergens • Outdoor: Trees, shrubs, weeds, grasses, molds, pollens, air pollution, spores • Indoor: Dust or dust mites, mold, cockroach antigen • Irritants: Tobacco smoke, wood smoke, odors, sprays • Exposure to occupational chemicals • Exercise • Cold air • Changes in weather or temperature• Environmental change: Moving to new home, starting new school, and so on
  • 140. • Triggers Tending to Precipitate or Aggravate Asthma Exacerbations Long-Term Respiratory Dysfunction • Colds and infections • Animals: Cats, dogs, rodents, horses • Medications: Aspirin, NSAIDs, antibiotics, beta-blockers • Strong emotions: Fear, anger, laughing, crying • Conditions: Gastroesophageal reflux, tracheoesophageal fistula • Food additives: Sulfite preservatives • Foods: Nuts, milk or other dairy products • Endocrine factors: Menses, pregnancy, thyroid disease
  • 141. • Asthma is the results from complex interactions among inflammatory cells, mediators, and the cells and tissues present in the airways . • Asthma can cause is bronchospasm and airflow obstruction. • The mechanisms responsible for the obstructive symptoms in asthma include • (1) inflammatory response to stimuli; • (2) airway edema and accumulation and secretion of mucus; • (3) spasm of the smooth muscle of the bronchi and bronchioles, which decreases the caliber of the bronchioles; and • (4) airway remodeling, which causes permanent cellular changes • Chronic inflammation may also cause permanent damage (airway remodeling) to airway structures, which cannot be prevented by and is not responsive to current treatments. Long-Term Respiratory Dysfunction
  • 142. • Cough • Hacking, paroxysmal, irritative, and nonproductive • Becomes rattling and productive of frothy, clear, gelatinous sputum • Respiratory-Related Signs • Shortness of breath • Prolonged expiratory phase • Audible wheeze • May have a malar flush and red ears • Lips deep, dark red color • May progress to cyanosis of nail beds or circumoral cyanosis • Restlessness • Apprehension • Prominent sweating as the attack progresses • Older children sitting upright with shoulders in a hunched-over position, hands on the bed or chair, and arms braced (tripod) • Speaking with short, panting, broken phrases Long-Term Respiratory Dysfunction
  • 143. • Chest • Hyperresonance on percussion • Coarse, loud breath sounds • Wheezes throughout the lung fields • Prolonged expiration • Crackles • Generalized inspiratory and expiratory wheezing; increasingly high pitched • With Repeated Episodes • Barrel chest • Elevated shoulders • Use of accessory muscles of respiration • Facial appearance—flattened malar bones, dark circles beneath the eyes, narrow nose, prominent upper teeth Long-Term Respiratory Dysfunction
  • 144. • The diagnosis is determined primarily on the basis of clinical manifestations, history, physical examination, and, to a lesser extent, laboratory tests. • Pulmonary function tests (PFTs) provide an objective method of evaluating the presence and degree of lung disease, as well as the response to therapy. Spirometry can generally be performed reliably on children by 5 or 6 years old. • Peak expiratory flow rate (PEFR), which measures the maximum flow of air (in liters per minute) that can be forcefully exhaled in 1 second using a peak expiratory flow meter (PEFM). • Bronchoprovocation testing, direct exposure of the mucous membranes to a suspected antigen in increasing concentrations helps to identify inhaled allergens. Exposure to methacholine (methacholine challenge), histamine, or cold or dry air may be performed to assess airway responsiveness or reactivity. • Skin prick testing (SPT) and serological testing (with quantification of sIgE) for allergen-specific immunoglobulin E (sIgE) may be used to identify environmental allergens that trigger asthma. • The presence of eosinophilia of greater than 500/mm3 suggests the presence of an allergic or inflammatory disorder. Long-Term Respiratory Dysfunction
  • 145. • Allergen control • Nonpharmacologic therapy is aimed at the prevention and reduction of exposure to airborne allergens and irritants. • Drug Therapy • Pharmacologic therapy is used to prevent and control asthma symptoms, reduce the frequency and severity of asthma exacerbations, and reverse airflow obstruction. • Asthma medications are categorized into two general classes: • long-term control medications (preventive medications) to achieve and maintain control of inflammation, and • quick-relief medications (rescue medications) to treat symptoms and exacerbations. • Inhaled corticosteroids, cromolyn sodium, long-acting β2-agonists (LABAs), methylxanthines, and leukotriene modifiers are used as long-term control medications. • Short-acting β2-agonists, anticholinergics, and systemic corticosteroids are used as quick-relief medications. Long-Term Respiratory Dysfunction
  • 146. • Many asthma medications are given by inhalation with a nebulizer or a metered-dose inhaler (MDI). • Corticosteroids are antiinflammatory drugs used to treat reversible airflow obstruction, control symptoms, and reduce bronchial hyperresponsiveness in chronic asthma. • β-Adrenergic agonists (short acting) (primarily albuterol, levalbuterol [Xopenex], and terbutaline) are used for treatment of acute exacerbations and for the prevention of EIB. • Salmeterol (Serevent) is a LABA (bronchodilator). This drug is added to antiinflammatory therapy and used for long-term prevention of symptoms, especially nighttime symptoms, and EIB. • Theophylline is a methylxanthine drug used for decades to relieve symptoms and prevent asthma attacks. • Cromolyn sodium stabilizes mast cell membranes; inhibits activation and release of mediators from eosinophil and epithelial cells; and inhibits the acute airway narrowing after exposure to exercise, cold dry air, and sulfur dioxide. • Leukotrienes are mediators of inflammation that cause increases in airway hyperresponsiveness. Leukotriene modifiers (e.g., zafirlukast [Accolate], zileuton [Zyflo], and montelukast sodium [Singulair]) block inflammatory and bronchospasm effects. • Anticholinergics (atropine and ipratropium [Atrovent]) help relieve acute bronchospasm. Long-Term Respiratory Dysfunction
  • 147. • Exercise • Exercise-induced bronchospasm (EIB) is an acute, reversible, usually self-terminating airway obstruction that develops during or after vigorous activity, reaches its peak 5 to 10 minutes after stopping the activity, and usually stops in another 20 to 30 minutes. • Swimming is well tolerated by children with EIB because they are breathing air fully saturated with moisture and because of the type of breathing required in swimming. • Breathing Exercises • Breathing exercises and physical training help produce physical and mental relaxation, improve posture, strengthen respiratory musculature, and develop more efficient patterns of breathing. Long-Term Respiratory Dysfunction
  • 148. • Hyposensitization • Immunotherapy is considered for asthma patients in the following situations • • Patient's preference • • Poor adherence to therapy • • Incomplete response to allergen avoidance • • Significant medication side effects or adverse effect • • Multiple and/or high dose medication requirements • Hyposensitization injections should be administered only with emergency equipment and medications readily available in the event of an anaphylactic reaction.. Long-Term Respiratory Dysfunction
  • 149. • Status Asthmaticus • Status asthmaticus is a medical emergency that can result in respiratory failure and death if untreated. • Status asthmaticus is a medical emergency that can result in respiratory failure and death if untreated. • O2 sat should maintain above 90% • Systemic corticosteroid (oral, IV or IM) is given to decrease the effects of inflammation. • Anticholinergic agent (ipratropium). Long-Term Respiratory Dysfunction
  • 150. • Prognosis • Some children's asthma symptoms may improve at puberty, but up to two thirds of children with asthma continue to have symptoms through puberty and into adulthood. • The younger child and adolescent age group appear to be the most vulnerable, with the greatest increase occurring in children younger than 4 years old and 12 to 17 years . • Risk factors for asthma-related deaths include early onset, frequent attacks, difficult-to-manage disease, adolescence, history of respiratory failure, psychological problems (refusal to take medications), dependency on or misuse of asthma drugs (high use), presence of physical stigmata (barrel chest, intercostal retractions), and abnormal PFT results. Long-Term Respiratory Dysfunction
  • 151. • Acute Asthma Care • When β2-agonists, supplemental oxygen, and corticosteroids are given, the child is monitored closely and continuously for relief of respiratory distress and signs of side effects. • When β2-agonists, supplemental oxygen, and corticosteroids are given, the child is monitored closely and continuously for relief of respiratory distress and signs of side effects. • The child in status asthmaticus should be placed on continuous cardiorespiratory (including blood pressure) and pulse oximetry monitoring. • The child in status asthmaticus should be placed on continuous cardiorespiratory (including blood pressure) and pulse oximetry monitoring. Long-Term Respiratory Dysfunction
  • 152. • Provide Long-Term Asthma Care • These may include asthma education in the primary care setting and in schools and other community settings, care of the child with asthma in the acute care setting, ambulatory care, care coordination, and intensive care. • Nurses also obtain information on how asthma affects the child's everyday activities and self-concept, the child's and family's adherence to the prescribed therapy, and their personal treatment goals. • Parents are taught how to prevent exacerbations, to recognize and respond to symptoms of bronchospasm, to maintain health and prevent complications, and to promote normal activities. Long-Term Respiratory Dysfunction
  • 153. • Avoid Allergens • Parents need to know how to avoid allergens that precipitate asthma episodes. • Parents are cautioned to avoid exposing a sensitive child to excessive cold, wind, and other extremes of weather; smoke (open fire or tobacco); sprays; scents; and other irritants. • Foods known to provoke symptoms should be eliminated from the diet. Long-Term Respiratory Dysfunction
  • 154. • Relieve Bronchospasm • Teach parents and older children to recognize early signs and symptoms of an impending attack. • Objective signs that parents may observe include rhinorrhea, cough, low-grade fever, irritability, itching (especially in front of the neck and chest), apathy, anxiety, sleep disturbance, abdominal discomfort, and loss of appetite. • Children who use a nebulizer, MDI, Diskus, or Turbuhaler to deliver drugs need to learn how to use the device correctly. • A spacer or AeroChamber device should be used with MDI inhalers. • A spacer or AeroChamber device should be used with MDI inhalers. • Teach breathing exercises and controlled breathing for motivated children, and the nurse should provide information concerning activities that promote diaphragmatic breathing, side expansion, and improved mobility of the chest wall. Long-Term Respiratory Dysfunction
  • 156. • CF is a life-shortening disease, inherited as an autosomal recessive trait. The affected child inherits the defective gene from both parents, with an overall risk of one in four if both parents carry the gene. Long-Term Respiratory Dysfunction
  • 157. • CF is characterized by several clinical features, which are increased viscosity of mucous gland secretions, a striking elevation of sweat electrolytes, an increase in several organic and enzymatic constituents of saliva, and abnormalities in autonomic nervous system function. • Children with CF demonstrate an increase in sodium and chloride in both saliva and sweat. • The primary factor, and the one that is responsible for many of the clinical manifestations of the disease, is mechanical obstruction caused by the increased viscosity of mucous gland secretions. Long-Term Respiratory Dysfunction
  • 159. • Meconium Ileus* • Abdominal distention • Vomiting • Failure to pass stools • Rapid development of dehydration • Gastrointestinal Manifestations • Large, bulky, loose, frothy, extremely foul-smelling stools • Voracious appetite (early in disease) • Loss of appetite (later in disease) • Weight loss • Marked tissue wasting • Failure to grow • Distended abdomen • Thin extremities • Sallow skinEvidence of deficiency of fat-soluble vitamins A, D, E, and K • Anemia Long-Term Respiratory Dysfunction
  • 160. • Pulmonary Manifestations • Initial signs: • Wheezy respirations • Dry, nonproductive cough • Eventually: • Increased dyspnea • Paroxysmal cough • Evidence of obstructive emphysema and patchy areas of atelectasis • Progressive involvement: • Overinflated, barrel-shaped chest • Cyanosis • Clubbing of fingers and toes • Repeated episodes of bronchitis and bronchopneumonia Long-Term Respiratory Dysfunction