Respiratory Alterations

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Respiratory Alterations

• NUR 264
• Pediatrics
• Angela J. Jackson, RN, MSN

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Respiratory Alterations Developmental Differences

• Lungs require longer gestation time to form than
  any other body system
• Children have a smaller nasopharynx easily
  occluded during infections
• Lymph tissue (tonsils, adenoids) grows rapidly in
  early childhood, atrophies after age 12
• Smaller nares easily occluded during infection.
  Infants are nose breathers
• Eustachian tubes are shorter and more horizontal,
  facilitating transfer of pathogens into the
  middle ear

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Respiratory Alterations Developmental Differences

• Long, floppy epiglottis vulnerable to swelling
  and obstruction
• Thyroid, cricoid, tracheal cartilages are
  immature and collapse when neck is flexed
• Diaphragmatic-abdominal breathing normal in
  neonate until approximately 5y/o due to position
  of ribs which affect chest wall expansion
• Chest wall is supple and very compliant
• Irregular patterns of breathing in newborns and
  infants
• Pediatric arrests usually occur from respiratory
  arrest or shock, not cardiac arrest

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Choanal Atresia

• Congenital membranous or bony obstruction between
  the nose and nasopharynx

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Choanal Atresia

• Can obstruct one or both posterior nasal openings
• Unilateral can be overlooked until open nasal
  passage becomes obstructed
• Bilateral severe signs of distress in newborn
• More common in girls
• Treatment surgery

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Congenital Laryngeal Stridor Laryngomalacia

• Laryngeal cartilage is soft and flaccid, causing
  the supraglottic structures to collapse into the
  airway, resulting in partial obstruction and
  stridor

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Laryngomalacia

• Stridor with retractions
• Infants cry is normal
• Cyanosis is uncommon
• Place in prone position to decrease obstruction
• Occurs more frequently in boys
• Treatment Tracheostomy

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Acute Viral Nasopharyngitis (Common Cold)

• Inflammation of the nasopharynx
• Self-limiting viral infection
• The inflammatory process is associated with
  tissue swelling and the formation of exudate.
• Nasal congestion caused by edema and secretions
  impede airflow through the nasal passages

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Acute Viral Nasopharyngitis Clinical
Manifestations

• Nasal stuffiness
• Rhinitis
• Sneezing
• Nasal discharge
• Coughing
• Sore throat
• Fever
• Irritability
• Malaise
• Poor feeding

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Acute Viral Nasopharyngitis Diagnosis and
Treatment

• Diagnosis is based on client history and physical
  exam
• Supportive care
• Decongestants
• Saline nasal spray
• Fluids
• Vaporizer
• Antipyretics
• Cough suppressants

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Acute Streptococcal Pharyngitis (Strep Throat)

• Bacterial pharyngitis
• Caused by Group A beta-hemolytic streptococcus
• Red throat, petechia on palate
• Throat pain
• Fever
• Abdominal pain
• Fine raised rash
• Anterior cervical adenopathy

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Strep Throat

• Diagnosed with throat cultures, rapid strep
  screen
• Treated with one dose IM penicillin or 10 day
  course of antibiotics
• Replace toothbrush
• Test and treat other members of family
• Complications acute glomerulonephritis,
  Rheumatic Fever

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Tonsillitis - Adenoiditis

• Viral or bacterial infection of the palatine and
  or pharyngeal tonsils (adenoids)
• Children are more prone to tonsillitis because of
  the large amount of lymphoid tissue and frequent
  respiratory infections

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Tonsillitis Adenoiditis Clinical Manifestations

• Sore throat
• Difficulty swallowing
• Fever
• Nasal congestion

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Tonsillitis Adenoiditis Diagnosis

• Based primarily on symptoms and visual inspection
  of the throat
• Throat cultures and rapid strep screening are
  used to determine etiologic agents

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Tonsillitis Adenoiditis Treatment

• Tonsillectomy may be indicated for recurrent
  infection, or when enlarged tonsils interfere
  with eating or breathing
• Viral infection supportive care
• Warm saline gargles
• Antipyretics

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Otitis Media

• Inflammation of the middle ear
• One of the most common infectious diseased in
  childhood
• Primary causative factor abnormal functioning of
  eustachian tube

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Otitis Media Clinical Manifestations

• Pain
• Fever
• Irritability
• Diarrhea and vomiting
• May have decreased hearing

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Otitis Media Diagnosis

• Otoscopic examination
• Red, bulging tympanic membrane
• Diminished movement with pneumatic otoscopic
  assessment

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Otitis Media Treatment

• Antibiotics for 10 days
• Tympanostomy tubes for recurrent or unresolving
  OM and/or hearing loss

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Acute Epiglottitis

• Serious obstructive inflammatory process of
  epiglottis
• Occurs principally in children between 2 and 5
  years of age
• Caused by infection with Haemophilus influenzae
• Requires immediate treatment

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Epiglottitis Clinical Manifestations

• Abrupt onset
• Child complains of sore throat and pain on
  swallowing
• Fever
• Child appears sicker than clinical findings
  suggest
• Insists on sitting upright and leaning forward,
  with the chin thrust out, mouth open and tongue
  protruding (tripod position)
• Drooling is common
• Child is irritable and extremely restless, has an
  anxious, apprehensive and frightened expression
• Voice is thick and muffled
• Inspiratory stridor

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Acute Epiglottitis Treatment

• Intubation or tracheostomy may be necessary for
  the child with respiratory distress
• Antibiotics, initially given IV followed by PO
  administration, for 10 days
• IV fluids, antipyretics, corticosteroids, keep
  child calm
• The epiglottal swelling usually decreases after
  24 hours of antibiotic therapy, and is near
  normal by the third day

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Laryngotracheobronchitis (Croup)

• Viral syndrome manifested by a croupy or
  barking cough, inspiratory stridor, and
  respiratory distress
• Inflammation of the larynx, trachea, and bronchi
  causes narrowing of the airways
• Seen predominately in children between 6months
  and 3 years of age

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Croup Clinical Manifestations

• Hoarse or barking cough
• Nasal drainage
• Sore throat
• Low-grade fever
• Tachycardia
• Tachypnea
• Inspiratory stridor

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Croup Treatment

• Nebulized racemic epinephrine
• Corticosteroids
• Fluids
• Rest
• Humidity

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Bronchiolitis

• Acute viral infection of the bronchioles,
  occurring most often in young children
• RSV is the most common causative agent
• 95 of children have had bronchiolitis by the age
  of 3

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Bronchiolitis Pathophysiology

• Inflammation causes airway edema
• The bronchioles are narrowed and occluded
• Occlusion causes air trapping, which leads to
  hyperinflation of some alveoli and atelectasis in
  others
• Overall effect is hypoventilation

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Bronchiolitis Clinical Manifestations

• Rhinorrhea
• Sneezing
• Decreased appetite
• Low-grade fever
• Coughing
• Wheezing, nasal flaring, retractions
• Crackles
• Tachypnea

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Bronchiolitis Diagnosis

• History and physical exam
• Nasopharyngeal washings
• Chest x-ray

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Bronchiolitis Treatment

• Humidified O2
• Bronchodilators
• Suctioning
• Oxygen saturation monitoring
• IV fluids
• Strict handwashing and contact precautions
• Prophylaxis Synergis IM once a month

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Pneumonia

• Acute inflammation of the pulmonary parenchyma
• Seen frequently in childhood, occurring most
  often in infancy and early childhood
• Viruses are the primary causative agent except in
  neonatal cases of pneumonia

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Pneumonia Clinical Manifestations

• Cough
• Malaise
• Chest pain
• Fever
• Anorexia
• Headache
• Tachypnea
• Wheezing

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Pneumonia Treatment

• Cough, deep breath, change position often
• CPT, O2, IS
• IV fluids
• Antibiotics, antipyretics
• Cool mist, suctioning
• Rest

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Asthma

• Chronic inflammatory disorder of airways with
  bronchoconstriction and bronchial
  hyperresponsiveness
• Most common pediatric chronic illness

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Asthma Pathophysiology

• Exposure to irritant causes constriction of
  bronchial smooth muscles, edema, increased mucus
  production, airway narrowing
• Bronchial muscles go into spasm, resulting in
  increased respiratory effort, increased airway
  resistance, air trapping, hyperinflammation of
  airway
• Risk factors hereditary, environmental stimuli,
  stress, weather changes, exercise, viral or
  bacterial agents, food additives

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Asthma Clinical Manifestations

• Recurrent episodes of wheezing
• Breathlessness
• Nasal flaring, retractions, head bobbing
• Chest tightness
• Cough
• Prolonged expiration
• Dyspnea
• Tachypnea, tachycardia, barrel chest develops

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Asthma Diagnosis

• Chest x-ray shows hyperinflation of the airways
• PFTs show decreased peak expiratory flow rate

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Asthma Treatment

• Avoidance of triggers
• Regular peak flow monitoring
• Medications
• Short-acting beta-2 agonists (albuterol)
• Inhaled corticosteroids (beclomethasone)
• Systemic corticosteroids
• Antileukotrienes (Singulair)
• Long-acting bronchodilators (Serevent)
• Anticholinergics (atrovent)

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Cystic Fibrosis

• Autosomal recessive disorder that affects the
  exocrine glands
• Causes the body to produce thick, sticky mucus
  that clogs the lungs, the GI tract and the GU
  tract
• Affects approximately 30,000 children and adults
  in the United States
• Median age of survival is 33.4 years

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Cystic Fibrosis Clinical Manifestations

• Salty taste to the skin
• Foul smelling, greasy stools
• Delayed growth
• Thick sputum
• Chronic coughing or wheezing
• Frequent chest and sinus infections with
  recurring pneumonia or bronchitis
• Clubbing of fingers and toes
• Intussusception
• Rectal prolapse
• Meconium ileus

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Cystic Fibrosis Diagnosis

• History and physical exam
• Sweat test
• DNA analysis

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Cystic Fibrosis Treatment

• Antibiotics
• Mucus-thinning drugs (Pulmozyme)
• Bronchodilators
• Bronchial airway drainage
• Oral enzymes
• High calorie diets
• Lung transplant

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Cystic Fibrosis Complications

• Chronic respiratory infections
• Bronchiectasis (irreversible dilation and
  destruction of the bronchial walls)
• Pneumothorax
• Cor pulmonale (failure of the right ventricle of
  the heart)
• Chronic diarrhea
• Severe nutritional deficiencies
• Type 1 diabetes
• Liver damage
• Infertility

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Cystic Fibrosis Nursing Considerations

• Infection control
• Maintain adequate nutrition
• Medication administration
• PPD
• Family teaching
• Support groups

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Bronchopulmonary Dysplasia

• Chronic lung disease that primarily affects
  premature infants who have respiratory distress
  syndrome
• 9 out of 10 babies with BPD weighed 1500 grams or
  less at birth
• 1 out of 3 babies born weighing less than 1000
  grams gets BPD
• 5,000 to 10,000 babies in the U.S. get BPD each
  year

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BD Pathophysiology

• Poor lung compliance requires mechanical
  ventilation
• Trauma to the pulmonary structures occurs,
  leading to interstitial edema and epithelial
  destruction
• Inflammatory response causes airway obstruction
• Tissue and pulmonary vasculature damage results
  in a ventilation/perfusion imbalance that leads
  to hypercapnia and hypoxemia

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BP Clinical Manifestations

• Rapid, shallow breathing
• Retractions
• Cough
• Wheezing
• Cor pulmonale
• Pulmonary edema
• Dependence on supplemental O2 for more than 28
  days
• Respiratory acidosis

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BP Diagnosis

• History and physical exam
• RDS that does not improve within two weeks
• Prolonged mechanical ventilation
• Prolonged need for supplemental O2
• Chest x-ray

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BP Treatment

• Prevention is the primary focus
• Prenatal steroids to promote the maturation of
  fetal lungs
• Administration of surfactant
• Diuretics, steroids, bronchodilators
• Supplemental O2

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BP Potential Complications

• Learning difficulties
• Poor coordination and muscle tone
• Trouble walking
• Activity intolerance
• Eye and ear problems
• Increased susceptibility to URIs and other
  infections

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BP Nursing Considerations

• Maintain mechanical ventilation
• Administration of medications (steroids,
  diuretics, bronchodilators, antibiotics)
• Monitor IO
• Provide adequate nutrition
• Family teaching
• Signs and symptoms of respiratory infection
• Importance of immunizations
• Medications
• O2 therapy
• CPR
• Follow-up

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Any Questions?