The Child with Respiratory Dysfunction

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The Child with Respiratory Dysfunction

• Unit 5

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Respiratory adult vs child

• infectious agent
• size/frequency
• age
• size of child
• resistance
• general condition
• pre-existing conditions

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Respiratory assessments

• nose breathers, flaring,grunting
• rate and ease
• abdominal breathing
• retractions
• cyanosis
• clubbing
• coughing must be described !

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Respiratory assessmentdescribed

• R 54 and shallow with intercostal retractions,
  intermittent non productive cough and continuous
  wheeze throughout lung fields

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Respiratory Nursing interventions

• Ease respiratory efforts pulse Ox, humidity,O2,
  RT
  
• promote rest age appropriate play
• promote comfort nose drops, nasal aspirator
• prevent infection spread hand washing, isolate
• reduce fever Tylenol, tepid sponging, fluids
  
  
• Promote hydration and nutrition

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Tracheotomy

• Plastic and silastic tubes
• Neck cord- allow 1 finger insert
• Weekly tube change
• Suction
• 80-100mm Hg pressure
• NS 2cc???? no
• 5 seconds of suctioning-assess
• 30-60seconds of rest periods in between and hyper
  oxygenate in between
  

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APNEA OF INFANCY

• Sx apnea 20 seconds
• Cyanosis and bradycardia
• Tx
• Apnea monitor
• parent teaching and CPR training
• if apneic, NEVER SHAKE

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Apnea of Infancy

• Pathologic apnea in infants 37 weeks gestation
• Clinical presentation of ALTE
• Therapeutic management
• Theophylline/caffeine
• Home apnea monitors
• Family support

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Disorders of Unknown Etiology

• Sudden infant death syndrome (SIDS)
• Apparent life-threatening events (ALTEs)
• Back to sleep campaign
• Risk factors for SIDS
• Maternal smoking, alcohol, drug use, adolescent
  mom,

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SIDS

• Risk factors for SIDS contd
• Prematurity, Small for gest age
• Twin, male, previous family SIDS
• Bronchopulmonary dysplasia
• Winter, poverty, soft pillows
• Prone, side lying or co- sleeping

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SIDS

• Smoke free environment
• Use firm mattress
• Do not overheat infants
• Breast feed

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Croup Syndromes

• Characterized by hoarseness, barking cough,
  inspiratory stridor, and varying degrees of
  respiratory distress
  
• Croup syndromes affect larynx, trachea, and
  bronchi
  
• Epiglottitis, laryngitis, LTB, tracheitis

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Acute Epiglottitis

• Clinical manifestations
• Sore throat, pain, tripod positioning,
  retractions, high fever
  
• Inspiratory stridor, mild hypoxia
• 4Bs dysphonia, dysphagia, drooling, distress
• A Medical Emergency with Potential for
  respiratory obstruction. DO NOT
  EXAMINE THROAT
  
• Prevention Hib vaccine

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Acute LTB

• LTB Laryngotracheobronchitis
• Most common of the croup syndromes
• Generally affects children
• Organisms responsible
• RSV, parainfluenza virus, Mycoplasma pneumoniae,
  influenza A and B

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Manifestations of LTB

• Inspiratory stridor
• Suprasternal retractions
• Barking or seal-like cough
• Increasing respiratory distress and hypoxia
• Can progress to respiratory acidosis, respiratory
  failure and death
  

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Acute Spasmodic Laryngitis

• AKA spasmodic croup, midnight croup
• Paroxysmal attacks of laryngeal obstruction
• Occur chiefly at night
• Inflammation mild or absent
• Most often affects children ages 1-3

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Therapeutic Management

• Airway management
• Maintain hydrationPO or IV
• High humidity Cool mist Croup Tent keep
  pt dry
  
• Nebulizer treatments
• Epinephrine
• Steroids

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Infections of the Lower Airways

• Considered the reactive portion of the lower
  respiratory tract
  
• Includes bronchitis and bronchiolitis
• Cartilaginous support not fully developed until
  adolescence
  
• Constriction of airways

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Bronchiolitis

• Dx ELISA assay
• Cause viral
• RSV apnea, pCO2 R acidosis
• Teatment
• Handwashing, Cohort isolation
• Croupette or hi humidity
• Racemic Epinephrine (rebound)
• Ribavirin- toxic to pregnant persons

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Pneumonia

• Sx fever, nonproductive cough, pallor,fatigue
• Dx chest Xray, CBC, P Ox, cultures
• Bacterial can be life threatening
• Nsg care
• hydration
• meds
• chest PT

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Aspiration Pneumonia

• Risk for child with feeding difficulties
• Prevention of aspiration
• Feeding techniques, positioning
• Avoid aspiration risks
• Oily nose drops
• Solvents
• Talcum powder

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Asthma

• Chronic inflammatory disorder of airways
• Bronchial hyper-responsiveness
• Episodic with triggers
• Limited airflow or obstruction that reverses
  spontaneously or with treatment
  
• Most common chronic illness in children

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Bronchial Asthma

• Mild, Moderate Severe attacks
• Note Respiratory effort, rate, breath
• sounds, speech patterns,
• Color, LOC
• Position, Pulse Ox, ABG, PH
• Peak Flow

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Bronchial Asthmareversible, obstructive,
reactive airway disease

• SX R, exp.wheeze, tight cough, decreased
  breath sounds
  
• Pathology
• broncho constriction
• mucosal edema
• thickened secretions
• Listen to breath sounds _at_
• http//www.med.ucla.edu./wilkes/intro.html

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Bronchial dilators for acute care

• Albuterol (Proventil/Ventolin)
• Levalbuterol (Xopenex)
• Metaproterenol (Alupent)
• Terbutaline (Brethine)

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Bronchial dilators for acute care contd

• Theophylline (Aminophylline) loading dose to
  reach blood level of 10 20 mcg/ml
  
• Toxic side effects of theophyllin are nv,
  tachycardia, headache, irritability
  
• Cromolyn Sodium (Intal)
• Epinephrine sc, quick acting for bronchial spasm

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Bronchial Asthma meds

• Cortiosteroids anti inflammatory
• Predisone (Solucortef) , Methylprednisone
  (Soul-Medrol)
  
• Side effects
• gastric ulcers
• masks infection
• growth delay
• Immunosupression cushing syndrome
• withdrawal symptoms
• Osteoporosis if long term use

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Bronchial Asthma meds

• Leukotrienes (Singulair)
• Anticholinergics
• Skin tests for allergens
• Magnesium Sulfate IV for Status Asthmaticus

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Asthma Diagnosis

• Repeated Attacks
• Peak Flow Monitoring
• Pulmonary Function tests
• Pulse Oximetry, ABG
• Chest x-ray
• WBC, RAST, Allergy skin tests

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Asthma Interventions

• Teach Family a Treatment Plan
• Avoid Triggers
• Chest physiotherapy (CPT)
• Hyposensitization
• Use of Meds

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Status Asthmaticus

• Respiratory distress despite vigorous therapeutic
  measures
  
• Emergency treatmentepinephrine 0.01 mL/kg SQ
  (max dose 0.3 mL)
  
• Concurrent infection in some cases
• Emergency Intubation prevents Respiratory arrest

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Cystic Fibrosis (CF)

• Exocrine gland dysfunction that produces
  multi-system organ involvement
  
• Most common lethal GENETIC illness among white
  children
  
• Approximately 3 U.S. Caucasian population are
  symptom-free carriers
  

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Cystic Fibrosis (contd) Incidence in U.S. Live
Births

• 1 in 3,500 Caucasians (95 cases)
• 116,000 African-Americans
• 132,000 Asians
• Family member with CF autosomal recessive trait
  increases risk
  

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Increased Sweat Electrolytes

• Basis of the most reliable diagnostic
  proceduresweat chloride test
  
• Sodium and chloride will be 2-5 times greater
  than the controls
  
• Children taste salty to kiss

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Increased Viscosity of Mucous Gland Secretion

• Results in mechanical obstruction
• Thick mucoprotein accumulates, dilates,
  precipitates, coagulates to form concretions in
  glands and ducts
  
• Respiratory tract and pancreas are predominately
  affected

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Presentation

• Wheezing respiration, dry nonproductive cough
• Generalized obstructive emphysema
• Patchy atelectasis
• Cyanosis
• Clubbing of fingers and toes
• Repeated bronchitis and pneumonia

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Presentation (contd)

• Delayed puberty in females
• Sterility in males
• Dehydration
• Hyponatremic/hypochloremic alkalosis
• Hypoalbuminemia

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Presentation (contd)

• Meconium ileus
• Distal intestinal obstruction syndrome
• Excretion of undigested food in stool increased
  bulk, frothy, and foul
  
• Wasting of tissues
• Prolapse of the rectum

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Diagnostic Evaluation

• Quantitative sweat chloride test
• Chest, abdominal x-rays
• Pulmonary, Pancreatic Function Tests
• Stool fat and/or enzyme analysis
• DNA testing

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Respiratory Manifestations

• Present in almost all CF patients but
  onset/extent is variable
  
• Stagnation of mucus and bacterial colonization
  result in destruction of lung tissue
  
• Tenacious secretions are difficult to
  expectorate-obstruct bronchi/bronchioles

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Respiratory Manifestations (contd)

• Decreased O2/CO2 exchange
• Results in hypoxia, hypercapnea, acidosis
• Compression of pulmonary blood vessels and
  progressive lung dysfunction lead to pulmonary
  hypertension, cor pulmonale, respiratory failure,
  and death

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Respiratory Management

• Bronchodilator medication
• CPT QID
• Forced expiration
• Aggressive treatment of pulmonary infections
• Home IV antibiotic therapy
• Aerosolized antibiotics

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Respiratory Management (contd)

• Pneumothorax
• Hemoptysis
• Nasal polyps
• Steroid use/nonsteroidal anti-inflammatory
• Transplantation

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Respiratory Progression

• Gradual progression follows chronic infection
• Bronchial epithelium is destroyed
• Infection spreads to peribronchial tissues
  weakening bronchial walls
  
• Peribronchial fibrosis

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GI Tract

• Thick secretions block ductscystic dilation
  degeneration diffuse fibrosis
  
• Prevents pancreatic enzymes from reaching
  duodenum
  
• Impaired digestion/absorption of fat-steatorrhea
• Impaired digestion/absorption of
  protein-azotorrhea

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GI Tract (contd)

• Endocrine function of pancreas initially stays
  unchanged
  
• Eventually pancreatic fibrosis occurs
• may result in diabetes mellitus.
• Focal biliary obstruction results in multilobular
  biliary cirrhosis
  
• Impaired salivation

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Clinical Manifestations of GI Tract

• Pancreatic enzyme deficiency
• Sweat gland dysfunction
• Failure to thrive
• Increased weight loss despite increased appetite
• Gradual respiratory deterioration

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GI Management

• Pancreatic enzymes ac (good for 30 min)
• High protein high calorie diet as much as 150
  RDA
  
• Intestinal obstruction
• Reduction of rectal prolapse
• Salt supplementation especially in hot weather

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Prognosis of CF

• Estimated life expectancy for child born with CF
  in 2003 is 40-50 years
  
• Maximize health potential
• Nutrition
• Prevention/early aggressive treatment of
  infection
  
• Pulmonary hygiene
• New researchhope for the future
• Gene therapy
• Bilateral lung transplants
• Improved pharmacologic agents

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Cardiopulmonary Resuscitation(CPR)

• Pediatric cardiac arrest frequently represents
  the terminal event following respiratory failure
  or progressive shock
  
• Pediatric cardiac arrest rarely results from
  sudden cardiac collapse, as in adult populations

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ARTERIAL BLOOD GAS

• 1. pH acid alkaline
• 2. pCO2 35-45 respiratory
• 3. HCO3 22-26 renal
• P O2 75-100
• O2 saturation 95-100

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R.O.M.E.

• Respiratory opposite

pH and pCO2 are changing in opposite directions

• Metabolic Equal
• pH and Hco3
• are changing in the
• same direction

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Assessment differences