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Respiratory Alterations

Respiratory Alterations. NUR 264 Pediatrics Angela J. Jackson, RN, MSN. 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

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Respiratory Alterations

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  1. Respiratory Alterations NUR 264 Pediatrics Angela J. Jackson, RN, MSN

  2. 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

  3. 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

  4. Choanal Atresia • Congenital membranous or bony obstruction between the nose and nasopharynx

  5. 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

  6. 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

  7. Laryngomalacia • Stridor with retractions • Infant’s cry is normal • Cyanosis is uncommon • Place in prone position to decrease obstruction • Occurs more frequently in boys • Treatment: Tracheostomy

  8. 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

  9. Acute Viral Nasopharyngitis: Clinical Manifestations • Nasal stuffiness • Rhinitis • Sneezing • Nasal discharge • Coughing • Sore throat • Fever • Irritability • Malaise • Poor feeding

  10. 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

  11. 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

  12. 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

  13. 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

  14. Tonsillitis – Adenoiditis: Clinical Manifestations • Sore throat • Difficulty swallowing • Fever • Nasal congestion

  15. 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

  16. 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

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

  18. Otitis Media: Clinical Manifestations • Pain • Fever • Irritability • Diarrhea and vomiting • May have decreased hearing

  19. Otitis Media: Diagnosis • Otoscopic examination • Red, bulging tympanic membrane • Diminished movement with pneumatic otoscopic assessment

  20. Otitis Media: Treatment • Antibiotics for 10 days • Tympanostomy tubes for recurrent or unresolving OM and/or hearing loss

  21. 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

  22. 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

  23. 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

  24. 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

  25. Croup: Clinical Manifestations • Hoarse or “barking” cough • Nasal drainage • Sore throat • Low-grade fever • Tachycardia • Tachypnea • Inspiratory stridor

  26. Croup: Treatment • Nebulized racemic epinephrine • Corticosteroids • Fluids • Rest • Humidity

  27. 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

  28. 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

  29. Bronchiolitis: Clinical Manifestations • Rhinorrhea • Sneezing • Decreased appetite • Low-grade fever • Coughing • Wheezing, nasal flaring, retractions • Crackles • Tachypnea

  30. Bronchiolitis: Diagnosis • History and physical exam • Nasopharyngeal washings • Chest x-ray

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

  32. 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

  33. Pneumonia: Clinical Manifestations • Cough • Malaise • Chest pain • Fever • Anorexia • Headache • Tachypnea • Wheezing

  34. Pneumonia: Treatment • Cough, deep breath, change position often • CPT, O2, IS • IV fluids • Antibiotics, antipyretics • Cool mist, suctioning • Rest

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

  36. 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

  37. Asthma: Clinical Manifestations • Recurrent episodes of wheezing • Breathlessness • Nasal flaring, retractions, head bobbing • Chest tightness • Cough • Prolonged expiration • Dyspnea • Tachypnea, tachycardia, barrel chest develops

  38. Asthma: Diagnosis • Chest x-ray shows hyperinflation of the airways • PFT’s show decreased peak expiratory flow rate

  39. 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)

  40. 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

  41. 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

  42. Cystic Fibrosis: Diagnosis • History and physical exam • Sweat test • DNA analysis

  43. Cystic Fibrosis: Treatment • Antibiotics • Mucus-thinning drugs (Pulmozyme) • Bronchodilators • Bronchial airway drainage • Oral enzymes • High calorie diets • Lung transplant

  44. 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

  45. Cystic Fibrosis: Nursing Considerations • Infection control • Maintain adequate nutrition • Medication administration • P&PD • Family teaching • Support groups

  46. 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

  47. 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

  48. BP: Clinical Manifestations • Rapid, shallow breathing • Retractions • Cough • Wheezing • Cor pulmonale • Pulmonary edema • Dependence on supplemental O2 for more than 28 days • Respiratory acidosis

  49. 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

  50. 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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