Respiratory Disorders

1. Respiratory Disorders Jan Bazner-Chandler CPNP, CNS, MSN, RN

2. Respiratory Bifurcation of trachea Change in chest wall shape

3. Upper Airway Characteristics • Narrow tracheo-bronchial lumen until age 5 • Tonsils, adenoids, epiglottis proportionately larger in children • Tracheo-bronchial cartilaginous rings collapse easily

4. Lower Airway Characteristics • Fewer alveoli in the neonate • Poor quality of alveoli until age 8 • Lack of surfactant that lines the alveoli in the premature infant • Inhibits alveolar collapse at end of expiration

5. Respiratory Characteristics • Basal metabolic rate is greater thus greater oxygen consumption • Immunoglobulin G (IgG) levels reach low point around 5 months of age

6. Focused Physical Assessment • Types of breathing: • Less than 7 years abdominal breathing • Greater than 7 years abdominal breathing can indicate problems

7. Respiratory Rate • Inspiratory phase slightly longer or equal to expiratory phase • Prolonged expiratory phase = asthma • Prolonged inspiratory phase = upper airway obstruction • Croup • Foreign body

8. Color • Observe color of face, trunk, and nail beds • Cyanosis = inadequate oxygenation • Clubbing of nails = chronic hypoxemia

9. Respiratory Distress • Grunting = impending respiratory failure • Severe retractions • Diminished or absent breath sounds • Apnea or gasping respirations • Poor systemic perfusion / mottling • Tachycardia to bradycardia = late sign • Decrease oxygen saturations

10. Chest Muscle Retraction

11. Chest Retractions • Retractions suggest an obstruction to inspiration at any point in the respiratory tract. • As intrapleural pressure becomes increasingly negative, the musculature “pulls back” in an effort to overcome the blockage. • The degree and level of retraction depend on the extent and level of the obstruction.

12. Diagnostic Tests • Detects abnormalities of chest or lungs • Chest x-ray • Sweat chloride Test • MRI • Laryngoscope / bronchoscopy • CT Scan

13. White Patchy Infiltrates

14. X-ray Hyperinflation of Lung Vh.org

15. Pleural Effusion

16. Pleural Effusion X-Ray vh.org

17. Sweat Chloride Test • Analysis of sodium and chloride • Contents in sweat • Gold Standard for diagnosis • May do genetic screening earlier • if positive family history Ball & Bindler

18. Foreign Body Aspiration A foreign body in one or the other of the bronchi causes unilateral retractions. *usually the right due to broader bore and more vertical placement.

19. Oxygen Therapy: Nursing Interventions • Proper concentration • Adequate humidity: make sure there is fluid in the bottle • Make sure prongs are in nose and that the nares are patent – suction out nares to increase oxygen flow • Monitor oxygen SATS: if alarm keeps on going off but the infant / child looks good, check the device • Monitor activity level or infant / child

20. Aerosol Therapy • Respiratory Therapist will do the treatment • Communicate with therapist – eliminated needless paging for treatments • Treatment should be done before the infant eats • When you make your morning rounds assess if there is any infant / child that needs an immediate treatment

21. Home Teaching Inhaled Medications • Correct dosage • Prescribed time • Proper use of inhaler • No OTC drugs • Encourage fluids • When to call physician

22. Aerosol Therapy Medication administered by oxygen or compressed air. Ball & Bindler

23. Nebulizer - infant

24. Outpatient Aerosol Treatment

25. CPT

26. CPT • In the small child you can position on your lap • Do first thing in the AM • Do before meals or one hour after • Do after the aerosol treatment since the treatment will help open the airways and loosen the mucous • Suction the infant after treatment – teach parents to do bulb suction – RN, LVN or RT to deep suction prn

27. Mechanical Ventilation

28. Alterations in Respiratory Function

29. Severe Respiratory Distress • Nasal flaring and grunting • Severe retractions • Diminished breath sounds • Hypotonia • Decreased oxygen saturations

30. What to do if infant / child in respiratory distress! • Stimulate the infant / child - remember crying or activity will help mobilize secretions and expand lungs • Have the older child sit up take deep breaths and cough • CPT to loosen secretions and suction! suction! suction! • Give oxygen • Assess if interventions work • Call for help if you need it – pull the emergency cord – yell for help

31. Allergic Rhinitis

32. Symptoms • Itching of nose, eyes, and throat • Sneezing and stuffiness • Watery nasal discharge / post nasal drip • Watery eyes • Swelling around the eyes

33. Rhinitis Treatment • Antihistamines • Competitive inhibitors for histamine at the mast cell receptor sites • Benadryl – OTC medication • Prescription –Cromolyn or steroid nasal spray • Environmental changes - avoidance of allergens • Do not use combination OTC medications especially those that contain pseudoephedrine

34. Sinusitis Sinuses not fully developed until age 12. Adam.com Sinuses are hollow cavities within the facial bones.

35. Sinusitis Symptoms • Fever • Purulent rhinorrhea • Pain in facial area • Malodorous breath • Chronic night-time cough Children more prone to sinusitis: children with asthma and cystic fibrosis.

36. Treatment • Normal saline nose drops • Warm pack to face • Acetaminophen for pain • Increase po fluid intake • Antibiotics • Recent studies question their effectiveness

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

38. Tonsillitis • Inflammation of the tonsils. • Part of the immune system to trap and kill bacteria and viruses traveling through the body.

39. Tonsillitis • Child may refuse to drink • Night snoring = enlarged tonsils or adenoids • Size of tonsils are obstructing airway

40. Treatment • Antibiotics x ten days if positive for beta strep • Acetaminophen for pain • Cool fluids • Saline gargles • Antiseptic sprays • Viral throat infections will not get better faster with antibiotics.

41. Tonsillectomy • Done if child’s respiratory status is compromised • Post operative care: • Side lying position • Ice collar • Watch for swallowing • Cool fluids / soft diet

42. Croup • Laryngotracheobronchitis or Acute spasmotic croup • Infants from 3 months to about 3 years • Respiratory symptoms are caused by inflammation of the larynx and upper airway, with resultant narrowing of the airway.

44. Symptoms • Symptoms: • Hoarseness • Inspiratory stridor • Barking cough • Afebrile • Often worsens at night

45. Management • Home care: • Cool mist • Fluids • Hospital care: • Racemic epinephrine inhalant • Mist tent – not used much anymore • Dexamethasone: IV over 1 to several minutes

46. Pertussis or whooping cough • Agent: Bordetella Pertussis • Source: respiratory • Transmission: droplet • Incubation: 10 days • Period of communicability: before onset of paroxysms to 4 weeks after onset

47. Management • Respiratory support as needed • Suctioning • Oxygen to keep oxygen saturation at > 98 % • Nutritional support • IV fluids • Erythromycin, Zithromax or Biaxin for child and all exposed family members

48. Isolation Precautions • Transmission through direct contact with discharges from respiratory mucous of infected persons. • Highly contagious with up to 90% of household contacts developing disease after contact. • Respiratory and contact isolation for 3-4 days after the initiation of antibiotic therapy.

49. Epiglottitis Bowden & Greenberg Tripod position

50. Epiglottitis Symptoms • Acute inflammation of supra-glottic structures. • Medical Emergency • Sudden onset • High fever • Dysphasia and drooling • Epiglottis is cherry red and swollen