respiratory alterations nur 264 pediatrics angela j. jackson, rn, msn
TRANSCRIPT
Respiratory Alterations
NUR 264Pediatrics
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 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
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
Choanal Atresia Congenital
membranous or bony obstruction between the nose and nasopharynx
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
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
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
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
Acute Viral Nasopharyngitis: Clinical Manifestations Nasal stuffiness Rhinitis Sneezing Nasal discharge Coughing Sore throat Fever Irritability Malaise Poor feeding
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
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
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
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
Tonsillitis – Adenoiditis: Clinical Manifestations
Sore throat Difficulty swallowing Fever Nasal congestion
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
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
Otitis Media Inflammation of
the middle ear One of the most
common infectious diseased in childhood
Primary causative factor: abnormal functioning of eustachian tube
Otitis Media: Clinical Manifestations
Pain Fever Irritability Diarrhea and vomiting May have decreased hearing
Otitis Media: Diagnosis
Otoscopic examination Red, bulging tympanic membrane Diminished movement with
pneumatic otoscopic assessment
Otitis Media: Treatment
Antibiotics for 10 days Tympanostomy tubes for recurrent
or unresolving OM and/or hearing loss
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
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
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
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
Croup: Clinical Manifestations
Hoarse or “barking” cough Nasal drainage Sore throat Low-grade fever Tachycardia Tachypnea Inspiratory stridor
Croup: Treatment
Nebulized racemic epinephrine Corticosteroids Fluids Rest Humidity
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
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
Bronchiolitis: Clinical Manifestations Rhinorrhea Sneezing Decreased appetite Low-grade fever Coughing Wheezing, nasal flaring, retractions Crackles Tachypnea
Bronchiolitis: Diagnosis
History and physical exam Nasopharyngeal washings Chest x-ray
Bronchiolitis: Treatment Humidified O2 Bronchodilators Suctioning Oxygen saturation monitoring IV fluids Strict handwashing and contact
precautions Prophylaxis: Synergis IM once a month
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
Pneumonia: Clinical Manifestations Cough Malaise Chest pain Fever Anorexia Headache Tachypnea Wheezing
Pneumonia: Treatment
Cough, deep breath, change position often
CPT, O2, IS IV fluids Antibiotics, antipyretics Cool mist, suctioning Rest
Asthma
Chronic inflammatory disorder of airways with bronchoconstriction and bronchial hyperresponsiveness
Most common pediatric chronic illness
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
Asthma: Clinical Manifestations Recurrent episodes of wheezing Breathlessness Nasal flaring, retractions, head bobbing Chest tightness Cough Prolonged expiration Dyspnea Tachypnea, tachycardia, barrel chest
develops
Asthma: Diagnosis
Chest x-ray shows hyperinflation of the airways
PFT’s show decreased peak expiratory flow rate
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)
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
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
Cystic Fibrosis: Diagnosis
History and physical exam Sweat test DNA analysis
Cystic Fibrosis: Treatment
Antibiotics Mucus-thinning drugs (Pulmozyme) Bronchodilators Bronchial airway drainage Oral enzymes High calorie diets Lung transplant
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
Cystic Fibrosis: Nursing Considerations
Infection control Maintain adequate nutrition Medication administration P&PD Family teaching Support groups
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
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
BP: Clinical Manifestations Rapid, shallow breathing Retractions Cough Wheezing Cor pulmonale Pulmonary edema Dependence on supplemental O2
for more than 28 days Respiratory acidosis
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
BP: Treatment
Prevention is the primary focus Prenatal steroids to promote the
maturation of fetal lungs Administration of surfactant Diuretics, steroids, bronchodilators Supplemental O2
BP: Potential Complications
Learning difficulties Poor coordination and muscle tone Trouble walking Activity intolerance Eye and ear problems Increased susceptibility to URI’s
and other infections
BP: Nursing Considerations Maintain mechanical ventilation Administration of medications (steroids,
diuretics, bronchodilators, antibiotics) Monitor I&O Provide adequate nutrition Family teaching:
Signs and symptoms of respiratory infection Importance of immunizations Medications O2 therapy CPR Follow-up
Any Questions?