RespiratoryNur 106

Respiratory System

• General Information

• Signs and symptoms of respiratory distress

• Common diagnostic tools

• Common medications and treatments

General Information

• Fetus practices breathing in utero

• Normal to have amniotic fluid in lungs

• Absorbed as soon as takes first breath

• Meconium in the amniotic fluid is problem

• Surfactant reduces surface tension in lungs so that lungs will remain open

• Neonates are obligant nasal breathers

General Information

• Normal respiratory rate: 30—50

• Lumen of respiratory system is smaller in children

• Eustachian tubes shorter and more horizontal

• Metabolic rates are higher than adults

Respiratory Assessment

• Auscultation– Absent or diminished lung sounds– Adventitious lung sounds

• Crackles—passage of air through moisture• Wheezes—Narrowed passageways

Respiratory Assessment

• Observation– Barrel Shaped Chest

Respiratory Assessment

• Observation– Cyanosis– Club fingers

Respiratory Assessment

• Observation– Presence of retractions

• Occur when airway obstructed in young children• Indication of severity of respiratory distress

Respiratory Assessment

• Infant’s chest walls more flexible, muscles immature, retractions common

Respiratory Assessment

• Retractions

Suprasternal

Substernal

Intercostal

Common Diagnostic Tests

• Chest xray

• Bronchoscopy—visualizes trachea and bronchi directly– Under anesthesia

• Pulmonary function tests—usually not until 5 to 6 years of age

• Sputum culture—best collected in morning

Common Diagnostic Tests

• Arterial blood gases– Heparinized syringe– Place on ice– Transport to lab immediately– Pressure to site for 5 minutes

• Pulse oximetry– Oxygen saturation

– SPo2

– 87—93% safe levels of saturation

Respiratory System

• Laryngotracheobronchitis (croup)

• Pnuemonia

• Respiratory distress syndrome

• Bronchopulmonary dysphasia

• Cystic Fibrosis

• Sudden Infant Death Syndrome (SIDS)

Respiratory System

• Asthma

• Respiratory Syncyntial Virus

• Pharyngitis

• Allergic Rhinitis

• Tonsillitis/adenoiditis

• Influenza

Laryngotracheobronchitis

• Generalized infection of larynx, trachea and bronchi

• Croup• Frequently shows symptoms of mild URI

during day; at night, awakens with hoarse barking cough and severe respiratory distress

• Most common organisms: RSV, parainfluenza virus and mycoplasma pneumoniae

LTBEtiology

• Affects children under 5 (smaller airways)

• Affects boys more frequently than girls• Inflammation causes narrowing of

airways• Onset gradual• May reoccur several nights in a row

LTB Symptoms

• Low-grade fever

• Barking cough

• Respiratory stridor

• Hypoxemia

• Tripod position

Respiratory DistressTripod Position

LTBTreatment

• At home:– Hot steamy bathroom– Cool night air– Sit upright– Cool mist vaporizer in “home made tent”– Elevate head of crib– Increase fluids

LTBTreatment

• Hospitalization– Croup tent– IV fluids—oral fluids may cause aspiration– Bronchodilators– Corticosteroids– Intubation equipment available

Epiglottitis

• Inflammation of epiglottis

• Life threatening obstruction

• Usually bacterial (hemophilus influenza)

• Sudden onset in healthy child: awakens with high fever, drooling and respiratory distress

• Do NOT examine throat—may lead to spasm and complete obstruction

Pneumonia

• Inflammation/infection of bronchioles and alveloar spaces

• Causative agents bacteria, viral, mycoplasma– Children under 5: Viral—RSV. Influenza,

adenovirus,rhinovirus– Children over 5: Bacteria—streptococcus

pneumoniae

Pneumonia

• Symptoms– Fever, cough, dyspnea, tachypnea– Rhonchi, crackles, wheezes– Decreased breath sounds with consolidation

• Diagnosis– Xray

• Treatment– Antibiotics, IV, fever control, airway

management

Respiratory Distress Syndrome

• Formally called Hyaline Membrane Disease• Disease primarily of premature

– Infant of a diabetic mother

– White children more frequent than black– Boys more often than girls

• Primary pathology is production deficiency in surfactant

Surfactant

Lung Compliance

Atelectasis Work of breathing

Ventilation

CO2Acidosis PO2 Anaerobic metabolism

Metabolic

RespiratoryAdapted from: London, M; Ladewig,

P; Ball, J; and Bindler, R. 2007. Maternal & Child Nursing Care, 2nd ed. Upper Saddle River, NJ, Prentice Hall, p.820.

Respiratory Distress Syndrome

• Diagnosis: x-ray—diffuse bilateral density (white-out), and atelectasis

• Antenatal prevention treatment: betamethasone

Respiratory Distress Syndrome

Nursing Care• Oxygenation/ventilation

– Transcutaneous oxygen/CO2 monitoring– Blood gas monitoring– Oxygen– Continuous positive airway pressure (CPAP)– Respirator

Respiratory Distress Syndrome

Nursing Care

• Correction of acid-base imbalance

• Temperature regulation

• Nutrition

• Protect from infection

Respiratory Distress Syndrome

• Surfactant Replacement Therapy– At birth and repeated as necessary– Endotracheal administration

Bronchopulmonary dysplasia

• BPD

• Chronic lung disease

• Precipitating factors: prematurity, high oxygen concentrations, positive pressure ventilation

• Symptoms: Persistent respiratory distress– Wheezing, tachypnea, pulmonary edema– Failure to thrive

Bronchopulmonary Dysplasia

• Nursing Care– Oxygen– Tracheostomy– Recurrent respiratory infections

• Palivizumab, RSV immune globulin

– Promote growth and development

Bronchopulmonary Dysplasia

• Medications:– Bronchodilators– Anti-inflammatory agents– Diuretics– Antibiotic Therapy– Vitamin A

Cystic Fibrosis

• Inherited—autosomal recessive– Both parents must be carriers– Each child has a 1 in 4 chance of being

affected– Affects primarily white children

Father Mother(carrier) (carrier)

Carrier Unaffected Affected Carrier

Cystic Fibrosis• Multi-system disease—affects exocrine

glands– Bronchioles, small intestines, pancreas,

bile ducts

• Exocrine secretions—thick and tenacious

• Abnormal sodium excretion– Sweat Chloride test– Heat Prostration

Cystic Fibrosis

• Lungs—Secretions pool in bronchioles leading to infection and atelectasis– Barrel shape chest– Cyanosis– Clubbing of fingers and toes– Recurrent respiratory infections

Cystic Fibrosis

• Pancreas—absence of pancreatic enzymes and malabsorption

• Small intestine—Meconium hardens leading to meconium ileus– Stools are bulky and fatty (steatorrhea)– Large belly, wasted extremities– Fat soluble vitamin deficiencies

Cystic Fibrosis

• Males usually sterile due to blocked vas deferens

• Females may have trouble conceiving due to thick mucus in the reproductive tract

Cystic Fibrosis

• Medical treatment– Bronchodilators– Antibiotics– Pancreatic enzymes– Vitamin supplements– Salt supplements in hot weather?

Cystic FibrosisNursing Interventions

• At birth—monitor for 1st meconium– Newborn screening—blood immunoreactive

trypsinogen• Genetic counseling• Parent Education

– High calorie, high protein, low fat diet– How to administer pancreatic enzymes– Protect from infection– Breathing exercises and care

Cystic FibrosisBreathing Exercises

• Physical activity

• Chest percussion and postural drainage

Cystic FibrosisMedications

• Aerosol Bronchodilators—opens lungs

• Aerosol DNAse—loosens secretions

• Corticosteroids—Anti-inflammatory

• Antibiotics—Treats infections

• Pancreatic enzymes—Aids in digestion

• Water soluble ADEK

Sudden Infant Death Syndrome

• Risk factors--infant– Race: (decreasing order of frequency)

American Indian, black, Hispanic, white, Asian– Males more often than females– 2—4 months of age– Winter– Exposure to passive smoke– Prone sleeping– Overheating

Sudden Infant Death Syndrome

• Risk factors--maternal– Age less than 20, short interval between

pregnancies– Prenatal smoking, binge alcohol, drug use– Anemia– Poor prenatal care, poor weight gain during

pregnancy– Hx of sexually transmitted disease or UTI

Asthma

• Hyper-reactive lungs

• Chronic condition with acute exacerbations

• Responds to environmental irritants

• Bronchial spasm, increased airway resistance, air trapping

Asthma--Etiology

• Triggers include: inhalants, airborne pollens, stress, weather changes, exercise, viral or bacterial agents, allergens, strong emotions, etc.

• Runs in families—genetics unclear

Asthma--Pathology

• Exposure to irritant• Constriction of bronchial smooth

muscles• Edema of lung tissues• Increased respiratory secretions• Airway narrowing

– Air trapping and hyperinflation of alveoli

Asthma--Symptoms

• Wheezing—can be heard at http://jan.ucc.nau.edu/~daa/heartlung/breathsounds/contents.html

• Cough• Air trapping and hyperinflation leads to

prolonged expiratory phase• Lips—dark red; may progress to cyanosis• Anxiety• Sitting upright, hunched over

AsthmaTreatment

• Quick relief medications– Nebulizer (metered dose inhaler)—note if

contains steroids, spacer should be used to prevent yeast infections of the mouth

AsthmaMetered Dose Inhaler--Use

• Shake the inhaler well before use (3 or 4 shakes) • Remove the cap • Breathe out, away from your inhaler • Bring the inhaler to your mouth. Place it in your

mouth between your teeth and close you mouth around it.

• Start to breathe in slowly. Press the top of you inhaler once and keep breathing in slowly until you have taken a full breath.

• Remove the inhaler from your mouth, and hold your breath for about 10 seconds, then breathe out.

www.asthma.ca/adults/treatment/meteredDoseInhaler.php

AsthmaMedications--Acute

• Corticosteroids—oral or inhaled– Prednisone, Methylprednisolone

• Β-Adrenergic agonists (Bronchodilators)– Albuterol, epinephrine, terbutaline– Short acting (inhaled) used to relieve an on-going

attack– Long acting (oral or inhaled) to control frequent

attacks

AsthmaMedications--Chronic

• Cromolyn sodium—used prophylactically– Inhalant– Suppresses inflammation– Not bronchodilator– Prevents release of histamine

AsthmaReducing Triggers

• Smoke free environment• Allergy proofing home:

– Bedroom of primary importance– Pillows and mattress enclased in covers– Eliminate stuffed toys, plants, carpets,

drapes– Do not store out of season clothing in room

Status Asthmaticus

• The continued presence of severe respiratory distress despite vigorous therapeutic measures

• Medical emergency that can lead to respiratory failure and death

• Sudden onset of agitation or the agitated child who suddenly becomes quiet may be seriously hypoxic

Bronchiolitis

• Inflammation of the bronchioles• Edema, accumulation of mucus, air

trapping and atelectasis• Major concern for small infants• Most common caustive agent is the

respiratory syncytial virus (RSV)• Often fatal

RSV

• Most important respiratory pathogen in infancy and early childhood

• Not airborne• Can remain viable for hours on

nonporous surfaces• Most frequent problem in winter and

spring

RSVPrevention

• Infants up to 24 months with chronic lung disease– RSV Immune Globulin (RSV-ICIV):

Antibodies against RSV. Given monthly IV beginning of season

– Palivizumab (monoclonal antibody): Given monthly IM

Pharyngitis

• “Sore throat”

• Most are caused by viruses

• Most common bacteria—group A beta-hemolytic streptococcus (strept throat)

• Symptoms—fever, sore throat, dehydration

• Treatment—symptomatically

• If bacterial—10 days of penicillin

Tonsillitis/adenoiditis

• Tonsils: Masses of lymphoid tissue located in pharyngeal cavitiy.

• Purpose: Filter pathogens

• Size: Children relatively large

• Infection can be viral or bacterial

• If greater than 3 infections per year, may do tonsillectomy

Tonsillectomy

• Surgical removal of palatine tonsils

• Adenoidectomy—surgical removal of pharyngeal tonsils

• Pre-op prep same as for all surgeries

Tonsillectomy

• Recovery room– Position on abdomen or side– Suction with care

•

Tonsillectomy

• Post op care– Bedrest for day– Clear liquids advance to full then soft

• Cold• Avoid red coloring

– Ice collar– Analgesics

Tonsillectomy

• Post op risk—hemorrhage

• Up to 10 days post op

• Symptoms– Bright red bloody emesis– Frequent swallowing– Pulse greater than 120

Tonsillectomy

• Recommendations to prevent post-op hemorrhage– Avoid irritating foods– Avoid gargles or vigorous toothbrushing– Discourage coughing or throat clearing– Use ice collar– Avoid medications known to promote bleeding– Limit activity

Allergic Rhinitis

• Hay fever

• Seen mostly in older children and adults

• Treatment: antihistamine, allergy avoidance

Influenza

• Viral

• Symptoms last 4 to 5 days

• Complications include pneumonia, encephalitis, otitis media

• Do not treat with aspirin because of possible link to Reye Syndrome

General Treatment for Respiratory Conditions

• Position to promote oxygenation• Humidification• Fluid intake—clear liquid, avoid milk• Oxygen???• Medications include bronchodilators,

anti-inflammatories, antibacterial and antiviral agents

Foreign Body Aspiration

• Peak age: under 3• Leading cause of death under 1• FB usually lodge in right main bronchus• Partial or complete obstruction• Sudden onset of coughing• Heimlich Maneuver• Surgical removal