Respiratory Disorders

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Respiratory Disorders

• Jan Bazner-Chandler
• CPNP, CNS, MSN, RN

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Respiratory
Bifurcation of trachea
Change in chest wall shape
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Upper Airway Characteristics

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

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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

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Respiratory Characteristics

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

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Focused Physical Assessment

• Types of breathing
• Less than 7 years abdominal breathing
• Greater than 7 years abdominal breathing can
  indicate problems

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Respiratory Rate

• Inspiratory phase slightly longer or equal to
  expiratory phase
• Prolonged expiratory phase asthma
• Prolonged inspiratory phase upper airway
  obstruction
• Croup
• Foreign body

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Color

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

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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

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Chest Muscle Retraction
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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.

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Diagnostic Tests

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

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White Patchy Infiltrates
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X-ray Hyperinflation of Lung
Vh.org
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Pleural Effusion
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Pleural Effusion X-Ray
vh.org
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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
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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.
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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

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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

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Home Teaching Inhaled Medications

• Correct dosage
• Prescribed time
• Proper use of inhaler
• No OTC drugs
• Encourage fluids
• When to call physician

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Aerosol Therapy
Medication administered by oxygen or
compressed air.
Ball Bindler
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Nebulizer - infant
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Outpatient Aerosol Treatment
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CPT
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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

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Mechanical Ventilation
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Alterations in Respiratory Function
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Severe Respiratory Distress

• Nasal flaring and grunting
• Severe retractions
• Diminished breath sounds
• Hypotonia
• Decreased oxygen saturations

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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

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Allergic Rhinitis
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Symptoms

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

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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

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

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

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

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

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Tonsillitis

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

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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.

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Tonsillectomy

• Done if childs respiratory status is compromised
• Post operative care
• Side lying position
• Ice collar
• Watch for swallowing
• Cool fluids / soft diet

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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.

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Symptoms

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

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Management

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

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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

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Management

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

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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.

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Epiglottitis
Bowden Greenberg
Tripod position
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Epiglottitis Symptoms

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

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Epiglottitis

• Has decreased dramatically since introduction of
  the Haemophilus influenzae type b or Hib vaccine
  in 1985.
• Incidence as of 2003 32 cases in children under
  5 years of age.
• Incidence in the adult population has increased
  from 0.8 to 3.1 per 100,000 adults

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Management

• Diagnosis made on presenting symptoms
• No tongue blade in mouth
• Emergency tracheostomy set
• No procedures until in the operating room
• Keep quiet
• Ceftriaxone third-generation cephalosporin for
  7 to 10 days.

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Apnea

• Apnea is cessation of respiration lasting longer
  than 20 seconds.
• Monitor in hospital for 48 hours for underlying
  problems.
• Discharge home with monitor

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Apnea Monitoring
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Foreign Body

• Severe inspiratory stridor
• Symptoms depend on location
• Unilateral chest movement
• Chest x-ray
• Bronchoscope to remove object

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Coin in Trachea
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Teaching

• No small hard candies, raisins, popcorn or nuts
  until age 3 or 4 years
• Cut food into small pieces
• No running, jumping, or talking with food in
  mouth
• Inspect toys for small parts
• Keep coins, earring, balloons out of reach

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Influenza

• Associated with community epidemic
• Febrile, URI, achy joints,
• Management
• Acetaminophen for fever
• Fluids
• Keep away from others
• Watch for signs of pneumonia

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Bronchiolitis

• Acute obstruction and inflammation of the
  bronchioles.
• Most common causative agent RSV
• Respiratory syncytial virus
• Bronchioles become narrowed or occluded as a
  result of inflammatory process, edema, mucus and
  cellular debris clog alveoli

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Symptoms

• Harsh dry cough
• Low grade fever
• Feeding difficulties
• Wheezing
• Respiratory distress with apnea
• Thick mucus

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Management

• Oxygen to maintain oxygen saturation gtthan 95
• Pulse oximeter
• Normal saline nose drops before suctioning
• Deep suction especially before feeding
• CPT to mobilize secretions
• Inhalation therapy not sure it is beneficial
• Mechanical ventilation as needed

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RSV Positive - Isolation

• RSV is spread from respiratory secretions through
  close contact with infected persons or contact
  with contaminated surfaces or objects.
• Patient should be on contact and respiratory
  isolation
• Can be placed with other RSV patients

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Pneumonia

• An inflammatory condition of the lungs
• in which alveoli fill with fluid or blood
• resulting in poor oxygenation and air
• exchange.

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Typical X-ray
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Symptoms

• High fever
• Thick green, yellow, or blood tinged secretions
• Grunting respirations
• Rales, crackles, diminished breath sounds
• Cough and cyanosis
• Infiltrate seen on x-ray

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Management

• Assess for respiratory distress
• NPO (rr gt 60 high risk for aspiration)
• IV fluids
• Oxygen as need to keep oxygen saturation above
  95
• CPT
• Deep suctioning
• Acetaminophen for fever / antibiotics

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Pneumonia Isolation

• Respiratory isolation
• May be taken off isolation if RSV negative and on
  antibiotics for 24 hours.

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Cystic Fibrosis
Inherited autosomal recessive disorder of the
exocrine glands.
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Pathophysiology Cystic Fibrosis

• A chronic, progressive, genetic illness involving
  the digestive system and lungs.
• Abnormality of the exocrine glands
• Sweat and mucous glands
• Mucus of CF is thick and viscous
• Causes scar tissue
• Leads to irreversible lung damage

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Exocrine Gland Dysfunction

• Mucous secretions are thick and tenacious
• Dysfunction of mucous producing glands leads to
  multiple gastrointestinal absorption problems.
• Blocked pancreatic ducts
• No secretion of digestive enzymes

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Cystic Fibrosis
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Cystic Fibrosis
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Symptoms

• Meconium ileus at birth
• Failure to thrive
• Steatorrhea stools / constipation
• Voracious appetite with poor weight gain
• Recurrent respiratory infections
• Chronic cough
• Malabsorption of intestines

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Diagnosis

• Positive sweat test
• Genetic marker
• Life long management
• Enzyme replacement with eating
• Daily CPT postural drainage
• Inhaled bronchodilators
• Control of lung infections
• Nutritional supplements as needed

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Medications

• Enzymes to help digest food
• Antibiotics to control infection
• Bronchodilators to open airways
• Vitamin C to improve absorption of other meds
• Vitamins E, A, D, K / fat soluble vitamins

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Long Term Complications

• Nasal polyps
• Sinusitis
• Rectal polyps / prolapse
• Hyperglycemia / diabetes
• infertility

Life span approximately 30 years of age
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Asthma

• Asthma is a chronic, inflammatory lung disease
  involving recurrent breathing problems.
• Caused by complex, multicellular reaction in the
  airway characterized by
• Airway inflammation
• Airway hyper-responsiveness to a variety of
  triggers

Asthma is the most common, chronic health
problem among children.
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Symptoms

• Wheezing
• Cough
• Tightness of chest
• Prolonged expiratory phase
• Hypoxemia
• X-ray hyper-expansion of lungs

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Medical Management

• High fowlers position / bed rest
• Pulse oximetry
• Nebulized albuterol
• CPT
• Methylprednisone / Solu-medrol IV
• IV fluids
• Oxygen to keep oxygen sats gt 95

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Home Management

• Peak flow spirometer
• Identify triggers
• Maximize lung function
• Optimal physical growth
• Optimal psycho-social state
• Maximum participation

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Peak Flow Monitoring

• Spirometry measures how
• much and how fast air is
• forcefully expelled from fully
• inflated lungs.
• Recommended standard of care
• for management of asthma.

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Home Medications

• Rescue drugs short acting albuterol beta 2
  agonist used as a quick-relief agent for acute
  bronchospasm and for prevention of exercise
  induced bronchospasm.
• Anti-inflammatory or preventative low-dose
  inhaled corticosteroid inhaled or oral
  prednisone
• Allergy Singulair

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Bronchodilators

• Bronchodilators rapidly relax the airway smooth
  muscle cells, thus reversing the bronchospasm
  until anti-inflammatory effect of steroids is
  attained.
• Aerosols
• Via mouth piece 3 years and older
• Via facial mask for less than 3 years

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Corticosteroids

• Steroids reduce the inflammatory component of
  bronchial obstruction, decrease mucus production
  and mediator release, as well as the late phase
  (cellular) inflammatory process.
• Methyl prednisone IV in severe cases
• May need Reglan if experiencing GI upset
• PO prednisone always give with food to decrease
  GI upset

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Anti-inflammatories

• Oral prednisone (Pedia-pred, Prelone, Liquid
  pred) recommended for short course in moderate or
  severe exacerbation
• Inhaled Pulmicort, AeroBid, Flovent
• Infant mask should fit firmly cataracts
• Older child rinse and spit after treatment to
  prevent thrush

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Family Teaching

• Teach how to use medication
• When to use and how often
• No OTC drugs
• Increase fluid intake
• Signs and symptoms of respiratory distress

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Normal Lungs
http//galen.med.virginia.edu/smb4v/tutorials/ast
hma/asthma1.html
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Asthma Attack
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Bronchopulmonary Dysplasia
Pediatric Nursing January/February 1999
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History

• It occurs in newborns who are born prematurely
  and or have a variety of pulmonary disorders and
  who require ventilatory support with high
  pressure and oxygen in the first 2 weeks of life.

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Pathophysiology

• Fibrosis of airways and marked hyperplasia of the
  bronchial epithelium
• Increased fluid in the lungs, as a result of
  disruption of the alveolar-capillary membrane
• Over distention due to damage to alveolar
  supporting structures resulting in air trapping
• Fibrosis, airway edema, and broncho-constriction

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BPD Symptoms

• Persistent respiratory distress
• Dependent on supplemental oxygen
• Failure to thrive
• Gastro-esophageal reflux
• Pulmonary hypertension

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Long Term Management

• Supplemental oxygen
• CPT
• Bronchodilators
• Diuretics (pulmonary hypertension)
• Anti-inflammatory medication
• Nutritional support po formula NG supplement
• Gastrostomy tube (GER)
• Bicarbonate in formula due to chronic state of
  acidosis

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Long-term Outcomes

• Oxygen dependent
• Visual problems
• Feeding difficulties
• Developmental delay
• Learning difficulties