Respiratory

1
Respiratory
Nur 106
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Respiratory System

• General Information
• Signs and symptoms of respiratory distress
• Common diagnostic tools
• Common medications and treatments

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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

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General Information

• Normal respiratory rate 3050
• Lumen of respiratory system is smaller in
  children
• Eustachian tubes shorter and more horizontal
• Metabolic rates are higher than adults

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Respiratory Assessment

• Auscultation
• Absent or diminished lung sounds
• Adventitious lung sounds
• Cracklespassage of air through moisture
• WheezesNarrowed passageways

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Respiratory Assessment

• Observation
• Barrel Shaped Chest

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Respiratory Assessment

• Observation
• Cyanosis
• Club fingers

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Respiratory Assessment

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

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Respiratory Assessment

• Infants chest walls more flexible, muscles
  immature, retractions common

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Respiratory Assessment

• Retractions

Suprasternal
Intercostal
Substernal
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Common Diagnostic Tests

• Chest xray
• Bronchoscopyvisualizes trachea and bronchi
  directly
• Under anesthesia
• Pulmonary function testsusually not until 5 to 6
  years of age
• Sputum culturebest collected in morning

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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
• 8793 safe levels of saturation

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Respiratory System

• Laryngotracheobronchitis (croup)
• Pnuemonia
• Respiratory distress syndrome
• Bronchopulmonary dysphasia
• Cystic Fibrosis
• Sudden Infant Death Syndrome (SIDS)

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Respiratory System

• Asthma
• Respiratory Syncyntial Virus
• Pharyngitis
• Allergic Rhinitis
• Tonsillitis/adenoiditis
• Influenza

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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

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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

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LTB Symptoms

• Low-grade fever
• Barking cough
• Respiratory stridor
• Hypoxemia
• Tripod position

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Respiratory DistressTripod Position

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LTBTreatment

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

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LTBTreatment

• Hospitalization
• Croup tent
• IV fluidsoral fluids may cause aspiration
• Bronchodilators
• Corticosteroids
• Intubation equipment available

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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 throatmay lead to spasm and
  complete obstruction

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Pneumonia

• Inflammation/infection of bronchioles and
  alveloar spaces
• Causative agents bacteria, viral, mycoplasma
• Children under 5 ViralRSV. Influenza,
  adenovirus,rhinovirus
• Children over 5 Bacteriastreptococcus
  pneumoniae

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Pneumonia

• Symptoms
• Fever, cough, dyspnea, tachypnea
• Rhonchi, crackles, wheezes
• Decreased breath sounds with consolidation
• Diagnosis
• Xray
• Treatment
• Antibiotics, IV, fever control, airway management

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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

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Surfactant
Lung Compliance
Atelectasis
Work of breathing
Ventilation
Metabolic
Respiratory
CO2
Acidosis
PO2
Anaerobic metabolism
Adapted 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.
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Respiratory Distress Syndrome

• Diagnosis x-raydiffuse bilateral density
  (white-out), and atelectasis
• Antenatal prevention treatment betamethasone

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Respiratory Distress Syndrome

• Nursing Care
• Oxygenation/ventilation
• Transcutaneous oxygen/CO2 monitoring
• Blood gas monitoring
• Oxygen
• Continuous positive airway pressure (CPAP)
• Respirator

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Respiratory Distress Syndrome

• Nursing Care
• Correction of acid-base imbalance
• Temperature regulation
• Nutrition
• Protect from infection

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Respiratory Distress Syndrome

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

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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

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Bronchopulmonary Dysplasia

• Nursing Care
• Oxygen
• Tracheostomy
• Recurrent respiratory infections
• Palivizumab, RSV immune globulin
• Promote growth and development

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Bronchopulmonary Dysplasia

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

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Cystic Fibrosis

• Inheritedautosomal 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
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Cystic Fibrosis

• Multi-system diseaseaffects exocrine glands
• Bronchioles, small intestines, pancreas, bile
  ducts
• Exocrine secretionsthick and tenacious
• Abnormal sodium excretion
• Sweat Chloride test
• Heat Prostration

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Cystic Fibrosis

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

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Cystic Fibrosis

• Pancreasabsence of pancreatic enzymes and
  malabsorption
• Small intestineMeconium hardens leading to
  meconium ileus
• Stools are bulky and fatty (steatorrhea)
• Large belly, wasted extremities
• Fat soluble vitamin deficiencies

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Cystic Fibrosis

• Males usually sterile due to blocked vas deferens
• Females may have trouble conceiving due to thick
  mucus in the reproductive tract

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Cystic Fibrosis

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

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Cystic FibrosisNursing Interventions

• At birthmonitor for 1st meconium
• Newborn screeningblood 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

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Cystic FibrosisBreathing Exercises

• Physical activity
• Chest percussion and postural drainage

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Cystic FibrosisMedications

• Aerosol Bronchodilatorsopens lungs
• Aerosol DNAseloosens secretions
• CorticosteroidsAnti-inflammatory
• AntibioticsTreats infections
• Pancreatic enzymesAids in digestion
• Water soluble ADEK

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Sudden Infant Death Syndrome

• Risk factors--infant
• Race (decreasing order of frequency) American
  Indian, black, Hispanic, white, Asian
• Males more often than females
• 24 months of age
• Winter
• Exposure to passive smoke
• Prone sleeping
• Overheating

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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

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Asthma

• Hyper-reactive lungs
• Chronic condition with acute exacerbations
• Responds to environmental irritants
• Bronchial spasm, increased airway resistance, air
  trapping

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Asthma--Etiology

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

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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

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Asthma--Symptoms

• Wheezingcan be heard at http//jan.ucc.nau.edu/d
  aa/heartlung/breathsounds/contents.html
• Cough
• Air trapping and hyperinflation leads to
  prolonged expiratory phase
• Lipsdark red may progress to cyanosis
• Anxiety
• Sitting upright, hunched over

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AsthmaTreatment

• Quick relief medications
• Nebulizer (metered dose inhaler)note if contains
  steroids, spacer should be used to prevent yeast
  infections of the mouth

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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
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AsthmaMedications--Acute

• Corticosteroidsoral or inhaled
• Prednisone, Methylprednisolone
• ?-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

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AsthmaMedications--Chronic

• Cromolyn sodiumused prophylactically
• Inhalant
• Suppresses inflammation
• Not bronchodilator
• Prevents release of histamine

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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

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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

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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

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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

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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

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Pharyngitis

• Sore throat
• Most are caused by viruses
• Most common bacteriagroup A beta-hemolytic
  streptococcus (strept throat)
• Symptomsfever, sore throat, dehydration
• Treatmentsymptomatically
• If bacterial10 days of penicillin

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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

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Tonsillectomy

• Surgical removal of palatine tonsils
• Adenoidectomysurgical removal of pharyngeal
  tonsils
• Pre-op prep same as for all surgeries

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Tonsillectomy

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

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Tonsillectomy

• Post op care
• Bedrest for day
• Clear liquids advance to full then soft
• Cold
• Avoid red coloring
• Ice collar
• Analgesics

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Tonsillectomy

• Post op riskhemorrhage
• Up to 10 days post op
• Symptoms
• Bright red bloody emesis
• Frequent swallowing
• Pulse greater than 120

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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

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Allergic Rhinitis

• Hay fever
• Seen mostly in older children and adults
• Treatment antihistamine, allergy avoidance

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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

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General Treatment for Respiratory Conditions

• Position to promote oxygenation
• Humidification
• Fluid intakeclear liquid, avoid milk
• Oxygen???
• Medications include bronchodilators,
  anti-inflammatories, antibacterial and antiviral
  agents

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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