Child with Child with Respiratory Respiratory dysfunctiondysfunction Emad Al Khatib, Emad Al Khatib,

RN,MSN,CNSRN,MSN,CNS

physical assessmentphysical assessment • Shape, size, symmetry of the

thoracic cavity• Type of breathing: diaphragmatic

respiration till age 7 years, then become thoracic

• Depth, regulatory of respiration • Color of face, trunk, nail beds• Quality of breathing: quite, non-

labored breathing

• Quality of breath sounds: vesicular, bronchovesicular, bronchotubular sounds

• Rales /crackles (pneumonia, CF, pulmonary edema), rhonchi (upper airway -bronchitis), wheeze (obstruction in the lower airway-asthma, bronchiolities), stridor (foreign body aspiration)

Developmental and Developmental and biological variancesbiological variances

• Central nervous system: rate and depth are controlled by chemoreceptor located in the circulatory system.

• These receptors are fewer in infants and young child than in adult.

• So they respond to hypoxemia and hypercapnia better than premature and younger child

• Airway: diameters are smaller therefore small amount of secretions or edema can significantly reduce the diameter and increases the resistance to airflow and work of breathing

• Conditions involve increase in production of secretions such as asthma, CF

• Up to the age 8 years the child trachea is shorter and the narrowest point of the larynx at the cricoid's area- if they needed endotracheal tube, usually dose not need cuffed one

• Trachea is shorter in pediatric than in adult.. 4cm in neonates, 7cm in infancy and 12cm in adults

• Chest wall: is more cartilaginous and more flexible-chest retractions are common in pediatric children

• Until age 7 or 8 years the ribs are horizontal in contract to 45-degree angle in older child- barrel shape, the muscles do not have the leverage to lift the ribs and aid in chest expansion during respirations

• Respiratory muscles: underdeveloped in pediatric child lacking tone, strength and coordination

• Diaphragm is located higher in the thorax in infants and young child, and inserted horizontally versus obliquely as in the adult

• So any condition affect diaphragmatic movement such as distention can critically compromise the respiratory status

• Lung tissue: lung compliance is the volume of air moved per unit pressure

• Normal adult lung is distensible or very compliant

• Many factors affect lung compliance such as the surfactant

• Pediatric lung tissue has decreased amount of elastic fibers in the septa of the alveoli

• This lead to higher incidence of pulmonary edema, pnemomediastenum and pneumothorax

•Upper respiratory tract infections

Allergic rhinitisAllergic rhinitis • Airborne allergens contact the mast

cells and basophiles at the mucosal surface

• The mast cells have the IgE receptors • Exposure to the appropriate airborne

allergens trigger the release of chemical mediators such as histamine, tryptase, leukotrirnes and prostaglandins

• These mediators causes an immediate reaction Sneezing, nasal itching, thin watery rhinorrhea and nasal congestion

• Could be seasonal or perennial around the year

• Nasal congestion is worse at the night • Child may have watering of the eye in

conjunction with nasal symptoms

• Transfers crease across the lower third of the nose caused by rubbing the nose

• Speculum examination: edematous mucosa, swollen boggy, pale pink to blue gray turbinate

• Nasal secretions are clear watery or white

• Bronchospasm with coughing, shortness of breath, chest tightness occur with children having asthma

Allergic rhinitis is often inherited • Common cold (rhinitis) accompanied

with fever, pharyngitis/laryngitis and purulent secretions

InterventionsInterventions • Avoidance of offending allergens • During pollen season, Pollen counts

are highest in the morning between 5-10am

• Bedrooms windows should be kept closed in the night

• Medical management involve Antihistamine and decongestant

• Cromolyn sodium act by stabilizing mast cells membrane –topical nasal spray

• Severe nasal symptoms require topical nasal steroids

• Non sedating antihistamine are not recommended for less than 12 years age child

Nasopharyngitis Nasopharyngitis (common cold) and (common cold) and pharyngitis (throat pharyngitis (throat

infection)infection)

• Average:• First 3 years of life: 4 respiratory

infections /year for children cared at home

• 5-6 respiratory infections /year for children cared in group daycare

• The inflammatory process initiated in the stratified squames epithelium lining the oropharynx and nasopharynx

• Excessive dryness of the mucus membrane during winter and passive or active smoking are contributing factors

• Viral infection: WBC usually normal, gradual onset, headache, low grade fever, rhinitis, cough, hoarseness, red pharynx & moderately enlarged tonsils

• No specific treatment, but provide rest, reduce fever, prevent spread of infection, facilitate breathing, prevent dehydration

• Usually no complication and symptoms resolve in 5-7 days

• Bacterial infection: usually group A beta hemolytic streptococcus

• WBC elevated (15,000-20,000/mm3, abrupt onset, headache, fever up to 40 C, abdominal discomfort, trouble swallowing, Erythema and enlarged tonsils with white exudates on posterior pharynx, firm tender cervical lymph nodes.

• Treatment include antibiotics to eradicate organism (penicillin or erythromycin for 10 days) plus symptomatic treatments

• Complications include otitis media, sinusitis, tonsillar abscesses, rheumatic fever, meningitis and acute glomerulonephritis

TonsillitisTonsillitis • Tonsils are fleshy clusters of tissue that lie

in Four pair located in the oral pharynx , and nasal (adenoids)

• Tonsillitis is an inflammation of the tonsils caused by an infection.

• In tonsillitis, the tonsils are enlarged as a result of recurrent infections, they reach their maximum size between 8-12 years age then began to shrink

• Hypertrophy of the tonsils must be carefully evaluated because the tonsils are normally large in size during early childhood years

• Tonsils may meet in the midline in some normal asymptomatic child

• Good skills to perform the inspection of the tonsils for younger children is needed

• Tonsillitis usually occurs as part of a pharyngitis (throat infection).

• In older children, illness usually begins with sudden sore throat and painful swallowing.

• A child may also experience loss of appetite, malaise (a generally ill feeling), chills, and fever above (38.3 degrees Celsius).

• Glands in the neck and at the angle of the jaw may be swollen and tender.

• In infants, tonsillitis may include symptoms that appear to be less focused on the throat, such as poor feeding, runny nose, and a slight fever.

• Tonsillitis may be caused by either viruses or bacteria, and often the symptoms are the same no matter which germ is causing the infection.

• Group A hemolytic streptococci bacteria are the kind that most commonly cause bacterial throat infections.

• The most common viruses in early childhood are adenoviruses influenza or flu virus, Epstein-Barr virus, Para influenza viruses (which cause respiratory infections such as croup, laryngitis, and bronchiolities), enteroviruses or type 1 herpes simplex virus 

• The incubation period varies widely according to the type of cause

• When tonsillitis is caused by group A streptococci, it is usually 2 to 7 days.

• 18 to 72 hours for influenza virus • 3 to 6 days for Para influenza,

herpes, or Coxsackie's virus• 4 to 8 weeks for Epstein-Barr virus.

• Duration• With antibiotic treatment, the illness is

usually cured within 1 week, but it may take several weeks for the tonsils and swollen glands to return to normal size.

• All forms of tonsillitis, whether caused by bacteria or viruses, are contagious illnesses. Tonsillitis usually spreads from person to person by contact with the throat or nasal fluids of someone who is already infected.

• Once a strep. infection has been confirmed, it is treated with penicillin derivatives that may either be injected or given by mouth

• Taking the full course of antibiotics will help prevent complications, such as rheumatic fever or an abscess around the tonsils.

• For children allergic to penicillin, erythromycin is usually given.

• When a child has frequent episodes of tonsillitis (usually seven episodes in 1 year), tonsillectomy is suggested

• Tonsillectomies may be performed in children with obstructive sleep apnea, a condition in which the child's tonsils are so big

• Post tonsillectomy child should be monitored for bleeding, control his pain, and encourage the oral intake when stable

• Apply ice collar externally around the neck, give ice ships orally, put the child in prone position and head turned to the side

Lower respiratory tract Lower respiratory tract infectionsinfections

• Bronchiolitis:• Bronchiolitis is a common illness of

the respiratory tract caused by a respiratory infection that affects the tiny airways, called the bronchioles

• As these airways become inflamed, they swell and fill with mucus, making it difficult for a child to breathe.

• The illness affects infants and young children most often because their small airways can become blocked more easily than those of older children or adults.

• Bronchiolitis typically occurs during the first 2 years of life, with the peak occurrence at about 3 to 6 months of age.

• It's more common in males, children who have not been breastfed, and children who live in crowded conditions.

• Exposure to cigarette smoke can also increase the likelihood that an infant will develop bronchiolitis.

• Conditions that increase the risk of severe infection include Prematurity, prior chronic heart or lung disease, and a weakened immune system due to illness or medications. Children who have had bronchiolitis may be more likely to develop asthma later in life

• Bronchiolitis is usually caused by a viral infection, most commonly respiratory syncytial virus (RSV).

• Other viruses associated with bronchiolitis include influenza and adenovirus.

• Signs and SymptomsThe first symptoms of bronchiolitis are usually the same as those of a common cold:

• stuffiness • runny nose • mild cough

• These symptoms last a day or 2 and are followed by worsening of the cough and the appearance of wheezes

• Sometimes more severe respiratory difficulties gradually develop, marked by:

• rapid, shallow breathing (60 to 80 times a minute)

• a rapid heartbeat

• drawing in of the neck and chest with each breath, known as retractions

• flaring of the nostrils • irritability, with difficulty sleeping

and signs of fatigue• The child may also have a fever, a

poor appetite, and may vomit after coughing.

• In severe cases, symptoms may worsen quickly. Cyanosis appear in the lips and fingernails.

• The child can also become dehydrated from working harder to breathe, vomiting, and taking in less during feedings.

• Prevention:-• The best way to prevent the spread of

viruses that can cause bronchiolitis is frequent hand washing.

• It may help to keep infants away from others who have colds or coughs. Infants who are exposed to cigarette smoke are more likely to develop more severe bronchiolitis, compared to babies from smoke-free homes.

• Therefore, it's important to avoid exposing children to cigarette smoke

• Although a vaccine for bronchiolitis has not yet been developed, there is a medication that can be given to lessen the severity of the disease. It consists of antibodies to RSV and is injected monthly during peak RSV season.

• The medication is recommended only for infants at high risk of severe disease, such as those born very prematurely or those with chronic lung disease.

• Incubation ranges from several days to 1 week, depending on the infection that leads to the bronchiolitis.

• Duration• Cases of bronchiolitis typically last

about 7 days, but children with severe cases can cough for weeks.

• The illness generally peaks on about the second to third day after the child starts coughing and having difficulty breathing and then gradually resolves.

• Treatment:• Antibiotics aren't useful for treating

bronchiolitis because it's caused by a viral infection, and antibiotics are only effective against bacterial infections.

• Medication are given to help open a child's airways.

• Infants who are moderately or severely ill may need to be hospitalized to be watched closely and to receive fluids and humidified oxygen.

• Rarely, in very severe cases, some babies are placed on respirators to help them breathe until they start to get better.

• Home Treatment:• The best treatment for most children is

time to recover and plenty of fluids. • To make breathing easier, many

parents use a cool-mist vaporizer during the winter months to keep the air in the child's room moist

• Dry winter air can dry out airways and make the mucus stickier.

• Avoid hot-water and steam humidifiers, which can be hazardous and can cause scalding.

• Tilting the child's mattress up slightly may help decrease the work of breathing.

• Using a bulb syringe and saline (saltwater) nose drops can also help to keep a baby's nose clear. This can be especially helpful just before feeding and sleeping.

• Give acetaminophen to reduce fever and make the child more comfortable.

• Croup syndrome:• Is a term that refers to the clinical

syndrome of hoarseness, respiratory strider, barking coup, and varying degrees of respiratory distress

• Croup involves inflammation to one or more of the following structures:

• Vocal cords and larynx, subglottic tissue, trachea, bronchi, bronchiols

• Peak incidence in 1-2 years old children, but can be seen in age 6 months to 4 years

• Usually occur in winter months

• Infectious agents might be viral or bacterial, some noninfectious Croup caused by asthma or allergic reactions or following endotracheal extubation

• Inflammation of the epithelial tissue of the airway cause vascular congestion and edema result in narrowing of the subglottic region

• Laryngeal muscle spasm and accumulation of secretions occur, surface mucosal ulceration may occur

• The onset of Croup is gradual, child rarely look ill but present increased respiratory rate

• Severity of airway obstruction may reach to respiratory distress including severe hypoxemia, and CO2 retention

• Parent anxiety is a common finding due to lack of sleep from child barking and experience of respiratory distress

• Management • Monitoring vital signs, give

antipyretics, provide environment rich in humidity –croup tent, or bath with warm running shower

• Child with severe symptoms should be admitted to the hospital to receive IV fluid, O2 and airway support

• Put the equipments of intubation or trachestomy standby

• Long-term respiratory dysfunction- Asthma:-

• Asthma is a chronic lung condition that can develop at any age.

• Asthma is the most common chronic condition in childhood and become a world concern due to the growing numbers of children affected

• Prevalence rate among children are increasing 6.9% … it accounts for 1/4 of school absenteeism.

• Deaths from asthma are usually preventable

• Risk factors for asthma mortality include inappropriate assessment for the severity of child’s asthma by parent and health practitioners, over reliance on bronchodilators and delay in seeking treatment during asthma attack

• Asthma is best defined as a condition characterized by reversible-in most cases- airway obstruction, airway inflammation and increase airway responsiveness to a variety of stimuli

• Two factors provoke asthma: • Triggers result in tightening of the

airways (bronchoconstriction). • Causes and inducers result in

inflammation of the airways• The most common inducers are

Respiratory viral infections

PathophysiologyPathophysiology • The airway is hyper responsive to a

number of precipitants or triggers • Mast cells in the airway release

inflammatory mediators such as histamine that cause smooth muscle constriction

• Mediators cause direct migration and activation of inflammatory infiltrates such as eosinophils and neutrophils and mast cells degranulation causes the release of leukotrienes and prostaglandins which intrun lead to inflammation

• Goblet cells hyper secrete mucus, plus epithelial damage lead to increase permeability and sensitivity to inhaled allergens

• Result is edema, mucus plugging, airway narrowing

• Exaggerated bronchoconstriction of the airway

• Common Asthma triggers include:• House dust collected in blanket, carpets,

beddings• Pollens from flowers, trees • Mold found in bathrooms, or damp areas• Smoke from cigarettes or wood burning,

and kerosene heaters • Animals such as cats, dogs, chickens,

horses, birds

• Inhalants/chemicals from cleaning products, paintings, hair spray, talcum powder, perfumes

• Foods such as chocolate, eggs, milk, nuts, fish, salicylates drugs

• Whether such as excessively cold air, infections such as colds, sore throat, exercise, and emotions such as fear, anger, crying

• Acute reaction called early asthmatic response EAR, generally resolved with treatment with bronchdilators within 1-3 hours

• Late asthmatic response LAR, airway obstruction persist and can last 24 hours or more

• LAR has the feature characteristic of chronic asthma: less responsive to bronchodilator

Asthma DiagnosisAsthma Diagnosis• The diagnosis of asthma involves all

of the following: • 1. A detailed history which would

include: • family history of asthma, allergies,

fever, eczema; children will have a greater chance of developing the above if there is a family history of allergies and asthma

• child's medical history including: • when parents first noticed the child

developed breathing problems, history of nasal (rhinitis), itchy eyes (allergic conjunctivitis) and eczema, which are common accompaniments to asthma, and urticaria

• history of recurrent and persistent cough following a cold, frequent colds, croup, seasonal changes (i.e. worse in the spring and fall), exercise limited by breathing problems, waking at night with symptoms.

• school absences, emergency room visits (hospitalizations)

• environmental history

• 2. Physical examination: i.e. listening to the lungs with a stethoscope

• 3. Chest x-ray may be done once to exclude the possibility of breathing problems being caused by something other than asthma.

• 4. Blood tests and sputum studies

• 5. Allergy skin testing: Skin tests can confirm the presence or absence of allergies and must be correlated to the history of symptoms

• 6. Spirometry is a breathing test which measures the amount and rate at which air can pass through airways

• if the airways are narrowed because of inflammation it will be more difficult for air to pass through the airways. This will result in changes in spirometry values.

• this test is not indicated with children under the age of five years, because there is a certain amount of effort and cooperation required. However, this is a very dependable method of making a diagnosis.

• 7. Challenge tests: Exercise challenge tests and methacholine inhalation tests are procedures used most frequently in clinical laboratories to evaluate airway responsiveness.

• 8. Differential diagnosis: Other possible causes of shortness of breath, wheeze, cough and chest tightness must be investigated in order to rule these out, such as heart disease, other lung conditions, gastro esophageal reflux

• 9. A trial use of asthma medications: If asthma medications are taken and improvement in symptoms is seen this further supports the diagnosis of asthma.

Goals of Asthma Goals of Asthma ManagementManagement

Normalize lifestyle (taking into account environmental control)

• Freedom from night/early symptoms: sleep should not be disturbed by asthma symptoms

• Relief or bronchodilator medications should not be required daily (other than with vigorous exercise)

• Normalize or optimize lung function as measured by peak flow or lung function testing

Long Term Asthma Long Term Asthma ManagementManagement

• Education:• In order to enhance the patient-physician

relationship, the family- and the child later, must be familiar with the following:

• Nature of the disease, identifying provoking factors

• Nature of medications and side effects • Proper technique of using devices

• Goals of treatment • Control the signs and symptoms

frequency during Daytime and Night-time, and symptoms severity and the need for b2-agonist

• Environmental Control: If exposure to inducers are avoided, less medication is required.

• identify what inducer is making the asthma worse by reviewing the history of symptoms carefully and keeping track of the symptoms.

MedicationsMedications • Anti-inflammatory • asthma management depends on using

anti-inflammatory medications with bronchodilators as needed for immediate and occasional relief of symptoms.

• 1. Anti-Inflammatory – Preventers and used to treat the inflammation that is caused by exposure to inducers.

• 2. Bronchodilators - Relievers Bronchodilators are used to relieve the bronchoconstriction provoked by triggers.

• Anti-Inflammatory • prevent and reduce inflammation,

swelling and mucus • prevent symptoms such as cough,

wheeze and breathlessness • need to be taken on a regular basis • are slow acting (hours or weeks)

• The most common ones include: Steroids (Corticosteroid Inhalers are the most effective) and Non-Steroidal

• side effects, in general, are usually restricted to the throat

• hoarseness and sore throat • thrush or yeast infection

• This can be prevented by rinsing the mouth and gargling

• other side effects if used long-term includes water retention, bruising, puffy face, increased appetite, weight gain and stomach irritation

• Bronchodilator Medications • They relax the muscle around the

bronchi, which allows breathing to become easier.

• provide quick relief of symptoms • useful with exercise induced

bronchospasm

• Types of Bronchodilator Drugs • The most common bronchodilators are: • B2-Agonists such as ventoline (salbutamol)

–they relax the muscle around the airways which allows breathing to become easier within minutes

• Side effects of B2-Agonists include: trembling, nervousness, flushing and increased heart rate

• B2-Agonists are safe when used properly; for example, when you are experiencing symptoms or before exposure to a trigger.

• Anticholinergic Inhaler: such as Atrovent opens the airways by blocking the signals from the nervous system which cause the airways to become narrow.

• Theophylline: is an oral bronchodilator that works directly on the airway muscle to relax it.

• It is used in the evening if shortness of breath disturbs sleep, or regularly if asthma is severe.

• Side effects include: diarrhea, nausea, heartburn, loss of appetite, headaches, nervousness, rapid heart beat, upset stomach

Taking Care of a Child With Taking Care of a Child With Asthma Asthma

• If you are a mother of a child with asthma, you join the ranks of many other women dealing with this challenging condition. Asthma is the leading cause of chronic illness in children, affecting 7 to 10 percent of all children, and twice as many boys as girls. In about half of all children with asthma, the condition becomes obvious by age three.

• The basic cause of the lung abnormality in asthma is not yet known but the best management approach involves a team of parent, child and health care provider. Working together, this team can identify and watch for asthma symptoms and individual triggers that initiate asthma episodes.

• A good way to develop a treatment plan (or modify an existing one that may not be working well) is to evaluate your child's most recent attack. You can take this description to your health care provider to help them learn a lot about both your child's asthma and the best treatment approach.

Try to answer the following Try to answer the following questions soon after an attack questions soon after an attack • Was coughing involved? Determine

when it occurred and how long it lasted.

• Was wheezing involved? When did it start, and was it provoked by exercise, a cold or an allergy?

• Was there mucus in the chest and throat? How long was it present?

• Was your child short of breath?

• What were the possible triggers? Illness (colds, headache, earache), molds, foods, chemicals, dust, cigarette smoke or cold weather?

• Did you "sense" that your child was about to have an attack?

• Did your child forget to take a medication?

• Children with asthma usually exhibit early warning signs of an impending attack. Learn to be a keen observer so you can help ward off an attack before it becomes serious.

• According to the American Lung Association, early warning signs include:

• An appearance that is anxious, pale and sweaty Hunched-over body posture Restlessness during sleep Fatigue Coughing and clearing of the throat Breathing that is fast, noisy and labored

• Children who display these symptoms should be helped to relax and moved away from any triggers. You should review your written treatment plan, institute any measures set by your health care provider and call them if the symptoms don't go away.

• As yet there is no cure for asthma, but it can be controlled with proper treatment. Your child can use the medicine prescribed by their health care provider to prevent or relieve their symptoms, and can learn ways to manage each episode. Most kids with asthma can gain control of the disease and lead an active life.