Respiratorywww.autocontrol.com

Key Pediatric Differences in the Respiratory System

• Lack of or insufficient surfactant (premature infant)

• Smaller airways and underdeveloped cartilage• Tonsilar tissue enlarged• More flexible larynx• Obligatory nose breather (infant)• Less well developed intercostal muscles• Brief periods of apnea common (newborn)• Faster respiratory rate• Increased metabolic needs• Eustachian tubes relatively horizontal

Child’s Respiratory Tract

Children are prone to:–Respiratory tract infection

–Respiratory failure

–Airway collapse

Respiratory Diseases and Disorders of Childhood

• Otitis Media• Pharyngitis• Epiglotitis• Broncholitis• Pneumonia• Asthma

exacerbation• Cystic Fibrosis• Tuberculosis

Upper Respiratory Tract Disorders

Otitis Media (OM)

• One of the most common illnesses in infancy and childhood

• Peak incidence: 6 months to 6 years• Infection or blockage of the middle ear• Acute, Chronic or Serous OM

Risks for Development of AOM

• Exposure to second hand smoke• Allergies• Bottle fed infants

(AOM) Acute Otitis Media

• Sudden temperature increases• Sharp pain • Otalgia (earache); pull on ear, rubbing face • Bulging, opaque red tympanic membrane• Irritability• Sleep disturbance• Persistent crying• Fever, vomiting, diarrhea, anorexia• Sudden relief and drainage=rupture TM

AOM

Treatment:• AOM could be viral or bacterial• Acetaminophen (pain, fever)• ABX (Amoxicillin) if bacterial• ALTERNATIVE- wait 72 hours then treat

Serous Otitis Media or Otitis Media with Effusion

(SOM/OME)• Result of chronic otitis media (3 in 6

mos, 4 in 1 year)• Epithelial cells of middle ear begin

producing secretions instead of absorbing them

Patient Teaching-Post Op

• Monitor for ear drainage

• Report any fever or increased pain

• Avoid blowing nose for 7-10 days

• Swimming, showers allowed only with earplugs

• Diving and swimming in deep water is prohibited

Pharyngitis (Tonsillitis)

• Inflammation and infection of the palatine tonsils

• Viral vs. Bacterial

• Peak age 4-7 years

Viral Pharyngitis

• Gradual Sore throat• Erythema, inflammation of pharynx and

tonsils (may be slight)• Vesicles or ulcers on tonsils• Fever (usually low grade)• Hoarseness, cough, rhinitis, conjunctivitis,

malaise, anorexia • Cervical lymph nodes may be enlarged,

tender• Usually lasts 3-4 days then resolves

spontaneously

Surgical Interventions

Myringotomy• surgical incision of the tympanic

membrane (mucoid material removed from middle ear)

Tympanostomy tubes: placed to equalize pressure on both sides of the tympanic membrane, keeps ear aerated

• Allows middle ear mucosa to return to normal and growth of the Eustachian tube to continue

Bacterial Pharyngitis

• Abrupt onset (may be gradual in children younger than 2 years)

• Sore throat (usually severe)• Erythema, inflammation of pharynx and

tonsils• Fever usually high (103-104F) but may be

moderate• Abdominal pain, headache, vomiting• Cervical lymph nodes may be enlarged,

tender• Requires antibiotics

Pharyngitis

Management:Pain relief; rest; bland, soft dietPCN if bacterialTonsillectomy is controversial

Tonsillectomy

Nursing Care (Pre-op)• Assess for current infection and

bleeding history• Check for loose teeth• Teach child and parent what to

expect post-op– May see dried blood in mouth and

teeth– Will still be able to talk– Pain management for optimal recovery

TonsillectomyNursing care (post-op)

• Assess for bleeding number one priority!!!!– Elevated P, decreased BP,

restlessness, frequent swallowing, vomiting bright red blood, fresh blood in throat

• Clear, cool liquids, no red juices!• Advance to full liquids and soft foods on

2nd day if no sign of hemorrhage• Pain relief 2nd priority-throat very sore

Nursing care (post-op)

• Encourage child to chew and swallow

• No straws, forks or sharp, pointed toys

• Discourage irritating the operative site

– coughing frequently– clearing the throat– blowing the nose

Manifestations of Croup• Begins at night; may be preceded by several

days of symptoms of upper respiratory tract infection

• Sudden onset of harsh, barky cough; sore throat; inspiratory stridor; hoarseness

• Could progress into use of accessory muscles to breathe

• Frightened appearance; agitation• Cyanosis

• Mostly viral in nature, resolves spontaneously

• Humidification and cold air resolves attacks

Epiglottitis• Bacterial form of croup (H influenza)

with unique symptoms and treatment

• Bacterial infection invades tissues surrounding the epiglottis

• Epiglottis becomes edematous, cherry red and may completed obstruct airway

• Progresses rapidly, child is unable to swallow, drooling

Cardinal signs and symptoms

• May have had mild URI few days prior

• Drooling• Dysphasia • Dysphonia • Distressed respiratory efforts• Tripod position: supported by arms,

chin thrust out, mouth open

ER Management

• NEVER leave child unattended• Don’t examine or culture throat or start

IV/Blood samples• Patent airway ASAP• Monitor oxygenation status, (continuous pulse ox, humidified

O2)• Antipyretics suppository• Calm the parent! Explain what is going on…a calm

parent=calmer child!• OR- intubation• Throat & blood cultures done after intubation• Usually extubated after 48h• Antibiotics for 7-10 days• Discharge

Nursing Interventions on unit once stable

• Continually assess for s/s of respiratory distress

• Maintain pulse ox above 95% with PaO2 between 80-100mmHg

• Maintain patent airway• Position for comfort (never force to lie

down)• Relieve anxiety• Monitor temp (antipyretics, ABX)

Lower Respiratory Tract Disorders

Broncholitis

Inflammation of the fine bronchioles and small bronchi.

• Occurs in children < 2yo; peak age 6mos• Highest in winter and spring• Most responsible pathogen: RSV

Signs and Symptoms

• 1-2 days of URI, then suddenly symptoms become worse

• nasal flaring• intercostal and subcostal retractions • wheezes, crackles or rhonchi• increased respiratory rate• low pulse oximetry• tachycardia and cyanosis

Management

Severe Symptoms• Hospitalization• Monitor: respiratory

status, pulse ox, blood gases

• Bronchdilator therapy

No antibiotics…Viral infection!

Mild-Mod symptoms• Antipyretics• Hydration• Humidification• Watch for increased

severity

Acute phase usually lasts for 2-3 days.

Nursing Interventions

• Position: for comfort, semi-fowlers• Decrease anxiety• Administration of IV fluids • Provide humidified O2 (40% then

wean) use BB• Determine in child is candidate for

Ribavirin therapy (antiviral agent used with severe RSV cases)

Pneunomia (PN)

• Inflammation of the alveoli usually following an URI

• Occurrence: late winter/early spring• Pneumococcal (bacterial) vs. Viral

Pneumonia(ABX vs. no ABX)

Signs and Symptoms

Viral- may have mild cold symptomsBacterial- distinctly ill

– High fever, may be diaphoretic– Cough (productive or non productive)– Tachypnea– Abnormal BS (fine crackles, rhonchi)– Dull percussion– Chest pain– Increased respiratory effort– CXR changes– Lab findings (increased WBC)– Irritable, restless, occasional N/V/D, low PO

intake

Ineffective Breathing Pattern: Interventions

• Assess breath sounds, VS, respiratory status q1-2h and PRN

• Administer humidified O2 via face mask, obtain ABG’s, pulse ox

• Administer ABX (Ampicillin, Cephalosporin), antipyretics

• Perform chest physiotherapy as ordered• Engage child in play activities (TCDB, IS)

Activity Intolerance: Interventions

• Balance activity with rest periods, cluster nursing care

• Provide small frequent meals

• Increase activity gradually

Risk for Deficient Fluid Volume: Interventions

• Obtain baseline weight, monitor daily

• Administer IV fluids as ordered• Offer fluids frequently (jello, ices,

etc.)• Administer antipyretics• Monitor I&O, urine for specific

gravity increases

Tuberculosis

• Bacterial infection that multiplies in the lung tissue, alveoli and lymph nodes

• Initially asymptomatic• Incubation period 2-12 weeks, will

test + PPD• Immune system can ward off full

development and become dormant• Children rarely develop active TB, but

are excellent transmitters to others

Risk Factors

• Contact with infected adults • Chronic illness, immunosuppression, HIV

infection, malnutrition• Young age (infancy, adolescence)• Nonwhite racial, ethnic groups,

immigrants from areas with high incidence

• Urban, low-income living conditions• Incarcerated adolescents• Contact with adults from high-risk groups

Active TB Symptoms

• +PPD• Malaise• Fever• Night Sweats• Slight cough• Weight loss• Anorexia• Lymphadenopathy• Confirmed by CXR, sputum sample, or

gastric washing

Management

Asymptomatic children

• INH x 9 months• 12 months if

HIV+• Household

contacts treat for 12 weeks

Symptomatic children• INH, rifampin and

pyrazinamide x 2 months

• Followed by INH and rifampin x 4 months

Side effects: GI, orange tears, urine= noncompliance

Chronic Lung Diseases

Asthma

A reversible obstructive airway disease characterized by

•Hypersensitivity of many cells (Mast, Eosinophils, T Lymphocytes)

•Increased airway responsiveness to a variety of stimuli

Asthma• Bronchospasm resulting from constriction of

bronchial smooth muscle

• Inflammation and edema of the mucous membranes that line the small airways and the subsequent accumulation of thick secretions in the airways

• Initial Symptom is a Cough (w/o illness) usually at night

• Wheezing is produced when there is decreased expiratory airflow

Acute Asthma Exacerbation Symptoms

• Chest tightness• Wheezing• Shortness of breath• Nonproductive cough (with or without

wheezing); later becomes productive• Tachypnea, orthopnea• Tripod position or straight

Triggers

• Cold air exposure• Smoke/fumes• Viral infection• Stress• Exercise• Odors (perfume)• Animal dander• Dust, cockroaches, rodents• Certain drugs (aspirin, NSAID’s)• GI reflux• Food allergens, outdoor allergens

Management of Acute Exacerbation

• Monitor respiratory rate and effort, color

• Provide oxygen therapy:warmed and humidifiedat 30-40% not 100%keep O2 sat > 95%; need CO2 stimulation for inhalation

Acute Asthma Exacerbation

• Administer short acting beta2 agonist bronchodilators– Ventolin, Proventil, Albuterol

• Administer corticosteroids– Predinsone, Prednisolone, Solumedrol

• Monitor effectiveness of meds

• Easily fatigable

• Frequent position changes

Acute Asthma Exacerbation

• Observe for Status Asthmaticus

• Occurs when child fails to respond to treatment (severe emergency)

• Often caused by pulmonary infection

• Call MD!

Asthma Severity

• Classified as– Mild intermittent

•Symptoms < 2 x week– Mild Persistent

•Symptoms > 2 x week, but less than once a day

– Moderate•Day symptoms 2 x week, 1 or more night

symptoms per week– Severe

•Continual day symptoms, frequent night symptoms

Maintenance Medications

• Mild asthma: – PRN anti-inflammatory

corticosteroids (Flovent inhaler QD)

• Moderate: – anti-inflammatory corticosteroids QD – long-acting bronchodilator

(Theophylline, Serevent)HS

Maintenance Medications

• Severe: – oral corticosteroid qd– inhaled corticosteroid qd – long-acting bronchodilator HS – short-acting beta-2-agonist bronchodilator

(Albuterol) if attack beginsAlso:– Mast Cell inhibitors (Intal),– Leukotriene Blocker (Singulair) (prevents severe bronchospasm, not effective if

symptoms present)

Discharge Planning

• teaching self-management– Identify triggers– Avoidance of allergens– May need skin testing and

hyposensitization

Nebulizer

• Assess availability of home meds (proper inhaler use and storage, nebulizer)

Teach use of Peak Flow Meter

• Measures maximum peak expiratory flow rate

• Need to first use when healthy to mark baseline

• Can use to predict acute exacerbation in kids 5-6 years and older

• Take a deep breath, blow out hard and fast• If peak flow is 30-50% of child’s predicted

baseline=ER

Cystic Fibrosis (CF)

• Mutated gene on chromosome 7 CFTR

• Inherited autosomal recessive trait

• Both parents carry gene

(1/4 chance of conceiving affected child)

CF

• Chronic multisystem disorder affecting the exocrine glands

• Affects: bronchioles, small intestines, pancreatic & bile ducts

• Incurable• Median life expectancy is 33 yrs• Usually diagnosed before 1st birthday• Symptoms worsen as disease

progresses

CF: Respiratory System

• Wheezing, dry, non-productive cough, repeated URI’s

• Copious, thick sputum• Crackles, wheezes, decreased breath sounds• Increasing signs of respiratory distress =>

emphysema & atelectesis• Clubbing, barrel chest

CF: Digestive System

• Steatorrhea: frothy, foul-smelling stools 2-3 times bulkier than normal

• Malnutrition and failure to thrive despite normal caloric intake

• Protuberant abdomen• Fat soluble vitamin deficiencies: K, A,

D, E (caused by inability to absorb fats)• Meconium illeus in the newborn might

be 1st sign

CF: Exocrine Glands

• Abnormally high concentrations of sodium and chloride in the sweat

• Sweat Test: determines amount of sodium chloride in sweat > 60 is diagnostic

• Risk for electrolyte imbalance during hot weather

CF: Reproductive System

• Average of 2 year delay in the development of secondary sex characteristics

• Females have thick cervical mucus (trouble getting pregnant)

• Some male patients sterile due to lack of sperm

Management

• Prevention and treatment of pulmonary infections

• Maintaining optimal nutritional status– High calorie, high protein– Enzyme supplements

• Managed at home most of time– Flutter device– CPT BID– Postural drainage– Exercise

Interventions for Hospitalized CF Child

• Facilitating airway clearance

• Prevent pooling of secretions

• Limit procedures

• CPT every 4 hours (1 hour before or 2 hours after meals, prior to bedtime)

• Forced expiration (“huffing”)

Interventions

• Administer bronchodilators and mucolytics • High-humidity cool-mist tent to mobilize

secretions• If 02 is required, low flow rate• IV ABX• Well balanced diet high in calories, protein,

carbohydrates• Pancreatic enzymes within 30 minutes of eating

all meals and snacks • Extra salt and fluid in hot weather

Long Term Support

• Cystic Fibrosis Foundation

• American Lung Association

• Coordination of care from home to school

• Increase self-esteem

• Foster independence

Dehydration and Fluid Loss

Dehydration and Fluid Loss

• Large portion of a child’s fluids is located in extracellular fluid (increased BSA)– Infants: 75-80% of the weight– 2 year old: 60% of weight

• First two years of life kidneys are not functionally mature

• Inefficient at excreting waste products

Dehydration and Fluid Loss

• Fluid and electrolyte imbalances develop and progress very quickly

• Sick children often have low PO intake and diarrhea and vomiting =

• Infants and young children are highly susceptible to rapid and profound fluid and electrolyte imbalances

Types of Fluid Loss

• Sensible Fluid Loss• Insensible Fluid Loss

Sensible Fluid Loss

• Can be measured and observed• Urine output• Drains and tubes• Emesis • Diarrhea

Insensible Fluid Loss

• Loss of fluid through lungs (2/3) and skin (1/3)

• Influenced by heat and humidity, body temp, respiratory rate (children have higher RR than adults)

• Basal metabolic rate increases 10% for each degree Celsius above normal body temperature

• Example 39 Celsius = 102.2F – BMR increases by 20% !

Electrolytes

• NA- major electrolyte in ECF– Needed to establish osmolarity

• K- major electrolyte in ICF– Needed for excitability of neurons and

muscles

Three Types of Dehydration

• Isotonic• Hypotonic• Hypertonic

Isotonic Dehydration

• Sodium and water deficits are the same (salt and water are lost in equal amounts in ICF and ECF)

• NA+ 130-150meq/L (normal)• Most common type in children

from low PO intake• Can result in hypovolemic shock

Hypotonic Dehydration

• Sodium deficit is greater than the water deficit

• Water moves from ECF to ICF• NA+ < 130meq/L• Results from GI losses (vomit,

diarrhea)

• May result in shock

Hypertonic Dehydration

• Water loss exceeds sodium loss• Body compensates with fluid

shifts from ICF to ECF• NA+ > 150meq/L• May be caused by severe

vomiting, too much IV NA• Can result in seizures

Know the S+S of Dehydration

• Mild– Normal VS, moist mucous membranes,

alert, normal urine output, normal turgor, fontanelle, normal cap refill, thirsty

• Moderate– Rapid pulse and RR, normal BP, dry

mucous membranes, irritable, dark urine and decreased output, poor turgor, sunken fontanelle, delayed cap refill, moderately thirsty

Know the S+S of Dehydration

• Severe• Changes in respirations depth and pattern,

rapid weak pulse, low BP, mucous membranes parched, can be comatose, absent urine output, very poor turgor, sunken fontanelle, cool skin

Monitor for Dehydration

URINE OUTPUT SHOULD BE AT LEAST 1-2 ml/kg/hr

ALL children are on I+O pay attention to the balance

Monitor labs for:– Increased BUN– Increased serum bicarb– Hyponatermia– Hyperkalemia– Increased urine specific gravity

PREVENT dehydration

• Monitor temperature, prevent overheating

• Give frequent fluids, may need oral rehydration (pedialyte) 50 ml/kg/ in 4 hours when febrile and GI losses

• Use small medicine cups, syringe without needed to administer fluids…even 1 tsp every few minutes

• Monitor IV fluid administration, ensure patent IV site

Administering IV Fluids

• Always use an infusion pump with a volume control device

• Prevents a sudden extracellular fluid volume overload

• Never use more than a 500 ml bag• Mechanical pumps can have faulty

performance, so check the intravenous line, bag, and rate often

Practice Questions!

A teenager with chronic asthma asks the nurse, “How come I make so much noise when I breathe?” The nurse’s best response is:

a. It is the sound of air passing through fluid in your alveoli

b. It is the sound of air passing through fluid in your bronchus

c. It is the sound of air being pushed through narrowed bronchi on expiration

d. It is the sound of air being pushed through narrowed bronchi on inspiration

Which school related activity might the school nurse prohibit for a child with asthma?

a. Swim teamb. The Bandc. Pet “show and tell”d. An art class

A toddler with cystic fibrosis is placed in a high-humidity cool-mist tent operated with compressed air. The nurse knows the primary reason for this therapy is to:

a. Provide oxygenb. Lower the child’s temperaturec. Moisten the airway and mobilize

secretionsd. Provide additional fluids

A preschooler with a diagnosis of epiglottitis is admitted to the hospital. Which MD order should the nurse question for this child?

a. Place a pediatric size tracheostomy tray in the room

b. Monitor pulse oxygen saturation every 15 minutes

c. Place in respiratory isolationd. Obtain CBC and Throat Culture

When assessing a child who is suspected of having asthma, the nurse should specifically ask the parents about which initial symptom that they may have noted?

a. Coughing a night in absence of respiratory infection

b. Coughing throughout the dayc. Expiratory wheezingd. Shortness of breath

When caring for a child who has recently undergone a tonsillectomy, the nurse should be aware that the child is discouraged from:

a. Talking and chewingb. Blowing the nosec. Eating lemon flavored ice popsd. Taking pain medication

When caring for a child who has had a tonsillectomy the nurse’s priority observation should be for:

a. Coffee ground emesisb. Frequent swallowingc. Complaints of a sore throatd. A slight increase in temperature

When assessing a child who is preverbal for otitis media, the nurse should anticipate that the child will:

a. Have difficulty swallowingb. Rub the affected side of head on the

mattressc. Have a runny nosed. Have vomiting and diarrhea

The nurse’s health care teaching to assist parents in preventing otitis media should include instructions to:

a. Finish the entire prescription of antibiotics

b. Administer acetaminophen to reduce painc. Apply warm compresses to affected eard. Refrain from putting the child to bed with

a bottle

• The nurse has admitted a child with diarrhea for 3 days. The child’s laboratory results reveal sodium of 126. The nurse understands this is:– 1. Isotonic Dehydration– 2. Hypotonic Dehydration– 3. Hypertonic Dehydration.– 4. Normal, the child is not dehyrated

The physician ordered pedialyte administration 50 ml/kg/ in 4 hours for a child weighing 33 lbs. Upon awakening, the child consumed 200ml of pedialyte at 9:00 am for breakfast. How many more ml does the child need to drink by 1 pm?1. 1650 ml2. 1450 ml3. 750 ml4. 550 ml