Alveoli o Continue to develop Ribs o how they are inserted o how chest can rise o size of sternum o due to this, children often do more abdominal breathing o Assess for change in chest configuration to accommodate for barrel trapping (barrel chest) o Pectus excabatum- chest wall starts to concave and come in May lead to pneumothorax Trachea Obligate nose breathers o Lymph tissue Lymphatic tissue does not really develop until two years old Tonsillectomies common Under two, prone to post op issues Other issues- repeated infections, sleep apnea from tissue enlargement 4-tonsils touching each other Pharyngeal tonsil (adenoids) Oropharynx Large head, weak neck muscles Chest wall
Pulmonary Physical Exam Color (Cyanotic or not?) o Cyanosis- blue tinge o If lacking oxygen- may have finger clubbing LOC Respiratory effort/pattern Position o Can que you into what is going on Breath sounds o Diminished o Always listen one side to another Evaluation of oxygenation o Pulse ox. >94; want kids to be oxygenated better Are they able to talk/cry?
Respiratory Distress: What do you see? Tachypnea (Fast RR), tachycardia (Fast HR), dyspnea (Difficulty breathing, increased work of breathing) Dusky, mottled Increased work of breathing Nasal flaring, grunting, retractions o Rib cage sucking intercostally (?) o More upper- suprasternal o Rib cage sinking in, and ribs protruding o Grunting done to increase CPAP; leaves air in body of alveoli alittle longer so exchange of co2 and lungs care occur o Start to see tugging- important to consider NPO status; because want to avoid aspiration Altered LOC Metabolic or cardiac component Metabolic Acidosis Alterations in perfusion o Less capillary refill, body is shunting Others: o Observe face for signs of anxiety o Hyperextension of neck o Increased fatigue and RR effort o Decreased ability to coordinate suck, swallow, and breath o Trouble with eating
Upper Respiratory Conditions Acute Otitis Media (AOM) Chronic Otitis Media Acute Otitis Externa (AOE) o Swimmings ear o Inflammation of ear canal or outer ear Otitis Effusion (OE) o Fluid in middle ear Sinusitis Foreign Body Aspiration (FBA) o Life threatening event, necessitates immediate removal of foreign body Upper Respiratory Infection (URI) o Epiglottis o Acute Laryngetrachebronchitis (croup)
Acute Otitis Media
o Standard ear infection o Highest in ages 6 mo to 2 yrs o Eustachian tube much shorter, broader, and more horizontally placed than an adults, making them susceptible to ear infection o To look at ear, pull ear down; pull up at ages 3 (technique) o Common associations: smoker in household, daycare attendance, bottle feeding o Etiology: Hemophyllus influenza Streptococcus pneumoniae Moraxella catarrhalis o Symptoms: Irritability, fever, pain, anorexia URI symptoms, diarrhea Congestion, sore throat, sinus issues o Complications: Conductive hearing loss Repeated ear infections Perforation Labrynthitis Vertigo, dizziness; change of pressure in ear Mastoiditis Infection/inflammation of mastoid area; can be serious when goes to fluid filled pockets Meningitis o Criteria for antibiotic use: > 3 OM in past year > 3 days duration + respiratory culture Immunosuppression (splenectomy, CF, HIV) Attendance at daycare Living with smoker o Medical Management: Medications CDC recommendation for antibiotics: Amoxicillin PO 80-90 mg/kg/day for ear infections Alternative agents: Cefuroxime 30 mg/kg/day Amoxicillin-clavulanate (Augmentin) 80-90 mg/kg/day For severe infections: Ceftraixone IM x3 days Auralagen ear drops for pain: Antibacterial, analgesic, and anesthetic combination Cortisporin ear drops for otitis externa Debrox ear drops for cerumen removal o Nursing Care: Monitor fever (WE DO NOT WANT FEVER MORE THAN 3 DAYS), symptoms of illness, dehydration (PUSH FLUIDS) Antibiotics for 10 days Monitor for side effects Diarrhea, GI discomfort issues Acetaminophen (Tylenol) For pain and fever Reassure parents of tx plan
Upper Respiratory Infection Etiology: Viral Symptoms: o Rhinitis o Cough o Fever o Irritability o Anorexia o Vomiting, diarrhea Colds o Medical treatment Fever control Decongestants/cough suppressants? Antihistamines? For allergies? Decongestant- cough suppressant; dont give bc we want them to cough this up! Antihistamine- No; would dry up secretions Should not give antihistamine to child under 5! Nursing Care Upper Respiratory Infection: o HOB elevated o Saline nose drops or warm water/bulb suction <1 year 1 drop each nostril til clear o Monitor fever, SOB, cough o Encourage fluids o Hygiene Frequent hand washing Isolation Clean/unclean areas No sharing utensils Fevers Most viral fevers last 2-3 days Call health provider if < 3 mo. old, T >41.5 C (105 F); looks sick, lethargic Reset set point (antipyretic medications) before using environmental measures Nursing care: Fever control: o Acetaminophen or ibuprofen (AAP doesnt recommend prescribing both at the same time for fevers as there is a high risk for liver/kidney problems r/t overdose) o AVOID ASPIRIN o Remove clothing o Luke warm sponge bath if T >40 C (104 F) o Fan A few words about fevers o A symptom, not a disease o Bodys natural defense to infection turns on immune system o Usual fevers 37.8-40C are not harmful o Most fevers caused by viral illness Pathophysiology Involving the Upper Airway o Sudden onset of coughing or choking o Inspiratory stridor o Hoarse cry/voice o Suprasternal retractions Tracheal tugging
Foreign Body Aspiration Life threatening event; calls for immediate removal Physiology of airway with respiration o Upper airways smaller with inspiration, larger with expiration o Lower airways larger with inspiration, smaller with expiration Types of obstruction( view pic in slide) o Partial Air able to move past the obstruction in one direction only. Air passages enlarge during inspiration and diminish during expiration o Larger o Complete Mechanism of Foreign Body Obstruction FBA Culprits o Common foods- hot dogs, round candy, peanuts, grapes o Latex balloons o Small objects: buttons, toy parts FBA Clinical Manifestations o Rapid onsetcheck hx! o Chocking, gagging, coughing o Hoarseness, stridor, aphonia o Dyspnea, wheezing, cyanosis o May develop pneumonia Epiglottis Acute inflammation of supraglottal structures precipitating mechanical obstruction Life threatening inflammation of epiglottis H. flu most common cause High mortality- bc of obstruction is creates in airway Complete airway obstruction can develop after onset or with manipulation of neck &/or airway o If suspecting, do not put anything in throat Clinical Manifestations: o Acute, sudden onset o High fever o Severe sore throat, dysphagia (difficulty swallowing) o Muffled voice o Drooling o Tripod position o Progresses to respiratory distress o Inspiratory stidor, retractions Management o Medical emergency o Emergency trach equipment nearby o DO NOT INSTRUMENT THOAT o Keep child calm, in parents lap o Antibiotics o Swelling usually down by 24 hours o Mortality rates have decreased from 32% - 7% since 1970s. Why? Incidence has decreased since Hib vaccine; H flu has greatly decreased since vaccination
Acute Laryngotracheobronchitis (Croup)
Usually viral cause (RSV, parainfluenza) Varied degrees of subglottic obstruction Causes edema in larynx Symptoms usually at night, or in cold weather May cause laryngeal spasm- when vocal cords in larynx somewhat freeze up o Spasming may go down with cool temperature Prior hx of URI 3-4 days ago Barking cough Inspiratory stidor Hoarseness Acute LTB Treatment: o Cool mist o Fluids o Recemic epinephrine Will help open up upper airway Watch for rebound symptoms; child must be watched closely o Steroids Reduce inflammation o Because viral, no antibiotic that child can receive Keep child comfortable, encourage liquids LTB vs EPIGLOTTIS Cough No dysphagia No or low fever Prior URI Sounds worse than looks Usually viral Position of comfort 3 months- 5 years
No cough Drooling High fever +/- URI Looks worse than sounds Usually H. flu Tripod position 3-8 years
Bronchopulmonary Dysplasia (BPD) The term bronchopulmonary dysplasia (BPD) describes chronic lung disease subsequent to oxygen and/or ventilator therapy for respiratory distress syndrome (RDS) in preterm newborns. o High 02 concentrations o Positive pressure ventilation o Fluid overload Chronic lung disease of prematurity (CLDP) is sometimes used interchangeably with BPD, but CLDP is best reserved for other chronic lung diseases of the preterm infant that can arise after initial period without oxygen or ventilator requirements One of most chronic respiratory diseases in children Seen in children with extremely low birth weights <2.2 lbs BPD Pathophysiology o Interstitial edema o Thickening of alveolar walls o Hyperaeration- can get air in, but hard to get back out o Paralyzed ciliary activity o Decreased surface area for O2/CO2 exchange Acute Management o Surfactant o Minimize positive pressure ventilation o Wean Fi02 as tolerated o Judicious fluid administration o Steroids Reduce inflammation o Bronchodilators o Provide adequate nutrition Most E used to breath Nursing Management o Nutritional supplementation o Small frequent feedings o Increase O2 with feedings o Parent teaching Home care needs, supplies Home O2 Parent support: What to do if CPR Minimize contact BPD Long-term Effects o Growth failure o Airway hyper reactivity o Increased incidence of respiratory infections o Decreased pulmonary function Lungs regenerate within 5 years o Lower bone density o Lower intelligence scores
Respiratory Syncytial Virus (RSV) Most important respiratory disease of infancy and early childhood Winter, spring incidence < 2 years of age (peak 2-5 months) Most common cause of bronchiolitis NOT bronchitis Pathophysiology o Inflammation of respiratory tract mucosa o Bronchiolar mucosa swell o Epithelial cells lose cilia o Lumina filled with exudate, mucus o Cells shed into bronchioles causing partial obstruction o Hyperinflation, atelectasis, air trapping RSV Transmission o Direct contact with respiratory secretion Hand-mucous membranes o Direct inoculation from aerosolized particles o Distant aerosolized inoculation unlikely o Can live for hours in dry environment o Most healthy people recover 1-2 weeks Signs/Symptoms: o Initial: Rhinorrhea Cough Low grade fever Otitis Conjunctivitis Pharyngitis Wheezes o Later signs: Increase wheeze, cough Air hunger Tachypnea Retractions Cyanosis Crackles Decreased breath sounds Management: o Diagnosis by nasal or NP swab Rapid results 90% accuracy o Symptomatic treatment of bronchiolitis Humidity Fluid Rest When to hospitalize o Listless o Poor fluid intake o Respiratory compromise o Tachypneic o Retractions o Hypoxic Treatment o Symptomatic and supportive care IV fluids, nutrition Oxygen Treat bronchospasm o Ribavirin controversial Antiviral agent Aerosolized via hood, mask, ventilator Controversy ? toxicity ? effectiveness- mortality, hospital (ICU) stay, mechanical ventilation Rarely used- usually with kids so sick on ventilators (hospitalized severely ill infants with RSV) o AAP recommendations for Ribavirin Use High risk infants w RSV Complex CHD Lung disease Preterm infant (<37 weeks) Hospitalized, severely ill infants with RSV bronchiolitis Immunocompromised infants w RSV SCID HIV Transplant patients Nursing Considerations o Patients in private room or cohorted o Consistent hand washing o Gown, glove for direct contact o Minimize # of personnel with patient o Ribavirin NO pregnant care providers Keep closed system RSV Prevention o Health teaching to minimize spread o Synagis- immunization Monoclonal antibody Monthly injection during RSV season Indication < 2 years with chronic lung disease Preterm infants < 32 weeks ? other chronic illnesses (CHD) Prognosis o Increased risk of developing asthma after RSV bronchiolitis
Cystic Fibrosis (CF) Most common life-threatening recessive genetic disease in Caucasions Inherited as an autosomal recessive disease 80% cases diagnosed by age 3 in past Newborn screening leads to dx at birth and is implemented in many countries of the world Almost 10% dx >18 years Exocrine gland dysfunction that produces multisystem involvement Most common lethal genetic illness among Caucasian children Aprx. 3% US Caucasian population are symptom-free carriers Autosomal recessive trait Inherits defective gene from both parents, with an overall incidence of 1:4 Increased Viscosity of Mucous Gland Secretion o Results in mechanical obstruction o Respiratory tract and pancreas are predominately affected Manifestations of CF o Present in almost all CF patients but onset and extent are variable o Collection of mucus and bacterial colonization result in destruction of lung tissue o Tenacious secretions are difficult to expextorate (remove), obstruct bronchi and bronchioles o Decreased O2-CO2 exchange o Results in hypoxia, hypercapnia, acidosis o Compression of pulmonary blood vessels and progressive lung dysfunction lead to pulmonary hypertension, cor pumonale, respiratory failure, and death GI tract o Thick secretions block ducts cystic dilation degeneration diffuse fibrosis o Prevents pancreatic enzymes from reaching duodenum o Impaired digestion and absorption of fat: steatorrhea o Impaired digestion and absorption of protein: azotorrhea o Endocrine function of pancreas initially stays unchanged o Eventually pancreatic fibrosis occurs; may result in DM o Focal biliary obstruction results in multiobular biliary cirrhosis o Impaired salivation Clinical Manifestations o Pancreatic enzyme deficiency o Progressive chronic obstructive pulmonary disease associated with infection o Sweat gland dysfunction o Failure to thrive o Increased weight loss despite increased appetite o Gradual respiratory deterioration Presentation o Wheezing respirations; dry, nonproductive cough o Generalized obstructive emphysema o Patchy atelactasis o Cyanosis o Clubbing of fingers and toes o Repeated bronchitis and pnemonia o Mech