Pediatrics Respiratory Dysfunction:
Airway picture.jpg

The oronasopharynx, the pharynx, the larynx, and the upper part of the trachea is called the upper respiratory tract.

Conversely, the lower respiratory tract includes the lower trachea, the mainstem bronchi, the segmental bronchi, the bronchioles and the alveoli.

Respiratory infections often spread among these structures due to the continuous nature of the mucosal lining.

Respiratory illnesses account for a lot of childhood illnesses!

Respiratory illnesses can be caused by viruses or bacteria.

Some of the viruses commonly causing respiratory illness are the respiratory syncytial virus, non-polio enteroviruses (coxsackie A&B), adenoviruses, parainfluenza viruses and metapneumoviruses.

Bacterial agents causing illness include Group A beta-hemolytic streptococci, staphylococci, Haemophilus influenza, Chlamydia trachomatis, Mycoplasma and pneumococci. Be aware that vaccines have been developed to protect children from Haemophilus influenza (ACT-Hib, Pedvax) and against 13 different strains of the pneumococci (Prevnar 13).

Full-term infants under 3 months of age experience some protection from infection from maternal antibodies. From 3-6 months this protection begins to wane. From 6 months until five years of age children experience numerous viral infections.

Anatomically the airways of children are smaller in diameter and the distances between various respiratory structures short. This can quickly compromise a young child due to swelling of these passages and blockage due to mucous and secretions.

Factors which can affect a child’s resistance to respiratory illness include: immune compromise, malnutrition, anemia, allergies, preterm birth, asthma, cystic fibrosis or cardiac anomalies.
Environmental factors such as daycare attendance, environmental smoke can also affect respiratory infection rate.


Breath Sounds:

In General - Signs and Symptoms of respiratory tract infection:
Fever
Poor feeding, anorexia
Vomiting
Diarrhea
Abdominal pain
Nasal discharge, blockage
Cough
Respiratory sounds: cough, stridor, hoarseness, grunting, wheezing, crackles, absence of breath sounds
Sore Throat
Meningismus

Nursing Assessment includes:
Rate/Rhythm, depth, ease of respirations, along with breath sounds, as well as, observation of the child’s color and vital signs.

Nursing Actions:Teach parents to be careful with OTC cold medications, as many will have Tylenol included…
Ease respiratory efforts – cool mist, shower steam, cool night air
Promote rest, decreased activity with illness
Promote comfort, saline, bulb syringe, nasal sprays 2 gtts then 10 minutes later repeat, ice or heat
Prevent spread – hand washing, cover mouths, tissues, absences
Reduce temperature - Motrin, Tylenol, cool liquids
Promote hydration – Pedialyte, Gatorade, count diapers
Provide nutrition – gelatin, popsicles, soup…


Complications of a respiratory illness can include:Earache
Respiratory rate >50-60 breaths per minute
Fever >101
Listlessness
Confusion
Increased irritability
Persistent cough for 2 days or more
Crying
Wheezing
Restlessness
Refusal to eat/drink
Low output, fewer wet diapers


Breath Sounds:




















This video offers an excellent demonstration of a newborn experiencing retractions and grunting.

Peds assessment triangle pic.jpg

Nasopharyngitis
Common, managed at home with mentioned supportive care
Most frequent complaint

Average is 6-10/year (adults 2-4)
Diagnosis based on history
Better within 48-72 hours

Assessment:
Vitals
Infants may have trouble eating due to congestion
Color and amount of secretions

Nursing diagnosis/Outcomes
Ineffective airway/ patent airway
Deficient fluid volume/ output 1ml/kg/hr
Acute pain/ comfort

Treatment:
Supportive care, rest, elevate head of bed
Nonaspirin analgesics (Tylenol, Motrin)
Humidifiers
Saline drops, bulb suction
Fluids - frequent rest periods
OTC medications not recommended
Usually viral so no antibiotics

Pharyngitis*80-90% are viral!
Strep throat at risk for scarlet fever, rheumatic fever, and acute glomerulonephritis
Culture

Clinical Manifestations:
Pharyngitis, tonsillar exudate, headache, fever, abdominal pain,
Strawberry tongue, a fine sandpaper rash, clear nasal airways - more indicative of Strep
Manifestations subside in 3-5 days but can be complicated with a peritonsillar abscess or sinusitis.
Acute glomerulonephritis can follow in 10 days or rheumatic fever in 18.

Treatment/Management:
Supportive care for viral
Warm salt water gargles, Nonsapirin analgesics (Tylenol and Motrin) for the pain, throat lozenges
Soothing liquids for hydration, rest
Bacterial rx: Penicillin G, deep IM, make sure parents understand that they may limp after the injection

Oral antibiotics preferred for this reason
Erythromycin if allergic to PCN.
Need to return if not significantly better in 24-48 hours.
Change toothbrush!


Strep:


Tonsillitis
Tonsils are masses of lymphoid tissue in the pharyngeal area.
Children have larger tonsils
Tonsillitis often accompanies pharyngitis, most are viral
Kissing tonsils makes swallowing difficult
Inflammed Adenoids makes breathing through the nose difficult

Tonsillectomy
Three or more infections despite adequate therapy
Not recommended if cleft palate, current infection or blood disorders
Not recommended for child less than 3 due to possibility of excessive blood loss Not recommended for child less than 3 also as lymphoid tissue can grow back!
Tonsillectomy Care:
Preparation for surgery

Diagnosis/OutcomesRisk for fluid deficit/ adequate hydrationPain/ minimize painRisk for injury (bleeding) due to incision/ observe for bleeding, no tongue blades, rough foods etc.
Interventions:
Placed on side post surgery to promote drainage
Soft liquid diet (cool, non carbonated, non-acidic), popsicles or drinks not red
Cool mist vaporizer
Throat lozenges
Tylenol, opioids, zofran
No coughing, clearing throat, blowing nose, vigorous toothbrushing

*Membrane forms over operative site, starts to pull off between 4 and 10 days
Hemorrhage may occur up to 10 days, sloughing of tissue
Frequent swallowing, restlessness, tachycardia can indicate bleeding!

Influenza

Types A, B and C
School children
Can be mild, moderate or severe


Clinical Manifestations:
Dry cough, throat, photophobia, myalgia, chills, fever, exhaustion

Treatment/Management:
Symptomatic care Tylenol, Motrin, fluids, rest
Amantadine hydrochloride – Symmetrel within 24-48 hours –for A
Zanamivir, Rimantadine, Tamiflu for A or B
Flu vaccines injectable or nasal (live)
No nasal for asthma, immune compromised, allergy eggs, hx Guillain-Barre
Greatest danger secondary infection


Otitis Media
This video is really cool as you can see the actual infected drum!

Otitis Media (OM), Acute Otitis Media (AOM),
Otitis Media with Effusion (OME)
Eustachian tubes protect from nasopharyngeal secretions (wider, straighter, shorter in infants)
Promote drainage of middle ear secretions into the nasopharynx, Ventilation of middle ear and to equalize air pressure
One of the most prevalent childhood diseases
Often preceded by respiratory infection
Most common in first 24 months of life
Rare after age 7
Factors affecting: Infections, feeding techniques, smoke exposure, daycare
Causes:
Streptococcus pneumoniae, H. influenzae, Moraxella catarrhalis

Pneumococcal disease


Clinical Manifestations:
Infant - fussy, crying, pulls ear, rolls head side to side, no appetite
Child – c/o pain, crying, irritability, lethargy, loss of appetite
Chronic – 3 or more in 6 months, can cause hearing loss, tinnitus, vertigo

Nursing diagnosis/ Outcomes:

Pain/ pain free
Infection/ afebrile
Delayed growth and evelopment/ no hearing loss
Fluid volume deficit/ adequate output

Treatment/Management:
Therapeutic antibiotics
Pain management
Prevent complications
Education: feeding practices, smoking
Tympanostomy – surgical placement of tubes, grommets, for air equalization
Myringotomy – surgical incision for drainage
If grommet falls out not an emergency but notify Dr.

Infectious Mononucleosis
Infectious Mononucleosis
Epstein-Barr virus (EBV)
Transmitted in saliva
Mildly contagious
Onset 10 days to 6 weeks after exposure
The spot test (Monospot)

Clinical Manifestations:
Headache, malaise, fatigue, chills, fever, loss of appetite, puffy eyes, sore throat, cervical adenopathy, Pharyngitis, tonsillitis, splenomegaly*, *rash often after antibiotics administered

Therapeutic Management:
No specific treatment
Rest, maybe activity restriction, analgesics, gargles, hot drinks
Antibiotics only in case of strep
Corticosteroids only in case of significant inflammation, anemia, thrombocytopenia or neurologic complications
Acute symptoms disappear in 7-10 days
Fatigue diminishes in 2-4 weeks

Croup Syndromes:

Epiglottitis:
*Is a severe life threatening emergency!
It is often caused by Haemophilus influenzae.

Hib



This is one of the vaccines administered at 2, 4, 6 months and at 15 months. It is known as ACT HIB (4 doses) or Pedvax (3 doses).
Clinical Manifestations:
Sudden onset.
Restlessness, high fever, sore throat
Dysphagia, drooling, muffled voice and tripoding.

Nursing Care:
*Do not examine the throat of a child with suspected epiglottitis, this can cause a spasm and close the airway*

Be prepared for a possible intubation or tracheostomy
Prepare for hospitalization in the ICU
Employ measures to decrease agitation
Administer antibiotics as prescribed
Maintain the child's positioning for optimum oxygenation (sitting)

Bacterial Tracheitis - similar to epiglottitis
Croup Syndromes: Acute Laryngitis, Acute Spasmodic Laryngitis

































Croup:
Most common between 6 and 36 months (<7)
Peaks in Autumn
Swelling of the trachea, with or without inflammation and mucous

Manifestations:
Hoarse barking cough, sudden onset, often at night
Stridor, retractions

Diagnosis:
Based on history, CBC, x-rays

Treatment:
Steroids, (dexamethasone) orally or IM
Nebulized epinephrine
O2, hydration, Antipyretics, Anxiety reduction, Humidifier, Cool night air



Bronchiolitis:
RSV (Respiratory Syncytial Virus) most common cause of bronchiolitis in children < 1 (75%)
Bronchiolitis peaks November to March
Factors affecting incidence: prematurity, siblings, exposure to tobacco
Narrowing of bronchioles leads to air trapping (hyperinflation) in alveoli and atelectasis (collapse)

Manifestations:
Present with cold like symptoms then progresses after several days
Irritable, coughing, anorexia, nasal congestion, nasal flaring, tachypnea, prolonged expiratory phase, wheezing, rales and a deteriorating respiratory condition.
Leading to poor feeding and respiratory fatigue

Nursing diagnosis/Outcomes:
Ineffective airway clearance/ clear lungs
Deficient fluid volume/ Output 1ml/kg/hr
Knowledge deficit/ educate about management

Nursing Actions:
Isolate - spread by droplet but contact isolation preferable
Monitor respiratory status
Bulb syringe
O2, raise head of bed
*Consolidate care (so frequent rest periods)

Hydrate, IV for hydration or feeding with frquent rest periods (I&O)
Mist or nebulized medications as needed
Antiviral agent - Ribavirin

*Palivizumab (Synagis) provides passive immunity for high-risk children. This series is generally only offered to children born prematurely with several co-morbidities. It is offered monthly (every 28 days) November to March. It is extremely expensive!*































Pneumonia


Tuberculosis





















Be aware that Tuberculosis is screened for using the Mantoux test with PPD (tuberculin purified protein derivative). This is an intradermal injection most commonly administered on the left forearm. It is read with in 48-72 hours. A reaction to the PPD indicates exposure to the bacterium.

Foreign Body Aspiration

ARDS - Acute Respiratory Distress Syndrome

Asthma



Inflammatory Reactive Airway Disease/Asthma
Characterized by edematous airways clogged with mucous
Smooth muscles of bronchi and bronchioles constrict
Air trapping occurs

Nursing Actions:
Monitor for respiratory distress
Administer bronchodilators and steroids as ordered, everyday meds, (maintanence meds) or emergency meds (rescue meds)
Maintain hydration
O2 and nebulizer therapy
Monitor blood gases and O2 sats, should be greater than 95%
Teach! Triggers, Allergens, use of metered dose inhaler (MDI), management







Cystic Fibrosis




Autosomal recessive disorder
Characterized by dysfunction of the exocrine glands impacting the lungs, pancreas, sodium and chloride levels.
Meconium ileus at birth approximately 10-20% of the time
recurrent respiratory infection characterized by copious mucous
Steatorrhea (fatty, greasy stools), foul smelling
Delayed growth, poor weight gain
Skin tastes salty
Cyanosis, CHF, nail bed clubbing appear later due to continued compromise

Nursing Actions:
Monitor respiratory status, observe for infection and distress
Administer antibiotics, pancreatic enzymes, and O2 treatments as ordered
Administer vitamins
Teach family about dietary needs - high calories, high protein, moderate to high fat, and low carbohydartes
Teach postural-drainage, percussion
Note the need for 'tune-ups'

*What is Bronchopulmonary dysplasia (BPD)?







References:

Hockenberry, M. J., & Wilson, D. (2009). Wong's essentials of pediatric nursing (8th ed.). St. Louis, MO: Mosby Elsevier.

Potts, N. L., & Mandleco, B. L. (2012). Pediatric nursing: Caring for children and their families (3rd ed.). New York, NY: Delmar Cengage Learning.

Videos:

Respiratory picture with captions
http://schoolbag.info/biology/humans/19.html

Breath sounds by Adam
https://youtu.be/O8OC7EiqBKQ

Breath Sounds by cararose17
http://youtu.be/NnuaHGW1cwU

Grunting/retractions by Jeremy Spangle
http://youtu.be/NBA9iigiDgk

Strep
https://youtu.be/8GucjMGONfI

Flu Attack by National Geographic
http://youtu.be/TVLo2CtB3GA

Otitis Media by theedexitvideo
http://youtu.be/UBobShigoFk

Otitis media/ruptured ear drum
https://youtu.be/8keTRPAuvKg

Mono by Children's Physician Medical Group
http://youtu.be/V2QkL9J_pXc

Stridor by Juliette Anderson
http://youtu.be/Qbn1Zw5CTbA

Croup
https://youtu.be/cUo-I-3DmXA
RSV at St. Joseph's Children's Hospital by ABC
http://youtu.be/4yjVD5jNY4Y

Pertussis Cough by Paul Gallagher
http://youtu.be/wuvn-vp5InE

Pneumonia
http://youtu.be/cWQ14x1URXo

TB by the CDC uploaded by Paul Cochrane
http://youtu.be/u7o93nmgp1E

Asthma by Bupa
http://youtu.be/vlZ7R07OrR4

Inhalers by Children's Hospital St. Louis
http://youtu.be/A7DhGX0p1KY

Asthma meds by Medicine Coach
http://youtu.be/hyahVlGISvc

Cystic Fibrosis by MedRise
http://youtu.be/l0dDhKFk2HU

Cystic Fibrosis
http://youtu.be/GGbuXM1ScSg
https://youtu.be/AlOIKzMWqcQ
BPD
http://youtu.be/36Ndn0UZWgg