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OXYGENATION VENTILATION TISSUE PERFUSION K. Choppi MSN Ed, RN, CPEN - 2013 Overview • Anatomy & Physiology Differences • Respiratory Distress vs. Failure • Airway Issues • Interventions • Acute Respiratory Conditions • Chronic Respiratory Conditions Objectives • Describe unique characteristics of pediatric • • • • • respiratory system Describe development of child’s respiratory system List respiratory conditions and injuries that cause respiratory distress in children Distinguish between mild , moderate, and severe respiratory distress Differentiate between signs and symptoms of upper and lower airway conditions Develop nursing care plans for children with acute and chronic respiratory conditions Anatomy & Physiology of Pediatric Differences • Upper Airway • Shorter & Narrower • Greater potential for obstruction • Trachea higher & different angle • Newborns obligatory nose breathers • Lower Airway • Less alveoli • Bronchi & bronchioles are lined with smooth muscle • Diaphragm breathers Airway Comparison Airway Comparison Respiratory Distress • Mild • Tachypnea • Tachycardia • Diaphoresis • Moderate • Flaring • Retractions • Grunting • Anxiety • Headaches Normal appearance Increase work of breathing Normal circulation to the skin Respiratory Failure • Dyspnea • Bradycardia • Altered level of consciousness • Lethargy • Cyanosis Abnormal appearance Increased or Decreased work of breathing Pale cyanotic skin color Respiratory Distress/Failure Interventions • Oxygenation • Positioning • Fluids • Medications • Bronchodilator • Anti-inflammatory • Corticosteroid Upper Airway Disorders • Signs & Symptoms • Tachypnea • Increased inspiratory effort • Changes in voice (snoring or High pitched stridor) • Poor chest rise • Poor air entry on auscultation • Intervention • Maintain position of comfort • Oxygen as tolerated • Suction as needed Lower Airway Disorder • Signs & Symptoms • Tachypnea • Wheezing • Expiratory more common, can have inspiratory wheezing • Prolonged expiratory phase • Cough • Intervention • Reverse bronchospasm • Improve hypoxia • Correct dehydration Disease/Fluid of the Lungs • Signs & Symptoms • Tachypnea • Tachycardia • Increased respiratory effort • Grunting • Hypoxemia • Crackles • Diminished breath sounds • Interventions • Antimicrobial therapy • Nebulized bronchodilator • CPAP/BiPAP • O2 Disordered Control of Breathing • Signs & Symptoms • Inadequate respiratory rate • Inadequate effort of breathing • Inadequate rate and effort • Interventions • Positive pressure ventilations • Definitive airway Airway Interventions • Basic • Allow the child to stay in a position of comfort • Use head tilt chin lift or jaw thrust to open the airway • Avoid over extending the head/neck in infants • Advanced • Intubation • CPAP • Cricothyrotomy Peds Pearl Anatomic Problem Physical Sign • Upper airway obstruction • Stridor • Lower airway obstruction • Wheezing • Disease/Fluid of the lungs • Crackles • Disordered control of • Inadequate RR, effort or breathing both Acute Respiratory Conditions • Aspirations • Foreign body • Croup Syndromes • Laryngotracheobronchitis • Epiglottitis • Bacterial tracheitis • Bronchiole/Alveolar Infection/Inflammation • Bronchitis • Bronchiolitis • Pneumonia Acute Respiratory Conditions • Conditions of Infancy • Apnea • Apparent Live Threatening Event (ALTE) • Sudden Infant Death Syndrome (SIDS) Airway Obstruction • Foreign body • Infants over 6 months of age • Aspiration • Food (solid or liquid), • Non food (toy) • Interventions • Maintain airway • Maintain position of comfort • Reduce anxiety of child and parent • Nursing Care • Childproofing home • CPR Croup Syndromes • Upper airway • Viral • Spasmodic laryngitis • Larygotracheitis • Laryngotracheobronchitis (LTB) • Bacterial • Bacterial Tacheitis • Epiglottis • Nursing Care • Airway support • Drug therapy • Emotional support Bronchiole/Alveolar Infection/Inflammation • Lower Airway • Bronchitis • Viral or bacterial • Trachea and bronchi • Bronchiolitis • Viral or bacterial • Inflammation & obstruction of the bronchioles • Peak age 2-6 months • Pneumonia • Viral, bacterial, or mycoplasmal • Inflammation or infection of the bronchioles and alveolar space • Nursing care • Maintaining respiratory function • Decreasing stress/promoting rest Apnea • ALTE • Greater than 37 weeks • Peak between 1 week and 2 months • Causes include • Infection • Gastroesophageal reflux • Seizures • Cardiac arrhythmias • Metabolic or endocrine problems • Nursing Care • Provide emotional support • Encourage parent participation in care • CPR for parents Sudden Infant Death • Pathophysiology • Genetic • Clinical Manifestations • Cardiopulmonary arrest • Seasonal • Nursing Care • Supportive Care for Family • Back to sleep Chronic Respiratory Conditions • Bronchopulmonary Dysplasia (BPD) • Asthma • Cystic Fibrosis • Systemic exocrine disorder Bronchial Pulmonary Dysplasia • Risk factors • Prematurity • Symptoms • Persistent signs of respiratory distress • Tachypnea • Wheezing, crackles, • Irritability • Nasal flaring, grunting, retractions • Interventions • Supportive care • Diuretics • Bronchodilators • Steroids Asthma • Factors • Environmental exposure • Viral illnesses • Allergens • Genetic predisposition • Symptoms • Breathing difficulty • Cough, wheezing, or shortness of breath • Interventions • Medications • Asthma action plan • Maintaining airway patency • Fluids • Rest Health Promotion • Triggers • Changes in weather • Dust/allergens • Smoke • Peak Flows • Green zone 80% - 100% • Yellow zone 50% - 80% • Red zone below 50% Cystic Fibrosis • Pathophysiology • Defective chloride-ion transport & decreased water flows • Abnormal accumulation of viscous mucous • Manifestations • Production of thick sticky mucus • Meconium ileus • Chronic moist productive cough • Frequent respiratory infections • Diagnosis • Sweat Chloride test (60 mEq/l) Cystic Fibrosis • Assessment • Physiologic • Psychosocial • Developmental • Respiratory Therapy • Chest Physiotherapy • Prophylactic antibiotics • Nutrition • Diet • Fat soluble vitamins • High protein • High caloric diet • Pancreatic Enzymes • Discharge Planning Cardiac Overview • Pulmonary Circulation • Cardiovascular Changes • Anatomical Differences • Assessment • Congestive Heart Failure • Congenital Heart Defects • Acquired Heart Defects Objectives • Discuss Pulmonary Circulation • Verbalize the Cardiovascular Changes that Occur • Describe the Anatomical Differences • Demonstrate a Cardiac Assessment • Summarize Congestive Heart Failure • Construct a Nursing Care Plan for a Child in CHF • Differentiate between Congenital Heart Defects • Discuss the differences between Acquired Heart Diseases Pulmonary Circulation • Oxygenated Blood • Pulmonary Vein to Left Atrium Aortic Valve to Aorta Mitral Valve, to Left Ventricle, Rest of Body • Deoxygenated Blood • Superior Vena Cava, to Right Atrium, Tricuspid Valve, to Right Ventricle, then Pulmonary Valve to Pulmonary Artery Lungs Cardiovascular Changes • Fetal to Pulmonary Circulation • Must shift within a few hours after birth • Increased left arterial pressure • Closure of foramen ovale • Higher O2 levels • Close ductus arteriosus Anatomical Differences • Cardiac • Compliance • Contractility • Stroke volume • Compensatory mechanisms Cardiac Assessment • Apex • 4th ICS left of the MCL • Apical pulse • Auscultate • Murmurs • S3 • Pulses • Infant • Brachial • Femoral Congestive Heart Failure (CHF) • Insufficient Cardiac Output • Circulatory and metabolic needs unmet • Due to Heart Problems • Congenital defects • Loss of contractility • Damage due to disease Pathophysiology • Blood volume overload • Obstructive congenital defects CHF • Signs & Symptoms • Infants • Tires easily when feeding • Loses weight • Sweats • Irritable • Prone to infections • Children • Exercise Intolerance • Dyspnea • Abdominal Pain • Peripheral Edema • Skin Mottling • Pallor Progression • Tachycardia • Tachypnea • Nasal Flaring, Grunting • Crackle • Signs of Fluid Retention • Edema in face • Jugular vein distension • Hepatomegaly • Cardiomegaly Clinical Manifestations CHF Cause Clinical Manifestations Pulmonary venous congestion Tachypnea, wheezing, crackles, retractions, cough, grunting, nasal flaring, feeding difficulties, irritability, tire with play Systemic venous congestion Hepatomegaly, ascites, peripheral edema Impaired cardiac output Tachycardia, diminished pulses, hypotension capillary refill time greater than 2 seconds, pallor, cool extremities, oliguria High metabolic rate Failure to thrive or slow weight gain Treatment Goals • Reduce Cardiac Workload • Treatment: rest, oxygen • Improve Cardiac Output • Treatment: digoxin, positioning • Remove Excess Fluid • Treatment: diuretics Drugs Drug Action Digoxin Increases myocardial contractility improving systemic circulations Furosemide Rapid diuresis Thiazides Maintenance diuresis, decreased absorption of Chorothiazide sodium, water, potassium, chloride, and Hydrochorothiaze bicarbonate in renal tubules Spironolactone Maintenance diuresis (potassium sparing) ACE inhibitors Promotes vascular relaxation and reduced peripheral vascular resistance Propranolol Increased contractility Nursing Diagnosis • Decreased Cardiac Output • Fluid Volume Excess • Risk for Altered Skin Integrity • Altered Nutrition: Less than Body Requirements • Ineffective Family Coping Nursing Interventions • Careful Medication Administration • Digoxin, Diuretics • Rest • Plan activities, feeding schedule • Protect Skin • Promote High-Calorie Nutrition Family Teaching • Medications • Administration, side effects • Support • Child: effects of disease, treatment • Family: emotional, financial impact • Optimize Development • Physical • Cognitive Congenital Heart Defects • More than 35 Known Defects • Begin during first eight weeks of fetal development • Survivability greater than 85% • Classified by Change in Blood Flow • Increased pulmonary • Decreased pulmonary • Obstructed systemic • Mixed systemic and pulmonary Increase Pulmonary Blood Flow • Pathophysiology • Septal defects (ASD, VSD) • Great arteries (PDA) • Atrioventricular Canal (AV canal) Decreased Pulmonary Blood Flow • Pathophysiology • Pulmonic Stenosis • Tetralogy of Fallot • Pulmonary or Tricuspid Atresia Mixed Blood Flow • Pathophysiology • Transposition of the Great Arteries • Truncus Arteriosus • Total Anomalous Pulmonary Venous Return Obstructed Blood Flow • Pathophysiology • Aortic Stenosis • Coarctation of the Aorta • Hypoplastic Left Heart Congenital Heart Defects • Signs & Symptoms • Auscultation • Murmurs, fluid in lungs, tachypnea • Inspections • Cyanosis, pallor, squatting, edema in face, fatigue • Poor weight gain • Palpation • Diminished pulses • Peripheral edema Nursing Care • Nursing Diagnoses • Delayed growth and development • Ineffective management of the therapeutic regiment • Imbalanced nutrition: Less than bodily requirements • Activity Intolerance • Caregiver role strain Nursing Care • Nursing Interventions • Optimize cognitive and physical development • Administer medications • Know and teach side effects • Reduce fatigue • Teach positioning • Optimize nutrition • Offer support to parents Heart Surgery • Preoperative • Assess for CHF • Teach surgical and post operative expectations • Provide support for uncertain outcome • Parental role • Promote good nutrition • Prevent infection • Ensure that immunizations are up to date Heart Surgery • Teach Child • Surgical experience and expectations • Expected sensations • Postoperative experience • Postoperative Care • Pain control • Prevent complications, • Infection, arrhythmia, impaired tissue perfusion • Manage fluids • Careful I/O • Carefully increase activity level Acquired Heart Diseases • Rheumatic Fever, • Infective Endocarditis • Kawasaki Disease Rheumatic Fever • Pathophysiology • Exact cause unknown • Autoimmune • Aschoff’s bodies • Diagnosis • Antistreptolysin O (ASLO) • Treatment • Antibiotics • Aspirin Nursing Care • Vital signs • Temp • Control joint pain • Alternate hot/cold compress • Limit physical exercise • Follow up Infective Endocarditis • Pathophysiology • Inflammation • Bacterial • Enteroccocci • Fungal • Diagnosis • Blood culture • Elevated ESR • Changes in EKG • Treatment • Antibiotics • Surgery to replace heart valves Kawasaki Disease • Pathophysiology • Inflammatory illness • Unknown etiology • 3 stages • Acute • Subacute • Convalescent • Diagnosis • Clinical signs • Elevated ESR • Treatment • IV Immunoglobulin • Aspirin Shock • Inadequate tissue delivery • Not dependent of blood pressure • Types • Hypovolemic • Distributive • Septic • Anaphylactic • Neurogenic • Cardiogenic • Obstructive Treatment of Shock • Goal • To improve O2 delivery. • Components of O2 delivery • Sufficient O2 in the blood • Adequate blood flow to the tissues (cardiac output) • Appropriate distribution of blood flow to the tissues Hypovolemic • Most common • Volume loss • Diarrhea, vomiting, hemorrhage, osmotic diuresis (DKA), third space losses • Decreased preload leading to reduced stroke volume and low cardiac output • Tachycardia, increased SVR, and increased cardiac contractility • Increased afterload Primary Assessment Clinical signs Airway Typically patient unless level of consciousness is significantly impaired Breathing Tachypnea without increased effort Circulation • Tachycardia • Adequate systolic blood pressure, narrow pulse pressure, • Weak or absent peripheral pulses • Delayed cap refill • Cool to cold, pale, mottled, diaphoretic skin • Dusky/pale distal extremities • Oliguria Disability Changes in level of consciousness Environment Extremities often cooler than trunk Treatment • Fluid resuscitation • 20ml/kg isotonic crystalloid rapidly • Failure to improve after 3 boluses indicate • Under estimated of fluid loss • May need colloid or blood • Ongoing fluid loss • Etiology of shock is wrong • Blood replacement • PRBC 10ml/kg bolus (warmed) • Whole blood 20ml/kg Distributive • • Inappropriate distribution of blood volume with inadequate organ and tissue perfusion Types – Septic • • – Reduced or increased SVR (vasodilation) Increased capillary permeability (loss of plasma in vascular space) Anaphylactic Vasodilation with pulmonary vasoconstriction – Neurogenic • Loss of vascular tone (high cervical spine injury) Primary Assessment Clinical signs Airway Usually patent unless change in level of consciousness Breathing Tachypnea without increased work of breathing Circulation • • • • Disability Changes in level of consciousness Environment • Fever or hypothermia • Extremities warm or cool • Petechial or purpura rash (septic shock) Tachycardia Bounding peripheral pulses Brisk or delayed cap refill Warm, flushed skin peripherally (warm shock) or Pale, mottled skin with vasoconstriction (cold shock) • Hypotension with a wide pulse pressure (warm shock) or Hypotension with a narrow pulse pressure (cold shock) • Normotensive • Oliguria Septic shock • Repeated 20ml/kg boluses of isotonic crystalloid • • • • • or more) Correct hypoglycemia and hypocalcaemia Administer first dose of antibiotics Normotensive – begin dopamine Hypotensive vasodilation (warm) shock – begin norepinephrine Hypotensive vasoconstriction (cold) shock – begin epinephrine (3-4 Anaphylactic • IM epinephrine • Fluid boluses 20ml/kg isotonic crystalloids • Albuterol • Antihistamine, corticosteroids • Epinephrine infusion Neurogenic • 20ml/kg isotonic crystalloids (repeat as needed) • Vasopressor • Norepinephrine • Epinephrine • Position the child flat or head down to improve venous return • Provide warming or cooling as needed Obstructive Cardiac output is impaired by a physical obstruction of blood flow • Causes • – Cardiac tamponade – Tension pneumothorax – Ductal dependent congenital heart lesions – Massive pulmonary embolism • Clinical signs vary according to the causes of the obstruction Cardiac Tamponade Primary Assessment Clinical signs Airway Usually patent Breathing Respiratory distress with increased respiratory rate and effort Circulation • Tachycardia • Poor peripheral perfusion (weak distal pulses, cool extremities, delayed cap refill) • Muffled or diminished heart sounds • Narrow pulse pressure • Pulses paradoxus (decrease in systolic blood pressure by >10mm Hg during inspiration) • Distended neck veins (may be difficult to see in infants, especially with severe hypotension) Disability Changes in level of consciousness Environment Extremities often cooler than trunk Intervention • Pericardiocentesis • 20ml/kg isotonic crystalloids Tension Pneumothorax Primary Assessment Clinical signs Airway • Varies (primary cause respiratory distress) • Tracheal deviation towards contralateral side (difficult to see in infants) Breathing • Respiratory distress with increased respiratory rate and effort • Hyperresonance of affected side; hyperexpansion of affected side • Diminished breath sounds on affected side Circulation • Distended neck veins • Pulsus paradoxus • Rapid deterioration in perfusion Disability Changes in level of consciousness Environment Extremities often cooler than trunk Intervention • Needle decompression • Thoracotomy Ductal Dependent Lesions Primary Assessment Clinical signs Airway Usually patent Breathing Respiratory failure with signs of pulmonary edema or inadequate respiratory effort Circulation • • • • Disability Rapid deterioration in level of consciousness Environment Cool skin Rapid progressive deterioration in systemic perfusion Congestive heart failure Higher preductal versus postductal blood pressure Higher (greater than 3% to 4% preductal versus postductalarterial O2 saturation • Absence of femoral pulses • Metabolic acidosis Intervention • Prostaglandin E1 • Consultation Pulmonary Embolism Primary Assessment Clinical signs Airway Usually patent Breathing Respiratory distress with increased rate and effort Circulation • • • • • Disability Changes in level of consciousness Environment Extremities may be cooler than trunk Tachycardia Cyanosis Hypotension Systemic venous congestion and right heart failure Chest pain Intervention • 20ml/kg isotonic crystalloids (repeat prn) • Consider thrombolytic anticoagulants • Consultation Cardiogenic • Inadequate tissue perfusion secondary to myocardial dysfunction • Causes include • Congenital heart disease, myocarditis, cardiomyopathy, arrhythmias, sepsis, poisoning or drug toxicity, myocardial injury • Severe or sustained shock of any type eventually causes impaired myocardial function Cardiogenic Airway Patient, unless level of consciousness is significantly impaired Breathing • Tachypnea • Increased respiratory effort (retractions, nasal flaring, grunting) resulting from pulmonary edema Circulation • Tachycardia • Normal or low blood pressure with a narrow pulse pressure • Weak or absent peripheral pulses • Normal and then weak central pulses • Delayed cap refill • Signs of congestive heart failure • Cyanosis Disability Changes in level of consciousness Environment Extremities often cooler than trunk Intervention Bradyarrhythmia/Tachyarrhythmia ◦ Follow algorithms CHD, Myocarditis, Cardiomyopathy, Poisoning ◦ 5 – 10ml/kg isotonic crystalloids (repeat prn) ◦ Diuretics & vasodilators ◦ Increase cardiac output by improving contractility Milrinone ◦ Cardiology consultation
