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Alteration in Respiratory Function Jan Bazner-Chandler RN, MSN, CNS, CPNP Allergic Rhinitis Assessment Itching of nose, eyes, and throat Sneezing and stuffiness Watery nasal discharge / post nasal drip Watery eyes Swelling around the eyes Assessment Allergic Shiner eMedicine.com Allergic Salute Rhinitis Interdisciplinary Interventions Avoid offending allergen – smoke / pets Pharmacologic management: Oral or nasal antihistamines - Benadryl Leukotriene modifiers - Singulair Mast cell stabilizers – cromylin – nasal / ophthalmic / inhaled Allergen-specific immunotherapy Do not use combination OTC medications especially those that contain pseudoephedrine No OTC Antihistamines for children under 6 years of age. Sinusitis Adam.com Assessment Fever Purulent rhinorrhea Nasal congestion Pain in facial area Malodorous breath Chronic night-time cough Children more prone to sinusitis: children with asthma and cystic fibrosis. Interdisciplinary Interventions Normal saline nose drops Warm pack to face Acetaminophen for pain Increase po fluid intake Antibiotics Recent studies question their effectiveness Tonsillitis Tonsils and adenoids are important to the normal development of the body’s immune system. Serve as part of the body’s defense against infection Can become the site of acute or chronic infection Repeated acute infections cause the tonsil tissue to swell Enlarged tonsils and adenoids impinge on the pharyngeal opening of the eustachian tube Assessment Child may refuse to drink Fever Reddened pharynx and tonsils Most common causative agent = group A beta-hemolytic stretococci Chronic tonsillitis may result in snoring due to enlarged tonsils and adenoids Tonsilitis “Kissing tonsils” occur when the tonsils are so enlarged they touch each other. Interdisciplinary Interventions Throat culture to determine causative agent Antibiotics for ten days if throat culture positive for beta strep Acetaminophen for pain Cool fluids Saline gargles Antiseptic sprays Viral throat infections will not get better faster with antibiotics. Tonsillectomy Done if child’s respiratory status is compromised Post operative care: Side lying position Ice collar Watch for swallowing Cool fluids / soft diet Croup Most common acute respiratory condition seen in early childhood. Highest incidence from 6 months to about 3 years Respiratory symptoms are caused by inflammation of the larynx and upper airway, with resultant narrowing of the airway. Severity depends on the area of the upper airway that is inflamed and narrowed. Most often viral – antibiotics are not needed Assessment Symptoms: Hoarseness Inspiratory stridor Barking cough Afebrile Often worsens at night Interdisciplinary Interventions Home care: Cool mist Fluids Hospital care: Racemic epinephrine inhalant Mist tent – not used much anymore Dexamethasone IV fluids if not taking po fluids Epiglottitis Bowden & Greenberg Tripod position Acute Epiglottitis Acute inflammation of supraglottic structures, the epiglottis and aryepiglottic folds. True pediatric emergency Delayed treatment may result in complete airway obstruction Most often seen in children 2 to 7 years Most common causative agent – H. influenzae type B Assessment Sudden onset High fever – 102.2 or greater Dysphasia and drooling Agitation, irritability and restlessness Epiglottis is cherry red and swollen Note: Do not look into the mouth – diagnosis often made by presenting symptoms or lateral neck x-ray Interdisciplinary Interventions Keep child quiet in a controlled medical environment with emergency airway equipment readily available. Do not put tongue blade in mouth to look in the throat – may cause epiglottis to spasm and shut Assess respiratory status Give humidified oxygen by mask and keep HOB elevated. Mild sedation may help the child relax Apnea Apnea is cessation of respirations lasting longer than 20 seconds. Monitor in hospital for underlying problems Discharge home with monitor Foreign Body Severe inspiratory stridor Symptoms depend on location Unilateral chest movement Chest x-ray Bronchoscope to remove object Coin in Trachea Teaching No small hard candies, raisins, popcorn or nuts until age 3 or 4 years Cut food into small pieces No running, jumping, or talking with food in mouth Inspect toys for small parts Keep coins, earring, balloons out of reach Influenza Associated with community epidemic Febrile, URI, achy joints Management: Acetaminophen for fever Fluids Keep away from others Watch for signs of pneumonia Hypoxia, high fever, increase work of breathing Bronchiolitis Acute obstruction and inflammation of the bronchioles. Most common causative agent: Respiratory Syncytial Virus (RSV) Bronchioles become narrowed or occluded as a result of inflammatory process, edema, mucus and cellular debris clog alveoli Assessment Harsh dry cough Low grade fever Feeding difficulties Wheezing Respiratory distress with apnea Thick mucus Interdisciplinary Interventions Oxygen to maintain oxygen saturation >than 95% Pulse oximeter Nasal suction as needed Chest percussion to mobilize secretions Inhalation therapy – not sure if it is beneficial Mechanical ventilation as needed if increased work of breathing is seen Increased heart rate, poor peripheral perfusion, apnea, bradycardia and hypercarbia RSV Positive - Isolation Respiratory Syncytial Virus is spread from respiratory secretions through close contact with infected persons or contact with contaminated surfaces or objects. Hospitalized patients should be on contact and respiratory isolation Can be placed with other RSV + patients Family members: use hand washing to decrease spread Pneumonia An inflammatory condition of the lungs in which alveoli fill with fluid or blood resulting in poor oxygenation and air exchange. Can be primary illness or develop as a complication of another illness. Incidence: 34 to 40 cases per 1000 children younger than 5 years Most likely to develop when the body is unable to defend against infectious agents. Typical X-ray Assessment High fever Thick green, yellow, or blood tinged secretions Grunting respirations Rales, crackles, diminished breath sounds Cough and cyanosis Increased work of breathing Hypoxia: oxygen saturations less than 92 % on room air Diagnostic tests: Infiltrate seen on x-ray Interdisciplinary Interventions • • • • • • • • Assess for respiratory distress NPO (respiratory rate > 60 = high risk for aspiration) IV fluids for hydration Supplemental Oxygen to keep oxygen saturation equal to or > 92% Chest percussion Nasal suctioning as needed Acetaminophen for fever Antibiotics – Ceftriaxone (3rd generation cephaloporin) Pneumonia Isolation Respiratory isolation May be taken off isolation if RSV negative and on antibiotics for 24 hours. Cystic Fibrosis Inherited autosomal recessive disorder of the exocrine glands Gene responsible for CF is located on chromosome 7 Life span is about 37 years Complex disease requiring a holistic approach CFTR Gene Mutation of the CFTR gene disrupts the function of the chloride channels, preventing them from regulating the flow of chloride ions and water across cell membranes. As a result cells that line the passage ways of the lungs, pancreas and other organs produce mucus that is thick and sticky Cystic Fibrosis Cystic Fibrosis Assessment History of Meconium ileus at birth Foul smelling, greasy, bulky stools / constipation Voracious appetite with poor weight gain Recurrent respiratory infections Persistent chronic cough Salty tasting skin Diagnosis Positive sweat test – Gold standard Genetic marker Medications Pancreatic enzymes to help digest food Inhaled antibiotics – antimicrobial for lung treatment Aerosol bronchodilators to open airways Mucolytic enzyme – to thin mucus H2 blocker – alters gastrointestinal acidic environment Prokinetic agents – enhances gastrointestinal motility Tagamet Reglan Vitamin C to improve absorption of other meds Vitamins E, A, D, K / fat soluble vitamins Oral and IV antibiotics – S. aureus, H. influenzae, P aeruginosa Long Term Complications Nasal polyps Sinusitis Rectal polyps / rectal prolapse Hyperglycemia / diabetes Infertility - male Asthma Asthma is a chronic, inflammatory lung disease involving recurrent breathing problems. Third leading cause of hospitalization among children younger than 15 years. Most common, chronic health problem in children Pathophysiology Reversible changes in airway that lead to bronchoconstriction, airway hyper-responsiveness and airway edema. At the cellular level mast cells release histamine causing smooth muscle contraction and bronchoconstriction. Increased mucous secretion by goblet cells causes epithelial damage Increased mucus secretion results in airway edema, mucus hypersecretion and plugging, airway narrowing, leading to airway obstruction Assessment Wheezing Cough Tightness of chest Prolonged expiratory phase Assessment Hypoxemia – universal in child with moderate to severe symptoms Hypercarbia – carbon dioxide retention from air trapping in the alveoli and ventilation – perfusion mismatch Monitor blood gases – PaCO2 level more than 50 mm Hg indicated ventilatory failure Diagnostics: chest x-ray = hyper-expansion of lungs Asthma Attack Interdisciplinary Interventions High fowlers position / bed rest Pulse oximetry Nebulized albuterol – beta 2 agonist Chest percussion to mobilize secretions Methylprednisone / Solu-medrol IV IV fluids / po fluids Oxygen to keep oxygen sats > 95% Home Management Peak flow spirometer Identify triggers Maximize lung function Optimal physical growth Optimal psycho-social state Maximum participation Peak Flow Meter Peak flow meters are used to measure PEFR and are designed for monitoring purposes rather than diagnosis of asthma. Home Medications Rescue drugs: short acting albuterol beta 2 agonist – used as a quick-relief agent for acute bronchospasm and for prevention of exercise induced bronchospasm. Anti-inflammatory or preventative: low-dose inhaled corticosteroid: inhaled or oral prednisone Allergy: leukotrines such as Singulair Bronchodilators Bronchodilators rapidly relax the airway smooth muscle cells, thus reversing the bronchospasm until antiinflammatory effect of steroids is attained. Aerosols Via mouth piece 3 years and older Via facial mask for less than 3 years Spacer mdi About.com: pediatrics Nebulizer About.com: pediatrics Corticosteroids Steroids reduce the inflammatory component of bronchial obstruction, decrease mucus production and mediator release, as well as the late phase (cellular) inflammatory process. Methyl prednisone IV in severe cases May need histamine H2 receptor antagonists (cimetadine or ranitidine) if experiencing GI upset PO prednisone – always give with food to decrease GI upset Inhaled Corticosteroids Inhaled corticosteroids: Pulmicort, AeroBid, Flovent Infant: mask should fit firmly to prevent cataracts Older child: rinse and spit after treatment to prevent thrush Family Teaching Teach how to use medication When to use and how often No OTC drugs Increase fluid intake Signs and symptoms of respiratory distress Neonate Disorders Bronchopulmonary Dysplasia Pediatric Nursing January/February 1999 History It occurs in newborns who are born prematurely and or have a variety of pulmonary disorders and who require ventilatory support with high pressure and oxygen in the first 2 weeks of life. Pathophysiology Fibrosis of airways and marked hyperplasia of the bronchial epithelium Increased fluid in the lungs, as a result of disruption of the alveolar-capillary membrane Over distention due to damage to alveolar supporting structures resulting in air trapping Fibrosis, airway edema, and broncho-constriction BPD Assessment Persistent respiratory distress Dependent on supplemental oxygen Failure to thrive Gastro-esophageal reflux Pulmonary hypertension Long-term Outcomes Oxygen dependent Visual problems Feeding difficulties Developmental delay Learning difficulties Long Term Management Supplemental oxygen CPT Bronchodilators Diuretics (pulmonary hypertension) Anti-inflammatory medication Nutritional support: po formula + NG supplement Gastrostomy tube (GER) Bicarbonate in formula due to chronic state of acidosis
