Download Disorders of Respiratory Function

Disorders of Respiratory
Function
Chapter 31
Respiratory Disorders

Acute respiratory infections
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


Extremely common
Range from minor to life threatening
Most involve viral pathogens
Bacterial infections involve:



Group A B-hemolytic streptococci
Staphylococcus aureus
Haemophilus influenza
Respiratory Distress Syndrome

Etiology





RDS, idiopathic respiratory distress syndrome,
hyaline membrane disease – severe lung disorder
Major cause of morbidity & mortality in neonatal
period
Deficiency of surfactant
Occurs in preterm, low birth weight infant
More common in males and C-sections
RDS

Etiology


Predisposing factors


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Infants of diabetic
mothers
Asphyxia
Maternal hemorrhage
Shock

Surfactant – reduces the
surface tension of fluids
that line the alveoli,
thereby permitting
expansion of the lungs &
alveolar inflation
Infant unable to keep
lungs inflated, alveoli
collapse



Hypoxia
Atelectasis
Respiratory acidosis
RDS

Clinical manifestations

Signs & symptoms apparent immediately after
birth
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Nasal flaring
Expiratory grunting
Intercostal, subcostal, or substernal retractions
Dusky color
Tachypnea
Low body temperature
Severe cases – die within hours
RDS

Diagnostic tests



Clinical presentation
Radiographic exam
Blood gases – degree of respiratory & metabolic
acidosis
RDS

Medical management

Supportive

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

Correction of imbalances
Oxygen therapy – continually evaluated



Neutral thermal environment
Adequate oxygenation
Prevent hypoxia
Prevent toxic effects
Nutritional support
RDS

Medical management

Administration of exogenous pulmonary surfactant



Has greatly reduced morbidity & mortality
Directly into the lungs
Corticosteroids – before delivery to increase
production of surfactant
RDS

Nursing/Patient teaching



Observing & assessing response to therapy
Continuous monitoring – oxygen therapy
Respiratory assessments




Suctioning as needed – can lead to bronchospasm,
airway damage, infection, pneumothorax, hypoxia, &
increased ICP
Positioning
Skin assessments
Emotional support for parents
RDS

Prognosis



Self limiting
Survive first 96 hours – reasonable chance of
recovery
Surfactant replacement therapy


Improve survival
Reduce the severity
Bronchopulmonary Dysplasia

Etiology


Chronic pulmonary disorder that develops in
premature infants
Associated with:





Meconium aspiration
RDS
High concentrations of oxygen
Positive pressure ventilation
Endotracheal intubation
BPD

Etiology

Chronic lung changes:



Thickening & necrosis of alveolar walls with
impairment of O2 diffusion from the alveoli to the
capillaries
Edema & inflammation of the capillary bed –cause
alveoli to collapse, some to hyperinflate, others to
rupture
Characterized by:



Diffuse infiltrates
Hyperinflation
Chronic pulmonary insufficiency
BPD

Clinical manifestations


Vary widely
Evidence of respiratory distress



Wheezing, retracting, nasal flaring, irritability, abundant
secretions, & cyanosis
More prone to upper respiratory infections
Frequent hospitalizations – poor respiratory status
BPD

Diagnostic tests



No specific tests
Radiographic exam & ABG’s - helpful
PFT – degree of lung dysfunction
BPD

Medical management




Prevent RDS & reduce ventilation & O2
requirements
Use lowest O2 possible
During weaning – bronchodilators used to decrease
airway resistance & increase lung compliance
Nutritional support
BPD

Nursing/Patient teaching





Rest periods – decrease effort & conserve energy
Small frequent feedings – prevent overdistention
of the stomach
Support parents & encourage them to participate
Counsel parents – reduce respiratory infections
CPR
BPD

Prognosis



High mortality rate the first year
Risk for chronic lung disease
Use of surfactant for RDS – greatly reduced
incidence of BPD
Pneumonia

Etiology


Acute inflammation of the pulmonary parenchyma,
small airways, & alveoli
Classified by etiologic agents:

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Bacterial
Viral
Mycoplasmal
Foreign body aspiration
Pneumonia



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
Common throughout childhood
More frequently in infants & young children
Viral pneumonias are more common than
bacterial
RSV - largest percentage of infections in
infants & young children
Bacterial pneumonias – streptococcal,
staphylococcal, pneumococcal, or H.
Influenzae
Pneumonia

Clinical manifestations

Cough
Wheezes or crackles
Respiratory distress
Chest pain
Anorexia
Irritability
Malaise
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Lethargy
Headache
Fever
Myalgia
Abdominal pain
Nasal discharge
Pneumonia

Diagnostic tests



CXR – location & extent
Blood tests – elevated WBC
Culture & gram stain – causative organism

No bacterial microorganism – considered viral
Pneumonia

Medical management



Improving oxygenation
Preventing dehydration
Treatment includes







Antibiotics
O2 therapy
CPT
Suctioning
Fluid administration
Bronchodilators
Antipyretics
Pneumonia

Medical management

Prevention of RSV in premature neonates


Monthly infusions of RSV immune globulin
Delivered outpatient from November through April
Pneumonia

Nursing/Patient
teaching



Respiratory
Skin color
Cardiovascular
Infection control
Supportive nursing

Observation &
assessment




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
Adequate rest periods
Maintain hydration
Gentle suctioning
Encourage parents to
participate in care
Pneumonia

Prognosis

Pneumococcal & streptococcal


Generally good with rapid resolution
Staphylococcal


Longer course
Effective
Sudden Infant Death Syndrome

Etiology





Sudden, unexpected, and unexplained death of a
healthy infant under 1 year of age
Postmortem exam fails to establish a cause
Peak incidence between 2 and 4 months of age
Always occurs during sleep
Leading cause of death in infants between 1 month
and 1 year of age
SIDS

Etiology



Occurs more in males & siblings of SIDS victims
Increased in winter months with peak in January
Associated with:

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Premature birth & low birth weight
Low apgar scores
Multiple births
CNS & respiratory dysfunctions
Maternal smoking, drug addiction, & maternal age <20
SIDS

Etiology



Breast fed infants with lower incidence
Cause unknown
Numerous theories:
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Abnormalities of cardiorespiratory regulation
Prolonged sleep apnea
Depressed ventilatory response
Excessive periodoc breathing
Sleep positions
SIDS

Clinical manifestations


Diagnostic tests


Occurs during sleep with no audible cry or signs of
distress
Postmortem – pulmonary edema & intrathoracic
hemorrhage
Medical management

Assisting the family
SIDS

Nursing interventions





Initial response – shock & disbelief
Guilt & blame
Non judgmental
Listen to & support the family
Grief & mourning
SIDS

Patient teaching

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Visit post death to help with feelings of isolation
Understand the SIDS phenomenon
Assist with siblings’ feelings
Refer to Sudden Infant Death Syndrome Alliance
Prevention

1992 AAP recommended:


Supine or non prone
“Back to Sleep” 38% decline in SIDS cases from 1992 to 1996
Acute Pharyngitis (Sore throat)

Etiology





Inflammation of the pharynx
80% of cases are viral
20% are bacterial – group A B hemolytic
streptococci
Frequently seen in age group of 4 & 12 years
Children < 3 years – usually infected with
Haemophilus influenzae – watch for meningitis
Acute pharyngitis

Clinical manifestations


Viral

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Low grade fever
Malaise
Anorexia
Pharyngeal erythema
Throat soreness
Headache
Cough
Hoarseness
Rhinitis
Conjunctivitis
Streptococcal
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
High fever
Throat soreness
White exudates on the
posterior pharynx &
tonsillar region
Vomiting
Abdominal pain
Diagnostic tests

Throat culture
Acute pharyngitis

Medical management

Viral



Treated symptomatically
Lozenges, gargles, and acetaminophen
Streptococcal

10 day course of antimicrobial therapy
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
Penicillin
Other antibiotics
Acute Pharyngitis

Nursing/Patient teaching

Throat discomfort

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


Relieved with saline gargles, lozenges, warm
compresses, & acetaminophen
Cool liquids
Soft bland foods next
Follow up for strep infections
Instruct the family on antimicrobial therapy
Acute Pharyngitis

Prognosis


Usually excellent
Inadequately treated strep infections


Rheumatic fever
Acute glomerulonephritis
Tonsillitis

Etiology

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

Tonsils are masses of lymphoid tissue believed to
protect the respiratory & alimentary tracts from
invasion by pathogenic microorganisms
Play a role in antibody formation
Usually occurs as a result of pharyngitis
Viral or bacterial
Tonsillitis

Clinical manifestations







Viral & bacterial are
similar
Sore throat
Headache
Edematous & tender
cervical lymph glands
Fever
Hoarseness
Cough

Strep
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


Vomiting
Muscle aches
Difficulty swallowing or
breathing
Diagnostic tests


CBC
Throat culture
Tonsillitis

Medical management

Comfort measures


Bacterial
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
Described in pharyngitis
10 day course of penicillin
Surgical removal


Controversial
Recommended for children with hypertrophied tonsils
that interfere with eating or breathing
Tonsillitis

Nursing interventions


Same as pharyngitis
Surgery

Prepares child
preoperatively

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
Infection
Loose teeth
Lab data

Postoperatively

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


Semi prone position
Monitor for excessive
bleeding
Analgesics as prescribed
Fluids (avoid acidic,
grape, red, or chocolate)
Soft diet follows
Tonsillitis

Patient teaching

Discharge instructions
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
Avoid foods that are irritating
Avoid use of gargles
Discourage from coughing or clearing the throat
Mild analgesics or ice collar for pain
Alert that hemorrhage may occur 5 to 10 days after
surgery – Any signs of bleeding require immediate
attention
Tonsillitis

Prognosis


Usually excellent
Inadequately treated strep infections
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
Rheumatic fever
Acute glomerulonephritis
Croup

Acute viral disease of childhood



Resonant barking cough
Suffocative & difficulty breathing
Laryngeal spasm
Croup

Etiology

Laryngotracheobronchitis (LTB)

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
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
Most common form of croup
3 months to 3 years of age
Usually viral
Follows an URI that descends
Gradual, progressive onset
Croup

Etiology

Acute epiglottitis
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


Severe, potentially life threatening bacterial infection
Older children
Usually caused by H. Influenzae, type B
Inflamed epiglottitis


Cherry red & edematous
Can lead to total airway obstruction
Croup

Clinical manifestations

LTB

Initially

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Hoarseness
Inspiratory stridor
Tachypnea
Nasal flaring
Suprasternal retractions
Barking cough
Temperature – normal to mildly elevated
Croup

Clinical manifestations

Epiglottitis



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
High fever
Muffled voice
Drooling
Progressive respiratory distress
Anxiety
Fear
Croup

Diagnostic tests

LTB




History of preceding URI
CBC with differential
Clinical signs & symptoms
Physical exam
Croup

Diagnostic tests

Epiglottitis





Tentative by signs & symptoms
OR/surgery room with emergency equipment
Intubation/trach supplies available
Visual examination of the pharynx & invasive
procedures are done with the child under anesthesia
Tracheal secretions are collected for culture &
sensitivity
Croup

Medical management

LTB


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

Maintain an open airway
High cool mist humidity
Low concentration O2
Epinephrine by aerosol – short lived
NPO
Adequate hydration
Never use sedatives
Croup

Medical management

Epiglottitis
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
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
Artificial airway
Humidification
Gentle suctioning
Epinephrine by aerosol
IV antibiotics & fluids
Third day – possible extubation
Croup
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Nursing/Patient teaching



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
Respond quickly in a calm manner
Support & reassure parents
Assess child’s response
Fowler’s position
Respiratory & cardiac status monitored
Keep intubation & trach equipment at bedside
Croup

Prognosis

LTB




Relatively mild
Recovery 3-7 days
Most serious complication – laryngeal obstruction
Epiglottitis


Prompt diagnosis & treatment
Rapid course can cause death within a few hours
Bronchitis (Tracheobronchitis)

Etiology






Inflammation of the large airways, the trachea, and
the bronchi
Usually follows URI
Almost always viral
Most common – rhinovirus
Others – parainfluenza, adenovirus, RSV
Mycoplasma pneumoniae – common cause in
children > 6 years
Bronchitis

Clinical manifestations

Onset gradual




Cough
Coryza
Little or no fever
2-3 days


Non productive, hacking cough becomes productive
Worsens at night
Bronchitis

Diagnostic tests

Severe signs & symptoms


CXR
Medical management




Basically palliative
Cough suppressants contraindicated unless sleep
significantly affected
Acetaminophen for fever
Lasts beyond 10 days – possible bacterial infection
Bronchitis

Patient teaching



Cool mist humidifier
Fluids
Prognosis

Self limiting
Acute Bronchiolitis

Etiology




Viral inflammation of the smaller airway passages,
the bronchioles, which become inflamed causing
edema
Accumulation of mucus & exudate can partially or
completely obstruct the lumen
RSV – majority of cases
Peak incidence 6 months of age
Bronchiolitis

Clinical manifestations




URI signs & symptoms
Worsening to signs &
symptoms of respiratory
distress





Retractions
Tachypnea
Nasal flaring
Paroxysmal
nonproductive cough
Wheezing
May have:





Low grade or very high
fever
Irritable
Fussy
Anxious
Difficulty eating
Progressively more
severe during the first 72
hours
Bronchiolitis

Diagnostic tests


Based on age & clinical signs & symptoms
CXR



Atelectasis
Hyperinflation
Nasal smears for RSV
Bronchiolitis

Medical management




High humidity via mist tent
If hypoxic – O2 therapy recommended
IV fluids if unable to tolerate oral feeds
Bronchodilators for severe cases
Bronchiolitis

Nursing/Patient teaching



Respiratory isolation precautions
Hand washing
Promoting:




Adequate oxygenation
Monitor respiratory status
Maintain hydration
Support parents
Bronchiolitis

Prognosis


Lasts 3-10 days
Generally good
Pulmonary Tuberculosis

Etiology




Chronic, bacterial lung infection
Caused by bacillus Mycobacterium tuberculosis
Public health problem in the US
Inadequate immune response


Age or impaired immune system
Primary source – infected adult
TB

Clinical manifestations




First infected – do not exhibit signs & symptoms
Extremely variable
Develop gradually
May go unnoticed
TB

Diagnostic tests

Most important screening measure


Confirm diagnosis



Tuberculin skin testing
Positive bacteriologic cultures – M. tuberculosis
Best way to obtain sputum sample is by gastric
aspiration
CXR – presence & extent of active lesions
TB

Patient teaching


Teach parents importance of med compliance
Usual course of treatment


no less than 12 months
18 to 24 months for serious cases
Cystic Fibrosis

Etiology

Inherited disorder of the exocrine glands






Mucus producing glands
Characterized by excessive thick mucus - obstructs the
lungs & GI tract
Multi organ disease
Death usually by pulmonary failure
Most common fatal genetic disorder
Affects both sexes equally
CF

Etiology


Bronchiolar obstruction – predisposes lung to
infections, bronchiectasis, & cystic dilations
Complications



Bronchial & bronchiolar obstruction
Pulmonary hypertension
Cor pulmonale
CF

Pancreatic

Obstruction leads to dilation & fibrosis


Hepatic


Decrease in pancreatic enzymes – results in
malabsorption
Obstruction leads to biliary cirrhosis, portal
hypertension, & splenomegaly
Elevated sodium chloride concentrations in
sweat & saliva – result of abnormal
reabsorption of chloride by epithelial cells
CF

Clinical manifestations






Steatorrhea (bulky, foul smelling, fatty stools)
Growth failure
Protruding abdomen
Thin, wasted extremities
Rectal prolapse – GI
Malabsorption – Vit K deficiency
CF

Pulmonary




Chronic cough
Wheezing
Sputum production
Dyspnea


Leads to hypoxia, clubbing of fingers & toes, &
cyanosis
Barrel chest
CF

Diagnostic tests




Family history
Absence of pancreatic enzymes
Pulmonary involvement
Positive sweat test
CF

Medical management

Goals




Good nutrition
Prevention & control of respiratory infections
Provide a normal lifestyle (as possible)
Pulmonary therapy



CPT & postural drainage
Breathing exercises
Inhalation therapy with bronchodilators
CF

Medical management


Pancreatic enzyme replacement
Diet high in calories, protein, & salt
CF

Nursing interventions







Improve pulmonary function
Facilitate lung clearance
Prevent or manage respiratory infections
Promote normal growth & development
Optimizing nutritional status
Education
Refer for counseling
CF

Respiratory treatments



Infection control measures
Pancreatic enzymes




CPT, postural drainage, nebulizers
Given before meals and snacks
Frequent hospitalizations – need support
Positive coping strategies
Ctstic Fibrosis Foundation
CF

Patient teaching



Educate on nutrition
Coordinate counseling, referrals to community
support, and home care services
Educate of disease process & management
CF

Prognosis


More then 50% live to adulthood
According to the CF Foundation's National Patient
Registry, the median age of survival for a person
with CF is in the mid-30s
Bronchial Asthma

Etiology




Reversible obstructive respiratory disorder
Common chronic illness
Familial tendency
Frequent cause – allergic hypersensitivity to
environmental factors
Asthma

Common factors
 Bronchospasm
 Mucosal edema
 Increased mucosal secretions

Classification based on symptom indicators of disease severity




Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
Asthma

Clinical manifestations



Tightness in the chest
Audible expiratory
wheeze
Progresses






SOB
Inspiratory & expiratory
wheezing
Tachypnea
Dyspnea
Coarse breath sounds
Prolonged expiration







Restlessness
Anxiety
Deep dark red color to
lips
Cyanosis
Paroxysmal cough
Fatigue
Diaphoresis
Asthma

Diagnostic tests







Clinical signs & symptoms
History
Physical exam
PFT
ABG
CBC
CXR – rule out other pathology
Asthma

Medical management

Medications









Long term control medications – preventive
Quick relief medications – rescue
Metered dose inhalers
Nebulized medications – infants & young children
Corticosteroids
Cromolyn sodium
Nedocromil sodium
B adrenergic agonists
Leukotriene modifiers
Asthma
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Nursing interventions
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Monitor VS
Adequate hydration
High Fowler’s position
Provide rest periods
Teach breathing exercises
Calm environment
Educate
Asthma

Nursing diagnosis
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Suffocation, risk for
Breathing pattern ineffective
Patient teaching
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Nature of the disease & allergens to avoid (once
determined)
How to use meds
Avoid exposure to extremes of weather
Self care
Asthma

Prognosis
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Outlook varies widely
Many lose signs & symptoms at puberty
Death rate has been rising steadily – despite
improvements in treatment