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RESPIRATORY SYSTEM
DR. REEM ALI
Fall Semester 2015-2016
Functions of Respiratory System

Taking in O2 and breathing out the CO2

Maintenance of acid-base balance
Regulation of H2O and heat balance
 Production of speech
 Facilitate the sense of smell

Respiratory system during
childhood years

infants are obligatory nasal breathers and they use
their abdominal muscle for breathing

Use more accessory muscles for breathing
At 2yrs the Rt bronchus become shorter, wider &
more vertical


Walls of the airways are small in size and have less
cartilage thus lung collapse after expiration is easier
than in adult
Assessment of Respiratory
Function

Inspection breathing:





Rate
Regularity
Symmetry of movement
Depth
Effort and the use of accessory muscles (during
sleep/quietly awake)

Auscultation: airway patency & adventitious sounds

Palpation & percussion: painful area and tissue density
Normal breath sounds

Bronchial sounds
Over trachea, bronchi
 Loud, harsh and high pitched
 Longer in expiration


Vesicular sounds
Air moving in and out alveoli
 Quiet and low pitched
 Longer in inspiration


Bronchovesicular sounds
Near main stem bronchi
 Moderately pitched
 Equal in inspiration and expiration phases

Adventitious sounds

Crackles (Rales)





Wheezes




Result of air passing through fluid in small airways
Simulated by rubbing a few strands of hair between fingers next to
the ear
Most common during inspiratory phase
Associated with COPD and pulmonary edema
Air passing through narrowed small airways
In expiration
Associated with asthma
Pleural friction rub



Pleural surfaces rubbing across each other
Grating sound
Associated with inflammation of the pleura
Noisy Breathing
Snoring
Indicates partial obstruction of the upper airway
that causes vibration of the air as it passes the
nasopharynx and oropharynx
May cause sleep apnea
Stridor
A harsh, continuous crowing sound
Mostly occurs during inspiration
Croup (Laryngotracheobronchitis)
Wheezing
Whistling/musical sound
Indicates a narrowing of the airways
Mainly heard during expiration
Accompanied by tightness of the chest and
labored breathing
Mostly caused by asthma
Respiratory Distress (RD)

Clinical Manifestations

Increased RR > 60 breath/min; Restlessness & apprehension

Retractions:









chest sinking with each breath
mostly observed interiorly at lower costal margins (Subcostal retraction)
Cyanosis around the mouth, fingernail
Grunting during expiration
Nasal flaring indicates labored breathing
Wheezing & Cough
Clubbing caused by chronic hypoxia
Use of accessory muscles of respiration
A child with RD should be kept NPO to Decrease the
work of breathing and prevent aspiration
Respiratory Distress (RD)

Chest Retractions
Nail Clubbing
O2 therapy
To treat hypoxemia
 Delivered by mask, nasal
cannula, tent, hood, face
tent or ventilator


Should be ordered by
physician

Should be humidified
before administered to the
patient
Therapeutic Techniques
 Aerosol
/nebulizer
therapy: used to
administer
medication and
avoid systemic side
effect
 Observe patient
during aerosol
therapy b/c it may
cause
bronchospasm
Therapeutic Techniques

Therapeutic Techniques

Chest physiotherapy (CPT)

When the children get a chest infection, the inability to
take good deep breaths and cough forcefully may make
the clearance of excess thick phlegm more difficult. This
is when chest physiotherapy is useful

CPT helps to clear the lungs and get the phlegm into the
mouth where it can be spat out, or to the back of the
throat where it can be swallowed

CPT uses of postural drainage in adjunctive techniques
including percussion, vibration, deep breathing &
coughing exercise
Therapeutic Techniques: Postural
drainage

Used to facilitate
removing
secretion from
airways by gravity.

Before meals but
following other
respiratory
therapy

20-30 minutes
Therapeutic Techniques: CPT
 Vibration
used to move secretions during exhale
 Hand held vibrators

Breathing exercises
 are used to help the child increase air entry into the lungs
and enlarge the tracheobronchial tree
 Expiration after deep breaths carry out secretions and
stimulate cough
 Blowing (pinwheel toy) stimulate deep breathing
 Cough exercise
 Children are encouraged to cough 1-2 after a deep breath

Therapeutic Techniques: CPT

Percussion
 This
is when the child's chest
is clapped gently with cupped
hands to help shake the
secretions loose.
 Most children
find this quite
soothing and effective, even
though it may sound as it
hurts.
Respiratory Distress (RD)


A child with RD should be kept NPO to Decrease the
work of breathing and prevent aspiration
Micro-organisms R/T Respiratory System

Bacterial pathogens
 Bordetella pertussis (gram negative): pertussis or whooping
cough
 Streptococcus pneumoniae (gram positive):
sinusitis, otitis
media and meningitis
 Haemophilus influenze (gram negative): acute
meningitis,
URTI (otitis media)
 Klebsiela pneumoniae (gram negative): pneumonia
 Mycobacterium tuberculosis: tuberculosis
 Pseudomonas aeruginosa (gram negative):
hospital acquired
infections, respiratory equipment can be source which cause
sepsis, pneumonia and URTI
Pharmacology R/T Respiratory System
Disorders

Bronchodilators
 reverse
bronchoconstriction thus opening the air
passages in the lungs by acting :
 Stimulating
beta-adrenergic sympathetic nervous system
receptors

short acting beta agonists (ventolin); A quick relief of acute
exacerbations and for the prevention of exercise-induced airway
constriction..

long acting (Foradil) directly relaxing bronchial smooth muscles
( Aminophylline, Theophylline)
 Major Side Effect

Dizziness (decrease in BP), CNS stimulation, Palpitation, GI
irritation
Pharmacology R/T Respiratory System
Disorders

Corticosteroids
 Anti-inflammatory effect
 Control
Asthma and improve pulmonary function
 Inhaled
preparation (Fluticasone) oral (Prednisone), IV
(hydrocortisone)
 Major side effect
 Inhaled: oropharyngeal candiadiasis (fungal
infection),
growth retardation and osteoporosis
 Oral
: with long-term use immunosuppression, increase Wt,
osteoporosis, gastric ulcer,
Pharmacology R/T Respiratory System
Disorders

Mucolytic Agents and Expectorants
 To
liquefy secretions in the respiratory tract, thus
promoting a productive cough
 Mucolytic directly
breaking up mucous plugs
(inhalation)
 Expectorants
increase respiratory tract secretions (oral)
 Major side effect
 GI
irritation
 Skin rash
 Oropharyngeal
irritation
Pharmacology R/T Respiratory System
Disorders

Antitussives
 To suppress
the cough reflex
 Preparation
with Narcotic (Codeine) without Narcotic
(Tessalon)
 Major side effect
 Drowsiness
 Nausea
 Dry mouth
(anticholingeric effect of antihistamine in
combination products)
Pharmacology R/T Respiratory System
Disorders

Antihistamines
 To
relieve symptoms of common cold and allergies
 Act
by blocking the action of histamine at receptor
sites, also exert antiemetic, anticholinergic and CNS
depressant effect
 Major side effect
 Drowsiness,
 GI
Dizziness
irritation
 Dry mouth
(anticholingeric effect of antihistamine in
combination products)
Respiratory Dysfunction
1. Upper respiratory tract infections
2. Lower respiratory tract infections
3. Long-term respiratory dysfunction
4. Physical defects of respiratory tract
5. Foreign body Aspiration
Respiratory Dysfunction
Upper respiratory tract infections
Otitis
media
Croup (laryngotracheobronchitis)
Epiglottitis
Respiratory Dysfunction: Otitis Media (OM)
 Acute
infection of the middle ear
 Prevalent
 Caused

between 6 months to 2 years..
by
Streptococcus pneumonia or Haemophilus influenza
 Noninfectious caused
by blocked Eustachian tube secondary
to URI, allergy
 There
is a relationship between formula-fed infants and OM
 Acute
OM rapid short onset of signs and symptoms
lasting for 3 weeks
 OM
with effusion middle ear inflammation with fluid
present
Respiratory Dysfunction: Otitis Media (OM)

Chronic OM may last more than 3 months

Prolonged OM may have consequences:
 Functional:
hearing loss which may affect speech,
language and cognition development
 Structural:
 tympanic membrane retraction which
leads to impaired
sound transmission
of the tympanic membrane); associated
with the dramatic relief of pressure and pain
 Perforation (rupture

Infection
Respiratory Dysfunction: Otitis Media (OM)

Clinical Manifestations
 Acute
 Pain:
OM..
infant rubs ear or rolls head from side to side
 Temp.
40, Vomiting & diarrhea
 loss of
appetite
 Tympanic membrane is
bright red and bulging, no light
reflex
 Discharge from the external auditory canal
Respiratory Dysfunction: Otitis Media (OM)

Clinical Manifestations
 OM

with effusion
No fever and No pain (mostly occurs after viral infection of
URI)
 fullness in the ear

Tympanic membrane gray and bulging
 After a few weeks-months fluid
become thick (glue ear)
causing possible loss of hearing
Respiratory Dysfunction: Otitis Media (OM)

Treatment
 Antibiotic, antipyretic, analgesic drugs
 Chronic OM:

Nursing Diagnosis
 Pain;

surgery ; insertion of tympanotomy tube
Risk for injury; Altered family process
Nursing care
 Assess pain,
S&S of infection
 Provide comfort, prevent complications
 Educate family about treatment (ear drop) and
complications
possible
Respiratory Dysfunction: Otitis Media (OM)

Instillation of ear drops
 For the child
under 3
years of age pull the
auricle down & back
 For an
older child, pull
the auricle up and back
Respiratory Dysfunction: Croup
(Laryngotracheobronchitis (LTB))

Laryngotracheobronchitis (croup), refers to the
inflammation or irritation of the larynx and
trachea and bronchial passageways

Mostly affect children under 5 years with peak
between 6 months to 3 years

Most common causative agents;

parainfluenza virus
 Respiratory syncytial
 Influenza A
&B virus
virus (RSV)
Respiratory Dysfunction: Croup
(Laryngotracheobronchitis (LTB))

CM:
 Gradual onset and
low grade fever
 Inspiratory stridor
 suprasternal retractions,
 barking cough and

hoarseness ..
Respiratory distress,
 possible hypoxia
 Respiratory acidosis
Respiratory Dysfunction: Croup
(Laryngotracheobronchitis (LTB))

Treatment
 Maintain
patent airway, high humidity with cool mist
(constrict edematous blood vessels)
 Ibuprofen
 NPO
if there is respiratory distress and start IV fluid
 For sever cases
Nebulized epinephrine or
dexamethasone
 Possible
intubation
Respiratory Dysfunction: Croup
(Laryngotracheobronchitis (LTB))

Nursing Care
 Observation and

assessment of respiratory status
Prepare for possible intubation if the patient
develops signs of airway obstructions including:

increased HR, RR,
 retractions,

flaring nares

increased restlessness
 Provide comfort,
spasm)
avoid eliciting gag reflex (Laryngo-
Respiratory Dysfunction: Epiglottitis

Acute obstructive inflammatory process of
epiglottis

Mostly occurs in children 2-6 years

Most often the causative agent is Hemophilus
influenza B

Abrupt symptoms
Respiratory Dysfunction: Epiglottitis

CM
 sore

throat and pain on swallowing
fever,
 muffled voice
 Tripod
& stridor,
sit
 drooling
saliva,
 irritable and
restless & possible retraction
 epiglottis red,
inflamed, large, cherry red and
edematous

airway obstruction leads to hypoxia and acidosis..
Respiratory Dysfunction: Epiglottitis

Treatment
 IV fluid
until the patient can swallow
 Antibiotic
 Corticosteroids to reduce the edema
 Tracheal
 Nursing
intubation in severe cases
Care
 Reduce the anxiety
 Comfortable position
 Avoid
using tongue depressor to inspect epiglottius
 Monitor respiratory
status
Croup
Epiglottitis
Age
6 month- 3 year
2 yr- 6 yr
Season
Fall/winter
Anytime
Worst S/S
Night and morning
24hrs
History
URI, gradual onset
Sudden onset, no URI
Fever
Low-grade
Med-high
Drooling
NO
YES
Cough
YES
NO
Position
Sitting, lying
Tripod sit
Stridor
Inspir/ expiration
Inspiration
voice
Hoarse
Muffled
Respiratory Dysfunction
Lower respiratory tract infections
Acute
bronchitis
Bronchiolitis/respiratory syncytial virus
(RSV)
Pneumonia
Respiratory Dysfunction: Acute Bronchitis

Inflammation of trachea , bronchi & bronchioles

Common in children older than 6 yrs

acute bronchitis usually occurs in association with
viral respiratory tract infection..

Causative agent of acute bronchitis is Mycoplasma
pneumonia (bacteria). Other causes include
chemical agent
Respiratory Dysfunction: Acute Bronchitis

CM:
 productive cough
 sometimes retrosternal
pain during deep..
breathing or coughing

It is a self-limited disease (5-10 days)

Treatment
 rest,
use of antipyretics, adequate hydration
 Symptomatic treatment
Respiratory Dysfunction:
Bronchiolitis/Respiratory Syncytial Virus
(RSV)
 Infection of
the lower respiratory tract
 Rarely occurs
in children over 2 years old (peak 2-5
months)
 Primarily occurs
in winter & spring
 50%
of cases caused by RSV, bacteria also cause
bronchiolitis
 The
bronchi and bronchioles are inflamed that leads to
obstruction of the airway
 Narrowing
of the airways during expiration causes
overinflation (emphyasema)
Respiratory Dysfunction:
Bronchiolitis/Respiratory Syncytial Virus
(RSV)

Starts with URT infection then spreads to lower
tract

CM;
Earlier S&S;
poor feeding and irritability
Initial
S &S; Rhinorrhea, low-grade fever, pharyngitis and
possible OM, conjunctivitis, cough
Progressive sign
increased cough, air hunger, tachypnea,
retractions & cyanosis
Severe S&S,
RR >70, listless, apneic spells
Respiratory Dysfunction:
Bronchiolitis/Respiratory Syncytial Virus
(RSV)

Symptomatically treatment
 antiviral medication may be used

Humidity

O2

Fluid & rest

If the pt is tachypnea NPO
Respiratory Dysfunction: Pneumonia

Is an inflammation of pulmonary parenchyma

Types of pneumonia based on the way the child
gets the infection or the germ;
 Aspiration
pneumonia; occurs when food or drink
accidently gets into lungs
 Community Acquired
pneumonia
 Most common type
 Caused
by viruses, bacteria or chemical irritants
 Mostly occurs in winter and spring
Respiratory Dysfunction: Pneumonia

Fast breathing is a sign
of pneumonia;
1
wk-2months 60 B/M or
more
 2mon-
12 mon 50 B/M or
more
1
2months – 5 yrs 40 B/M
or more
Respiratory Dysfunction: Pneumonia

The severity of pneumonia is classified based on:
 Not severe;
Tachypnea only
 Severe pneumonia
 Wheezes
 stridor
 Retractions
 Cyanosis
 Nasal
flaring
 Poor feeding
 convulsion
Respiratory Dysfunction: Viral Pneumonia

mostly caused by RSV in children under 5 yrs
 Gradual
onset
 Viral
infection make the pt susceptible to bacterial
pneumonia
 Treatment
is symptomatically
 O2
 Comfort
 Fluid
 CPT
 Postural drainage
Respiratory Dysfunction: Bacterial
Pneumonia
 Streptococcus pneumonia
is the most causative
bacterium

others causative agent; group B streptococcus,
hemophilus influenza type b, group A streptococcus
 Abrupt onset
 CM:
 productive cough,
tachypnea, fever, ronchi or fine crackles,
chest pain, retraction, nasal flaring, cyanosis, lethargy
 Chest X-ray shows patchy
infiltration
 Irritable
 Anorexia, vomiting, diarrhea and abdominal pain
Respiratory Dysfunction: Bacterial
Pneumonia

Treatment
 Penicillin
G ( for allergic pt erythromycin,
chloramphenical, cephalosporin)
 Antipyretic,
antitussive (cough)
 Rest
 Increase
 O2
fluid intake
may be required for RD children
Respiratory Dysfunction: Bacterial
Pneumonia

Nursing diagnosis: Ineffective breathing pattern
R/T inflammatory effects of pneumonia

Nursing Care
 Thorough respiration assessment (signs of
 Provide comfort and

RD)
O2, Cool humidification
Encourage cough and deep breathing
 Increase fluid
intake & Monitor I &O
 Provide rest &
Maintain semi-fowler’s position
 Standard precautions &
precautions
use of air-borne and droplet
Respiratory Dysfunction
Long-term respiratory dysfunction
 Asthma
Cystic fibrosis
Respiratory Dysfunction: Asthma
 Chronic
inflammatory disorder of the airway
 Asthma causes
recurrent episodes of wheezing,
breathlessness, chest tightness & cough particularly at
night or in the early morning
 Associated
with reversible airflow limitation or
obstruction
 Asthma causes
stimuli
bronchial hyperresponsiveness to
Respiratory Dysfunction: Asthma

Factors aggravate asthmatic exacerbation
 Allergens
(airpollution, dust), Irritants (odor spray,
smoking)
 Changes
in weather temperature, Cold air
 Environmental
changes ( new home)
 Infections
 Animals
 Strong
 Food
emotions
additives, nuts, dairy product
 Other factors
( menses, pregnancy)
Respiratory Dysfunction: Asthma

The mechanisms
responsible for the
obstructive symptoms in
asthma include:



Inflammation and edema of the
mucus membrane.
Accumulation of tenacious
secretions from mucus glands.
Spasm of the smooth muscle of
the bronchi and bronchioles,
which decreases the diameter of
bronchioles.
Respiratory Dysfunction: Asthma
 CM:
 Asthmatic episode begins with:
irritability, restlessness,
headache, feeling tired
 Dyspnea
 Cough:
hacking (harsh), irritative and nonproductive
then cough becomes rattle & productive
 Prolonged expiratory phase with wheezing
 Flaring
nares , distended neck veins
 Silent chest (
severe obstruction in status asthmaticus)
Respiratory Dysfunction: Asthma
 Management
 Eliminate or avoiding
irritant/ offending factors
 long-term control
medication anti-inflammatory
(Corticosteroids, Cromolyn sodium), bronchodilators
(albuterol)
 Most long
term or quick relief medications administered
by inhaler
 CPT:
relaxation and strengthen respiratory muscles
Respiratory Dysfunction: Asthma
 Status Asthmaticus
 A severe prolonged asthma exacerbation that has
not been
broken with repeated doses of bronchodilators
 It
is an emergency and may cause respiratory failure
 Symptoms

Extreme difficulty in breathing, restlessness and anxiety

Little or no breath sounds, inability to speak, cyanosis and
heavy sweating
 Management by
large doses of corticosteriod and
bronchodilators, & O2
Asthma: Nursing Diagnosis

Ineffective airway clearance R/T allergic response and inflammation

Ineffective breathing pattern R/T bronchial edema, constriction and
increased secretion

Risk for suffocation R/T bronchospasm, edem and mucus secretion

Activity intolerance R/T imbalance between O2 supply and demand

Altered family process R/T having a child with chronic disease

Risk for fluid volume deficit R/T insensible fluid loss (
hyperventilation & diaphoresis) & difficultly to take fluid,

Risk for injury (respiratory acidosis & electrolyte imbalance) R/T
hypoventilation and dehydration
Asthma: Nursing Care
 Teaching
 Inhaler use
 Rinse mouth after use of
 Caution child
the steroid inhaler
& parent about overuse of inhaler
 Improve ventilation
 High
fowler’s position
 Breathing exercise
 Regular exercise (swimming)
 Assess environmental
 Allergens
 infections
triggering factor
Cystic Fibrosis (CF)

Cystic Fibrosis (CF)

Autosomal recessive trait disorder affect Exocrine
(mucus –producing) gland
 Involves abnormality
in electrogenic chlroide
channels and its regulations (abnormal transport of
chloride and sodium across an epithelium causing
thick secretions
 Increased
viscosity of mucous gland secretions &
mechanical obstruction is responsible for most
clinical findings
 Sweat gland:
high Na & Cl (3-5 times higher than normal)
 sweat chloride test above
60 mEq/L are diagnostic
Cystic Fibrosis (CF)
Cystic Fibrosis (CF)

Early manifestations
 Meconium
 Baby
ileus in newborn infants
tastes salty
 Failure
to regain normal 10% weight loss at birth
 Presence of
cough or wheezing during first 6 months
of age
 Sweat chloride

test > 60mEq/L
Chest X-ray shows patchy atelactesis
Cystic Fibrosis (CF): Clinical Manifestations

Respiratory tract
 Increased
viscosity of bronchial mucus with
incomplete expectoration causes obstruction and
serves as a media for bacterial growth
 Dry
nonproductive cough, Wheezing
 Hypoxia,
hypercapnia and acidosis, clubbing of finger
 Barrel-shaped
 Obstruction
 Scattered
chest and distended neck veins
interfering with expiration (emphysema)
atelectasis and emphysema
Cystic Fibrosis (CF): Clinical Manifestations

GI tract

High thick secretion blocked the ducts in pancreas leading fibrosis

Marked impairment of pancreatic enzymes which affects digestion of
fats and protein thus affecting normal growth

Pancreas: Becomes fibrotic, decrease production of pancreatic enzymes


Decrease in Lipase cause steatorrhea (fatty, foul, bulky stool)

Decrease in Trypsin increase nitrogen in stool

Decrease Amylase cause inability to break down polysacharides

Increased bulk of feces ( undigested and unabsorbed fat and protein)

Wt loss & FTT
High incidence of DM in children with CF
Cystic Fibrosis (CF): Clinical
manifestations

Cardiovascular; Cardiac enlargement

Rectal prolapse

Liver; possible cirrhosis from biliary obstruction

Reproductive
 Delayed

puberty in females, mostly males are sterile
Integumentary: salty taste, risk of hypochloremic
and hyponatremic
Cystic Fibrosis (CF) affect the whole body

Cystic Fibrosis (CF) affect the whole body

Cystic Fibrosis (CF): Treatment

Pulmonary problems
 Chest physiotherapy
 Bronchodilators
 Antibiotic

therapy as indicators
Gastrointestinal problems
 Pancreatic enzyme supplements
 Balanced
nutritional intake
Cystic Fibrosis (CF): Nursing Diagnosis

Ineffective airway clearance R/T secretion of thick
tenacious mucus

Ineffective breathing pattern R/T mechanical
tracheobronchial obstruction

Altered family process R/T situational crisis

Altered nutrition R/T inability to digest nutrients
Respiratory Dysfunction
Physical defects of respiratory tract

Esophageal atresia
Tracheoesophageal
fistula
Diaphragmatic hernia
Esophageal Atresia & Tracheoesophageal
Fistula

Esophageal Atresia & Tracheoesophageal
Fistula

Most common type proximal
esophagus ends in a blind pouch and
distal esophagus is connected to the
trachea

Usually occurs in low birth weight

May be associated with other
abnormalities

Occurrence is 1 in 800 to 5000 births
Esophageal Atresia & Tracheoesophageal
Fistula

Indications
 Excessive salivation (drooling)

in newborn
chocking, coughing, cyanosis (3 Cs) sneezing & when
newborn fed the fluid returns through the nose and the
mouth

Complication: aspiration and RD

Tx: surgical repair

Nursing diagnosis
 Ineffective airway clearance R/T abnormal opening
between esophagus
 Impaired
swallowing
Foreign Body Aspiration

Risk for old infant and 1-3 years
 Most common
foreign body: food (peanuts),
balloon, coins
 CM:
 chocking,
gagging, cough
 Laryngotracheal
obstruction: dyspnea, cough, stridor,
hoarseness, possible cyanosis
 Bronchial
obstruction: paroxysmal cough (sudden severe
attack), wheezing, asymmetric breathing sound, dyspnea
 Progressive obstruction:
discoloration of the face , no
voice , unconscious and asphyxiation
Foreign Body Aspiration
 Management
5
(For infants)
times Back blow
5 times Chest thrust
Foreign Body Aspiration
 Management
 For a child
Heimlich maneuver: short, abrupt pressure
against the abdomen (between umbilicus and xiphoid)
to raise the intrarespriratory pressure
Foreign Body Aspiration

Management

If the infant is conscious

tongue-jaw lift (look for object),
ventilate, continue blows and chest
thrusts
 call

for CPR
If the child is unconscious
 Lie the child
on the floor, CAB
(compressions, airway and
breathing), look for object,
ventilate, 5 abdominal thrusts
 Call
for CPR