RESPIRATORY

1 Alterations in Respiratory Functions 2 Pediatric versus Adult Respiratory System Anatomy and Physiology Anatomy of upper airway • A smaller nasopharynx is easily occluded during infections. • A small oral cavity and a large tongue increase the risk of obstruction • The large amounts of soft tissue and loosely anchored mucous membranes increase the risk of edema and obstruction. • Cartilage around trachea flexible • Airway diameter – Trachea shorter and narrower → increased airway resistance → increased respiratory effort 3 Pediatric versus Adult Respiratory System Anatomy and Physiology • Position of trachea – Right bronchus acute angle at bifurcation → increased foreign body aspiration 4 Pediatric versus Adult Respiratory System Anatomy and Physiology Anatomy of lower airway • Use diaphragm to breathe until 6 years of age • Immature chest muscles and ribs → retractions • Suprasternal and intercostal • https://youtu.be/n66CTtQRf60 • Subcostal and intercostal • https://youtu.be/FOsxPhJsZrE • Substernal • https://youtu.be/TUWk4t_RTq4 5 Respiratory Distress and Respiratory Failure • Respiratory failure – Partially occluded airway NUFT 433- PEDS- ALTERATION IN RESPIRATORY FUNCTIONS 1

– Malfunction of the respiratory center – Fatigued muscles of respiration – Body can no longer maintain effective gas exchange. – 6 Respiratory Distress and Respiratory Failure Mild Respiratory Distress: Attempting to Compensate – Restlessness – Tachypnea – Tachycardia – Diaphoresis Moderate Respiratory Distress: Early Decompensation – Nasal flaring – Retractions – Grunting , wheezing – Anxiety, irritability, mood changes, confusion Severe Respiratory Distress: Respiratory Failure/Imminent Arrest – Dyspnea – Bradycardia – Cyanosis (note that cyanosis is a late sign) – Stupor, coma 7 Pediatric Emergencies 8 Brief resolved unexplained event (B R U E) • Frightening episode of one of the following: apnea, decreased breathing, cyanosis or pallor, change in muscle tone, and altered level of responsiveness in a child less than 1 year of age. • Lasts less than 1 minute • Common causes • Gastroesophageal reflux • Seizures • Lower respiratory disorders • Cardiac arrhythmias 9 Brief resolved unexplained event (B R U E) Diagnostics • CBC, electrolytes • Blood and urine cultures • EKG • EEG • pH study • MRI Management NUFT 433- PEDS- ALTERATION IN RESPIRATORY FUNCTIONS 2

14 Laryngotracheobronchitis (LTB) Causes Parainfluenza RSV Influenza Adenoviruses Enteroviruses Who? Children 3 months- 3 years old Manifestations Early Fever Barking-seal Stridor Restlessness, irritable Later Retractions Increased stridor Cyanosis 15 Laryngotracheobronchitis (LTB) • Monitor for airway obstruction • Cool mist • Administer O2 if needed • Administer corticosteroids (oral dexamethasone) as ordered • Administer nebulized racemic epinephrine 16 Epiglottitis • Usually caused by Haemophilus Influenzae • MEDICAL EMERGENCY • Progresses rapidly → complete airway obstruction • Absence of cough, drooling • Tripod position 17 Epiglottitis Management • Immediate endotracheal intubation • Supplemental oxygen • IV antibiotics Nursing Care • Protect airway- prepare for intubation • Monitor continuous oximetry • Droplet precautions for first 24 hours • Avoid throat culture NUFT 433- PEDS- ALTERATION IN RESPIRATORY FUNCTIONS 4

18 Bronchiolitis • Lower respiratory tract illness that causes inflammation and obstruction in bronchioles • Leading cause of hospitalization in first year of life • Most common cause: Respiratory syncytial virus (RSV) • Transmitted through direct respiratory secretions or contaminated surfaces • Occurs October through March 19 RSV Bronchiolitis Risk factors for severe infection: • Age- younger the child, the higher the risk • Immunosuppression • Very low birth weight • Lung disease • Neuromuscular disease • Congenital heart defects 20 RSV Bronchiolitis How is it tested? – Nasopharyngeal secretions What are the symptoms? – Early : Runny nose, nasal congestion, sneezing, cough, fever, wheezing – Progresses to tachypnea, retractions, refusal to feed, dehydration – Severe: RR > 70/min, listlessness, poor breath sounds, poor air exchange, apneic 21 RSV Bronchiolitis Nursing Care • Symptom management – Humidified oxygen – Maintain airway – Fluid intake – Nasal suction as needed – Provide a private room or cohort the patient. Designated equipment in room. – Bronchodilators are not recommended – Steroids are controversial – Antibiotics for a coexisting bacterial infection 22 Pneumonia • Inflammation or infection of the bronchioles and alveoli • Occurs most often in infants and young children • Caused by viruses and bacteria – > 5 years old Mycoplasma • Usually preceded by a URI • Symptoms – Fever, crackles, wheezes, cough, tachypnea, restlessness, decreased breath sounds, chest pain, retractions, nasal flaring 23 Pneumonia NUFT 433- PEDS- ALTERATION IN RESPIRATORY FUNCTIONS 5

Nursing management • Assess respiratory status • Ensure adequate nutrition • Promote growth and development 28 Asthma • Chronic disorder characterized by bronchial constriction, hyperresponsive airways, and airway inflammation • Triggers – Allergens – Exercise – Cold air – Infections – Strong emotions 29 Asthma Physical Assessment Findings • Dyspnea • Cough • Wheezing • Coarse lung sounds • Restlessness, irritability • Use of accessory muscles • Decreased oxygen saturation 30 Asthma • Four categories – Intermittent – Mild persistent – Moderate persistent – Severe persistent • Diagnostics – Pulmonary function tests • Most accurate diagnostic test • Baseline at diagnosis and then routinely – Peak expiratory flow rate 31 Pulmonary Function Test NUFT 433- PEDS- ALTERATION IN RESPIRATORY FUNCTIONS 7

32 Asthma Treatment • Bronchodilators – Watch child for tremors, tachycardia, irritability and vomiting with albuterol – Observe child for dry mouth with ipratropium • Anti-inflammatory agents – Oral steroids can be given for 3 or 10 day course • Encourage to take with food – Inhaled steroids can be given daily as preventative • Rinse mouth after the use of corticosteroid inhaler – Leukotriene modifiers 33 Asthma Nursing Care • Respiratory assessment • Monitor for shortness of breath, dyspnea, and wheezing • Position the child to maximize ventilation • Monitor pulse oximeter • Administer oxygen as prescribed • Administer medications as ordered 34 Asthma Education • Identify personal triggers and avoid them • Asthma action plan • Teach child and family how to use a peak flow meter and keep records • Teach how to recognize an exacerbation – Decreased peak flow – Increased used of rescue inhaler NUFT 433- PEDS- ALTERATION IN RESPIRATORY FUNCTIONS 8

– Device that uses an electrical current to stimulate sweat production – Collection from two different sites – Confirmative diagnosis • Chloride >40 mEq/L infants less than 3 months old • Chloride >60 mEq/L for all others • Sodium > 90mEg/L • PFTs, Sputum culture • Abdominal x-ray • Stool analysis 40 Cystic Fibrosis Medications • Respiratory – Albuterol, ipratropium – Dornase alfa-decreases the viscosity of mucus • Antibiotics – Pulmonary infections • Pancreatic enzymes – Treats pancreatic insufficiency – Given with all meals and snacks – Swallow or sprinkle capsules on food • Vitamins 41 Cystic Fibrosis Nursing management • Assist in airway clearance techniques (ACT) • Encourage physical exercise • Administer diet high in protein, fat, calories • Administer pancreatic enzymes within 30 min of eating • Encourage oral fluid intake • Administer vitamin supplements • Monitor blood glucose levels • Administer laxatives/softeners as needed for constipation 42 Cystic Fibrosis Nursing education • Help parents create schedule for medication administration. • Teach respiratory therapy techniques; create schedule. • Determine nutritional needs. • Determine if financial assistance is needed. • Plan for exercise. • Promote regular provider visits, emphasize immunizations 43 Pneumothorax Air enters pleural space because of penetrating chest injury or tears in the tracheobronchial tree. • Open Pneumothorax – Caused by a penetrating injury – Sucking sound might be heard – Symptoms NUFT 433- PEDS- ALTERATION IN RESPIRATORY FUNCTIONS 10

• Restlessness, cyanosis – Treatment • Water-tight bandage • Thoracostomy → chest tube 44 Pneumothorax • Closed pneumothorax – Caused by blunt chest trauma with no evidence of rib fracture – Following motor vehicle crash or abuse, bicycle, scooter, skateboard, skate accident – Manifestations • Breath sounds are decreased on the injured side • Respiratory distress – Treatment • Thoracostomy → chest tube 45 Pneumothorax • Tension Pneumothorax – Life threatening emergency – Air leaks into the chest during inspiration but cannot escape during expiration – Pressure increases → lung collapse → mediastinal shift → decreased cardiac output – Manifestations • Respiratory distress • Decreased breath sounds • Paradoxical breathing – Treatment • Needle thoracentesis → Chest tube 46 Pneumothorax Nursing Management • Monitor respiratory status • Monitor vital signs • Assess surgical site Complications • Hemothorax • Lung tissue injury • Scarring from poor tube placement 47 Alterations in Respiratory Function Questions??? NUFT 433- PEDS- ALTERATION IN RESPIRATORY FUNCTIONS 11