The Child with
Respiratory
Dysfunction
Chapter 23
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General Aspects of
Respiratory Infections
• Upper respiratory tract
– Nose, pharynx
• Lower respiratory tract
– Bronchi and bronchioles
• Croup syndromes
– Infections of epiglottis, larynx
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Infectious Agents
• Viruses
– RSV
• Others
– Group A ß-hemolytic streptococcus
– Staphylococci
– Chlamydia trachomatis,
mycoplasma, pneumococci
– Haemophilus influenzae
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Age
• Infants <6 months: maternal antibodies
• 3-6 months: infection rate increases
• Toddler and preschool ages: high rate of
viral infections
• >5 yrs: increase in mycoplasma
pneumonia and ß-strep infections
• Increased immunity with age
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Size
• Diameter of airways
• Distance between structures is shorter,
allowing organisms to rapidly move down
• Short eustachian tubes
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Resistance
• Immune system
• Allergies, asthma
• Cardiac anomalies
• Cystic fibrosis
• Day care
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Seasonal Variations
• Most common during winter and spring
• Mycoplasmal infections more common in
fall and winter
• Asthmatic bronchitis more frequent in
cold weather
• RSV season considered winter and
spring
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Clinical Manifestations
• Vary with age
• Generalized signs and symptoms and local
manifestations differ in young children
– Fever
– Anorexia, vomiting, diarrhea, abdominal pain
– Cough, sore throat, nasal blockage or
discharge, ear pain or nonverbal signs,
halitosis
– Adventitious lung sounds
– “allergic salute”, nasal crease, “allergic
shiners”
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Nursing Care
• Assessment—S/S, VS, heart and lungs,
lymphadenopathy, skin color, inflamed
mucous membranes, nasal d/c, sputum
characteristics, S/S dehydration
• Interventions—warm shower mist, cool
mist vaporizer, quiet and rest, nose drops
or spray, throat gargles, cold or warm
compresses, reduce fever, handwashing,
tissue isolation, covering moth and nose,
staying away from others, FF, support
nutrition, antibiotics prn
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Tonsillitis (795)
• Infection and inflammation of tonsils.
Usually involved palatine and adenoids
• May be viral or bacteria
• Dx by throat culture because viral can
look as bad as bacterial
• Tx for viral is palliative, but bacterial
(GABHS) is tx with PCN, unless allergic,
then azithromycin. Repeated cases or
sleep apnea warrant tonsillectomy
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Tonsillectomy
• MD may do just tonsils or may do T&A
• Postop nursing care:
– Observe for hemorrhage
– HOB up
– Routine VS
– Ice collar
– Non-red full liquids to soft bland diet
– Antibiotics, analgesics
– Home care p. 797
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Otitis Media (OM) (797)
• Infection of middle ear behind eardrum with
inflammation of canal and eardrum
• Purulent and fluid collection causes bulging and
pain
• Loss of light reflex and bony landmarks
• Usually caused from dysfunctioning eustachian
tube
• Bacterial infection from strep, haemophilus, or
moraxella is usually preceded by RSV or
influenza
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OM cont’d
• Risk factors include
– Family hx
– Second-hand smoke
– Day care or other crowded settings
– Hx allergies
– Bottle feeding in supine position
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OM cont’d
• Treatment includes
– Antibiotic tx for all children < 6 months
because of immature immunity
– Antibiotic tx for all children < 2 years if fever
and severe pain is present
– “Watchful waiting” x 72h for all others
– If antibiotics are used, amoxicillin 80-90
mg/kg x 10d
– If allergic—azithromycin, cephalosporins
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OM cont’d
• For repeated and resistant cases, myringotomy
with placement of tympanostomy tubes
• Parental education includes
– Causes of infection
– S/S of infection
– Prevention of recurrence
– Med administration
– Complications (meningitis, mastoiditis,
hearing loss)
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Croup Syndromes (800)
• Characterized by hoarseness, “barking” cough,
inspiratory stridor, and varying degrees of
respiratory distress
• Croup syndromes affect larynx, trachea, and
bronchi
– epiglottitis—life-threatening*
– spasmodic laryngitis
– laryngotracheobronchitis (LTB)—most
common*
– tracheitis
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Acute Epiglottitis
• Usually caused by Haemophilus.
• Clinical manifestations include sore throat, pain,
tripod positioning, drooling, protruding tongue,
agitation, restlessness, retractions, inspiratory
stridor, mild hypoxia, distress, can progress to
airway obstruction (exam can cause obstruction)
• Need aggressive antibiotic tx, IV fluids, steroids,
and intubation equipment available
• Prevention: Hib vaccine
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Acute LTB
• Primarily viral
• Most common of the croup syndromes
• Generally affects children <5 yrs
• Organisms responsible
– RSV, parainfluenza virus, Mycoplasma
pneumoniae, influenza A and B
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Manifestations of LTB
• Inspiratory stridor
• Suprasternal retractions
• Barking or “seal-like” cough
• Increasing respiratory distress and hypoxia
• Can progress to respiratory acidosis, respiratory
failure and death
• Stages—p. 802. Stage 1 can be treated at
home, but progression to stage 2 warrants
medical intervention
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Therapeutic Management
• Airway management
• Maintain hydration—PO or IV
• High humidity with cool mist
• Nebulizer treatments
– Epinephrine
– Steroids
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Respiratory Syncytial Virus
(RSV) (804)
• Acute, highly contagious, viral infection causing
80% of cases of bronchiolitis
• Causes inflammation, mucus production, edema,
partial obstruction, and air trapping
• S/S—Box 23-8
• CXR shows hyperinflation with consolidation
• Dx by antibody detection from nasal washings
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RSV cont’d
• Most treated at home with high humidity,
adequate fluid intake and rest
• Hospitalization is recommended for child with
– Chronic illness
– Inadequate caregiver
– Apnea
– Marked retractions
– Listlessness
– Poor fluid intake
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RSV cont’d
• In-hospital treatment includes
– Assessments, O2 sats, ABGs, oxygen
therapy, IVF (po may be restricted due to
fatigue)
– Contact precautions with handwashing,
gloves, gowns, masks, goggles. Need
separate room and nurses not caring for hirisk patients
– Respiratory treatments with Ribavirin is
controversial—toxic & teratogenic. Need
special mask
• Prevention with RSV immune globulin IV or
palivizumab IM for children with CLD, heart
defects,and preemies.
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Asthma (813)
• Chronic airway disorder characterized by
inflammation, edema, spasm, and
tenacious mucus production
• Bronchial hyper-responsiveness to
triggers in environment (Box 23-14)
• Clinical manifestations—Box 23-15. Can
progress to hypoxemia, respiratory
acidosis, and respiratory failure.
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Asthma Severity Classification in
Children 5 yrs and Older
• Step I: mild, intermittent asthma
• Step II: mild, persistent asthma
• Step III: moderate, persistent asthma
• Step IV: severe, persistent asthma
• Clinical features of each classification are
found in Box 23-13
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Asthma cont’d
• Diagnostics include:
– CXR—shows hyperinflation in acute
episodes
– PFT—shows decreased forced expiratory
volume.
– PEFR measures the maximum flow of air
that can be forcefully exhaled in one second
and is interpreted on p. 815 in Guidelines.
Families use this as a way of assessing the
child’s status on a daily basis.
– Eosinophilia is usually present
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Drug Therapy for Asthma
• Long-term control meds—corticosteroids,
bronchodilators (albuterol), mast cell
stabilizers (Cromolyn), and leukotriene
modifiers (block inflammation and
bronchospasm) usually given by MDI or
HHN
• Quick relief meds—bronchodilators given
by inhalation, orally, or IV (albuterol,
Theophylline)
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Asthma Interventions
• Exercise—use of albuterol or cromolyn
can prevent exercise induced asthma
• Chest physiotherapy (CPT)—includes
breathing exercises and physical training
to help learn more effective breathing
methods, stregthen respiratory muscles,
and promote relaxation.
• Hyposensitization—limited to those that
cannot be controlled
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Goals of Asthma Management
• Avoid exacerbation
• Avoid allergens—see p. 816 “Family
Home Care”
• Relieve asthmatic episodes promptly
• Monitor function with peak flow meter—
see p. 822
• Self-management of inhalers, devices,
and activity regulation—see p. 822
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Cystic Fibrosis (CF) (824)
• Exocrine gland dysfunction that
produces multi-system involvement
• Most common lethal GENETIC
illness among white children
• Approximately 3% U.S. Caucasian
population are symptom-free carriers. CF is
inherited as autosomal recessive trait—child
has to inherit defective gene from both
parents to have disease
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Pathophysiology of CF
*Multisystem disease with most
devastating effects on respiratory and GI
systems
• Mucous glands produce thick mucus
which causes glands and their ducts to
clog, enlarge, and harden, obstructing
small passages in the pancreas and
bronchioles
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Diagnostics
• Basis of the most reliable diagnostic
procedure—sweat chloride test. Sodium and
chloride will be 2-5 times greater than the
controls
• Parents say that child tastes “salty”
• 72 hour fecal fat test
• Liver functions
• CXR, sputum cultures, PFTs
• Meconium ileus may be first diagnostic clue
• Many children are diagnosed by symptoms—
poor growth, greasy stools, frequent respiratory
infections. 50% by 6 mos; 90% by 8 yrs
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Respiratory Manifestations
• Present in almost all CF patients but
onset/extent is variable
• Stagnation of mucus and bacterial
colonization result in destruction of lung
tissue
• Tenacious secretions are difficult to
expectorate-obstruct bronchi/bronchioles
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Respiratory Manifestations (cont’d)
• Decreased O2/CO2 exchange results in hypoxia,
hypercapnea, acidosis
• Respiratory infection spreads to bronchial
tissues, weakening walls, and destroying
bronchial epithelium.
• Peribronchial fibrosis results
• Compression of pulmonary blood vessels and
progressive lung dysfunction lead to pulmonary
hypertension, cor pulmonale, respiratory failure,
and death
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Infectious Pathogens
• Pseudomonas aeruginosa
• Burkholderia cepacia
• Staphylococcus aureus
• Haemophilus influenzae
• Escherichia coli
• Klebsiella pneumoniae
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GI Tract
• Thick secretions block ducts—cystic
dilation — degeneration — diffuse fibrosis
• Prevents pancreatic enzymes from
reaching duodenum
• Impaired digestion/absorption of fatsteatorrhea
• Impaired digestion/absorption of proteinazotorrhea
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GI Tract (cont’d)
• Endocrine function of pancreas initially
stays unchanged
• Eventually pancreatic fibrosis occurs;
may result in diabetes mellitus.
• Focal biliary obstruction results in
multilobular biliary cirrhosis
• Impaired salivation
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Other Manifestations
• Rectal prolapse
• Excretion of undigested food in stool—
increased bulk, frothy, and foul
• Delayed puberty in females
• Sterility in males
• Dehydration
• Hypoalbuminemia
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Goals
• Prevent/minimize pulmonary
complications
• Adequate nutrition for growth
• Assist in adapting to chronic illness
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Respiratory Management
• CPT
• Bronchodilator medication
• Forced expiration thru mucus clearing device
• Aggressive treatment of pulmonary infections
• Home IV antibiotic therapy
• Aerosolized antibiotics and D-Nase (decreases
viscosity)
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GI Management
• Replacement of pancreatic enzymes will
increase absorption of nutrients and
decrease abnormal stools.
• High protein high calorie diet as much as
150% RDA. More fat in diet requires
more capsules
• Salt supplementation
• Tube feedings or TPN if FTT
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Prognosis of CF
•
Estimated life expectancy for child born with
CF in 2003 is 40-50 years
•
Maximize health potential
– Nutrition and good skin care (thin)
– Prevention/early aggressive treatment of
infection
– Pulmonary hygiene
•
New research—hope for the future
– Gene therapy
– Bilateral lung transplants
– Improved pharmacologic agents
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Family Support
• Coping with emotional needs of child and
family
• Child requires treatments multiple times/
day
• Frequent hospitalization
• Implications of genetic transmission of
disease
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