Respiratory
Nur 106
Respiratory System
• General Information
• Signs and symptoms of respiratory
distress
• Common diagnostic tools
• Common medications and treatments
General Information
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Fetus practices breathing in utero
Normal to have amniotic fluid in lungs
Absorbed as soon as takes first breath
Meconium in the amniotic fluid is problem
Surfactant reduces surface tension in
lungs so that lungs will remain open
• Neonates are obligant nasal breathers
General Information
• Normal respiratory rate: 30—50
• Lumen of respiratory system is smaller in
children
• Eustachian tubes shorter and more
horizontal
• Metabolic rates are higher than adults
Respiratory Assessment
• Auscultation
– Absent or diminished lung sounds
– Adventitious lung sounds
• Crackles—passage of air through moisture
• Wheezes—Narrowed passageways
Respiratory Assessment
• Observation
– Barrel Shaped Chest
Respiratory Assessment
• Observation
– Cyanosis
– Club fingers
Respiratory Assessment
• Observation
– Presence of retractions
• Occur when airway obstructed in young children
• Indication of severity of respiratory distress
Respiratory Assessment
• Infant’s chest walls more flexible, muscles
immature, retractions common
Respiratory Assessment
• Retractions
Suprasternal
Intercostal
Substernal
Common Diagnostic Tests
• Chest xray
• Bronchoscopy—visualizes trachea and
bronchi directly
– Under anesthesia
• Pulmonary function tests—usually not until
5 to 6 years of age
• Sputum culture—best collected in morning
Common Diagnostic Tests
• Arterial blood gases
– Heparinized syringe
– Place on ice
– Transport to lab immediately
– Pressure to site for 5 minutes
• Pulse oximetry
– Oxygen saturation
– SPo2
– 87—93% safe levels of saturation
Respiratory System
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Laryngotracheobronchitis (croup)
Pnuemonia
Respiratory distress syndrome
Bronchopulmonary dysphasia
Cystic Fibrosis
Sudden Infant Death Syndrome (SIDS)
Respiratory System
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Asthma
Respiratory Syncyntial Virus
Pharyngitis
Allergic Rhinitis
Tonsillitis/adenoiditis
Influenza
Laryngotracheobronchitis
• Generalized infection of larynx, trachea and
bronchi
• Croup
• Frequently shows symptoms of mild URI
during day; at night, awakens with hoarse
barking cough and severe respiratory distress
• Most common organisms: RSV,
parainfluenza virus and mycoplasma
pneumoniae
LTB
Etiology
• Affects children under 5 (smaller
airways)
• Affects boys more frequently than girls
• Inflammation causes narrowing of
airways
• Onset gradual
• May reoccur several nights in a row
LTB
Symptoms
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Low-grade fever
Barking cough
Respiratory stridor
Hypoxemia
Tripod position
Respiratory Distress
Tripod Position
LTB
Treatment
• At home:
– Hot steamy bathroom
– Cool night air
– Sit upright
– Cool mist vaporizer in “home made tent”
– Elevate head of crib
– Increase fluids
LTB
Treatment
• Hospitalization
– Croup tent
– IV fluids—oral fluids may cause aspiration
– Bronchodilators
– Corticosteroids
– Intubation equipment available
Epiglottitis
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Inflammation of epiglottis
Life threatening obstruction
Usually bacterial (hemophilus influenza)
Sudden onset in healthy child: awakens
with high fever, drooling and respiratory
distress
• Do NOT examine throat—may lead to
spasm and complete obstruction
Pneumonia
• Inflammation/infection of bronchioles and
alveloar spaces
• Causative agents bacteria, viral,
mycoplasma
– Children under 5: Viral—RSV. Influenza,
adenovirus,rhinovirus
– Children over 5: Bacteria—streptococcus
pneumoniae
Pneumonia
• Symptoms
– Fever, cough, dyspnea, tachypnea
– Rhonchi, crackles, wheezes
– Decreased breath sounds with consolidation
• Diagnosis
– Xray
• Treatment
– Antibiotics, IV, fever control, airway
management
Respiratory Distress Syndrome
• Formally called Hyaline Membrane Disease
• Disease primarily of premature
– Infant of a diabetic mother
– White children more frequent than black
– Boys more often than girls
• Primary pathology is production
deficiency in surfactant
Surfactant
Lung Compliance
Atelectasis
PO2
Anaerobic metabolism
Adapted from: London, M; Ladewig,
P; Ball, J; and Bindler, R. 2007.
Maternal & Child Nursing Care, 2nd
ed. Upper Saddle River, NJ, Prentice
Hall, p.820.
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Work of breathing
Acidosis
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Ventilation
CO2
Respiratory Distress Syndrome
• Diagnosis: x-ray—diffuse bilateral density
(white-out), and atelectasis
• Antenatal prevention treatment:
betamethasone
Respiratory Distress Syndrome
Nursing Care
• Oxygenation/ventilation
– Transcutaneous oxygen/CO2 monitoring
– Blood gas monitoring
– Oxygen
– Continuous positive airway pressure (CPAP)
– Respirator
Respiratory Distress Syndrome
Nursing Care
• Correction of acid-base imbalance
• Temperature regulation
• Nutrition
• Protect from infection
Respiratory Distress Syndrome
• Surfactant Replacement Therapy
– At birth and repeated as necessary
– Endotracheal administration
Bronchopulmonary dysplasia
• BPD
• Chronic lung disease
• Precipitating factors: prematurity, high
oxygen concentrations, positive pressure
ventilation
• Symptoms: Persistent respiratory distress
– Wheezing, tachypnea, pulmonary edema
– Failure to thrive
Bronchopulmonary Dysplasia
• Nursing Care
– Oxygen
– Tracheostomy
– Recurrent respiratory infections
• Palivizumab, RSV immune globulin
– Promote growth and development
Bronchopulmonary Dysplasia
• Medications:
– Bronchodilators
– Anti-inflammatory agents
– Diuretics
– Antibiotic Therapy
– Vitamin A
Cystic Fibrosis
• Inherited—autosomal recessive
– Both parents must be carriers
– Each child has a 1 in 4 chance of being
affected
– Affects primarily white children
Father
(carrier)
Carrier
Unaffected
Mother
(carrier)
Affected
Carrier
Cystic Fibrosis
• Multi-system disease—affects exocrine
glands
– Bronchioles, small intestines, pancreas,
bile ducts
• Exocrine secretions—thick and
tenacious
• Abnormal sodium excretion
– Sweat Chloride test
– Heat Prostration
Cystic Fibrosis
• Lungs—Secretions pool in bronchioles
leading to infection and atelectasis
– Barrel shape chest
– Cyanosis
– Clubbing of fingers and toes
– Recurrent respiratory infections
Cystic Fibrosis
• Pancreas—absence of pancreatic
enzymes and malabsorption
• Small intestine—Meconium hardens
leading to meconium ileus
– Stools are bulky and fatty (steatorrhea)
– Large belly, wasted extremities
– Fat soluble vitamin deficiencies
Cystic Fibrosis
• Males usually sterile due to blocked vas
deferens
• Females may have trouble conceiving due
to thick mucus in the reproductive tract
Cystic Fibrosis
• Medical treatment
– Bronchodilators
– Antibiotics
– Pancreatic enzymes
– Vitamin supplements
– Salt supplements in hot weather?
Cystic Fibrosis
Nursing Interventions
• At birth—monitor for 1st meconium
– Newborn screening—blood immunoreactive
trypsinogen
• Genetic counseling
• Parent Education
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High calorie, high protein, low fat diet
How to administer pancreatic enzymes
Protect from infection
Breathing exercises and care
Cystic Fibrosis
Breathing Exercises
• Physical activity
• Chest percussion and postural drainage
Cystic Fibrosis
Medications
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Aerosol Bronchodilators—opens lungs
Aerosol DNAse—loosens secretions
Corticosteroids—Anti-inflammatory
Antibiotics—Treats infections
Pancreatic enzymes—Aids in digestion
Water soluble ADEK
Sudden Infant Death Syndrome
• Risk factors--infant
– Race: (decreasing order of frequency)
American Indian, black, Hispanic, white, Asian
– Males more often than females
– 2—4 months of age
– Winter
– Exposure to passive smoke
– Prone sleeping
– Overheating
Sudden Infant Death Syndrome
• Risk factors--maternal
– Age less than 20, short interval between
pregnancies
– Prenatal smoking, binge alcohol, drug use
– Anemia
– Poor prenatal care, poor weight gain during
pregnancy
– Hx of sexually transmitted disease or UTI
Asthma
• Hyper-reactive lungs
• Chronic condition with acute
exacerbations
• Responds to environmental irritants
• Bronchial spasm, increased airway
resistance, air trapping
Asthma--Etiology
• Triggers include: inhalants, airborne
pollens, stress, weather changes,
exercise, viral or bacterial agents,
allergens, strong emotions, etc.
• Runs in families—genetics unclear
Asthma--Pathology
• Exposure to irritant
• Constriction of bronchial smooth
muscles
• Edema of lung tissues
• Increased respiratory secretions
• Airway narrowing
– Air trapping and hyperinflation of alveoli
Asthma--Symptoms
• Wheezing—can be heard at
http://jan.ucc.nau.edu/~daa/heartlung/breaths
ounds/contents.html
• Cough
• Air trapping and hyperinflation leads to
prolonged expiratory phase
• Lips—dark red; may progress to cyanosis
• Anxiety
• Sitting upright, hunched over
Asthma
Treatment
• Quick relief medications
– Nebulizer (metered dose inhaler)—note if
contains steroids, spacer should be used
to prevent yeast infections of the mouth
Asthma
Metered Dose Inhaler--Use
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Shake the inhaler well before use (3 or 4 shakes)
Remove the cap
Breathe out, away from your inhaler
Bring the inhaler to your mouth. Place it in your
mouth between your teeth and close you mouth
around it.
• Start to breathe in slowly. Press the top of you
inhaler once and keep breathing in slowly until
you have taken a full breath.
• Remove the inhaler from your mouth, and hold
your breath for about 10 seconds, then breathe
out.
www.asthma.ca/adults/treatment/meteredDoseInhaler.php
Asthma
Medications--Acute
• Corticosteroids—oral or inhaled
– Prednisone, Methylprednisolone
• Β-Adrenergic agonists (Bronchodilators)
– Albuterol, epinephrine, terbutaline
– Short acting (inhaled) used to relieve an on-going
attack
– Long acting (oral or inhaled) to control frequent
attacks
Asthma
Medications--Chronic
• Cromolyn sodium—used prophylactically
– Inhalant
– Suppresses inflammation
– Not bronchodilator
– Prevents release of histamine
Asthma
Reducing Triggers
• Smoke free environment
• Allergy proofing home:
– Bedroom of primary importance
– Pillows and mattress enclased in covers
– Eliminate stuffed toys, plants, carpets,
drapes
– Do not store out of season clothing in room
Status Asthmaticus
• The continued presence of severe
respiratory distress despite vigorous
therapeutic measures
• Medical emergency that can lead to
respiratory failure and death
• Sudden onset of agitation or the
agitated child who suddenly becomes
quiet may be seriously hypoxic
Bronchiolitis
• Inflammation of the bronchioles
• Edema, accumulation of mucus, air
trapping and atelectasis
• Major concern for small infants
• Most common caustive agent is the
respiratory syncytial virus (RSV)
• Often fatal
RSV
• Most important respiratory pathogen in
infancy and early childhood
• Not airborne
• Can remain viable for hours on
nonporous surfaces
• Most frequent problem in winter and
spring
RSV
Prevention
• Infants up to 24 months with chronic lung
disease
– RSV Immune Globulin (RSV-ICIV):
Antibodies against RSV. Given monthly IV
beginning of season
– Palivizumab (monoclonal antibody): Given
monthly IM
Pharyngitis
• “Sore throat”
• Most are caused by viruses
• Most common bacteria—group A betahemolytic streptococcus (strept throat)
• Symptoms—fever, sore throat,
dehydration
• Treatment—symptomatically
• If bacterial—10 days of penicillin
Tonsillitis/adenoiditis
• Tonsils: Masses of lymphoid tissue
located in pharyngeal cavitiy.
• Purpose: Filter pathogens
• Size: Children relatively large
• Infection can be viral or bacterial
• If greater than 3 infections per year, may
do tonsillectomy
Tonsillectomy
• Surgical removal of palatine tonsils
• Adenoidectomy—surgical removal of
pharyngeal tonsils
• Pre-op prep same as for all surgeries
Tonsillectomy
• Recovery room
– Position on abdomen or side
– Suction with care
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Tonsillectomy
• Post op care
– Bedrest for day
– Clear liquids advance to full then soft
• Cold
• Avoid red coloring
– Ice collar
– Analgesics
Tonsillectomy
• Post op risk—hemorrhage
• Up to 10 days post op
• Symptoms
– Bright red bloody emesis
– Frequent swallowing
– Pulse greater than 120
Tonsillectomy
• Recommendations to prevent post-op
hemorrhage
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Avoid irritating foods
Avoid gargles or vigorous toothbrushing
Discourage coughing or throat clearing
Use ice collar
Avoid medications known to promote bleeding
Limit activity
Allergic Rhinitis
• Hay fever
• Seen mostly in older children and adults
• Treatment: antihistamine, allergy
avoidance
Influenza
• Viral
• Symptoms last 4 to 5 days
• Complications include pneumonia,
encephalitis, otitis media
• Do not treat with aspirin because of
possible link to Reye Syndrome
General Treatment for Respiratory
Conditions
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Position to promote oxygenation
Humidification
Fluid intake—clear liquid, avoid milk
Oxygen???
Medications include bronchodilators,
anti-inflammatories, antibacterial and
antiviral agents
Foreign Body Aspiration
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Peak age: under 3
Leading cause of death under 1
FB usually lodge in right main bronchus
Partial or complete obstruction
Sudden onset of coughing
Heimlich Maneuver
Surgical removal