The Child with Respiratory Problems Acute Otitis Media An infection of the middle ear cavity most common in healthy children between 6 months & 2 years. 8590% of all children has at least one episode before school age. Incidence increases in winter months, boys>girls, higher in families with smokers, daycare attendance, cleft palate, Down Syndrome. Often proceeded by a URI or allergy, which results in edema and congestion of the mucosa of nasopharynx, eustacian tubes and middle ear leading to eustacian tube dysfunction. Etiology of OM: Can be a bacterial infection, but most often viral. – Contributing factors: • In children, eustacian tubes are short, wide and straight, lying relatively horizontal. • Abundant pharyngeal lymphoid tissue readily obstructs tube • Usual lying down position favors pooling of fluids, ex., formula in pharyngeal cavity • Most common organisms are: streptococcus pneumoniae, haemophilus influenza and viruses • Organism gains access when normal patency of tube is blocked. Air trapped in middle ear is reabsorbed, creating negative pressure allowing reflux of bacteria, viruses. • Bacteria, viruses + obstruction of flow of secretions leads to middle ear effusion (fluid). Clinical Manifestations: Rhinorrhea, malaise, irritability, restlessness, pain in the ear, pulling or tugging at the ear, purulent discharge, diarrhea or vomiting, fever 102 or higher (common, but not universal symptom), vertigo, loss of appetite, enlarged post auricular and cervical lymph nodes. Tympanic membrane is normally translucent, pearly, pin/gray. With OM, TMintense erythema, bulging toward examiner, immobile with loss of identifiable landmarks (short process, handle of malleus and reflex) However, hyperemia (redness) of TM also occurs from crying, fever. Discharge from ear perforation of TM with acute relief of pain Treatment and Nursing Care If suspected bacterial infection: Amoxicillin for 10 days, reexamine TMs. If no improvement in 48 hrs. dosage may be increased, or different abxs tried. Many PMD’s are now opting not to treat OM as most (<90%) are viral infections. Auralgan otic solution if TM is not perforated for comfort. Teach parents how to instill eardrops. <3 years, pull pinna down and back, instill drops straight into canal – do not warm solution, use at room temperature – let child lie with affected ear up for several minutes. Do not use antihistamines in young children thicken secretions and may cause systemic complications. Parent can use Dimetapp for decongestion to allow child to sleep. TX/ NSG Care cont.. Children’s Tylenol or Ibuprofen for fever >102 Teach parents need for follow up care, repeated or incompletely treated OM can & WILL lead to hearing deficits. Long term complications of AOM – conductive hearing loss. AOM with effusion – sensorineural hearing loss Teach parents not to put child to sleep with a bottle. Recurrent infections (3 episodes in 6 months or 2 episodes in <6 months or 4 episodes /year – may be treat with prophylactic abx at ½ dose of amoxicillin at bedtime in winter and early spring. If prophylaxis fails: myringotomy with placement of tympanostomy tubes – for persistent middle ear effusion (collection of fluid in middle ear). Allows for ventilation and drainage, Eustachian tube healing. Parent teaching Teach parents tubes will “come out” on their own, child must not put his head under water in shower, bath or swimming. If TM is ruptured (parent reports child suddenly has not pain and there is drainage from ear), tell parent to wipe drainage with clean gauze or cloth. Topical abs otic suspension may be given. Teach installation of drops. Healthy TM Bulging TM Acute OM OM with effusion Perforated TM Tubes Bronchiolitis RSV (respiratory syncytial virus) • • • • Rare >2 years, VERY common winter/spring, Common respiratory illness of young children, Associated with exposure to adults with URIs and daycare. Clinical Manifestations: • If it is Oct/Nov and young child (under 2) presents with runny nose, cough, fever THINK RSV • Rhinorrhea, sneezing, cough, low-grade fever followed in several days by tachypnea and wheezing from inflammation of small airways. • Inflammation leads to trapped air (hyperinflation) • Plugging of small airways with mucus and debris • Signs of acute respiratory distress: nasal flaring, tachypnea, intermittent cyanosis, retractions, prolonged expiratory phase caused by hypoxemia, tracheal tug Dx: RSV cultures from nasal secretions rapid test/ viral cx Tx/ Nursing Care Bronchodilators (Proventil) by nebulizer, Solu-Medrol (corticosteroid) IV, Tylenol or Motrin for fever. Croup or mist tent: Teach parents, tent must stay closed, change child’s clothes often because they will become damp from moist, cool atmosphere Ribavirin aerosol – antiviral agent given by nebulizer for high-risk children (congenital cardiac or respiratory problems) *Drug is teratogenic – high risk for pregnant staff or mother*. RSV globulin/Synagis • RSV globulin for preemies at high risk, administered monthly by IV infusion during winter months. • Synagis, an antibody solution given by IM monthly (November-march) , few side effects except pain and transient redness at site. – Both are very expensive, not all insurance company’s will pay for them. Treatment • In healthy child, RSV/Bronchiolitis resolves in 7-10 days may be treated at home if no respiratory distress present. Acute Epiglottitis • ETIOLOGY: An obstructive inflammatory process principally occurring in children ages 2-5 years, but can occur from infancy to adulthood. True medical emergency. • Usually caused by haemophilus influenza bacteria (Hib) and can be virtually eliminated (95% reduction) by Hib vaccine given at 2 - 4, 6 months and a booster at 12-15 months. Upper Airway Anatomy . • PATHOLOGY: fulminate, abrupt onset with rapid progression. Usually preceded by a sore throat, less often by cold symptoms. Child usually awakens with sore throat and pain on swallowing. Fever, pulse, respiration – child is sicker than clinical findings suggest and looks worse than he or she sounds. Presentation • Classic diagnostic picture: “tripod position” child insists on sitting upright and is leaning forward with chin thrust out and mouth open with tongue protruding, drooling from pain of swallowing saliva • Absence of spontaneous cough, “toxic” looking appearance, extreme restlessness (air hunger), irritability • Child has an anxious, frightened expression • Voice is thick, muffled with a frog-like croaking sound on inspiration, but not hoarse • May have supra and substernal retractions, mild hypoxia to frank cyanosis may be present. • Throat is red and inflamed with cherry red epiglottis and a classic “thumb nail” sign on lateral x-ray. Nursing Interventions • Never force child to lie down, can lead to complete airway obstruction. • Never visualize throat, no tongue depressors or throat cultures. Throat should be examined only with anesthesiologist and intubation tray at bedside. (preferably in the OR with full resuscitation equipment and tracheotomy set available) • Have child sit in parent’s lap , decreases anxiety, encourage slow, quiet breathing which will provide better air exchange. • NO IV’s or blood drawing • Notify physician immediately and prepare an intubation tray. Child needs to be intubated by nasotracheal tube before obstruction occurs. Call anesthesia because he needs to be intubated while sitting up, should be done in the OR, ideally. • Have portable x-ray done, or MD who can perform immediate intubation or tracheostomy should accompany if child must go to radiology. Treatment after airway stabilization • Treated with Ceftriaxone (Rocephin) 5075mg/Kg/day q12h. Produces rapid clinical recovery; child can be extubated in 48-72 hours. • Teach parents the importance of Hib vaccine. Acute Laryngotracheobronchitis (LTB) “Croup” • ETIOLOGY: viral infection affecting children <5 years, primarily toddlers, (range 3 mos-8 yrs). Usually preceded by a URI, which descends to adjacent structures. 1 mm swelling of edema in the trachea, bronchi of an infant or toddler closes 75% of their airway Acute tracheoebroncitis “Croup” • PATHOLOGY: gradual onset with low-grade fever, slowly progressive respiratory stridor (hallmark sign) caused by child struggling to inhale air past the obstruction (inflammation of lining of larynx and trachea causing narrowing). • Classic cough (barking or seal like) after several days of coryza. • Slight to moderate respiratory distress with mild wheezing, non-toxic appearance, hoarseness of voice, lower rib cage retractions to tracheal tug depending on severity of obstruction • Irritable, restless • Obstruction severe enough to cause inadequate exhalation of CO2 causes respiratory acidosis and can lead to respiratory failure. Airway in croup Treatment and nursing interventions • Children without stridor at rest can be treated at home for mild croup with a cool air vaporizer, which constricts edema – the effect of mist therapy may be psychological. • Allow child to drink any fluids, helps lessen secretions • For severe respiratory distress, >60 breaths per minute, stridor at rest, retractions, difficulty breathing must be hospitalized. Treatment - Medical 1) Racemic epinephrine (nebulized) and alphaadrenergic drug mucosal vasoconstriction and edema. Rapid onset of relief in 10-15 minutes. May need to repeat q1-2 hours. 2) Solu-Medrol IVPB – anti-inflammatory agent, edema. Takes approximately 6 hours for onset of relief. Give for 12-24 hours for improvement (by O2 sat and respiratory rate). 3) Proventil (bronchodilator) by nebulizer q2-4 hours as needed. Treatment - Nuring • Continuously monitor O2 sat, pulse (tachycardia) and respirations • Signs of impending airway obstruction: pulse and respirations, sub, suprasternal retractions, intercostal retractions, flaring nostrils, tracheal tug, restlessness. • Child should be kept quiet and at rest. Reassure parents who may be frightened by child’s appearance (struggling to breathe). Recovery is generally prompt. Acute Spasmodic Larygitis, also known as “midnight croup”, • Less severe variant is viral, characterized by attacks of laryngeal obstruction that occur at night, common 1-3 years. • Sudden onset, history of URI or previous attack, familial, without signs of inflammation. • Child awakens with barking, metallic cough, hoarseness, dyspnea, inspiratory stridor, restlessness, but afebrile. • Child is frightened, anxious, prostrated. Nursing interventions • Treatment can be done at home: cool mist from vaporizer, take child outside in winter or into a cold garage, or open freezer door OR warm mist from running hot water in bathroom until spasm subside. Try either treatment for 30 minutes, if no improvement, take child to ER, may be epiglottitis • Usually benign, self-limiting disorder. If severe respiratory distress, treat same as LTB. Anatomy – Lower Respiratory . “ All that wheezes is not asthma, but asthma usually wheezes.” Reactive Airway Disease - Asthma • ETIOLOGY: Considered an exaggerated response to a respiratory trigger (antigen), possibly mediated by immunologic factors, physical and chemical stimuli, and viruses. Most common chronic disease of childhood. • PATHOLOGY: intermittent with symptom-free periods with no meds or chronic with frequent or continuous medical treatment needed. – Characterized by: bronchospasm, secretion of mucus, inflammation and edema of respiratory tree. – Wheezing on expiration, dyspnea, SOB, course crackles rhonchi. With increased severity wheezing may also be heard on inspiration. Presentation • Children often experience a prodromal itching on front of neck or upper back. May c/o headache, feeling tired or “tight” chest, irritable, hacking, paroxysmal cough, irritable and non-productive from bronchial edema. Accumulated secretions cause coughing. • With production of mucus, cough becomes rattling with thick sputum. Bronchial spasm size of airway which can be occluded by a mucus plug. • Hallmark diagnostic sign: coughing at night in the absence of a respiratory infection. Disrupts sleep, child suffers in school. Presentation • With a severe episode: an audible wheeze with prolonged expiration as child tries to breathe more deeply. Lips dark redcyanosis, also in nail beds and skin, especially circumoral. Child sits up, is anxious and frightened, diaphoretic. Speaks with short, panting, broken phrases. Child may be diaphoretic and refuse to lie down. • Infants normally have a high respiratory rate making this more difficult to diagnose. Lungs will be hyperresonant (too much “old” trapped air). Problem is not breathing in, but breathing out. Anatomy – Distal Respiratory Asthmatic Changes Cautions - Asthma • With severe spasm or obstruction, breath sounds may become inaudible, cough is ineffective, respiration increases respiratory failure with imminent asphyxia. • With airway rigidity (edema), wheezing will be expiratory AND inspiratory. Systemic steroids are needed. • Not all asthmatics wheeze- be careful! Treatment • Treatment – very individualized. Assist child to live as normal a life as possible. Prevent exposure to allergen, if possible, ex. Cigarette smokes, animal dander, dust mites, protein foods (chocolate, strawberries etc). Treatment goals • Drug therapy – goal is to manage underlying inflammation. Use inhaled steriods daily. Will prevent attacks by controlling inflammation, but is not used for an acute attack. Must be used daily, by MDI (metered dose inhaler), 2-4 weeks before effect takes place. Inhalers can be used with a spacer for young children who cannot coordinate breathing and pressing on inhaler. • Proventil/Albutrerol (bronchodilator) by MDI – beta-adrenergic agonist (mimics adrenaline/epinephrine). Used for acute exacerbations and for prevention of exercise induced asthma. • Singulair (leukotriene inhibitor) once daily, works by inhibiting reaction of mast cells in respiratory tree to antigen, inhibiting IgE. • Remember that an allergic reaction like asthma involves the immune system response Nursing interventions • Teach child how to measure peak flow with a meter. PEFR (peak expiratory flow rate) measures flow velocity during a forced expiration, varies according to child’s age, height, sex. Child needs to establish his/her “personal best” over a 2-3 week period, 3 times/day to establish a base line. Peak Flow PEFR is base on green, yellow, red colors to help child remember. Green zone = 80-100% of personal best. No symptoms present, routine treatment plan can be followed. Yellow zone = 50-80% of personal best signals caution. Acute exacerbation may be present. Maintenance therapy may need to be increased. Call health care provider if no improvement. Red zone =below 50% of personal best signals a medical alert. Severe airway narrowing may be occurring. Take immediate bronchodilator. Notify provider immediately if PEFR does not return and stay in yellow or green zone. Child has pre-determined plan to follow based on above results. Cystic Fibrosis CF • ETIOLOGY: a generalized dysfunction of the exocrine glands (those that secrete externally through a skin surface) that produces a multisystem disorder. Inherited as a recessive trait. • PATHOLOGY: thick, sticky, tenacious mucous secretions that obstruct the ducts of exocrine glands Clincal Manifestations • Newborn: meconium ileus (thick, tar-like) may cause intestinal obstruction requiring surgery • Child has frequent, recurrent pulmonary infections: bronchitis, pneumonia and ultimately COPD caused by obstruction of respiratory tract with thick, tenacious secretions • Malabsorption syndrome: failure to gain weight, distended abdomen, thin arms and legs, lack of subcutaneous fat from inability of pancreatic enzymes to reach digestive tract resulting in impaired digestion and absorption of nutrients. • Steatorrhea: bulky, foul-smelling, frothy, fatty stools predisposes to rectal prolapsed Clinical manifestations • Sexual development: boys sterile due to aspermia, girls difficulty conceiving and bearing children (from increased viscosity of cervical mucus which acts as a plug and blocks entry of sperm) • Parent will generally report that child “tastes salty”. Sweat test reveals high sodium and chloride levels in sweat, a symptom unique to CF Treatment • Treatment involves controlling symptoms, not cure. Postural drainage morning, between meals, before bedtime to loosen respiratory secretions. • High fluid (Gatorade) intake to decrease viscosity of secretions, prevent dehydration and electrolyte imbalances. Exercise such as swimming increases lung capacity. Treatment • Nebulizer treatments with Bronchodilators, mucolytics, expectorants. Child may sleep in a mist tent. Nursing interventions Prevent infection • • • • • • Prophylactic abx avoid people with URIs report any URIs immediately adequate nutrition Genetic counseling Diet: fat, protein, calories. Administer fat-soluble vitamins A, D, E, K, multivitamins, iron. Extra slat to compensate for losses, especially in hot weather. Nursing interventions • Administer pancreatic enzyme before every meal and every snack to enhance absorption of fats. Tablets or powder (mix powder with cold food ex. applesauce) approximately 30 minutes before eating. Dose depends on condition of stools. • Teach child-increasing responsibility for own treatment, diet, meds, etc. • Encourage verbalization of anger or frustration at being “different”. • Refer parent and child to Cystic Fibrosis Foundation center and local support groups Pneumonia • ETIOLOGY: a common childhood disease occurs more frequently in infancy and early childhood as a primary infection or a complication of other diseases. • PATHOLOGY: Classified as either lobar (large segment of one or more lobes), interstitial (confined mostly to alveoli) or bronchial (confined to terminal bronchioles) depending on anatomic site in respiratory tree. Pneumonia - Types 2 types: viral and bacterial Viral pneumonia occurs more frequently than bacterial, often associated with URIs and RSV disease. Although less severe, viral infections can lead to secondary, superimposed bacterial infection because of damage to mucosa. Signs and symptoms • fever, generally over 102, cough, unproductive to productive with whitish sputum, tachypnea • breath sounds can include rhonchi, fine crackles, dullness to percussion, chest pain often exaggerated by deep breathing, retractions, nasal flaring, pallor to cyanosis • Bacterial pneumonia can also cause chills, and referred pain to the abdomen. Child appears very ill with rapid, shallow respirations, malaise. May also exhibit signs of meningeal irritation (CNS) with irritability, restlessness, lethargy • Children also may have vomiting, diarrhea • Most children can be treated at home if respiratory distress is not present. Treatment nursing care& nursing interventions • Antibiotic therapy, oxygen, fluids, chest PT, Tylenol or Ibuprofen for fever reduction. • Administer antitussives (cough medicines) if cough is disturbing and won’t allow child to rest or sleep. Monitor I&O, vital signs, breath sounds frequently. Young infants and toddlers may need suctioning of secretions with a bulb syringe in their nostrils. • Plan nursing care so child can rest. • May be in a cool mist tent to help moisten the airways and provide oxygen (change clothes frequently because of dampness) • If child is isolated, provide for family visiting and diversional activities to reduce psychological stress which makes breathing more difficult. • Child may lie in any position, but is usually more comfortable in low Fowler’s, or lying on affected side of chest which helps splint chest when coughing Parent teachings • Although bacterial pneumonia takes longer to resolve, prognosis is generally good, 7-10 days. • Teach parents importance of vaccination available to prevent pneumococcal disease: (Prevnar) one of the most common types of bacterial pneumonia, especially if child is in day care.