Alteration in Respiratory Function
Jan Bazner-Chandler RN, MSN, CNS, CPNP
Allergic Rhinitis
Assessment
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Itching of nose, eyes, and throat
Sneezing and stuffiness
Watery nasal discharge / post nasal drip
Watery eyes
Swelling around the eyes
Assessment
Allergic Shiner
eMedicine.com
Allergic Salute
Rhinitis Interdisciplinary Interventions
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Avoid offending allergen – smoke / pets
Pharmacologic management:
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Oral or nasal antihistamines - Benadryl
Leukotriene modifiers - Singulair
Mast cell stabilizers – cromylin – nasal / ophthalmic / inhaled
Allergen-specific immunotherapy
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Do not use combination OTC medications especially those that
contain pseudoephedrine
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No OTC Antihistamines for children under 6 years of
age.
Sinusitis
Adam.com
Assessment
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Fever
Purulent rhinorrhea
Nasal congestion
Pain in facial area
Malodorous breath
Chronic night-time cough
Children more prone to sinusitis: children with asthma
and cystic fibrosis.
Interdisciplinary Interventions
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Normal saline nose drops
Warm pack to face
Acetaminophen for pain
Increase po fluid intake
Antibiotics
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Recent studies question their effectiveness
Tonsillitis
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Tonsils and adenoids are important to the normal
development of the body’s immune system.
Serve as part of the body’s defense against infection
Can become the site of acute or chronic infection
Repeated acute infections cause the tonsil tissue to swell
Enlarged tonsils and adenoids impinge on the pharyngeal
opening of the eustachian tube
Assessment
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Child may refuse to drink
Fever
Reddened pharynx and tonsils
Most common causative agent = group A beta-hemolytic
stretococci
Chronic tonsillitis may result in snoring due to enlarged
tonsils and adenoids
Tonsilitis
“Kissing tonsils” occur when the tonsils
are so enlarged they touch each other.
Interdisciplinary Interventions
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Throat culture to determine causative agent
Antibiotics for ten days if throat culture positive for beta
strep
Acetaminophen for pain
Cool fluids
Saline gargles
Antiseptic sprays
Viral throat infections will not get better faster with
antibiotics.
Tonsillectomy
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Done if child’s respiratory status is compromised
Post operative care:
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Side lying position
Ice collar
Watch for swallowing
Cool fluids / soft diet
Croup
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Most common acute respiratory condition seen in early
childhood.
Highest incidence from 6 months to about 3 years
Respiratory symptoms are caused by inflammation of the
larynx and upper airway, with resultant narrowing of the
airway.
Severity depends on the area of the upper airway that is
inflamed and narrowed.
Most often viral – antibiotics are not needed
Assessment
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Symptoms:
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Hoarseness
Inspiratory stridor
Barking cough
Afebrile
Often worsens at night
Interdisciplinary Interventions
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Home care:
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Cool mist
Fluids
Hospital care:
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Racemic epinephrine inhalant
Mist tent – not used much anymore
Dexamethasone
IV fluids if not taking po fluids
Epiglottitis
Bowden & Greenberg
Tripod position
Acute Epiglottitis
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Acute inflammation of supraglottic structures, the
epiglottis and aryepiglottic folds.
True pediatric emergency
Delayed treatment may result in complete airway
obstruction
Most often seen in children 2 to 7 years
Most common causative agent – H. influenzae type B
Assessment
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Sudden onset
High fever – 102.2 or greater
Dysphasia and drooling
Agitation, irritability and restlessness
Epiglottis is cherry red and swollen
Note: Do not look into the mouth – diagnosis often
made by presenting symptoms or lateral neck x-ray
Interdisciplinary Interventions
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Keep child quiet in a controlled medical environment with
emergency airway equipment readily available.
Do not put tongue blade in mouth to look in the
throat – may cause epiglottis to spasm and shut
Assess respiratory status
Give humidified oxygen by mask and keep HOB elevated.
Mild sedation may help the child relax
Apnea
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Apnea is cessation of respirations lasting longer than 20
seconds.
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Monitor in hospital for underlying problems
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Discharge home with monitor
Foreign Body
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Severe inspiratory stridor
Symptoms depend on
location
Unilateral chest
movement
Chest x-ray
Bronchoscope to remove
object
Coin in Trachea
Teaching
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No small hard candies, raisins, popcorn or nuts until age 3
or 4 years
Cut food into small pieces
No running, jumping, or talking with food in mouth
Inspect toys for small parts
Keep coins, earring, balloons out of reach
Influenza
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Associated with community epidemic
Febrile, URI, achy joints
Management:
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Acetaminophen for fever
Fluids
Keep away from others
Watch for signs of pneumonia
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Hypoxia, high fever, increase work of breathing
Bronchiolitis
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Acute obstruction and inflammation of the bronchioles.
Most common causative agent: Respiratory Syncytial Virus
(RSV)
Bronchioles become narrowed or occluded as a result of
inflammatory process, edema, mucus and cellular debris
clog alveoli
Assessment
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Harsh dry cough
Low grade fever
Feeding difficulties
Wheezing
Respiratory distress with apnea
Thick mucus
Interdisciplinary Interventions
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Oxygen to maintain oxygen saturation >than 95%
Pulse oximeter
Nasal suction as needed
Chest percussion to mobilize secretions
Inhalation therapy – not sure if it is beneficial
Mechanical ventilation as needed if increased work of
breathing is seen
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Increased heart rate, poor peripheral perfusion, apnea,
bradycardia and hypercarbia
RSV Positive - Isolation
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Respiratory Syncytial Virus is spread from respiratory
secretions through close contact with infected persons or
contact with contaminated surfaces or objects.
Hospitalized patients should be on contact and
respiratory isolation
Can be placed with other RSV + patients
Family members: use hand washing to decrease spread
Pneumonia
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An inflammatory condition of the lungs in which alveoli
fill with fluid or blood resulting in poor oxygenation and
air exchange.
Can be primary illness or develop as a complication of
another illness.
Incidence: 34 to 40 cases per 1000 children younger than
5 years
Most likely to develop when the body is unable to defend
against infectious agents.
Typical X-ray
Assessment
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High fever
Thick green, yellow, or blood tinged secretions
Grunting respirations
Rales, crackles, diminished breath sounds
Cough and cyanosis
Increased work of breathing
Hypoxia: oxygen saturations less than 92 % on room air
Diagnostic tests: Infiltrate seen on x-ray
Interdisciplinary Interventions
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Assess for respiratory distress
NPO (respiratory rate > 60 = high risk for aspiration)
IV fluids for hydration
Supplemental Oxygen to keep oxygen saturation equal to
or > 92%
Chest percussion
Nasal suctioning as needed
Acetaminophen for fever
Antibiotics – Ceftriaxone (3rd generation cephaloporin)
Pneumonia Isolation
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Respiratory isolation
May be taken off isolation if RSV negative and on
antibiotics for 24 hours.
Cystic Fibrosis
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Inherited autosomal recessive disorder of the exocrine
glands
Gene responsible for CF is located on chromosome 7
Life span is about 37 years
Complex disease requiring a holistic approach
CFTR Gene
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Mutation of the CFTR gene disrupts the function of the
chloride channels, preventing them from regulating the
flow of chloride ions and water across cell membranes. As
a result cells that line the passage ways of the lungs,
pancreas and other organs produce mucus that is thick
and sticky
Cystic Fibrosis
Cystic Fibrosis
Assessment
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History of Meconium ileus at birth
Foul smelling, greasy, bulky stools / constipation
Voracious appetite with poor weight gain
Recurrent respiratory infections
Persistent chronic cough
Salty tasting skin
Diagnosis
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Positive sweat test – Gold standard
Genetic marker
Medications
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Pancreatic enzymes to help digest food
Inhaled antibiotics – antimicrobial for lung treatment
Aerosol bronchodilators to open airways
Mucolytic enzyme – to thin mucus
H2 blocker – alters gastrointestinal acidic environment
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Prokinetic agents – enhances gastrointestinal motility
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Tagamet
Reglan
Vitamin C to improve absorption of other meds
Vitamins E, A, D, K / fat soluble vitamins
Oral and IV antibiotics – S. aureus, H. influenzae, P aeruginosa
Long Term Complications
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Nasal polyps
Sinusitis
Rectal polyps / rectal prolapse
Hyperglycemia / diabetes
Infertility - male
Asthma
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Asthma is a chronic, inflammatory lung disease involving
recurrent breathing problems.
Third leading cause of hospitalization among children younger
than 15 years.
Most common, chronic health problem in children
Pathophysiology
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Reversible changes in airway that lead to
bronchoconstriction, airway hyper-responsiveness and
airway edema.
At the cellular level mast cells release histamine causing
smooth muscle contraction and bronchoconstriction.
Increased mucous secretion by goblet cells causes
epithelial damage
Increased mucus secretion results in airway edema, mucus
hypersecretion and plugging, airway narrowing, leading to
airway obstruction
Assessment
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Wheezing
Cough
Tightness of chest
Prolonged expiratory phase
Assessment
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Hypoxemia – universal in child with moderate to severe
symptoms
Hypercarbia – carbon dioxide retention from air trapping
in the alveoli and ventilation – perfusion mismatch
Monitor blood gases – PaCO2 level more than 50 mm Hg
indicated ventilatory failure
Diagnostics: chest x-ray = hyper-expansion of lungs
Asthma Attack
Interdisciplinary Interventions
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High fowlers position / bed rest
Pulse oximetry
Nebulized albuterol – beta 2 agonist
Chest percussion to mobilize secretions
Methylprednisone / Solu-medrol IV
IV fluids / po fluids
Oxygen to keep oxygen sats > 95%
Home Management
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Peak flow spirometer
Identify triggers
Maximize lung function
Optimal physical growth
Optimal psycho-social state
Maximum participation
Peak Flow Meter
Peak flow meters are used to measure
PEFR and are designed for monitoring
purposes rather than diagnosis of
asthma.
Home Medications
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Rescue drugs: short acting albuterol beta 2 agonist – used
as a quick-relief agent for acute bronchospasm and for
prevention of exercise induced bronchospasm.
Anti-inflammatory or preventative: low-dose inhaled
corticosteroid: inhaled or oral prednisone
Allergy: leukotrines such as Singulair
Bronchodilators
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Bronchodilators rapidly relax the airway smooth muscle
cells, thus reversing the bronchospasm until antiinflammatory effect of steroids is attained.
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Aerosols
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Via mouth piece 3 years and older
Via facial mask for less than 3 years
Spacer mdi
About.com: pediatrics
Nebulizer
About.com: pediatrics
Corticosteroids
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Steroids reduce the inflammatory component of
bronchial obstruction, decrease mucus production and
mediator release, as well as the late phase (cellular)
inflammatory process.
Methyl prednisone IV in severe cases
May need histamine H2 receptor antagonists (cimetadine
or ranitidine) if experiencing GI upset
PO prednisone – always give with food to decrease GI
upset
Inhaled Corticosteroids
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Inhaled corticosteroids: Pulmicort, AeroBid, Flovent
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Infant: mask should fit firmly to prevent cataracts
Older child: rinse and spit after treatment to prevent thrush
Family Teaching
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Teach how to use medication
When to use and how often
No OTC drugs
Increase fluid intake
Signs and symptoms of respiratory distress
Neonate Disorders
Bronchopulmonary
Dysplasia
Pediatric Nursing January/February 1999
History
It occurs in newborns who are born prematurely and or
have a variety of pulmonary disorders and who require
ventilatory support with high pressure and oxygen in the
first 2 weeks of life.
Pathophysiology
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Fibrosis of airways and marked hyperplasia of the
bronchial epithelium
Increased fluid in the lungs, as a result of disruption of the
alveolar-capillary membrane
Over distention due to damage to alveolar supporting
structures resulting in air trapping
Fibrosis, airway edema, and broncho-constriction
BPD Assessment
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Persistent respiratory distress
Dependent on supplemental oxygen
Failure to thrive
Gastro-esophageal reflux
Pulmonary hypertension
Long-term Outcomes
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Oxygen dependent
Visual problems
Feeding difficulties
Developmental delay
Learning difficulties
Long Term Management
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Supplemental oxygen
CPT
Bronchodilators
Diuretics (pulmonary hypertension)
Anti-inflammatory medication
Nutritional support: po formula + NG supplement
Gastrostomy tube (GER)
Bicarbonate in formula due to chronic state of acidosis