Care of the Pediatric Patient with Respiratory Problems Elizabeth Allen RN, MSN

Learning Objectives Describe Unique Characteristics of Pediatric Respiratory System List Respiratory Conditions and Injuries that Cause Respiratory Distress in Children Distinguish between Mild, Moderate, and Severe Respiratory Distress Differentiate between Signs and Symptoms of Upper and Lower Airway Conditions

Differences in A&P Newborn- 3 months obligatory nose breathers Child’s airway is shorter and more narrow<6 years breathe with diaphragm- intercostal muscles immature A newborn’s chest is circular until age 6. Decreased muscularity is responsible for the thin chest wall in infants.

Differences in A&P Child epiglottis longer, floppier Higher oxygen demand in children Immature Infant Respiratory and Neurologic System Offers Less-Efficient Response to Hypoxia and Elevated PCO2

Pediatric Respiratory Assessment Noises Stridor Wheeze Cough Grunting Cry Work of Breathing Rate Head bobbing Retractions Nasal flaring Pulse Oximetry Auscultate

Diagnostic Tests Pulmonary Function Radiology Chest Neck Arterial Blood Gases Capillary Blood Gases Pulse oximetry

How Long can the child maintain Respiratory Distress Can Lead to Respiratory Failure Early recognition and intervention vital Mild Tachypnea, tachycardia, diaphoresis, mild retractions Moderate Flaring, moderate retractions, grunting, wheezing Anxiety, irritability, confusion, mood changes Severe Dyspnea, severe retractions Bradycardia, bradypnea Stupor, coma Cyanosis = late sign How Long can the child maintain that level of effort?

Respiratory Distress Tripod Position Interventions Assessment Oxygen Airway positioning Medications Racemic Epinephrine Beta 2 Agonists/ Bronchodilators Corticosteroids Antibiotics Tripod Position

Apparent Life Threatening Event (ALTE) 1 week to 2 months Identifying diseases and conditions GERD, acute respiratory infections, seizures, Congenital heart defects, metabolic conditions, child abuse (Munchausen by proxy) Lab work Diagnostic testing Monitoring Home Education

Sudden Infant Death Syndrome (SIDS) Etiology / Pathophysiology Genetic Clinical Manifestation Cardiopulmonary arrest Season Collaborative Care Back to Sleep Nursing Management Supportive Care Safe Sleep Environment Safe Sleep Environment

Respiratory Infection Transmission Airborne Isolation Small particles negative pressure room Droplet Isolation Large particles- drop 3 feet Contact Isolation

Upper Airway Problems Strep Throat/ Tonsillitis Viral tonsillitis Supportive care Strep Throat- Streptococcus infection Fevers, gastritis Positive rapid strep test or positive culture Treat with antibiotics No longer contagious 24 hrs. after first antibiotic dose

Upper Airway Problems Tonsillectomy and possible Adenoidectomy Post Op Care Pain management Maintain hydration Evaluate for bleeding, swelling or airway compromise

Upper Airway Problems Croup Laryngealtracheobronchitis Viral Treatment Keep child calm!!! Cold, humid night air Corticosteroids Racemic epinephrine Albuterol as needed Croup Upper airway illness causing inflammation in larynx and epiglottis Viral or bacterial Symptoms: “Barking” cough Stridor Hoarseness Often “croup” refers to LTB caused by a virus An x ray of the upper airway may show a “steeple sign” that is a symmetric narrowing below the epiglottis. NO examination of the inner mouth or throat as these may cause laryngospasms that can result in complete airway obstruction!!!

Upper Airway Treatment Cool Mist Tent

Upper Airway Problems Epiglottitis Inflammation of the epiglottis – life threatening Bacterial Streptococcus Staphylococcus Haemophilus influenzae type B Hx: Acute fever, sore throat, dysphonia and dysphagia Diagnostic testing X-ray? Treatment/Interventions Antibiotics Cephalosporin Airway management Evaluation Symptoms: 3 D’s Dysphagia Drooling Dysphonia Rare in US with Hib vaccination Tripod position, Drooling!!!

Upper Airway Problems Foreign Body Aspiration Aspiration Developmental- older infants and Toddlers Usually bronchial obstruction, R bronchial Signs Cough, weak cough Stridor Respiratory Distress Muffled or hoarse voice Drooling Anxiety, irritability Unilateral diminished breath sounds Treatment Keep child calm Position of comfort Monitor cardiorespiratory status Airway intervention if necessary CXR Endoscopy OR

Upper Airway Problems Otitis Media Inflammation of middle ear 84% infants have at least 1 case before age 3 years More common in: Kids with allergies Families who smoke Pacifiers American Indian Symptoms Ear pain/ pulling at ear Fever Vomiting/diarrhea Irritability Treatment Guidelines AAP Avoid over treatment with antibiotics Educate families to complete course- avoid drug resistance

Figure 19–9 This young child is pulling at the ear and acting fussy, two important signs of otitis media. Ask the parents about the presence of fever and night awakenings, additional signs that are often observed in children with this condition.

Upper Airway Problems Otitis Media Repeated Otitis Media Hearing Loss Speech delay Tympanostomy Tubes Fall out on own Drainage

Lower Airway Problems Bronchitis/ Bronchiolitis Clinical Therapy Viral or bacterial Underlying chronic illness Bronchiolitis (bronchioles) RSV, parainfluenza, adenovirus Edema, debris clog and narrow airway Clinical Therapy Maintain Respiratory Function Close monitoring Keep airways clear! Oxygen Humidity Hydration Nutrition Rest Anxiety Discharge Planning Inflammation of the trachea and bronchi and bronchioles. Underlying prematurity, congenital heart disease, neuromuscular disease at increased risk for complications. Synagis vaccine Lower airway issue because air becomes trapped and chest hyperinflated

Lower Airway Problems Nursing Diagnoses for bronchiolitis? What’s your priority? Breathing pattern, ineffective Ineffective airway clearance Fluid volume deficit, risk for Anxiety

Lower Airway Problems Asthma Interventions Medications Etiology/Patho-physiology Clinical Therapy Assessment Peak Expiratory Flow Rate Respiratory Distress Triggers Interventions Medications Maintain Airway Patency Meet Fluid Needs Pediatric Considerations Discharge Planning Evaluation Resource http://www.nhlbi.nih.gov/files/docs/public/lung/asthma_actplan.pdf Pathophysiology: edema and mucus secretions narrow airway. Wheezing sound is air moving through narrowed spaces. Air trapping in lungs Assessment of respiratory distress and lung sounds, Peak Expiratory Flow Rate

Lower Airway Problems Asthma Exacerbation: Across the Room Assessment LOC Respiratory rate Retractions Audible wheezing Head bobbing Grunting Speaking Then listen for wheezing, diminished breath sounds Asthma Exacerbation Video- follow link https://www.youtube.com/watch?v=EK8nzKzdnIM

Lower Airway Problems Know your Peak Flow Green zone: 80%-100% Yellow zone: 50%-80% Red zone: below 50% This zone approach is based on peak flows. Older children and adults use a peak flow meter which measure their forced expiratory volume. Remember in lower airway disorders there is air trapping and difficulty exhaling air through narrowed spaces. The percentages may be based on baseline measurements for each client or on predicted volumes based on age and size

Lower Airway Problems Asthma Severity Scale Medications http://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf Medications Intermittent asthma to Persistent Asthma requiring daily medications Short acting Beta2 agonist Inhaled corticosteroid Montelukast Evaluate control with medications PFT Symptom tracking

Lower Airway Problems (London et. al., 2014) The asthma severity classification is based on symptom control, nighttime awakenings, SABA use, interference with normal activity and risk- classified as the number of episodes requiring oral systemic steroids. (London et. al., 2014)

Lower Airway Problems (London et. al., 2014) This stepwise approach to asthma management and treatment is used by prescribers. You should be generally familiar with it. Children can move up and down the steps based on the severity of their asthma- per the last page. You should be familiar with an example medication for each step. Flovent is an example of an inhaled corticosteroid, albuterol is an example of a SABA. You should also be familiar with montelukast, the generic name for Singulair. (London et. al., 2014)

Lower Airway Problems (London et. al., 2014) This classification is for children age 5 to adult. You’ll see now that peak flows have been added, noted as FEV which stands for forced expiratory volume. (London et. al., 2014)

Lower Airway Problems (London et. al., 2014)

Lower Airway Problems Cystic Fibrosis Autosomal recessive disorder Incidence Pathophysiology Defective chloride secretion and increased sodium absorption. Rate of progression varies among children Clinical manifestations Diagnostic Procedures- Sweat Chloride Test Resource http://www.cff.org/ Incidence approx 30,000 indiv in US. People with CF may live into 30- 40’s Sweat chloride >60 mEq/L is diagnostic of CF. Normal is 40 mEq/L

Defective chloride-ion transport and decreased water flow across cell membranes – excessive electrolyte loss.

Lower Airway Problems Cystic Fibrosis Assessment Physiologic Psychosocial Developmental Respiratory Therapy (including) Chest Physiotherapy Prophylactic antibiotics? Nutrition Pancreatic Enzymes Discharge Planning

Lower Airway Problems Cystic Fibrosis Medications Clinical Therapy Maintain respiratory function Manage infection Optimize nutrition Prevent gastrointestinal blocking Nursing Diagnoses Medications Pancreatic enzymes Antibiotics- oral and inhaled Osmotic medication- polyethylene glycol High calorie formula, MCT H2 blocker, PPI

Tracheostomy Tracheostomy Care Suctioning Routine Care Emergency care

Tracheostomy