2. RESPIRATORY

3. Pediatric Differences Surfactant is lacking in premature infants Immature immune system Smaller lower airways Undeveloped supporting cartilage Neonate airway is 50% smaller that an adult Lung size is proportional to body height Infants are mandatory nose breathers Diaphragm is the neonate’s major respiratory muscle Brief periods of apnea (10-15 sec) are common in the neonate Children’s normal respiratory rate is higher than an adult

4. Pediatric Differences An increased metabolic rate increases oxygen needs Alveolar continues to develop up to age 8 years Lung surface increases until 5 – 8 years Actual lung growth continues in the adolescent years Eustachian tubes are relatively horizontal Tracheal size approximately triples by adulthood Tonsillar tissue is normally enlarged in early-schooled-age children Infants and children use abdominal muscles to inhale until about age 5 – 6 years Child’s flexible larynx is more susceptible to spasm

5. Respiratory Why children less than 3 years are at greater risk Immature immune systems Smaller upper and lower airways Underdeveloped supporting cartilage Preventive measure Adequate rest Good nutrition Good hygiene HANDWASHING

6. Teaching Good home care techniques Observation and recognition of signs and symptoms When to call their physician

7. Diagnostic Test Blood Gas Analysis (ABG) Arterial blood gas is more reliable than capillary or venous Primarily to determine acid-base balance

8. Pulmonary Function Test Assess the degree of pulmonary disease Response to therapy Presence of restrictive or obstructive disease Test response to bronchodilators Measures ( spirometry) vital capacity Expiratory flow rate

9. Pulse Oximetry Measures oxygen saturation Non invasive Used to determine need of or response to oxygen therapy Oxygen saturation greater than 95%

10. Guidelines for accuracy of pulse ox Place sensor probe over clean and dry skin that is exposed to minimal movement. Avoid sites with nail polish as this can interfere with the sensor Check the oxygen saturation level when the child is not moving, (motion can give false readings) Avoid exposing sensor probe to bright light or sunshine (False increase in reading Check child’s hemoglobin level. If child anemic, a normal pulse ox reading may not reflect good oxygen transport to tissues Make sure heart rate detected by pulse ox matches the child’s heart rate. (cold to cool extremity with vasoconstriction may not be picked up)

11. Transcutaneous Monitoring Continuously checks oxygen and carbon dioxide concentrations Non invasive Place electrode on child’s skin Electrode sites changed every 3 to 4 hours Prevent burning the skin Must recalibrate Accuracy is jeopardized if poor tissue perfusion

12. Diagnosis of respiratory illness History Presenting signs and symptoms Physical Examination Diagnostic testing

13. Respiratory Tract Infections Assessments Respiratory rate Age dependent Depth – use of accessory muscles Work of breathing ease of respirations Cough Adventitious breath sounds: wheezing, stridor Drainage is purulent Sputum Cyanosis– a late and ominous sign

15. Treatment of Respiratory Illness 1. Facilitate respiratory effort 2. Promote rest 3. Promote comfort 4. Promote hydration 5. Family education and support

16. Bronchiolitis lower respiratory infection Obstruction of the small airways, Inflammation of Bronchioles Production of mucus Usually follows Upper respiratory infection (URI) Ages 2 and younger Etiology RSV ( >50% of cases) RESPIRATORY SYNCYTIAL VIRUS Parainfluenza Adenovirus rhinovirus Signs and Symptoms Respiratory distress early signs Irritability Rhinorrhea Pharyngitis Coughing Sneezing Wheezing Diffuse rhonchi and crackles Intermittent fever

18. Bronchiolitis

19. Illness progresses Increased coughing Sneezing Air hunger Tachypnea Retractions Cyanosis Severe Tachypnea > 70 breaths/min Listlessness Apneic spells Poor air exchange Markedly diminished breath sounds

20. Bronchiolitis Diagnostic study Nasal washing for RSV Chest X-ray show hyperaeration and areas of consolidations Epidemiology Seasonal illness starting in fall ending Spring Re-infection is common Transmission Respiratory contact Gown and gloves WASH HANDS Survives on surfaces 1 to 6 hours

21. Bronchiolitis Contagious (Contact Isolation) When any secretions are present Contagious up to 14 days after start of symptoms Assessment Incubation 5 to 8 days URI several days Cough Rhinorrhea clear Monitor Respiratory status Hydration status Oral intake versus IV fluid Oxygenation Oxygen therapy High humidity Elevate head of bed CPT Nebulized aluterol or xopenex recemic epi

22. Bronchiolitis Home management Promoting rest Promoting adequate fluid intake Managing the fever Hospitalization Bronchodilators Steroids Humidified oxygen Intravenous fluids Mechanical ventilation required for respiratory failure Antibiotics required for secondary bacterial pneumonias Specific treatment is Ribavirin (Virazole) Reserve for high risk children Aerosol antiviral medication

23. Bronchiolitis Ribavirin (Virazole) Monitor for anemia if treatment exceeds 7 days Health care provider risks May precipitate on contact lenses causing a conjunctivitis Pregnant health care workers should not care for children receiving this medication

24. Bronchiolitis Preventive measures Respigam (Respiratory Syncytial Immune Globulin) Uses for prevention of RSV infections in children < 24 months of age with BPD or history of preterm birth< 35 weeks gestation Given monthly as IV over 3 to 4 hours 1.5 ml/kg/hr for first 15 minutes 3.0 ml/kg/hr for next 15 minutes 6.0 ml/kg/hr for the remainder of the infusion Respigam (Respiratory Syncytial Immune Globulin) Children receiving respigam must delay measles containing and varicella vaccinations

25. Brochiolitis Palivizumab (Synagis) Clinical indications similar to Respigam Administered as a monthly injection 15mg/kg monthly Does not interfere with measles containing vaccines

26. In practice Provide rest Reduce fever Prevent the spread of infection Facilitate respirations and promote comfort Prevent dehydration Nutrition Medications

27. Apnea Cessation of breathing for a period of 20 seconds or longer Can be for a shorter period if accompanied by bradycardia or cyanosis Life-threatening events Sudden episodes Apnea Color change Change in muscle tone Choking or gagging Infants 37 weeks gestational age or older while sleeping feeding or awake

28. Apnea Evaluation Cardiorespiratory Neurophysicologic Nurse should record Time Duration of episode Skin color change Heart rate Oxygen saturation What it took for infant to start breathing again Tactile stimulation oxygen

29. Choking Foreign body aspirations CPR Choking