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

2. 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

3. 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.

4. 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

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

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

7. 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?

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

9. 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

10. 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

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

12. 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

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

14. 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!!!

15. Upper Airway Treatment
Cool Mist Tent

16. 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!!!

17. 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

18. 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

19. 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.

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

21. 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

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

23. 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
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

24. 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

25. 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

26. Lower Airway Problems Asthma Severity Scale Medications
Medications
Intermittent asthma to Persistent Asthma requiring daily medications
Short acting Beta2 agonist
Inhaled corticosteroid
Montelukast
Evaluate control with medications
PFT
Symptom tracking

27. 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)

28. 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)

29. 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)

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

31. 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
Incidence approx 30,000 indiv in US. People with CF may live into ’s
Sweat chloride >60 mEq/L is diagnostic of CF. Normal is 40 mEq/L

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

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

34. 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

35. Tracheostomy
Tracheostomy Care
Suctioning
Routine Care
Emergency care

36. Tracheostomy