1. The child with respiratory dysfunction
By: Murad Sawalha RN, MSN Basel Abdul-Qader RN, MSN

3. Anatomy of the Respiratory System

4. Anatomy of the Respiratory System (cont.)
What is respiration?
Respiration is the act of breathing:
inhaling (inspiration) - taking in oxygen.
exhaling (expiration) - giving off carbon dioxide.
What makes up the respiratory system?
The respiratory system is made up of the organs involved in the interchanges of gases, and consists of the:
- nose pharynx
- larynx trachea
- bronchi lungs

5. Anatomy of the Respiratory System (cont.)
The upper respiratory tract includes the following:
nose
nasal cavity
Sinuses: ethmoid, frontal, maxillary, sphenoid
larynx
trachea
The lower respiratory tract includes the following:
lungs
airways (bronchi and bronchioles)
air sacs (alveoli)

6. Anatomy of the Respiratory System (cont.)
What is the function of the lungs?
The lungs take in oxygen, which cells need to live and carry out their normal functions. The lungs also get rid of carbon dioxide, a waste product of the body's cells.
The lungs are enveloped in a membrane called the pleura.
The right lung has three sections, called lobes.
The left lung has two lobes.

7. PEDIATRIC AIRWAY DIFFERENCES
Small airways
Airway Resistance
Obligate Nose Breathers
Fewer alveoli
Constantly Growing
Alveoli Increase in Number & Size Until 12 yr (8 according to Potts & Mandleco)
The Taller the Child, the Greater the Lung Surface Area
Primarily diaphragmatic breathers until ~ 6 yr
Increased chest compliance: poor expansion & decreased lung volume

9. ASSESSMENT(1) Observation
Level of Consciousness, Activity; Awareness of Environment (Recognizes Parents?)
Skin Color: Pink, Pale, Mottled?
Child with Mild Cyanosis

10. ASSESSMENT(2) Observation (conti.)
Respiratory Rate & Work of Breathing
Grunting: Audible at End of Expiration; Attempt to Keep Airway Open
Stridor: High-pitched sound produced by an obstruction of the trachea or larynx that can be heard at inspiration or expiration.
Nasal Flaring: Nostrils Flare in Attempt to Increase Airway Diameter
Retractions: Chest Wall is Drawn Inward During Inspiration Due to Flexible (Cartilage) Airway

13. ASSESSMENT(3) Auscultation
CRACKLES: Coarse or Fine; Related to Fluid in Airway (Pneumonia, CHF)
WHEEZES: Musical Sound Related to Turbulent Airflow in Constricted Airway (Asthma)
DESCRIBE Location of Retractions & Adventitious Airway Sounds; Use LANDMARKS

14. Location of Retractions

15. UPPER RESPIRATORY TRACT INFECTION

16. Nasopharyngitis Nasopharyngitis: common cold .
Causes: rhinovirus, adenovirus, influenza virus, Resp. syncytial virus (RSV), Para influenza virus.
Clinical manifestations:
Younger child :fever, irritability, restlessness, sneezing, vomiting, diarrhea.
Older child: dryness, irritation of nose, & Throat, cough, sneezing , chilly sensation, muscular aches.
Physical signs: edema& vasodilatation of mucosa.

17. Nasopharyngitis (cont.)
Therapeutic management:
- Mostly treated at home , no vaccine, antipyretics for fever.
Decongestants: nose drops more effective than orally.
Cough: suppressant 22% with alcohol but not for young child.
Antihistamine are ineffective.
Antibiotic: usually not indication.
Nursing consideration:
For nasal obstruction: elevate head of bed, suctioning and vaporization, saline nasal drops.
Maintain adequate fluid intake to prevent dehydration.
Avoiding spread the virus.

18. Pharyngitis
Causes : 80-90%of cases are viral cause , other is group A and B hemolytic streptococci (GABHS).
Clinical manifestation:
May be mild so no symptoms.
Headache, fever, abdominal pain exudates on pharynx& tonsils, 3-5 days usually symptoms are subside
Complication if not treated :
Acute glumerulonephritis syndrome in about 10 days.
Acute Rheumatic Fever (ARF) in an average 18 days those complication if the cause is GABHS.

19. Pharyngitis (cont.)
Diagnostic evaluation: throat culture should be performed to rule out: GABHS
Therapeutic management:
- If streptococcal sore throat infection: oral Penicillin for 10 days ,or IM Benzathine penicillin G.
Oral Erythromycin if the child has allergy to penicillin.
Nursing consideration:
- Obtain throat swab for culture.
Administer penicillin & analgesic.
Cold or warm compresses to the neck may provide relief.
Warm saline gargles.

20. Pharyngitis (cont.) Nursing consideration (cont.)
Soft liquid food are more acceptable than solid.
Continue oral medication to complete the course.
IM injection applied in deep muscle as vastus lateralis or ventrogluteal muscle, use Emla cream before IM around 2 hours.
Nurse role to prevent the spread of disease.
- Children are considered non infectious to other 24 hours after initiation of antibiotics therapy.

21. Tonsillitis
Tonsils are masses of lymphoid tissue, first immune defense.
Tonsillitis often occur with pharyngitis, viral or bacterial causes.
Common cause of morbidity in young children
S& S:
enlarge tonsils, difficult breathing & swallow.
Enlargement of adenoid, blocked postnasal space &mouth breathing.

22. Tonsillitis Therapeutic management:
throat culture to determine the causative agent ,viral or bacterial as GABHS.
Tonsillectomy & adenoidectomy (T&S) or (Ts &As).
Contraindicating for Ts &As: cleft palate, tonsillitis, blood disorder.
Nursing consideration:
Providing comfort & maintain minimize activities.
A soft or liquid diet is prescribed.
Warm salt water gargles
Analgesic, antipyretic.

23. Tonsillitis Post operative care:
Position (place child on abdomen or side).
Discourage child from coughing frequency.
Some secretion are common as dried blood.
Crushed ice& ice water to relief pain.
Analgesic may be rectally or IV, avoid oral route.
Avoid red or brown fluid, and citrus juice.

24. Tonsillitis Post operative care (cont.):
Soft food, milk or ice cream not offered.
Check post operative signs of Hemorrhage:
Increase pulse more than 120b/min.
Pallor.
Frequent swallowing.
Vomiting of bright blood
Decrease blood pressure is late sign of shock.
** Note: use good light to look direct on site of operation.

25. Otitis Media:OM OM is inflammation of middle ear.
Episode of acute OM occur in the first 24 month, decrease at 5 years, r/to drainage through the Eustachian tube & inflammatory of Resp. system.
Etiology:
- Acute (AOM): streptococcus, Haemophilus influenza, moraxella catarrhlis, are the most common bacteria.
OM: blocked Eustachian tube from edema of URTI , allergic hypertrophy adenoid.
Chronic (COM): extension of AOM.

26. Otitis Media:OM (cont.)
Diagnostic evaluation: assessment of tympanic membrane with otoscope:-
AOM: purulent discolored effusion, bulging
S&S: otalgia (earache), fever, purulent discharge, infant rolls his head from side to side, loss of appetite, crying or verbalized feeling of discomfort (older child).
COM: hearing loss, feeling of fullness, vertigo, tinnitus.

27. Otitis Media:OM (cont.)
Therapeutic management:
Antibiotic for days e.g. Amoxicillin.
Myringotomy: surgical incision of eardrum& grommets.
Hear test after 3 month of AOM.
Nursing consideration:
Relieving pain. analgesic drug +ice bag on ear.
Facilitate drainage & topical A.Biotics.
Preventing complication.
Instruct family to be careful when deal with child. With temporary hearing loss.
Preventing OM during infant feeding and setting after that.

29. Lower respiratory tract infections

30. Infection of the Lower Air ways
Cartilaginous support of the air ways is not fully developed until adolescence, consequently the smooth muscle in these structures represents a major factor in the constriction of the airway.

31. Bronchitis
Bronchitis or tracheobronchitis is inflammation of larger air way (trachea and bronchi).
Causative agents: viruses or mycoplasma pneumonia.
Ch-ch & symptoms: dry, nonproductive cough that worsens at night then become productive in 2-3 days.
Bronchitis is a mild disease required symptomatic treatment as antipyretic, analgesic and humidity, cough suppressants may be useful at night.

32. Bronchiolitis & Resp. Syncytial Virus RSV
Bronchiolitis: is an acute viral infection with maximum effect at the bronchiolar level, and rare in children older of 2 years.
One of the Most Frequent Cause of Hospitalization in Infants
Virus or Bacteria Causes Inflammatory Response & Obstruction of Small Airways From Edema
RSV is responsible of 80% of cases during epidemic periods.

33. Bronchiolitis & Resp. Syncytial Virus RSV (cont.)
Transmission (It is easily spread): direct contact (from hand to eye, nose or other mucous membranes); virus can survive for hours on countertop, cloth, gloves; ½ hours on skin
Clinical Manifestations:
URI Symptoms: Nasal Stuffiness; Cough; Fever
Symptoms Increase & Cough Worsens, Respirations More Labored, Respirations Rapid, Shallow & With Nasal Flaring & Retractions
Infant Acting Ill, Not Playing, Decreased Eating, & Spits Up Thick Mucous

34. Bronchiolitis & Resp. Syncytial Virus RSV (cont.)
Respiratory Syncytial Virus (RSV)
Invades Mucosal Lining of Lungs, Destroys Cells, & Causes Inflammatory Response With Increased Mucous Production Which May Cause Airway Obstruction
Airway Swelling & Mucous Obstruction Cause Air Trapping & Further Inflammation
Impaired Gas Exchange Leads to Resp. Failure
RSV antigen detection (ELISA), Viral Culture
Medical Management is Supportive

35. Bronchiolitis & Resp. Syncytial Virus RSV (cont.)
Medical therapy is controversial: Albuterol & Steroids??
Ribavirin, the only FDA approved antiviral agent for RSV, Not Use Currently b/c its Side Effects
Child Hospitalized if Has O2 Requirement, Cannot Drink, or Has Apnea & Needs Continuous Monitoring
Preventive Measure for RSV Bronchiolitis
Synagis: IM, monthly. During RSV season
RespiGam (RSV IGIV, given IV, monthly)

36. Bronchiolitis & Resp. Syncytial Virus RSV (cont.)
Nursing Management:
Handwashing (most important)
Patient needs separate-room (Resp. isolation) by using gloves, gown, mask, and goggles..
Maintain Respiratory Function
Support Physiologic Function
Group care
Discharge Planning & Home Care Teaching

37. Pneumonia Pneumonia: is inflammation of the pulmonary parenchyma.
Common in children but more frequently occur in infancy & early childhood.
Types of pneumonia (depend on place):
Lobar- Pneumonia: one-lobe or more (bilateral or double Pneumonia).
Broncho Pneumonia: begins in the terminal bronchioles form consolidated patches in nearly lobules, also called lobular Pneumonia .
Interstitial Pneumonia: inflammatory process is confined within the alveolar walls and peribronchial and interlobular tissues.

38. Pneumonia (cont.)
Morphology classification: viral, bacterial, mycoplasma , aspiration of foreign body, fungal.
Viral Pneumonia:
Occurs more than bacterial.
Causes: RSV, parainfluenza, influenza, adenovirus.
Clinical symptoms: fever, cough, abnormal breath sound; whitish sputum, nasal flaring, retraction, chest pain, pallor to cyanosis, irritable, restless, anorexia, vomiting, diarrhea, abdominal pain.

39. Pneumonia (cont.) Viral Pneumonia (cont.): Treatment:
symptomatic: O2 therapy, Comfort.
Chest physiotherapy and postural drainage.
Antipyretics, Fluid intake, & Family supports.
Primary atypical pneumonia: It is caused by mycoplasmas, the smallest free-living agents of human disease, which have the characteristics of both bacteria or viruses, but which are not classified as either, most common in children between 5-12 years, mostly in winter months, symptomatic treatments within 7-10 days.

40. Bacterial Pneumonia
Streptococcus Pneumonia is the most common cause in children and adult
In infant mainly followed viral infection.
Symptoms: fever, malaise, rapid& shallow respiration, cough, chest pain, abdominal pain?? Appendicitis, meningeal symptoms.
Treatment: AB therapy , bed rest, antipyretic, fluid intake, need hospitalization when pleural effusion or empyema, I.V fluid, O2 therapy.

41. Bacterial Pneumonia (cont.)
Complication:
Tension pneumothorax and empyema if the causative agent is staphelococcus auoraus,
AOM,PE, lung abscess if pnumococcal pneumonia.
Prognosis: is generally good if recognize the disease early & treat early.
Prevention: pnumococcal poysaetheride vaccine for children older than 2 years who is risk.

42. Bacterial Pneumonia (cont.)
Nursing consideration:
Administer of O2 therapy ,AB, rest, humidity.
Assess Resp. status frequently.
I.V fluid intake.
Antipyretic.
Lying the child on affected side.
Suctioning by bulb syringe for infant.
Chest physiotherapy & postural drainage.
Family support & reassurance.