Respiratory - PowerPoint by shimeiyan

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									Respiratory Disorders

    Jan Bazner-Chandler

Bifurcation of trachea   Change in chest wall shape
Upper Airway Characteristics

   Narrow tracheo-bronchial lumen until age 5
   Tonsils, adenoids, epiglottis proportionately
    larger in children
   Tracheo-bronchial cartilaginous rings
    collapse easily
Lower Airway Characteristics

   Fewer alveoli in the neonate
   Poor quality of alveoli until age 8
   Lack of surfactant that lines the alveoli in the
    premature infant
       Inhibits alveolar collapse at end of expiration
Respiratory Characteristics

   Basal metabolic rate is greater thus greater
    oxygen consumption

   Immunoglobulin G (IgG) levels reach low
    point around 5 months of age
Focused Physical Assessment

   Types of breathing:
       Less than 7 years abdominal breathing

       Greater than 7 years abdominal breathing can
        indicate problems
Respiratory Rate

   Inspiratory phase slightly longer or equal to
    expiratory phase
       Prolonged expiratory phase = asthma
       Prolonged inspiratory phase = upper airway
           Croup
           Foreign body

   Observe color of face, trunk, and nail beds

       Cyanosis = inadequate oxygenation

       Clubbing of nails = chronic hypoxemia
Respiratory Distress

   Grunting = impending respiratory failure
   Severe retractions
   Diminished or absent breath sounds
   Apnea or gasping respirations
   Poor systemic perfusion / mottling
   Tachycardia to bradycardia = late sign
   Decrease oxygen saturations
Chest Muscle Retraction
Chest Retractions

   Retractions suggest an obstruction to
    inspiration at any point in the respiratory tract.
   As intrapleural pressure becomes
    increasingly negative, the musculature “pulls
    back” in an effort to overcome the blockage.
   The degree and level of retraction depend on
    the extent and level of the obstruction.
Diagnostic Tests

   Detects abnormalities of chest or lungs
       Chest x-ray
       Sweat chloride Test
       MRI
       Laryngoscope / bronchoscopy
       CT Scan
White Patchy Infiltrates
X-ray Hyperinflation of Lung

Pleural Effusion
Pleural Effusion X-Ray

Sweat Chloride Test

                 •Analysis of sodium and chloride
                 •Contents in sweat
                 •Gold Standard for diagnosis
                 •May do genetic screening earlier
                  if positive family history

Ball & Bindler
Foreign Body Aspiration

                     A foreign body in one
                     or the other of the bronchi
                     causes unilateral

                     *usually the right due to
                     broader bore and more
                     vertical placement.
Oxygen Therapy: Nursing Interventions

   Proper concentration

   Adequate humidity: make sure there is fluid in the bottle

   Make sure prongs are in nose and that the nares are patent –
    suction out nares to increase oxygen flow

   Monitor oxygen SATS: if alarm keeps on going off but the infant /
    child looks good, check the device

   Monitor activity level or infant / child
Aerosol Therapy

   Respiratory Therapist will do the treatment
   Communicate with therapist – eliminated
    needless paging for treatments
   Treatment should be done before the infant
   When you make your morning rounds assess
    if there is any infant / child that needs an
    immediate treatment
Home Teaching Inhaled Medications

   Correct dosage
   Prescribed time
   Proper use of inhaler
   No OTC drugs
   Encourage fluids
   When to call physician
  Aerosol Therapy

by oxygen or

                    Ball & Bindler
Nebulizer - infant
Outpatient Aerosol Treatment

   In the small child you can position on your lap
   Do first thing in the AM
   Do before meals or one hour after
   Do after the aerosol treatment since the
    treatment will help open the airways and
    loosen the mucous
   Suction the infant after treatment – teach
    parents to do bulb suction – RN, LVN or RT to
    deep suction prn
Mechanical Ventilation
Alterations in Respiratory Function
Severe Respiratory Distress

•   Nasal flaring and grunting
•   Severe retractions
•   Diminished breath sounds
•   Hypotonia
•   Decreased oxygen saturations
What to do if infant / child in respiratory
   Stimulate the infant / child - remember crying or
    activity will help mobilize secretions and expand
   Have the older child sit up take deep breaths and
   CPT to loosen secretions and suction! suction!
   Give oxygen
   Assess if interventions work
   Call for help if you need it – pull the emergency cord
    – yell for help
Allergic Rhinitis

   Itching of nose, eyes, and throat
   Sneezing and stuffiness
   Watery nasal discharge / post nasal drip
   Watery eyes
   Swelling around the eyes
Rhinitis Treatment

   Antihistamines
   Competitive inhibitors for histamine at the
    mast cell receptor sites
       Benadryl – OTC medication
       Prescription –Cromolyn or steroid nasal spray
       Environmental changes - avoidance of allergens
       Do not use combination OTC medications
        especially those that contain pseudoephedrine

                                   Sinuses not fully developed
                                   until age 12.


Sinuses are hollow cavities within the facial bones.
Sinusitis Symptoms

   Fever
   Purulent rhinorrhea
   Pain in facial area
   Malodorous breath
   Chronic night-time cough

Children more prone to sinusitis: children with asthma
and cystic fibrosis.

   Normal saline nose drops
   Warm pack to face
   Acetaminophen for pain
   Increase po fluid intake
   Antibiotics
       Recent studies question their effectiveness

          “Kissing tonsils” occur when the tonsils
          are so enlarged they touch each other.

   Inflammation of the tonsils.
   Part of the immune system to trap and kill
    bacteria and viruses traveling through the

   Child may refuse to drink

   Night snoring = enlarged tonsils or adenoids

   Size of tonsils are obstructing airway

   Antibiotics x ten days if positive for beta strep
   Acetaminophen for pain
   Cool fluids
   Saline gargles
   Antiseptic sprays
   Viral throat infections will not get better faster
    with antibiotics.

   Done if child’s respiratory status is
   Post operative care:
       Side lying position
       Ice collar
       Watch for swallowing
       Cool fluids / soft diet

   Laryngotracheobronchitis or Acute spasmotic
   Infants from 3 months to about 3 years
   Respiratory symptoms are caused by
    inflammation of the larynx and upper airway,
    with resultant narrowing of the airway.

   Symptoms:
       Hoarseness
       Inspiratory stridor
       Barking cough
       Afebrile
       Often worsens at night

   Home care:
       Cool mist
       Fluids
   Hospital care:
       Racemic epinephrine inhalant
       Mist tent – not used much anymore
       Dexamethasone: IV over 1 to several minutes
Pertussis or whooping cough

   Agent: Bordetella Pertussis
   Source: respiratory
   Transmission: droplet
   Incubation: 10 days
   Period of communicability: before onset of
    paroxysms to 4 weeks after onset

   Respiratory support as needed
   Suctioning
   Oxygen to keep oxygen saturation at > 98 %
   Nutritional support
   IV fluids
   Erythromycin, Zithromax or Biaxin for child
    and all exposed family members
Isolation Precautions

   Transmission through direct contact with
    discharges from respiratory mucous of
    infected persons.
   Highly contagious with up to 90% of
    household contacts developing disease after
   Respiratory and contact isolation for 3-4 days
    after the initiation of antibiotic therapy.

      Bowden & Greenberg
                           Tripod position
Epiglottitis Symptoms

   Acute inflammation of supra-glottic
   Medical Emergency
   Sudden onset
   High fever
   Dysphasia and drooling
   Epiglottis is cherry red and swollen

   Has decreased dramatically since
    introduction of the Haemophilus influenzae
    type b or Hib vaccine in 1985.
   Incidence as of 2003: 32 cases in children
    under 5 years of age.
   Incidence in the adult population has
    increased from 0.8 to 3.1 per 100,000 adults

   Diagnosis made on presenting symptoms
   No tongue blade in mouth
   Emergency tracheostomy set
   No procedures until in the operating room
   Keep quiet
   Ceftriaxone – third-generation cephalosporin
    for 7 to 10 days.

Apnea is cessation of respiration lasting longer
 than 20 seconds.

   Monitor in hospital for 48 hours for underlying

   Discharge home with monitor
Apnea Monitoring
Foreign Body

   Severe inspiratory
   Symptoms depend on
   Unilateral chest
   Chest x-ray
   Bronchoscope to
    remove object
Coin in Trachea

   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
   Inspect toys for small parts
   Keep coins, earring, balloons out of reach

   Associated with community epidemic
   Febrile, URI, achy joints,
   Management:
       Acetaminophen for fever
       Fluids
       Keep away from others
       Watch for signs of pneumonia

   Acute obstruction and inflammation of the
   Most common causative agent: RSV
   Respiratory syncytial virus
   Bronchioles become narrowed or occluded
    as a result of inflammatory process, edema,
    mucus and cellular debris clog alveoli

   Harsh dry cough
   Low grade fever
   Feeding difficulties
   Wheezing
   Respiratory distress with apnea
   Thick mucus

   Oxygen to maintain oxygen saturation >than
   Pulse oximeter
   Normal saline nose drops before suctioning
   Deep suction especially before feeding
   CPT to mobilize secretions
   Inhalation therapy – not sure it is beneficial
   Mechanical ventilation as needed
RSV Positive - Isolation

   RSV is spread from respiratory secretions
    through close contact with infected persons
    or contact with contaminated surfaces or
   Patient should be on contact and respiratory
   Can be placed with other RSV + patients

   An inflammatory condition of the lungs

in which alveoli fill with fluid or blood

resulting in poor oxygenation and air

Typical X-ray

   High fever
   Thick green, yellow, or blood tinged
   Grunting respirations
   Rales, crackles, diminished breath sounds
   Cough and cyanosis
   Infiltrate seen on x-ray

   Assess for respiratory distress
   NPO (rr > 60 = high risk for aspiration)
   IV fluids
   Oxygen as need to keep oxygen saturation
    above 95%
   CPT
   Deep suctioning
   Acetaminophen for fever / antibiotics
Pneumonia Isolation

   Respiratory isolation
   May be taken off isolation if RSV negative
    and on antibiotics for 24 hours.
 Cystic Fibrosis

Inherited autosomal recessive disorder of the exocrine glands.
Pathophysiology: Cystic Fibrosis

   A chronic, progressive, genetic illness
    involving the digestive system and lungs.
   Abnormality of the exocrine glands
       Sweat and mucous glands
       Mucus of CF is thick and viscous
       Causes scar tissue
       Leads to irreversible lung damage
Exocrine Gland Dysfunction

Mucous secretions are thick and tenacious

•   Dysfunction of mucous producing glands leads to
    multiple gastrointestinal absorption problems.

    •   Blocked pancreatic ducts

    •   No secretion of digestive enzymes
Cystic Fibrosis
Cystic Fibrosis

   Meconium ileus at birth
   Failure to thrive
   Steatorrhea stools / constipation
   Voracious appetite with poor weight gain
   Recurrent respiratory infections
   Chronic cough
   Malabsorption of intestines

   Positive sweat test
   Genetic marker
   Life long management
       Enzyme replacement with eating
       Daily CPT postural drainage
       Inhaled bronchodilators
       Control of lung infections
       Nutritional supplements as needed

   Enzymes to help digest food
   Antibiotics to control infection
   Bronchodilators to open airways
   Vitamin C to improve absorption of other
   Vitamins E, A, D, K / fat soluble vitamins
Long Term Complications

   Nasal polyps
   Sinusitis
   Rectal polyps / prolapse
   Hyperglycemia / diabetes
   infertility

    * Life span approximately 30 years of age

    Asthma is a chronic, inflammatory lung disease
     involving recurrent breathing problems.
    Caused by complex, multicellular reaction in the
     airway characterized by:
        Airway inflammation
        Airway hyper-responsiveness to a variety of triggers

* Asthma is the most common, chronic health problem among children.

   Wheezing
   Cough
   Tightness of chest
   Prolonged expiratory phase
   Hypoxemia
   X-ray = hyper-expansion of lungs
Medical Management

   High fowlers position / bed rest
   Pulse oximetry
   Nebulized albuterol
   CPT
   Methylprednisone / Solu-medrol IV
   IV fluids
   Oxygen to keep oxygen sats > 95%
Home Management

   Peak flow spirometer
   Identify triggers
   Maximize lung function
   Optimal physical growth
   Optimal psycho-social state
   Maximum participation
Peak Flow Monitoring

                Spirometry measures how
                much and how fast air is
                forcefully expelled from fully
                inflated lungs.

                Recommended standard of care
                for management of asthma.
Home Medications

   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
   Allergy: Singulair

   Bronchodilators rapidly relax the airway
    smooth muscle cells, thus reversing the
    bronchospasm until anti-inflammatory effect
    of steroids is attained.
       Aerosols
           Via mouth piece 3 years and older
           Via facial mask for less than 3 years

   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

   Oral prednisone (Pedia-pred, Prelone, Liquid
    pred) recommended for short course in
    moderate or severe exacerbation
   Inhaled: Pulmicort, AeroBid, Flovent
       Infant: mask should fit firmly: cataracts
       Older child: rinse and spit after treatment to
        prevent thrush
Family Teaching:

   Teach how to use medication
   When to use and how often
   No OTC drugs
   Increase fluid intake
   Signs and symptoms of respiratory distress
Normal Lungs
Asthma Attack
  Bronchopulmonary Dysplasia

Pediatric Nursing January/February 1999

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

   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 Symptoms

   Persistent respiratory distress
   Dependent on supplemental oxygen
   Failure to thrive
   Gastro-esophageal reflux
   Pulmonary hypertension
Long Term Management

   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
Long-term Outcomes

   Oxygen dependent
   Visual problems
   Feeding difficulties
   Developmental delay
   Learning difficulties

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