The Child with Respiratory Dysfunction

The Child with Respiratory Dysfunction Unit 5 1 Respiratory adult : vs child • • • • • • • infectious agent size/frequency age size of child resistance general condition pre-existing conditions 2 Respiratory assessments • • • • • • • nose breathers, flaring,grunting rate and ease abdominal breathing retractions cyanosis clubbing coughing must be described ! 3 Respiratory assessment described • R= 54 and shallow with intercostal retractions, intermittent non productive cough and continuous wheeze throughout lung fields 4 Respiratory Nursing interventions Ease respiratory efforts: pulse Ox, humidity,O2, RT promote rest: age appropriate play promote comfort: nose drops, nasal aspirator prevent infection spread: hand washing, isolate reduce fever: Tylenol, tepid sponging, fluids Promote hydration and nutrition 5 Tracheotomy • • • • Plastic and silastic tubes Neck cord- allow 1 finger insert Weekly tube change Suction – – – – 80-100mm Hg pressure NS 2cc???? no 5 seconds of suctioning-assess 30-60seconds of rest periods in between and hyper oxygenate in between 6 APNEA OF INFANCY • Sx: apnea> 20 seconds Cyanosis and bradycardia • Tx: – – – Apnea monitor parent teaching and CPR training if apneic, NEVER SHAKE 7 Apnea of Infancy • Pathologic apnea in infants >37 weeks gestation • Clinical presentation of ALTE • Therapeutic management – Theophylline/caffeine – Home apnea monitors – Family support 8 Disorders of Unknown Etiology • Sudden infant death syndrome (SIDS) • Apparent life-threatening events (ALTE’s) • ―Back to sleep‖ campaign • Risk factors for SIDS – Maternal smoking, alcohol, drug use, adolescent mom, 9 SIDS Risk factors for SIDS – cont’d • Prematurity, Small for gest age • Twin, male, previous family SIDS • Bronchopulmonary dysplasia • Winter, poverty, soft pillows • Prone, side lying or co- sleeping 10 SIDS •Smoke free environment •Use firm mattress •Do not overheat infants •Breast feed 11 Croup Syndromes • Characterized by hoarseness, ―barking‖ cough, inspiratory stridor, and varying degrees of respiratory distress • Croup syndromes affect larynx, trachea, and bronchi – Epiglottitis, laryngitis, LTB, tracheitis 12 Acute Epiglottitis • Clinical manifestations – Sore throat, pain, tripod positioning, retractions, high fever – Inspiratory stridor, mild hypoxia – 4B’s dysphonia, dysphagia, drooling, distress A Medical Emergency with Potential for respiratory obstruction. DO NOT EXAMINE THROAT Prevention: Hib vaccine 13 Acute LTB • LTB = Laryngotracheobronchitis • Most common of the croup syndromes • Generally affects children <5 yrs • Organisms responsible – RSV, parainfluenza virus, Mycoplasma pneumoniae, influenza A and B 14 Manifestations of LTB Inspiratory stridor Suprasternal retractions Barking or ―seal-like‖ cough Increasing respiratory distress and hypoxia • Can progress to respiratory acidosis, respiratory failure and death 15 • • • • Acute Spasmodic Laryngitis • AKA spasmodic croup, midnight croup • Paroxysmal attacks of laryngeal obstruction • Occur chiefly at night • Inflammation: mild or absent • Most often affects children ages 1-3 16 Therapeutic Management • Airway management • Maintain hydration—PO or IV • High humidity & Cool mist = ―Croup Tent‖ – keep pt dry • Nebulizer treatments – Epinephrine – Steroids 17 Infections of the Lower Airways • Considered the ―reactive‖ portion of the lower respiratory tract • Includes bronchitis and bronchiolitis • Cartilaginous support not fully developed until adolescence • Constriction of airways 18 Bronchiolitis ELISA assay  Cause: viral  RSV:  Dx: apnea, pCO2 R acidosis Teatment: – Handwashing, Cohort isolation – ―Croupette‖ or hi humidity – Racemic Epinephrine (rebound) – Ribavirin- toxic to pregnant persons 19 Pneumonia • Sx: fever, nonproductive cough, pallor,fatigue • Dx: chest Xray, CBC, P Ox, cultures • Bacterial can be life threatening • Nsg care: – hydration – meds – chest PT 20 Aspiration Pneumonia • Risk for child with feeding difficulties • Prevention of aspiration • Feeding techniques, positioning • Avoid aspiration risks – Oily nose drops – Solvents – Talcum powder 21 Asthma Chronic inflammatory disorder of airways Bronchial hyper-responsiveness Episodic with ―triggers‖ Limited airflow or obstruction that reverses spontaneously or with treatment • Most common chronic illness in children • • • • 22 Mild, Moderate & Severe attacks Note Respiratory effort, rate, breath sounds, speech patterns, Color, LOC Position, Pulse Ox, ABG, PH Peak Flow Bronchial Asthma 23 reversible, obstructive, reactive airway disease Bronchial Asthma • SX: R, exp.wheeze, tight cough, decreased breath sounds • Pathology – broncho constriction – mucosal edema – thickened secretions Listen to breath sounds @ http://www.med.ucla.edu./wilkes/intro.html 24 Bronchial dilators for acute care – Albuterol (Proventil/Ventolin) – Levalbuterol (Xopenex) – Metaproterenol (Alupent) – Terbutaline (Brethine) 25 Bronchial dilators for acute care cont’d – Theophylline (Aminophylline) – loading dose to reach blood level of 10 – 20 mcg/ml – Toxic side effects of theophyllin are n&v, tachycardia, headache, irritability – Cromolyn Sodium (Intal) – Epinephrine: sc, quick acting for bronchial spasm 26 Bronchial Asthma: meds Cortiosteroids: anti inflammatory – Predisone (Solucortef) , Methylprednisone (Soul-Medrol) – Side effects: • • • • • • gastric ulcers masks infection growth delay Immunosupression & cushing syndrome withdrawal symptoms Osteoporosis if long term use 27 • • • • Leukotrienes (Singulair) Anticholinergics Skin tests for allergens Magnesium Sulfate IV for Status Asthmaticus Bronchial Asthma: meds 28 Asthma Diagnosis • • • • • • Repeated Attacks Peak Flow Monitoring Pulmonary Function tests Pulse Oximetry, ABG Chest x-ray WBC, RAST, Allergy skin tests 29 Asthma Interventions • • • • • Teach Family a Treatment Plan Avoid Triggers Chest physiotherapy (CPT) Hyposensitization Use of Meds 30 Status Asthmaticus • Respiratory distress despite vigorous therapeutic measures • Emergency treatment—epinephrine 0.01 mL/kg SQ (max dose 0.3 mL) • Concurrent infection in some cases • Emergency Intubation prevents Respiratory arrest 31 Cystic Fibrosis (CF) • Exocrine gland dysfunction that produces multi-system organ involvement • Most common lethal GENETIC illness among white children • Approximately 3% U.S. Caucasian population are symptom-free carriers 32 Cystic Fibrosis (cont’d) Incidence in U.S. Live Births • 1 in 3,500 Caucasians (95% cases) • 1:16,000 African-Americans • 1:32,000 Asians • Family member with CF autosomal recessive trait increases risk 33 Increased Sweat Electrolytes • Basis of the most reliable diagnostic procedure—sweat chloride test • Sodium and chloride will be 2-5 times greater than the controls • Children taste ―salty to kiss‖ 34 Increased Viscosity of Mucous Gland Secretion • Results in mechanical obstruction • Thick mucoprotein accumulates, dilates, precipitates, coagulates to form concretions in glands and ducts • Respiratory tract and pancreas are predominately affected 35 Presentation • Wheezing respiration, dry nonproductive cough • Generalized obstructive emphysema • Patchy atelectasis • Cyanosis • Clubbing of fingers and toes • Repeated bronchitis and pneumonia 36 Presentation (cont’d) Delayed puberty in females Sterility in males Dehydration Hyponatremic/hypochloremic alkalosis • Hypoalbuminemia • • • • 37 Presentation (cont’d) • Meconium ileus • Distal intestinal obstruction syndrome • Excretion of undigested food in stool — increased bulk, frothy, and foul • Wasting of tissues • Prolapse of the rectum 38 Diagnostic Evaluation • • • • • Quantitative sweat chloride test Chest, abdominal x-rays Pulmonary, Pancreatic Function Tests Stool fat and/or enzyme analysis DNA testing 39 Respiratory Manifestations • Present in almost all CF patients but onset/extent is variable • Stagnation of mucus and bacterial colonization result in destruction of lung tissue • Tenacious secretions are difficult to expectorate-obstruct bronchi/bronchioles 40 Respiratory Manifestations (cont’d) • Decreased O2/CO2 exchange • Results in hypoxia, hypercapnea, acidosis • Compression of pulmonary blood vessels and progressive lung dysfunction lead to pulmonary hypertension, cor pulmonale, respiratory failure, and death 41 Respiratory Management Bronchodilator medication CPT QID Forced expiration Aggressive treatment of pulmonary infections • Home IV antibiotic therapy • Aerosolized antibiotics 42 • • • • Respiratory Management (cont’d) Pneumothorax Hemoptysis Nasal polyps Steroid use/nonsteroidal antiinflammatory • Transplantation • • • • 43 Respiratory Progression • Gradual progression follows chronic infection • Bronchial epithelium is destroyed • Infection spreads to peribronchial tissues weakening bronchial walls • Peribronchial fibrosis 44 GI Tract • Thick secretions block ducts—cystic dilation — degeneration — diffuse fibrosis • Prevents pancreatic enzymes from reaching duodenum • Impaired digestion/absorption of fatsteatorrhea • Impaired digestion/absorption of protein-azotorrhea 45 GI Tract (cont’d) • Endocrine function of pancreas initially stays unchanged • Eventually pancreatic fibrosis occurs; may result in diabetes mellitus. • Focal biliary obstruction results in multilobular biliary cirrhosis • Impaired salivation 46 Clinical Manifestations of GI Tract Pancreatic enzyme deficiency Sweat gland dysfunction Failure to thrive Increased weight loss despite increased appetite • Gradual respiratory deterioration • • • • 47 GI Management • Pancreatic enzymes: ac (good for 30 min) • High protein high calorie diet as much as 150% RDA • Intestinal obstruction • Reduction of rectal prolapse • Salt supplementation especially in hot weather 48 Prognosis of CF • Estimated life expectancy for child born with CF in 2003 is 40-50 years • Maximize health potential – – – • New research—hope for the future – – – Gene therapy Bilateral lung transplants Improved pharmacologic agents Nutrition Prevention/early aggressive treatment of infection Pulmonary hygiene 49 Cardiopulmonary Resuscitation(CPR) • Pediatric cardiac arrest frequently represents the terminal event following respiratory failure or progressive shock • Pediatric cardiac arrest rarely results from sudden cardiac collapse, as in adult populations 50 ARTERIAL BLOOD GAS • 1. pH: acid <7.35-7.45 > alkaline • 2. pCO2 : 35-45 respiratory • 3. HCO3: 22-26 renal • P O2 : 75-100 • O2 saturation : 95-100% 51 R.O.M.E. • Respiratory opposite • Metabolic Equal pH and pCO2 are changing in opposite directions pH and Hco3 are changing in the same direction 52 Assessment differences CYANOSIS CARDIAC 1. When crying 2. Give O2 3. Liver palable Worsens unchanged Yes RSD Gets pink pink no 53