(pedia lecture onrespiratory disorders)

8/7/2019 (pedia lecture onrespiratory disorders)

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RESPIRATORY DISORDERS

Epiglottitis - is an acute bacterial infection and inflammation of the epiglottis

and the surrounding areas that causes airway obstruction.

-Sudden onset and infection progress rapidly causing acute respiratorycausing acute respiratory difficulty

-Occurs more often in winter-Considered an emergency situation-Occurs more frequently between 2 to 5 years of ageEtiology:

-Can either be bacterial or viral( staphylococci, streptococci, pneumococci,candidas albicans

-Hemophilus influenza type BSigns and symptoms;

yBegin as a mild upper respiratory tract infectionyRespiratory difficulty which can progress to severe respitatory distress ina matter of minutes or hours; inspiratory stridoryDysphagiayDrooling of salivayDematous, cherry- red epiglottisyMuffled voiceySudden increase in temperatureyTripod positioning- while supporting the body with hands, the child

thrustsyHoarse or brassy cough( may or may not be present)


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Complications:

yAirway obstructionyLaryngospasmyDeath

Management:

yMaintain a patent airwayyAssess respiratory status and breath sound noting:

-nasal flaring

- use of accessory muscles- presence of inspiratory stridor

- presence of circumoral cyanosis

- presence of intercostals retractions

yMaintain position of comfort and security for the child to facilitatebreathing

yNever leave the child unattendedy

Maintain NPO

yDo not restrain the childyDo not force the child to lie downyAdminister antibiotics( e.g. cefriaxone{ Xtenda}, ampicillin +

Sulbactan{Unasyn} as ordered

yIV fluids as orderedyPrepare tracheostomy set or intubation for severe respiratory distressyProvide cold, mist oxygen or moist air therapy, or cold humidificationyEnsure child is up to date with immunization ( Hib Vaccine) to prevent

occurrence of epiglottitis

yAssess temperature by axillary routeyNo attempt should be made to visualize the throat or to obtain a throat

culture due to risk of laryngospasm which will result to complete airway

obstruction or respiratory collapse


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Interventions:

yMaintain a patent airwayyAssess respiratory status: nasal flaring, sterna retraction, inspiratory

stridor

yElevate head of bedyProvide bed restyProvide humidified oxygen via cool mist tent for hospitalized childyInstruct parents to use cool air vaporizer or humidifier at home; other

measure include having the child breath in a cool night air, or the air from

an open freezer, or taking a child to a cool basementyEncourage fluid intakeyIVF as prescribed to maintain hydrationyBronchodilators to relax smooth muscles and relieve stridoryCorticosteroids a prescribed for the anti inflammatory effect

(Dexamethazone, Hydrocortizone)

yAdminster nebulized epinephrineyAdminister antibiotis as prescribed if bacterial infection is presentyHave resuscitation equipment available


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BRONCHITIS

-Infection of the major bronchi that may be referred to astracheobronchitis.Laboratory/ Diagnostic test:

-Throat swab- to determine causative agent-Chest and neck X- ray end stage is to rule out epiglottitis

Signs and symptoms:

yFeveryDry, hacking and non- productive cough that is worse at night and

becomes productive in 2 to 3 days

Interventions:

yMonitor for respiratory distressyProvide cool humidified airyMonitor for signs of dehydration: sunken fontanel, poor skin turgor,

decreased and concentrated urine outputyIncrease fluid intake; acetaminophen for fever


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Bronchiolitis

-Inflammation of the fine bronchioles and small bronchi that causes a thickproduction of mucus that occludes bronchioles and small bronchi-Highly communicable and is transferred by hands

Cause: Respiratory syncytial virus (RSV), also known as humanpneumovirus

-RSV invades bronchioles causing increased production of mucus andairway edema

Signs and symptoms:

yUpper respiratory infection symptoms such as rhinorrhea and low- gradefever, increased tenacious mucus production

yLabored, rapid breathingyNasal flaring and retractionsyDifficulty feeding or refusal to eatyIrritability from air hungeryExpiratory wheezes or gruntyMalaiseyDiminished breath soundyHacking coughyTachypnea

Interventions:

yMaintain patent airwayyPosition the child at a 30 to 40 degree angle with the neck slightly

extended to maintain an open airway and decrease pressure on the

diaphragm

yProvide cool humidified airyEncourage fluids


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yIsolate the child in a single room or place in a room with another childwith RSV

yMaintain good handwashing procedureyEnsure that nurses caring for this children do not care for other- high risk

children

yWear gowns when soiling of clothing may occur during careyAdminister Ribavirin (Virazole) an anti- viral respiratory medications

Administration ofRibavirin:

Administer via aerosol by hood, tent, mask, or through ventilatortubing

Pregnant health care provider should not care for a child receivingRibavirin

Nurses wearing contact lenses should wear goggles when coming incontact withRibavirin, because the mist may dissolve soft lenses

oPrepare for administration ofRSV immune globulin vaccine( RSV -IGIV)

-Used prophylactically to prevent RSV infection in high- risk infant-Not administered to infants or children with congestive heart failure


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PNEUMONIA

-Inflammation of the pulmonary tissue associated with consolidation ofthe alveolar space.-Inflammation of the alveoli caused by a virus, mycoplasmal agents,

bacteria, or the aspiration of foreign substances

-Causative agent is usually introduced into the lungs through theinhalation or from the blood stream

Classifications:

1.Pneumonitis inflammation of the wall of the alveoli, alveolar sacs andducts of bronchioles.

2.Lobar pneumonia inflammation of one or more lobes of the lungs withcomplete consolidation

3.Bronchopneumonia inflammation of the bronchioles with exudates

1.Viral Pneumonia occurs more frequently than bacterial and oftenassociated with a viral upper respiratory infection.Signs and symptoms:

oMild fever, cough, malaise, high feveroSevere non- productive cough or productive cough with small

amount of whitish sputum

oWheezes or fine cracklesInterventions:

oOxygen with cool mist as prescribedoIncrease fluid intakeoAntipyretics for fever as prescribedoChest physiotherapy and postural drainage as prescribedoAntimicrobial therapy is reserved for children in whom the

presence of infection is demonstrated by cultures


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2.Primary atypical Pneumonia- Mycoplasma pneumonia-most common cause of pneumonia in children between the ages- of 5 and12-Occurs primarily in the f al and winter months and prevalent in crowded

living conditions

Signs and symptoms:

oFever, chills, anorexia, headache, malaise and muscle painoRhinitis, sore throat, dry hacking coughoNon- productive cough initially then production of seromucoid

sputum that becomes mucopurulent or blood- streaked

Interventions: Symptomatic

3.Bacterial pneumonia- is often a serious complication; hospitalization isindicated when pleural effusion or empyema accompanies the disease

and is mandatory for children with staphylococcal pneumonia

For infant:

oAcute onset, fever , toxic appearanceoIrritability, lethargy, poor feeding, fever maybe accompanied by

seizure

oRespiratory distress( air hunger, tachypnea and circumoralcyanosis)

Or older children:

oHeadache chills, abdominal pain , chest pain, meningeal symptomsoDiminished breath sound or scattered cracklesoAs the infection resolves, coarse crackles, and wheezing are heard

and the cough becomes productive with purulent sputum


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Interventions:

oAntimicrobial therapy as soon as diagnosis is establishedoOxygen for respiratory distressoSuction mucusoChest physiotherapy and Postural drainageoEncourage child to lie on affected side( is pneumonia is

unilateral)

oIncrease fluid intakeoInstitute isolation with pneumococcal or staphylococccal


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TUBERCULOSIS( pimary complex in children)

-Is a contagious disease caused by Mycobacterium tuberculosis, an acid-0fast bacillus

-Mode of transmission: inhalation of droplets from individuals with activetuberculosis

Signs and Symptoms;

Maybe asymptomaticBody malaise

The test will

AnorexiaWeight lossLymphadenopathySpecific symptoms related to site of infection such as brain, lungs or

bones maybe present

Diagnostic Exam:

1.Mantoux test:

will produce a positive reaction 2- 10 weeks after the initialinfection

Determines whether the child has been infected and has developeda sensitivity to the protein of the tubercle bacillus; a positive

reaction in a previously negative test indicates that the child has

been infected since the last test

2. Sputum culture:

Definite diagnosis is made by demonstrating the presence ofmycobacteria in a culture


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Interventions

1.Medications:Isoniazid (INH), Rifampin( RIfadin), PyrazinamideA 9-month course ofINH maybe prescribed to prevent a latent

infection from oproigressing to clinically active TB

A 12- month course maybe prescribed for the child infected withHIV

Recommendation for the child with active TB:oIsoniazid, Rifampin, Pyrazinamide daily for 2 months,

then INH and Rifampin 2 times weekly for 4 months

2.Place on airborne precautions until medications have been initiated3.Stress importance of adequate rest and diet4.Instruct measure to prevent transmission of tuberculosis


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ASTHMA

-A chronic inflammatory disease of the airways or spasm of the bronchialsmooth muscles-Common symptoms is coughing in the absence of respiratory infection

especially at night

-Most common chronic disease among childrenCauses (Triggers)

Indoor allergens:a)Dust mites c) stuffed toys/ furnituresb)Pollution d)Pet dander

Outdoor allergens:a)Pollens b)Molds

Food allergensChocolates b)Fudge brownies

Tobacco smokeChemical irritantsCold air/ temperature changesExtreme emotional arousal/stressRespiratory infectionActivityStatus asthmaticus - a condition wherein the child displays respiratory

distress despite vigorous treatment measures.

Three components ofAsthma attack:

1.Bronchospasm 2.Mucus production 3.Airway edema


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Signs and Symptoms:

Expiratory wheezing is the major signDyspnea with prolonged expiration; reduced expiratory flow;respiratory distress

Chest tightnessCough particularly at night or in the early morningNasal flaringRetractions/ use of accessory musclesAnxiety, irritabilityDiaphoresisYounger children assume a tripod sitting positionTachypneaExercise intolerance

Treatment:

Avoidance of triggers is the best therapyPosition comfortably on bedRespiratory statusAdminister quick relief medications ( rescue medications) to treat

symptoms and exacerbations

oShort acting B2 agonist decrease acute bronchospasm;Ex.Salbutamol ( Ventolin)

oAnticholinergic: decrease bronchospasm and secretion of mucus inairways ; used for severe symptoms; Ex. Ipratropium

bromide(Atrovent)

oSystemic corticosteroids decrease inflammation in airways; totreat reversible airway obstruction


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Long- term control preventer medicationoTo achieve and maintain control of inflammationoooCorticosteroids: Ex. Prednisone, Methylprednisolone (Medrol),

Hydrocortisone( Solu- cortef), Budesonide(Budecort),

Fluticasone(Flixotide)

oNon-steroidal anti-inflammatory drugs (NSAIDS)oLong-acting B2 agonists- not for quick relief

Ex.Salmeterol(Serevent); Salmeterol+ Fluticasone (Seretide)

oLeukotriene Inhibitors:Prevents inflammatory response caused by exposure to allergens; Ex .

Montelukast (Singulair), Zafirlukast(Accolate)

Auscultate breath sounds for baseline assessment and to determineresponse to medication

Chestphysiotherapy including breathing exercises and physical trainingAllergen control- prevention and reduction of exposure to airborne and

environmental allergens,and extreme environmental temperature; Skin

testing to identify allergensAvoid exposure to individuals with viral respiratory infectionEncourage increase oral fluid intakeEarly recognition of an asthma attackAdequate rest, sleep and well- balanced dietDevelop an exercise programCough effectivelyKeep immunization up- to- date; Annual influenza vaccination is

recommended


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SUDDEN INFANT DEATH SYNDROME (SIDS)- INFANT CRIB DEATH

Unexpected death of an apparently healthy infant under 1 year ofunknown causeMost frequent during winter monthsDeath occur usually during sleepAge: frequent from 2 4 months of lifeHigher incidence in:

oMalesoMultiple birth an premature infantsoNewborn with low APGAR scoreoInfants with CNS disturbancesoInfants with respiratory disordersoInfants sleeping on abdomenoInfants using soft moldable pillows and mattress

Appearance when found:oApneic, blue, lifelessoFrothy blood in nose and mouthoChild maybe found in any position but typically is found in a

disheveled bed with blankets over the head and huddled in a corner

oChild maybe clutching beddingsoChild maybe wet and full of stool

Prevention:oPlace infant in supine position for sleepoSoft , moldable mattress and beddings such as pillows or quilts

should not be used

oStuffed animals should be removed from cribs while infant iussleeping

oDiscourage bed sharing( sleeping with adults)


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Interventions;oAvoid implying wrongdoing, abuse or neglectoSupport parents;oBe nonjudgmental abt. Parents attempts at resuscitation

ENT DISORDERS:

EPISTAXIS:

yBleeding from the nose caused by:A local disturbance of the tissue which usually occur from trauma such aspicking of the nose, from falling, hit on the nose by another child

Decreased humidityCan occur with nasal polyps, sinusitis, allergic rhinitisStrenous exerciseSerious systemic disorder such as blood dyscrasias

yAssessment:oHistory of frequency and duration of bleedingoClotting time and Hgb leveloAmount of blood lost is estimated by noting the amount of

saturated paper

yIntervention:oKeep child in upright position with head slightly tilted forwardoApply pressure to the sides of the nose with your fingersoApply cold compressoMake effort to quiet the child and help him stop cryingo

Last resort: Epinephrine (1:1000) maybe applied to the bleeding site

to constrict blood vessels

oNasal packing to provide continuous pressure


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OTITIS MEDIA

Infection of the middle ear occurring as a result of a blocked eustachiantube which prevents normal drainageCauses:

oBottle proppingoCleft lip/palateoURTI

Signs and symptoms:oFever , irritabilityoLoss of appetiteoRolling of head from side to sideoPulling on or rubbing the earoEarache ( otalgia)oSigns of hearing lossoPurulent, foul smelling ear dischargeoRed opaque, bulging tympanic membrane

Complication:oBacterial meningitisInterventions:oIncrease oral fluid intakeoTeach patient to fed infant in an upright positionoProvide local heat and have the child lie with the affected ear downoTSB if there is feveroAdminister analgesics as prescribedoInstruct parents in the appropriate procedure to clean drainage from

the ear with sterile cotton swabsoInstruct on procedure in administration of medicationoMassive dosage of antibiotic to prevent bacterial meningitisoScreening for hearing loss


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oSurgery: Meringotomy with tympanostomy tube insertionInterventions postoperatively:

oKeep ears dryoWear earplugs during bathing, shampooing and swimmingoDiving and submerging under water are not allowed


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Tonsillitis and Adenoiditis

Tonsillitis- inflammation and infection of the tonsils

Adenoiditis Inflammation and infection of the adenoid

Signs and symptoms:

Persistent or recurrent sore throatEnlarged, bright red tonsils that maybe covered with white exudatesDifficulty in swallowing

Mouth breathing and unpleasant mouth odor

Fever, coughEnlarged adenoids may cause nasal quality of speech, mouth breathing,

hearing difficulty; snoring or obstructive sleep apnea

Interventions:

Preoperatively:-Assess for signs of active infection-Assess bleeding and clotting studies-Prepare the child preoperatively-Assess for any loose teeth to decrease the risk of aspiration

during surgery

Postoperatively:Position the client prone or side- lying to facilitate drainageHave suction equipment ready but do not suction unless there is airway

obstruction

Monitor for signs of hemorrhageDiscourage coughing or clearing the throatProvide clear, cool non- citrus and non- carbonated fluidsAvoid milk products initially because they will coat the throat

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Avoid red liquids which will simulate the appearance of blood whenpatient vomits

Do not give straw, spoon or sharp objects that can be put in the mouthAdminister acetaminophen for sore throatNotify physician for bleedingKeep child away from crowds until healing occurred


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CYSTIC FIBROSIS

A chronic autosomal recessive multisystem disorder characterized byexocrine gland dysfunction

The mucus produced by the exocrine gland is abnormally thick, causingobstruction of the small passageways of the affected organ.

Characterized by serious and persistent lung infection, loose foulsmelling stool and failure to gain weight

The most common symptoms are pancreatic enzyme deficiency caused

by duct blockade, progressive chronic lung disease associated withinfection and sweat gland dysfunction resulting in increased sodium

and chloride sweat concentration

Respiratory distress is prominentAn increase in sodium and chloride in sweat and saliva forms the basis

for the most reliable diagnostic test the sweat chloride test

Meconium ileus- is the earliest symptom of cystic fibrosis in newborninfant which is t he obstruction of sticky, viscid meconium.

Diagnostic Test:

1.Quantitative sweat chloride test:-The production of sweat is stimulated ( Pilocarpine

iontoporesis), the sweat is collected and the sweat

electrolytes are measured.

-Less than 40mEq/L normal sweat chloride concentration-A chloride concentration greater than 60 mEq/L is a positive

test result

2.Chest X- ray to reveal atelectasis and obstructive emphysema3.Pulmonary function test- to provide evidence of abnormal small

airway obstruction


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4.Stool/ fat or Enzyme analysis a 72 hour stool sample is collectedto check the fat and/or enzyme content. Food intake is recorded

during the collection

Signs and Symptoms( Cystic Fibrosis)

RESPIRATORY:

LUNGS:

Symptoms are produced by the stagnation of mucus in the airway, leadingto bacterial colonization and destruction of lung tissues.

Emphysema and atelectasis occur as the airways become increasinglyaffected

Contraction and hypertrophy of the muscle fibers in pulmonary arteriesand arteriole due to chronic hypoxemia, eventually leading to pulmonary

hypertension and eventually cor pulmonale

Pneumothorax from ruptured bullae and hemoptysis from erosion ofthe bronchial wall through an artery occur as the disease progresses

Wheezing and dry non-productive coughDyspnea, cyanosisClubbing of fingersRepeated episodes of bronchitis and pneumonia

GASTROINTESTINALSYSTEM;

PANCREAS:

Meconium ileus in neonate

Intestinal obstruction ( distal intestinal obstruction syndrome)SteatorrheaDeficiency of the fat- soluble vitamins which causes easy bruising and

edema

Rectal prolapsed


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INTERGUMENTYARYSYSTEM:

Abnormally high concentration of sodium and chloride in sweatInfants tastes salty when kissedDehydration and electrolyte imbalance especially during hyperthermic

condition

Frosting of t the skinREPRODUCTIVE SYSTEM:

Can delay puberty in girlsFertility can be inhibited due to a highly viscous cervical secretions

which act as a plug and block entrance of sperm

Males are usually sterile, caused by the blockade of the vas deferens byfailure of normal development of duct structures

INTERVENTIONS;

1.RESPIRATORY:Preventing and treating pulmonary infection by removing

secretionsAntimicrobialChest physiotherapy n awakening and in the eveningBronchodilatorTeach child forced expiratory technique (huffing) to mobilize

secretions

Develop a physical exercise programOxygen as prescribedMonitor for hemoptysisLung transplantation is a final therapeutic option for the child with

end- stage disorder


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2.GASTROINTESTINALSYSTEM:Replace pancreatic enzymes- administer with meals and snacks or

within 30 minutes of eating meals and snacks to ensure that

digestive enzymes are mixed with food in the duodenum.

Enteric coated pancreatic enzymes should not be crushed orchewed

Encouraged a well- balanced, high protein, high caloric dietMultivitamins and AD E and K are givenAssess weight and monitor failure to thriveMonitor for constipation and intestinal obstructionEnsure adequate salt intake during extremely hot weather


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(pedia lecture onrespiratory disorders)

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