Respiratory Disorders

Nursing IIILinda Speranza PhD, ARNP-C

Respiratory Assessment Count respiration

for 1 full minute Infants – obligatory

nose breathers Identify signs of

respiratory distressListen to breath

sounds 1st! Stridor- thrill harsh

sound Rhonchi Wheezing

Respiratory Assessment Quality of respirations Quality of pulse Color- pale, cyanotic, mottling Cough- croupy- loose, wet, dry Behavior change- tired of breathing fast?,

restless?, lethargic?, change in LOC Signs of dehydration- low I&O, L skin turgor- check

in abd or sternum, lack of tears in older children,

Respiratory Assessment

Nasal Flaring Widening of the nares during inspirationRepresents an increased effort by the

infant to breathe

Retractions Depth and location of retractions

indicate the severity of distress Intercostal retractions- mild Subcostal - moderate Suprasternal – moderate Supraclavicular- severe Use of accessory muscles- severe

Anatomy is Different!• Development • Airways – shorter and more narrower • Increase in airway resistance in children • Flexible larynx • Tongue is proportionally larger– can cause obstruction

• Obligate nose breathers– plugging can cause respiratory distress

A Child’s Respiratory Anatomy

Respiratory Distress Syndrome Result of a primary

absence, deficiency, or alteration in the production of pulmonary surfactant

Prematurity

Surfactant deficiency disease

Signs & Symptoms of RDS Shortness of breath Grunting Nasal flaring Cyanosis Apneic spells Increased work of

breathing – tachypnea 1st sign of

respiratory distress Retractions

Management/Treatment of RDS Support adequate

ventilation

Surfactant replacement therapy

Monitor for Complications

Nursing Interventions Risk for ineffective breathing pattern

Check prenatal meds Monitor vitals and skin Clear airway prn with bulb syringe Give warm humidified O2

Ineffective thermoregulation Warm all inspired gases. Cold air= more need of O2

and high metabolic rate Respiratory distress can lead to metabolic acidosis.

Check for acrocyanosis, bradycardia, apnea, etc

Altered nutrition: less If there is respiratory distress do not give oral fluids. Start

parenteral nutrition per MD Give calories to prevent metabolic acidosis due to

starvation. TPN is an alternative Risk for fluid vol deficit

Record I& O hourly and daily weights. Circulatory overload= pulmonary edema

Check signs of dehydration: poor skin turgor, pale mucous memb, sunken anterior fontanelle. Specific gravity, etc

Check IV sites for infiltration, infection (edema, and erythema)

Croup Syndrome Broad classification of upper airway illnesses that

result from swelling of the epiglottis and larynx Viral

Spasmodic laryngitis Laryngotracheitis Laryngotracheobronchitis (LTB)

Bacterial Bacterial trachitis Epiglottitis

Laryngotracheobronchitis (LTB) LTB, most common form of croup Usually caused by virus;

Adenovirus, Respiratory Syncytial Virus (RSV) Influenza Virus

Inflammation and narrowing of the laryngeal and tracheal areas.

Clinical Manifestations of LTB Upper respiratory infection (URI) symptoms that

gradually progress to signs of distress. Hoarseness, barky cough Inspiratory stridor Retractions Restlessness and irritability Pallor and cyanosis Sometimes a low grade fever

Potential complication: airway obstruction Difficulty swallowing or drooling= epiglotitis

Treatment/Management of LTB Lateral neck x-ray

confirms diagnosis Maintain Airway

Patency Supplemental

oxygen with humidity

Cool mist tent Meet fluid and

nutritional needs

Treatment/Management of LTBMedication

Racemic epinephrine Bronchodilators – Albuterol

Side tachycardia Steroid therapy- IV or inhaled

Keep calm and comfortableNO Throat cultures or visual

inspections of the mouth Continue to monitor- Respiratory effort,

responsiveness, signs of respiratory distress

Constant attendance

Epiglottitis• An inflammation of the epiglottis, the long

narrow structure that closes off the glottis during swallowing

• A life-threatening condition!!! This is a Medical Emergency

• Bacterial- Caused by strep, staph, and haemophilus influenzae type B • Hib vaccine reduces risk for epiglottitis

Clinical Manifestation of Epiglottitis Sudden onset CARDINAL SIGNS- intense sore

throat/difficulty swallowing/ drooling Cherry red, edematous epiglottis High fever- 102 Dysphonia Dysphagia Inspiratory stridor Respiratory distress Tripod position

Diagnosis of Epiglottitis Diagnosis confirmed by lateral neck films High Oxygenation to reverse hypoxemia Cool mist oxygen

Cools airway and lowers swelling! Antipyretics, ab, & steroids to decrease

inflammation May use a tracheostomy to bypass the problem

Treatment/ Management Epiglottitis Closely Monitor Respiratory status. Do

not attempt to examine the throat. Axillary temp only!

Medications include antibiotics and steroids to decrease inflammation

Minimize fear and anxiety to decrease oxygen consumption

Bronchitis Lower airway disorder

Inflammation of the trachea and bronchi

Cause- mainly viral

Symptoms Fever, dry hacking cough

non productive. Productive in a couple of days

Management Cool, humid air, increase

fluids, antipyretics, cough suppressants

Bronchiolitis Caused when a virus

or bacterium causes inflammation and obstruction (mucus) of the small airways

Occurrence- First 2 years Peak: 6 months

Cause – Respiratory Syncytial Virus (RSV)

Bronchiolitis

Pathophysiology Cell debris- death virus after bursting to

invade Irritation= Swelling/mucus Bronchospasm Inhalation, poor exhalation Wheezing, hypoxemia, respiratory failure

Clinical Manifestation of Bronchiolitis Illness may have been occurring for a few

days- upper respiratory

Lower respiratory

Severe respiratory distress. Thick mucus occludes bronchioles Initial: Rhinitis, cough, low fever, tachypnea,

poor feeding, v & d, dehydration, less playful

Clinical Therapy For Bronchiolitis History and Physical Chest x-ray

Hyperinflation, atelectasis and inflammation Nasal swab- to find bacteria Ribavirin – antiviral for RSV. Used for

immunocompromised Bulb syringe & Saline Isolation Risk Factors – lung disease, low weight,

siblings that go to school, passive smoke, premmie

Treatment/Management Bronchiolitis Rest & elevate HOB to 30 Clear fluids (NPO if resp rate >60)

I& O x 8 h & daily weights, mucous memb Maintain respiratory functions. Use suctioning-

Also before feeding Cool, humidified oxygen Albuterol updrafts Steroids Infants often hospitalized due to feeding

difficulties, increased respirations Hand washing!- RSV is recurrent

Bronchopulmonary Dysplasia (BPD)

Chronic Lung Disease Results from an acute respiratory disorder that

begins during infancy Risk Factors

Prematurity Lung immaturity High inspired oxygenation concentrations, Positive pressure ventilation Patent ductus arteriosus Vitamin A deficiency

Clinical Manifestation of BPD Persistent signs of respiratory distress

Tachypnea Wheezing Crackles Irritability Nasal flaring Grunting Retractions Pulmonary edema FTT- Failure to Thrive- O2 demands ↑ + fatigue Intermittent bronchospasm & mucous plugs

Tracheostomy Keep small toys, dust away from child Careful when bathing! No showers Observe and clean skin daily Suction prn

Only 5 sec, sterile gloves, intermittent suction when withdrawing cath

Notify if secretions increase or turn purulent, or fever Have an emergency bag w extra cath and tubes No smoking O2 away from heat

BPD Diagnoses

Chest x-ray shows hyperexpansion, atelectasis, and interstitial thickening

Air trapping can cause “Barrel Shape” Chest Treatment

Support respiratory function- supplemental O2 w humidity. Chest physiotherapy + meds

Medications Nutrition

Prognosis

Otitis Media Inflammation of

the middle earOccurrence- 6-36

m (winter)Risk FactorsCausative

organisms Streptococcus

pneumoniae H. flu. Moraxella catarrhalis

Otitis Media Etiology – Eustachian tube dysfunction Pathophysiology

Preceding upper respiratory infection Edema Blocked air Air reabsorbed to bloodstream Fluid is pulled from mucosal lining Tympanic membrane becomes infected

Otitis MediaS & Sx

Pulling at the ear Diarrhea, vomiting, & fever Irritability, awakens at night crying

Diagnosis Otoscopic examination- Shows a red,

bulging, non-mobile tympanic membrane

Treatment Antibiotics Myringotomy/Tympanostomy (PE tubes) Pain relief – Tylenol/Ibuprofen, anesthetic

ear drops- verify integrity of tympanic membrane

Tonsillitis Infection or

inflammation of the palatine tonsils

Clinical Manifestations Frequent throat

infection Breathing and

swallowing difficulties Persistent redness Enlargement of cervical

lymph nodes

Tonsillectomy Before surgery

H&P Are tonsils simply large or inflamed w

exudate? Past tonsillar infections and lengh of present

discomfort Free from sore throat, fever, respiratory

infection for week before surgery No aspirin or ibuprofen for 2 weeks Check other home medication

Tonsillectomy

Tonsillectomy After Surgery

May have sore throat for 7-10 days Drink cool fluid and chew gum Give Acetaminophen elixir Apply ice collar around child’s neck Side-lying position- difficult to swallow

Sore throat: cool fluids, chew gum, ice collar, gargle ½ tsp. of each baking soda and salt in water, rinse w viscous lidocaine and swallow. No citrus liquids

Report bright red blood or increased swallowing immediately Avoid red, purple or brown liquids= difficult to

assess for bleeding Normal: white, and odor on back of throat in

the first wk. Report fever 102 F

AsthmaChronic inflammatory disorder of the

airway Airway obstruction Increased airway responsiveness Acute exacerbations or persistent symptoms

Onset- before age 5Causes of asthma & respiratory problems

in children Smoking, pet dander

Pathophysiology of Asthma After exposure to various “triggers”

Bronchospasm Inflammation and edema of the bronchial

mucosa Production of thick mucus

Asthma triggers- perfume

Pathophysiology of Asthma Reactive airway responses Antigen binds to the specific

immunoglobulin E surface on the mucosal mast cell

Histamine is released Intercellular chemical mediators are

released- histamines, prostaglandins, leukotrienes Release cytokines that make permanent

airway remodeling- thickening Result: bronchospasm, mucosal edema, &

mucus secretion

Clinical Manifestations of Asthma

Airway Inflammation Obstruction (narrowing) Hyperreactivity

“Asthma Attack”- sudden cough, wheeze, or SOB

“Silent” asthma- frequent coughing, especially at night (airway is very sensitive)

Clinical Manifestations of Asthma Respirations Appears tired Nasal flaring- 4 wks Intercostal retractions Productive cough Expiratory wheezing Decreased air movement Respiratory fatigue In severe obstruction

Diagnosis of Asthma

4 key elements Symptoms of episodic airflow obstruction

Partial reversal of bronchospasm with bronchodilator treatment

Exclusion of alternative

Diagnosis confirmation by spirometry

Evaluation of Asthma Spirometry

Shows how much a person can exhale- evidence of episodic airflow obstruction and airway hyper-responsiveness. Place mouth covering entire mouth piece… Breathe out as hard as possible and then breathe in deeply

Evaluation of Asthma Peak flow meter (expiratory flow meter)

Blow into it every morning to see if you need treatment like a nebulizer to open up the airway.

Warns of impending attack Green- ok Yellow Red- less than 50%= Warning!

Skin testing- to id triggers Medications

Medications Used for AsthmaShort-acting bronchodilators

Albuterol/ventolin/proventil- drug of choice Terbutaline- not very common

Long & short acting beta agonists Salmeterol- can use for exercise and night sx

Mast cell inhibitor Intal/cromolyn- Can be used in nebulizer Ex Singulair- Minimizes allergies

Corticosteroids Prednisone or solumedrol

Status Asthmaticus

Severe respiratory distress & bronchospasm in an asthmatic

It persists in spite of pharmacologic and supportive interventions

Considered a medical emergency

Without immediate intervention, it will progress to respiratory failure & death

Meds Continuous nebulized albuterol Inhaled inpratropium, iv corticosteroids,

magnesium, aminophylline Check electrolytes Nonivasive positive pressure ventilation intubation

Cystic Fibrosis

Cystic Fibrosis is an autosomal recessive multisystem disorder with dysfunction of the exocrine glands Genetic testing Expected lifespan- 30 years (terminal

disease) Results in physiologic alterations in

several systems

Cystic Fibrosis Abnormal secretion of thick, tenacious mucus

causes obstruction and dysfunction of all body organs with mucous ducts.

This includes the pancreas, lungs, salivary glands, sweat glands, and reproductive organs.

Clinical Manifestations Production of thick sticky mucus Meconium ileus Constipation Chronic moist productive cough Frequent respiratory infections Chronic sinus infections Difficulty gaining & maintaining weight Short stature Clubbing of finger tips & toes

Clubbing of Fingers

Diagnostic & Evaluation of CF 3 presentations

Meconium ileus Malabsorption- steatorrhea Chronic recurrent respiratory infections

The Sweat test is the standard diagnostic test for CF Spirometer Sputum cultures

Treatment & Management Chest physiotherapy (CPT): Can use percussion

to help move secretions downward so they can cough it up. Position: head of baby downward to use gravity

3-4 x day to prevent increase of hospitalizations and infections

Do not perform immediately after eating Give bronchodilator to open bronchi for easier

expectoration before therapy AM Exercise stimulates mucus expectoration Use forced expiratory technique to mobilize

secretion- Huffing

Treatment & Management of CF

Antibiotics (oral, IV, & inhalation) Pancreatic enzymes with meals,

Pancrease or Creon. To help digest food Aerosol bronchiodilators Steroids Diet- high calorie & protein, extra salt in

hot weather, ADEK vitamins Psychosocial concerns

Allergic Reactions Allergy- abnormal or altered reaction to an

antigen Allergens – antigens that cause allergy

Allergic reaction - antigen-antibody reaction that can manifest as anaphylaxis, atopic dermatitis, serum sickness or contact dermatitis

Hypersensitivity response

Allergy Assessment

Physical exam- history of exposure to allergens, itching, tearing, burning of eyes and skin, rashes, nose twitching, stuffiness

Lab X-ray Pulmonary function studies Nasal function Skin testing

Treatment of Allergies

Avoidance

Desensitization

For skin allergies

Allergy alert bracelet

Teaching about allergens in the home

Skin Allergy Testing

Question One: Which of the following respiratory

conditions is always considered a medical emergency? A. Asthma B. Epiglottitis C. Cystic Fibrosis D. Laryngotracheobronchitis

Question Two: In a child with asthma, albuterol is

administered primarily to do which of the following? A. Dilate the bronchioles B. Decrease postnasal drip C. Reduce airway inflammation D. Reduce secondary infections

Question Three: When developing a care plan for a child

diagnosed with cystic fibrosis, which of the following must the nurse keep in mind? A. CF is an autosomal dominant hereditary

disorder B. Pulmonary secretions are abnormally thick. C. Obstruction of the endocrine glands occur D. Elevated levels of K+