The Child with Respiratory Dysfunction 01/11/2010

Emphasis on our ability to perform a pediatric respiratory assessment

Pulmonary Embryology

• Segmentation of main bronchi starts at 5-6 weeks and continues

• Heart completely done developing in 42 days, not true of

pulmonary system

• Breathing primary problem of premies

• Fetuses don’t have any alveoli until ??

Pulmonary Development

• Neonate – born w/ approx 20 million alveoli

• Adult – 300-600 million alveoli

• Puberty – 24 orders of segmented bronchi present

• **Asthma that disappears between ages 6-8 -> bronchioles

grew & resolved the asthma.

Alveolar Development

• 20 million present at birth

• Adult number is 300-600 million

• Surface area is “about the size of 3 tennis courts” – research being

done in how to get meds converted to inhaled form to access those

capillaries of the alveoli

• Bronchiolar smooth muscle has autonomic innervations

Congenital Malformations

• TE Fistula (TEF)

○ Most common – esophagus is just a pouch (EA – esophageal

atresia - with distal TEF)! Lower esophagus connects to

stomach but is also continuous with trachea.

○ Hallmark is coughing, choking, cyanosis – since gastric acid

refluxes into the trachea

○ High risk for aspiration

○ Must be corrected quickly & immediately

• Diaphragmatic Hernia

○ Devastating defect
 ○ Weakness in muscle wall of diaphragm – so loops of bowel

ooze up into the chest & press on other organs – poor

pulmonary development, an issue even if this is surgically

corrected.

○ Easy to see on US. Visualized post-birth as a flattened belly

& full chest area

• Bronchopulmonary Dysplasia (BPD)

○ Chronic condition primarily in pre-term infant or full term on

prolonged O2 or ventilation – high O2 conc can be toxic over

long periods of time -> affects retinas of eyes & pulmonary

tissue

○ Risk Factors: Preemies, RDS, no surfactant given at birth

(given intra-tracheally to premies after born, since not

present until 28 weeks gestation), no antenatal steriods

(transferred to baby to decrease initial inflammation), sepsis,

PDA

○ More prone to infxn & other long term complications, may

need O2 at home for awhile, but most kids grow out of BPD

○ Pathogenesis of BPD
  Many factors that influence postnatal lung development

Assessment – Stand back and look first! – Can get general sense of

Bad/Good

• RR & Effort?

• Shiny mucous membranes?

• Skin Color? (Remember that cyanosis is a sign of early death / late

hypoxia

• Position of comfort? – informative in an older child

• Appropriate Cry?

• Interaction with caregiver & environment – even if upset at least

they are engaging, we don’t want to see a baby that just doesn’t

care

• Babies are belly breathers!

○ Lag on respirations -  WOB

○ Seesaw respirations – recruitment of accessory resp muscles

& loss of synchronized resp

• Retractions

○ Subcostal & subxyphoid & sternal – big areas of retractions

for kids
 ○ Can also suck chest towards backbone

• Pic of girl – bad! Leaning forward, retractions, mouth hanging open

Auscultation

• In lap of caregiver or at least when CALM

• Auscultate in the mid axillary line & side to side – chest wall is so

small, easy to hear other sounds if you listen too medially

• Use appropriate size stethoscope

• Tough to distinguish normal breath sounds from airway noise in

kids

• LOC, RR, WOB & mechanics, skin & mucus mbne color – according

to video these are the 4 key areas to assess for respiratory

• **See slide re: where to listen!!

LATE signs of distress (Early Death)

• Irritability

• Bradycardia – Get the Crash Cart – Terminal Rhythm in pediatrics –

5% chance of successful resuscitation. Peds have cardiac arrest for

much different reasons than adults do.

• Cyanosis
• Slowing RR

• Asthmatic who stops wheezing (b/c no air is moving)

• Essential that nurses are vigilant about respiratory status &

intervene early

Airway

• Current ability to protect the airway

• Obtain the history

• Assess SECRETIONS and child’s ability to handle (or clear)

• Consider the current situation– Is the child at risk for airway

problems?

Risk of Development of Airway Problems

• Discussion of damages to muco-ciliary fxn

• Recent intubations, surgery or bronchoscopy

• Acute inflammation

• Anesthesia

• Trauma or congenital malformation

• Foreign body or chemical inhalation

• Disease affecting mucociliary function

Anatomical Airway Differences

• Pharynx smaller

• Epiglottis is larger

• Endo-tracheal intubation much more challenging in kids

• Airway narrowest at crichoid cartilege

Anatomical Differences in Pediatrics

• See slide

• 1mm of swelling in airway much bigger deal for kids since they

have narrower airway

Congenital Laryngomalacia/Tracheomalacia

• Malacia = weakness

• Congenital weakness/floppiness of tracheal wall – on inspiration the

trachea collapses

• Darkness on xray = air, so can note the lessening of air on the slide

Upper Airway Problems

• The Common Cold (URI)

○ Vast majority are viral (adenovirus, parainfluenza, rhinovirus,

meta-pneumovirus)

○ Consider strep if positive contacts and > 2yo without

exudate in pharynx

○ Symptom relief (Hydration!) – cold meds often do nothing!!

○ Culture positive: treatment with penicillin; erythromycin for

resistant

○ Big movement in pediatric world to get some cold meds

pulled from the market

• Acute Otitis Media

○ Probably not seen in hospital unless they have something else

going on

○ Highest incidence in kids 6mo-2 years

○ More in homes with smokers

○ Usual causes are Strep and atypical H Flu – H Flu a part of the

normal vaccine schedule - **should know pediatric

vaccination schedule for nclex!**

○ Dysfunctioning eustachian tubes

 ○ Bright red bulging Tympanic Membrane, neg light reflex and

landmarks

○ Placement of tubes in membranes to help the gooey fluid

drain

○ Bottle in mouth w/kid lying supine – can affect teeth (bottle

mouth) but also fluid is being pushed back up into eustatian

tubes – prime area for bacterial growth

○ Acute risk – meningitis – infection can transfer from middle

ear to CNS/meninges

○ Chronic risk – hearing loss

○ Management of AOM

 Pain Management

 Antibiotics where indicated – will not help with a viral

infxn!!

 Myringotomy

 Tympanostomy tubes

 Prevention!!!!

 See slide w/algorhythm of when to treat

• Pharyngitis
 ○ Bacterial sore throat (acute) often without nasal Sx—

CULTURE

○ Nodes? Mono? – palpate nodes to see if mono could be

present – caused by Epstein Barr virus

○ Group A-β hemolytic strep—usually Pen

○ Comfort and Hydration – won’t want to drink d/t sore throat –

give cold liquids/popsicles etc.

○ Complications! – Can develop Scarlet Fever, Rheumatic Fever,

Glomerulonephritis, Cardiac Issues

• Foreign Body Aspiration

○ Acute onset with no prior sxs , esp if afebrile & fits with

developmental group (crawler, esp with older kids that have

tiny toys i.e. legos) –different from URI

○ Assess the airway

○ Procedure for clearing the airway

○ Oxygen and Humidity

○ Age of patient

○ Consider in the differential diagnosis with acute croup /

epiglottitis
• Maneuvers to open the airway

○ Remember BLS !!

○ Head Tilt, chin lift

○ Back Blows if under 12 months of age

○ Heimlich if over 12 months – b/c high risk of pushing the

xyphoid right into the liver – use back blows!

○ If talking or crying, leave alone!!

• Acute Airway Obstruction

○ Foreign Body Aspiration accounts for about 3000 deaths

annually

○ 85% occur in children less than 3 years old

○ Anticipatory Guidance for new parents and parents of young

children with older siblings

• Croup (Laryngotracheobronchitis)

○ Most Common in kids <5 years

○ Follows URI—a nocturnal exercise! – kid wakes up with this

after an illness
○ Can be caused by Parainfluenza, RSV or rarely mycoplasma

○ Inflammation of mucosa at level of larynx

○ Manifestations

 Low grade fever

 Loud, “barking” , “seal-like” cough

 STRIDOR

 Inflammation can be severe enough to obstruct airway

 Cold, moist environment good for the airways – picture

of croup tent

 Steeple sign on CXR/neck films – upper part of trachea

steeples like a church

○ Treatment

 Cool humidified air (it’s the COLD that helps reduce

swelling)

 Racemic (nebulized) Epinephrine (topical

vasoconstrictor to the airways to reduce swelling)----be

alert for “rebound” effect with worse swelling than they

had to begin with, used to hold kids in ER for

observation 4 hours post-tx

  Single dose corticosteroids in ED (may continue with

po)

 Cause is usually viral; antibiotics are not indicated

 Decongestants and antihistamines have no benefit

• Acute Epiglottitis (Croup is part of differential dx for this)

○ Most often in kids 2-5 years old

○ Rapid onset of severe airway obstruction—Toxic appearance,

sitting up & drooling, differentiates this from croup

○ Usual organism WAS H Flu (Haemophilus Influenzae)

○ Medical Emergency!!

○ Management

 Don’t lie child flat

 Don’t put anything in the mouth

 Don’t leave them alone or make cry!!! (don’t start an

IV)

 Intubation by most skilled personnel (OR) – too many

attempts to intubate or poke around the tissue will

make it even more swollen.

 IV Antibiotics
  Airway monitoring

Upper Airway Problems

• Bronchitis

○ Inflammation of the large airways associated with URI’s

○ Dry, hacking, non-prod. (Night) cough, becomes productive

after 2-3 days

○ Usually viral

○ Treat with cough suppressants – b/c cough is making kids

lose a lot of fluid & interferes w/sleep. Would not do this with

a productive cough

○ Can be distinguished from croup b/c croup tends to be littler

kids & croup also characterized by upper airway stridor

• RSV Bronchiolitis

○ Acute inflammation & mucus production at the BRONCHIOLAR

level

○ Seasonal variations YOUNG kids

○ Primary if not sole Cause: Almost exclusively Respiratory

Syncytial Virus – common virus that can be gotten over &

over again.

○ High Risk: Preemies, 6-8 wks old, CHD, Chronic Lung

Disease, immuno-suppressed

○ Clinically this child looks v similar to asthmatic child – have

expiratory wheezes

○ Also caused by parainfluenza and adeno viruses

○ Pathology: airway inflammation, epithelial necrosis – long

term cough, epithelial lining is sloughing off & being coughed

up, plugging of airway lumen, hyper-inflation and atelectasis

○ Diagnosis: Clinically and Nasopharyngeal swabs ELISA or

IFA) positive for RSV

○ Course:

 cough and rhinorrhea (clear) ~3d after exposure

 low grade fever

 severe resp. distress by day 5

 resolution in 10+ days

○ Tends to occur within a season, but year-round in Hawaii

○ Strong connection between this & asthma – debate about

this, whether it is the first asthmatic episode – CXR in this kid

would look a lot like someone with asthma

○ Viral disease is the primary trigger for asthma in kids

○ Treatment

 SYMPTOMATIC: O2, humidity, fluids, monitoring,

suctioning

 Bronchodilators vs. racemic epinephrine – big debate

about this, one has not been shown to be definitively

better

 Ribavirin—antiviral meds (controversial) – enormously

teratogenic drug, keep away from pregnant nurse!

 RespiGam (IVIG: Intravenous Immunoglobulin G)

provides passive immunity

○ Prevention

 RSV-IVIG (RespiGam) for passive immunity

 Synagis® (Palivizumab) - vaccine

 $$$$$$$ - very expensive

 Only given to high risk patients (ex-preemies) or those

with chronic lung disease, or immunocompromised

  Monthly injections throughout season (5 mo)

 Infection Control in hospitalized patients!!!! – RSV can

live on a hard surface for up to 24 hours!

○ RSV Season

 Season in Region 9 (San Francisco) Mid November –

Mid March, slight variation

 Varies throughout the US and and world (RSV seen all

12 months in Hawaii!)

 “Tends” to be worse every other year

• H1N1

○ Some folks think another spike of H1N1 is coming in Feb –

see slide with website tracking

○ Sickest tend to be the youngest – 0-4 yrs

• Pneumonia

○ Inflammation of the pulmonary parenchyma

○ Described by location

○ Primary or secondary disease

○ Viral (most) vs bacterial vs atypical vs aspiration

○ Causes – slide contains table 19.2 in book

○ Pathophysiology

 Inflammation of the alveoli and terminal airspaces in

response to an infectious agent

 Inflammation causes plasma leak and loss of surfactant,

resulting in consolidation and air loss b/c alveoli

collapse

 PneumonITIS results from toxins or irritants

 May originate from upper respiratory tract or

hematogenous

 On Xray – more whiteness seen since air is not visible:

lobes are “socked in” by exudate or fluid

○ Manifestations

 Usually an antecedent URI

 Fever

 Cough

 Tachypnea

 Poor Feeding, vomiting, diarrhea

 Abdominal pain in older kids

 Some kids end up with trach

○ Predisposing Factors

 Prematurity

 Exposure to cigarettes

 Underlying chronic illness

 Neurologic deficits (aspiration risk)

 Low socioeconomic status

 Malnutrition

○ Treatment

 Majority are viral (no antibiotics), but can have

secondary bacterial invasion

 Common Bacteria:

 Streptococcus, Pneumococcus and staphylococcal,

Atypical (Mycoplasma)

○ Supportive Therapy!

 Hydration

 May necessitate IV fluids – mouth breathing & rapid RR

 O2 Saturation monitoring

 Oxygen / suctioning as needed

 Elevate HOB (infant seats)

 Analgesics
  Parent / Family Education

What is the best way to give O2 to a child? Any way that they tolerate

it – must be age appropriate & appropriate to the patient such that they will

comply/tolerate. Base effectiveness on clinical appearance & O2 sat (i.e. a

child w/NC who is mouth breathing – probably needs more O2!)

• Cystic Fibrosis

○ Autosomal Recessive disease affecting chloride metabolism

○ A “white person’s” disease

○ Result is exocrine dysfunction; THICK secretions which affect

primarily the pancreas and lungs – impede food digestion,

specifically the digestion & absorption of fat

○ Diagnosed by sweat chloride test (babies taste salty!) & poop

is really bulky stinky/smelly poop

○ Kids must take pancreatic enzymes with each meal

○ Effects

 See slide

 All that fluid/secretion buildup = risk for infection

○ Treatment
  Airway Clearance Techniques (Inhaled meds:

Pulmozyme®, TOBI®) P &PD, CPT (chest physical

therapy, percussion & postural drainage)

 Antibiotics

 Nutrition – big deal since they’re not absorbing facts

 Alternative Therapies (antioxidants, ibuprofen)

 Continued Research

 Gene Therapy – many hopes for this

 Lung Transplantation

• Asthma

○ THE chronic disease of childhood

○ Affects between 6 and 7 million kids in US (22 million total!)

○ Incidence and Severity are increasing

○ Differences in SES/Ethnicity

○ NAEPP updated in 2007 (NHLBI—see posting for the

“summary” document)

○ Facts

 Accounts for at least 15% of all pediatric hospital

admissions
  As many as 20% of children in US may have asthma

 Highest incidence in children under 4 years; many DO

“outgrow” it

 Much higher incidence in boys but in adults much higher

in women

 Although death rate declined, incidence is climbing

○ Symptoms:

 Coughing (worse at night)

 Wheezing

 Shortness of Breath

 Atopy

 “tightness”

 Frequent URI

 **Nclex loves asthma & lifespan diseases!!** -> most

little kids < 4 have atypical presentation: cough w/o

wheeze

 Goal is to manage sxs so kids can be fully participatory,

esp. in exercise

○ Allergies & Environments

  Strongest predisposing factor for developing asthma is

atopy

 Most common are inhaled allergens—DUST MITES

(inner cities: cockroach dung)

 Environmental Triggers

 House dust mites

 Tobacco smoke

 Cockroach exposure / dung

 Other Triggers

 Foods

 Exercise

 Cold

 Pollutants

 Virus: biggest trigger in peds

○ Treatment

 Rule of 2’s – are they using their Beta/rescue

meds/albuterol > 2x/week, sxs with night-waking >

2x/month, refilling asthma meds > 2x/year. If yes to

all of these, then asthma is poorly controlled.

 Symptom Management
  Treatment is based on classification and step (See

NHLBI! And Kyle 19.4)

 Long Term Control Med

 AntiInflammatory Meds

 Quick Relief Meds

 Use of inhalers in kids – proper technique/ aim essential

for the dose to reach the lungs. Also impossible to tell

when the inhalers are empty

○ Asthma Control

 See slide – table 19.5 from book

 TEACHING IS EVERYTHING!!!

Case #1

• Looks Bad! Open mouth though getting N/C, looks v sick, in

“sniffing” with shoulder roll positioning to open airway

• Little fever, 2-3 day hx not drinking, drooling, looking out of it

• r/o epiglottitis, pneumonia

• Remember A,B,Cs & use this to guide actions

Case #2 – inhaler positioning looks v bad

Summary – slide

• Describe the essential components of the respiratory exam in

children.

• Differentiate signs of respiratory distress in children from those

commonly seen in adults.

• Compare clinical findings seen in the most common pediatric

respiratory conditions and propose a diagnosis for a given set of

findings.

• Prioritize nursing actions for children in acute respiratory distress.

• Identify preventive and treatment strategies for children with RSV

bronchiolitis, asthma and pneumonia.

• Categorize asthma severity and propose appropriate treatment.

01/11/2010
01/11/2010