1 Care of the Pediatric Patient with Respiratory ProblemsElizabeth Allen RN, MSN
2 Learning Objectives Describe Unique Characteristics of Pediatric Respiratory System List Respiratory Conditions and Injuries that Cause Respiratory Distress in Children Distinguish between Mild, Moderate, and Severe Respiratory Distress Differentiate between Signs and Symptoms of Upper and Lower Airway Conditions
3 Differences in A&P Newborn- 3 months obligatory nose breathersChild’s airway is shorter and more narrow<6 years breathe with diaphragm- intercostal muscles immature A newborn’s chest is circular until age 6. Decreased muscularity is responsible for the thin chest wall in infants.
4 Differences in A&P Child epiglottis longer, floppierHigher oxygen demand in children Immature Infant Respiratory and Neurologic System Offers Less-Efficient Response to Hypoxia and Elevated PCO2
5 Pediatric Respiratory AssessmentNoises Stridor Wheeze Cough Grunting Cry Work of Breathing Rate Head bobbing Retractions Nasal flaring Pulse Oximetry Auscultate
7 How Long can the child maintainRespiratory Distress Can Lead to Respiratory Failure Early recognition and intervention vital Mild Tachypnea, tachycardia, diaphoresis, mild retractions Moderate Flaring, moderate retractions, grunting, wheezing Anxiety, irritability, confusion, mood changes Severe Dyspnea, severe retractions Bradycardia, bradypnea Stupor, coma Cyanosis = late sign How Long can the child maintain that level of effort?
9 Apparent Life Threatening Event (ALTE)1 week to 2 months Identifying diseases and conditions GERD, acute respiratory infections, seizures, Congenital heart defects, metabolic conditions, child abuse (Munchausen by proxy) Lab work Diagnostic testing Monitoring Home Education
10 Sudden Infant Death Syndrome (SIDS)Etiology / Pathophysiology Genetic Clinical Manifestation Cardiopulmonary arrest Season Collaborative Care Back to Sleep Nursing Management Supportive Care Safe Sleep Environment Safe Sleep Environment
11 Respiratory Infection TransmissionAirborne Isolation Small particles negative pressure room Droplet Isolation Large particles- drop 3 feet Contact Isolation
13 Upper Airway Problems Tonsillectomy and possible AdenoidectomyPost Op Care Pain management Maintain hydration Evaluate for bleeding, swelling or airway compromise
14 Upper Airway Problems CroupLaryngealtracheobronchitis Viral Treatment Keep child calm!!! Cold, humid night air Corticosteroids Racemic epinephrine Albuterol as needed Croup Upper airway illness causing inflammation in larynx and epiglottis Viral or bacterial Symptoms: “Barking” cough Stridor Hoarseness Often “croup” refers to LTB caused by a virus An x ray of the upper airway may show a “steeple sign” that is a symmetric narrowing below the epiglottis. NO examination of the inner mouth or throat as these may cause laryngospasms that can result in complete airway obstruction!!!
15 Upper Airway TreatmentCool Mist Tent
16 Upper Airway Problems EpiglottitisInflammation of the epiglottis – life threatening Bacterial Streptococcus Staphylococcus Haemophilus influenzae type B Hx: Acute fever, sore throat, dysphonia and dysphagia Diagnostic testing X-ray? Treatment/Interventions Antibiotics Cephalosporin Airway management Evaluation Symptoms: 3 D’s Dysphagia Drooling Dysphonia Rare in US with Hib vaccination Tripod position, Drooling!!!
17 Upper Airway Problems Foreign Body Aspiration AspirationDevelopmental- older infants and Toddlers Usually bronchial obstruction, R bronchial Signs Cough, weak cough Stridor Respiratory Distress Muffled or hoarse voice Drooling Anxiety, irritability Unilateral diminished breath sounds Treatment Keep child calm Position of comfort Monitor cardiorespiratory status Airway intervention if necessary CXR Endoscopy OR
18 Upper Airway Problems Otitis Media Inflammation of middle ear84% infants have at least 1 case before age 3 years More common in: Kids with allergies Families who smoke Pacifiers American Indian Symptoms Ear pain/ pulling at ear Fever Vomiting/diarrhea Irritability Treatment Guidelines AAP Avoid over treatment with antibiotics Educate families to complete course- avoid drug resistance
19 Figure 19–9 This young child is pulling at the ear and acting fussy, two important signs of otitis media. Ask the parents about the presence of fever and night awakenings, additional signs that are often observed in children with this condition.
21 Lower Airway Problems Bronchitis/ Bronchiolitis Clinical TherapyViral or bacterial Underlying chronic illness Bronchiolitis (bronchioles) RSV, parainfluenza, adenovirus Edema, debris clog and narrow airway Clinical Therapy Maintain Respiratory Function Close monitoring Keep airways clear! Oxygen Humidity Hydration Nutrition Rest Anxiety Discharge Planning Inflammation of the trachea and bronchi and bronchioles. Underlying prematurity, congenital heart disease, neuromuscular disease at increased risk for complications. Synagis vaccine Lower airway issue because air becomes trapped and chest hyperinflated
23 Lower Airway Problems Asthma Interventions MedicationsEtiology/Patho-physiology Clinical Therapy Assessment Peak Expiratory Flow Rate Respiratory Distress Triggers Interventions Medications Maintain Airway Patency Meet Fluid Needs Pediatric Considerations Discharge Planning Evaluation Resource Pathophysiology: edema and mucus secretions narrow airway. Wheezing sound is air moving through narrowed spaces. Air trapping in lungs Assessment of respiratory distress and lung sounds, Peak Expiratory Flow Rate
24 Lower Airway Problems Asthma Exacerbation: Across the Room AssessmentLOC Respiratory rate Retractions Audible wheezing Head bobbing Grunting Speaking Then listen for wheezing, diminished breath sounds Asthma Exacerbation Video- follow link https://www.youtube.com/watch?v=EK8nzKzdnIM
26 Lower Airway Problems Asthma Severity Scale Medications Medications Intermittent asthma to Persistent Asthma requiring daily medications Short acting Beta2 agonist Inhaled corticosteroid Montelukast Evaluate control with medications PFT Symptom tracking
27 Lower Airway Problems (London et. al., 2014)The asthma severity classification is based on symptom control, nighttime awakenings, SABA use, interference with normal activity and risk- classified as the number of episodes requiring oral systemic steroids. (London et. al., 2014)
28 Lower Airway Problems (London et. al., 2014)This stepwise approach to asthma management and treatment is used by prescribers. You should be generally familiar with it. Children can move up and down the steps based on the severity of their asthma- per the last page. You should be familiar with an example medication for each step. Flovent is an example of an inhaled corticosteroid, albuterol is an example of a SABA. You should also be familiar with montelukast, the generic name for Singulair. (London et. al., 2014)
29 Lower Airway Problems (London et. al., 2014)This classification is for children age 5 to adult. You’ll see now that peak flows have been added, noted as FEV which stands for forced expiratory volume. (London et. al., 2014)
30 Lower Airway Problems (London et. al., 2014)
31 Lower Airway Problems Cystic Fibrosis Autosomal recessive disorderIncidence Pathophysiology Defective chloride secretion and increased sodium absorption. Rate of progression varies among children Clinical manifestations Diagnostic Procedures- Sweat Chloride Test Resource Incidence approx 30,000 indiv in US. People with CF may live into ’s Sweat chloride >60 mEq/L is diagnostic of CF. Normal is 40 mEq/L
32 Defective chloride-ion transport and decreased water flow across cell membranes – excessive electrolyte loss.
34 Lower Airway Problems Cystic Fibrosis Medications Clinical TherapyMaintain respiratory function Manage infection Optimize nutrition Prevent gastrointestinal blocking Nursing Diagnoses Medications Pancreatic enzymes Antibiotics- oral and inhaled Osmotic medication- polyethylene glycol High calorie formula, MCT H2 blocker, PPI
35 Tracheostomy Tracheostomy Care Suctioning Routine Care Emergency care