1 Chapter 23– Respiratory ComplicationsLaura Salisbury RN, MSN/Ed.

2 Respiratory InfectionsInfectious organisms Mostly viruses Also Group A beta-hemolytic streptococci (GABHS), h. flu, chlamydia, mycoplasma, etc Age Under age 3 months: fewer infections (protected by mom) Susceptible to specific organisms=pertussis Increasing infection rages after 3 months Fewer viral infections by age 5, more mycoplasma Some viruses mild in older children, worse in young Size Younger children=smaller airway diameter, shorter distance between structures Short, straight eustachian tube

3 Respiratory InfectionsResistance Depends on the child; some factors cause decreased resistance Daycare increases likelihood of infection Seasonal variations Usually winter/spring epidemics Mycoplasma: fall/winter Manifestations KNOW box 23-1 (p 756) signs/symptoms of resp infection in infants/small children

5 Nursing Care ManagementReduce body temperature Acetaminophen or ibuprofen Be cautious of multi-symptom remedies Promote hydration Infants particularly prone to dehydration Offer favorite fluids frequently No caffeine=acts as diuretic Do not force fluids or wake up child to give fluid Tell parents to observe frequency of voiding, count number of wet diapers Provide nutrition Feed child when they are hungry, don’t push too much Family support and home care Avoid old antibiotics If child is on antibiotics, give entire course Give encouragement to tired parents!

6 URI’s Upper respiratory tract infectionsNasopharyngitis—“common cold” (pg 759) Caused by numerous viruses RSV, rhinovirus, adenovirus, influenza and parainfluenza viruses Treat at home Be careful w/cough suppressants Antihistamines not helpful Pharyngitis (pg 762) Screen for GABHS Rapid screen may not always be accurate, get a culture Treat GABHS with antibiotics (PCN best choice)

7 URI’s Upper respiratory tract infectionsTonsillitis (Pg 763) Children have larger tonsils than adults Tonsillitis can be viral or bacterial Recurrent tonsillitis: may need tonsillectomy No coughing, blowing nose, clearing throat post-tonsillectomy Give cool/cold fluids: nothing red or brown (to distinguish from bleeding); no milk products Watch for postop hemorrhage Frequent swallowing early sign of hemorrhage Can occur up to 10 days post surgery

8 URI’s Upper respiratory tract infectionsInfluenza (pg 764) Usually needs symptomatic treatment Amantadine for type A influenza: shortens disease if given early Zanamivir, rimantadine, oseltamivir (Tamiflu) for A or B Vaccines to prevent: not given to children w/egg allergies

9 URI’s Upper respiratory tract infectionsOtitis Media (OM) (pg 765) Mostly in first 24 months of life, small increase when child enters school Smokers in home=increased risk Eustachian tubes blocked=secretions don’t drain=infection Sometimes viral; antibiotics wouldn’t help; may want to “wait and watch” in healthy infants/children Myringotomy: surgical incision of eardrum; often w/tube placement Will cause drainage from ears w/infections Avoid getting water in ear, especially lake/river water or water w/soap If chronic fluid in ears (OME): watch hearing

10 URI’s Upper respiratory tract infectionsInfectious mononucleosis (pg 768) Caused by Epstein-Barr virus (EBV) Monospot test detects Symptomatic treatment Check for spleen or hepatic involvement Watch swallowing ability/airway compromise

11 URI’s Upper respiratory tract infectionsCroup Syndromes (pg 769) Characterized by hoarseness, “barking” cough, inspiratory stridor, and varying degrees of respiratory distress Croup syndromes affect larynx, trachea, and bronchi Epiglotitis, laryngitis, LTB, tracheitis:

12 URI’s Upper respiratory tract infectionsAcute Epiglottitis (pg 769) Sore throat, pain, tripod positioning, retractions Inspiratory stridor, mild hypoxia, distress Potential for respiratory obstruction Keep child calm, nothing in the throat Prevention: Hib vaccine

13 URI’s Upper respiratory tract infectionsAcute Laryngitis (pg 770) More common in older children and adolescents Usually caused by virus Chief complaint is hoarseness Generally self-limiting and without LT sequelae Treatment: symptomatic

14 URI’s Upper respiratory tract infectionsAcute LTB Laryngotracheobronchitis Most common of the croup syndromes Generally affects children <5 yrs Organisms responsible

15 URI’s Upper respiratory tract infectionsManifestations 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 Therapeutic Management Airway management, Maintain hydration—PO or IV, High humidity with cool mist, Nebulizer treatments, Epinephrine, Steroids, Watch for airway obstruction

16 URI’s Upper respiratory tract infectionsAcute Spasmodic Laryngitis (pg 771) 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 Treat w/cool mist, sometimes corticosterioids 

17 URI’s Upper respiratory tract infectionsBacterial Tracheitis (pg 772) Infection of the mucosa of the upper trachea Distinct entity with features of croup and epiglotitis Clinical manifestations similar to LTB May be complication of LTB Thick, purulent secretions result in respiratory distress

18 Infections of the Lower AirwaysConsidered “reactive” portion of the lower respiratory tract Includes bronchi and bronchioles Cartilaginous support not fully developed until adolescence Bronchitis-- AKA tracheobronchitis Inflammation of large airways Self-limiting; treat symptoms Bronchiolitis and RSV

19 Infections of the Lower AirwaysViral infection of bronchioles RSV = common cause of bronchiolitis Starts w/URI symptoms Quick test for RSV from nasal/nasopharyngeal secretions Keep oxygenation over 90% Suction secretions, Hydration, Cohort RSV patients Ribavirin: Antiviral for very ill patients No pregnant caregivers administering ribavirin (inhaled) Prevention: High-risk kids get palivizimab Monthly IM injections during fall/winter

20 Pneumonias Etiology of Pneumonias Bacterial Viral AspirationHistomycosis, coccidiomycosis, other fungi “Atypical pneumonias” SARS Avian influenza KNOW box (symptoms of pneumonia) p. 775 Prognosis for children w/pneumonia generally good Treated according to cause, symptoms

21 Other Respiratory infectionsPertussis (Whooping Cough) prevention with DTaP Highly contagious Most risk to young infants Bacterial; treat w/ antibiotics

22 Tuberculosis Tuberculosis (TB) ( pg 777)Caused by Mycobacterium tuberculosis human and bovine varieties Usually transmitted through and affects respiratory tract KNOW box (manifestations) Screen through PPD tuberculin skin test Postive reaction indicates that bacillus has entered individual; not necessarily active disease Reading test depends on risk factors

23 Management of TB INH, Rifampin, PZA, 6 month regimenMulti-drug resistant—streptomycin IM Prophylaxis for high-risk pt: INH 9-12 mos Prognosis: most serious for HIV positive, disseminated disease, infants, adolescents Prevention BCG vaccine: not given in US (will make PPD screening positive) Nursing considerations: watch for high-risk kids w/constant cough

24 Aspiration Foreign Body Aspiration (pg780)Highest risk among children 1-3 Watch for children w/respiratory symptoms but not other disease symptoms, sudden onset Choking: do abdominal thrusts if child cannot Aspiration Pneumonia (pg 781) Risk for child with feeding difficulties Prevention of aspiration: thickened foods, careful feeding Avoid aspiration risks

25 Inhalation Inhalation Injury: Smoke and Carbon Monoxide (pg 782)Severity depends on nature of substance, environment, and duration of contact Causes local and systemic injury CO poisoning: causes hypoxia…not seen on pulse Passive Smoking Causes increased asthma, OM, SIDS

26 Asthma Chronic inflammatory disorder of airwaysBronchial hyper-responsiveness Episodic Limited airflow or obstruction that reverses spontaneously or with treatment Dyspnea, wheezing, coughing Symptoms may vary Lack of air movement: ominous sign Drug Therapy for Asthma LT control meds, Quick relief meds, MDI, Corticosteroids

27 Asthma Asthma InterventionsExercise, Chest physiotherapy (CPT), Hyposensitization Status Asthmaticus Respiratory distress continues despite vigorous therapeutic measures Emergency treatment—epinephrine 0.01 mL/kg SQ (max dose 0.3 mL) Concurrent infection in some cases

28 Asthma Goals of Asthma Management Avoid exacerbation Avoid allergensRelieve asthmatic episodes promptly Relieve bronchospasm Monitor function with peak flow meter Self-management of inhalers, devices, and activity regulation

29 Cystic Fibrosis -- CF Exocrine gland dysfunction that produces multi-system involvement Most common lethal GENETIC illness among white children Approximately 3% of U.S. Caucasian population are symptom-free carriers NOT just a RESPIRATORY disorder

30 Cystic Fibrosis -- CF Etiology of CF Autosomal recessive traitInherits defective gene from both parents with an overall incidence of 1:4 Pathophysiology of CF Characterized by several unrelated clinical features Increased Viscosity of Mucous Gland Secretion Results in mechanical obstruction Respiratory tract and pancreas are predominately affected

31 Cystic Fibrosis -- CF Increased Sweat ElectrolytesBasis of the most reliable diagnostic procedure—sweat chloride test Other Factors Increased organic/enzymatic constituents of saliva Abnormalities of the autonomic nervous system

32 Cystic Fibrosis -- CF Respiratory ManifestationsPresent 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 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

33 Cystic Fibrosis -- CF Respiratory ProgressionGradual progression follows chronic infection Bronchial epithelium is destroyed Infection spreads to peribronchial tissues weakening bronchial walls Peribronchial fibrosis Decreased O2/CO2 exchange

34 Cystic Fibrosis -- CF GI TractThick secretions block ducts—cystic dilation — degeneration — diffuse fibrosis Prevents pancreatic enzymes from reaching duodenum Impaired digestion/absorption of fat-steatorrhea Impaired digestion/absorption of protein-azotorrhea 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

35 Cystic Fibrosis -- CF Clinical Manifestations of GI TractPancreatic enzyme deficiency Progressive COPD associated with infection Sweat gland dysfunction Failure to thrive Increased weight loss despite increased appetite Gradual respiratory deterioration

36 Cystic Fibrosis -- CF General PresentationWheezing respiration, dry nonproductive cough Generalized obstructive emphysema Patchy atelectasis Cyanosis Clubbing of fingers and toes Repeated bronchitis and pneumonia Meconium ileus Distal intestinal obstruction syndrome

37 Cystic Fibrosis -- CF General Presentation (cont):Excretion of undigested food in stool — increased bulk, frothy, and foul Wasting of tissues Prolapse of the rectum Delayed puberty in females Sterility in males Parents report children taste “salty” Dehydration Hyponatremic/hypochloremic alkalosis Hypoalbuminemia

38 Cystic Fibrosis -- CF Diagnostic EvaluationQuantitative sweat chloride test Chest x-ray PFT– pulmonary function test Stool fat and/or enzyme analysis Barium enema Goals Prevent/minimize pulmonary complications Adequate nutrition for growth Assist in adapting to chronic illness

40 Cystic Fibrosis -- CF GI Management Replacement of pancreatic enzymesHigh protein high calorie diet as much as 150% RDA Intestinal obstruction Salt supplementation

41 Cystic Fibrosis -- CF Prognosis of CFEstimated life expectancy for child born with CF in 2003 is years Maximize health potential Nutrition Prevention/early aggressive treatment of infection Pulmonary hygiene New research—hope for the future Gene therapy Bilateral lung transplants Improved pharmacologic agents

42 Cystic Fibrosis -- CF Family SupportCoping with emotional needs of child and family Child requires treatments multiple times/ day Frequent hospitalization Implications of genetic transmission of disease

43 Cardiopulmonary Resuscitation-- CPRPediatric 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