Transcript Developmental Alterations in the Respiratory System of the

Alterations in Respiratory
Function
Ball and Bindler
Spring 2007
Donna Hills EdD APN
Developmental Alterations in the
Respiratory System of the infant
and child.
• Critical anatomical differences between the
infant/child/adult
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–
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smaller diameter and shorter
faster respir rate
narrower airway
infants up to 1-2 mo of age are obligate nose
breathers
– tongue is larger in proportion to the oral cavity
– larger lymphoid tissue until about age 6yr.
Critical anatomical differences
between the infant/child/adult
• Lower airway
– children up to 6yr are primarily diaphragmatic
breathers
– intercostal muscles are immature and less
effective in aiding respir before age 6.
– Chest wall is flexible due to ribs being
primarily cartilage; more prone to movement
FIGURE 25–2 In children, the trachea is shorter and the angle of the right bronchus at bifurcation is more acute than in the adult. Where
is an aspirated foreign body likely to land? When you are resuscitating or suctioning, you must allow for the differences in the length of the
trachea as it is easier to slip into the right bronchus with an endotracheal tube or suction catheter.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Assessment Guidelines for a Child in
Respiratory Distress
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Ball & Bindler: Box 25-1, p. 825
Quality of respirations
Quality of pulses
Color
Cough
Behavior changes
Signs of dehydration
FIGURE 25–4 The chest wall is flexible in infants and young children because the chest muscles are immature and the ribs are
cartilaginous. With respiratory distress, the negative pressure created by the downward movement of the diaphragm to draw in air is
increased, and the chest wall is pulled inward causing retractions. Intercostal retractions are seen in mild respiratory distress. As the severity
of respiratory distress increases, retractions can be seen in the substernal and subcostal areas. In cases of severe distress, accessory muscles
(sternocleidomastoid and trapezius muscles) are used, and retractions are seen in the supraclavicular and suprasternal areas.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Abnormal Alterations in the
Respiratory System of the infant
and child.
• Apnea: cessation of respir >20 sec.
– May or may not be accompanied by cyanosis,
pallor, hypotonia, bradycardia.
– Apnea may be the first sign of distress in the
infant; respir dysfunction,, sepsis,
meningitis/encephalitis.
– Apnea of prematurity: occurs in preterm infants
due to lack of maturity of the neuro/respiratory
systems.
Apparent Life Threatening Event
• episode of apnea accompanied by color
change, hypotonia, choking, gagging,
occuring in a near term infant (>37wks).
• May occur during sleep or wakefulness, or
feeding.
• Child is usually admitted for monitoring
Sudden Infant Death Syndrome:
SIDS
• sudden death of an infant <1yr of age that
remains unexplained after a complete
autopsy, death scene investigation and
review of the history.
• Leading cause of death in infants (1mo1yr), with 90% occurring before 6mo..
• Rarely occurs in infants <2wks.
• Unpredictable and unpreventable.
• First sign is cardiopulmonary arrest.
Signs of Respiratory Distress
• hypoxemia;low O2 level in the blood;
assessed by O2 saturation or ABG/VBG.
• Hypercapnia: high CO2 level in the blood:
ABG/VBG
• irritability, lethargy, cyanosis, dyspnea
(flaring, grunting, retracting), tachypnea.
• Any of the above signs needs action and
needs to be reported immediately to the
Instr, RN or MD.
Nursing Management of
Respiratory Distress
• If O2 sats are less than 95%, confirm that
the tracing is believable; (sine wave form
and correlates with heart rate).
• At the same time, raise the HOB or sit child
up if able.
• Determine O2 sat probe is functioning
• open airway
• administer O2 by blow-by first, then face
mask, then bag/valve if sats <90.
Nsg. Management Resp Dist.
(cont)
• assess the child for changes in:
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vital signs, esp. HR, RR and BP.
mentation/responsiveness
tone,
color
• alert the appropriate person to communicate
changes in O2 sat and responses to
treatment; obtain order for O2 or any other
actions. Transfer child if required.
Reactive Airway Disorders
• occur as a response to invasion by a virus,
bacterium, allergen or irritant.
• Response includes inflammation, edema,
increased mucous production and
bronchospasms
– AKA the 3 S’s: secretions,swelling, spasm.
• Can involve both the upper and lower
airways
• include croup, asthma and bronchiolitis
Croup Syndromes
• classified as upper airway syndrome
• can have swelling of :epiglottis, larynx,
trachea, and/or bronchi.
• 3 viral syndromes:
– acute spasmodic laryngitis (spasmodic croup)
– laryngotracheitis
– laryngotracheobronchitis (LTB)
• 2 bacterial syndromes:
– bacterial tracheitis and epiglottitis
Summary of Croup Syndromes
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Ball and Bindler, p. 838
Acute spasmodic laryngitis
Laryngotracheitis
Laryngotracheo-bronchitis
Bacterial tracheitis
Epiglottitis
Classic parameters that
distinguish each condition:
• Acute spasmodic croup peaks at night,
resolves by morning but reoccurs
• High fevers are associated with the bacterial
syndromes: Bacterial Tracheitis and
Epiglottitis, which are treated with
antibiotics
• The child with LTB sounds worse than they
look: the child with Epiglottitis is worse
than they sound.
LTB: Laryngotracheobronchitis
• most common: 3mo-8yrs
• potential for airway obstruction esp in
younger age group
• Influenza,Parainfluenza types I and II, RSV;
esp seen in winter.
• barking cough, inspiratory stridor,
retractions.
Epiglottitis: Supraglottitis
• inflammation and subsequent edema of the
epiglottis causing airway obstruction within
minutes to hours.
• Causes: HIB, staphylococcus and
streptococcus
• Recent decreased incidence with increased
immunization rates of HIB vaccine.
• Avoid making the child cry to avoid desat
and increased laryngospasm.
Epiglottitis: Special
Considerations
• life threatening with rapid progression
• drooling, incr HR/RR, prefer sitting upright,
with chin thrust
• avoid throat culture, tongue depressor or
palpation of the tonsillar fossa, as this
manipulation could produce severe
laryngospasm
• if suspected, keep pt calm, transport in
sitting position with O2: alert ENT.
FIGURE 25–11 The phrase “thumb sign” has been used to describe this enlargement of the epiglottis. Recall the trachea’s usual “little
finger” size. Do you see the stiff, enlarged “thumb” above it in this lateral neck radiograph?
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Case Presentation
• Three yr old presents with a few days of
URI symptoms with low grade fever
(<102), now develops hoarseness and
barking cough. Appetite less than usual but
still drinking clear liquids and voiding
5x/day. Clear nasal discharge which he
clears with his sleeve; wakes up at night
coughing. Is cranky but consolable. Temp
100 ax, HR 130, RR 28, sat 95% RA in no
distress. Color good. Chest coarse; no retr.
Assessment of Case Presentation
• What other questions would you like to ask
the parent to determine data needed?
• Any further assessment or tests needed?
• What behaviors in the child might signal
that the child was experiencing increased
airway distress?
• What do you think the child has and why?
Management for Case
Presentation
• Might give a trial neb of Albuterol 2.5mg
in 2cc NS over 5-10min. Reassess response.
• Monitor for signs of stridor, F/G/R, activity,
ability to take fluids, breath sound quality.
• If sats are > or = 95% on RA even with
activity, there is no suspicion of epiglottitis
or air way narrowing on lateral neck xray
(steeple sign), and good aeration, would
give parameters for home management.
Parameters for Home
Management
• Assess parents ability to assess child, and
obtain emergency help if needed
• If child awakes with barking cough and
stridor, and/or has coughing with increased
work of breathing, either bring into the
bathroom with shower on and door closed
(fan off) or bring outside in cool night air
(wrap in a coat or blanket) for a few
minutes. Distress usually subsides.
Home Management continued
• If coughing subsides with this cool
humidification treatment, offer clear liguids
and settle back to sleep. Can give a home
neb of Albuterol or even just mist. Episode
my reoccur.
• If respiratory distress continues despite
these efforts, bring to the nearest ER or call
911 if color poor, child is limp or lethargic,
child drooling, quiet and wants to sit up.
Asthma
• chronic inflammatory disorder with acute
exacerbations or persistent symptoms
• effects the large and small airways with
increased mucous production, swelling and
bronchospasm
• triggers: exercise, infection, allergies and
environmental irritants (second-hand smoke
abrupt change in weather).
Pathophysiology
• Multiple allergic pathways may be
stimulated: IgE, Leukotrienes, Compliment.
• Airway swelling and spasm results in
airway narrowing, particularly significant in
children with smaller airways.
• Air trapping occurs distal to mucus plugs
• Bronchospasm/coughing can feed into the
cycle of anxiety which further increases the
bronchospasm.
Acute Care Management
• Assess for degree of respiratory distress:
RR, HR, color/O2sat, F/G/R, cap refill.
• Breath sounds, air movement, I/E ratio,
peak flow (if able).
• Nebulizer with O2 via mask of
Albuterol/Atrovent, (or Xopenex); use
Epinephrine if respiratory distress is severe.
• Start steroids at 1-2mg/Kg/day divided BID.
Acute Care Management( cont):
• assess fluid status; increased RR leads to
increased insensible loss of water, dries out
mucous airways and risk of aspiration.
• Monitor output: number of wet diapers/day,
number of voids or actual measurement
• provide emotional support for child and
parents.
• promote rest to conserve energy, decrease
O2 need and decrease bronchospasm
FIGURE 25–17 Acute exacerbations of asthma may require management in the emergency department. The child is placed in a
semisitting position to facilitate respiratory effort. Providing support to both the child and parent is an important part of nursing care during
these acute episodes. The mother is exhausted after a sleepless night of caring for her son.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
FIGURE 25–18
and stress.
Medications given by aerosol therapy allow children to get optimal therapy without injections and their associated pain
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Management at Home
• Primary goal is prevention
• use peak flow meter to monitor degree of
obstruction; divided into zones
• avoid triggers:
– refer to allergist to determine if candidate for
desensitization (shots)
– maintenance meds to avoid histamine and/or
leukotriene stimulation
• rescue agent for acute symptoms: Albuterol
Home management cont.
• Determine need for a home nebulizer vs
spacer used with an MDI (metered dose
inhaler).
• Keep a home log of need for treatment and
adjustments in the environment, activity,
diet, etc.
• Determine need for steroids for
maintenance and prevention
• Determine a clear follow-up plan.
Revised Asthma Severity
Classification
• 2002 National Asthma Education and
Prevention Program Classification System
of Asthma Severity
Mild Intermittent
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brief exacerbations < 2x/wk
night time symptoms < 2x/month
PEFR > or = 80%
quick relief with bronchodilators PRN, but
if needed > 2x/wk then moves to the next
level.
Mild Persistent
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exacerbations > 2x/wk but < 1x/day.
Night time sx > 2x/month
May affect activity
PEFR > or = 80%
daily anti-inflammatory med.
Quick relief bronchodilator PRN
Moderate Persistent
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daily symptoms
daily short-acting beta-agonist
exacerbations >2x/wk; lasts for days
night time sx > 1x/wk
affects activity
PEFR >60% but <80%
daily anti-inflammatory meds; medium dose
bronchodilator up to 3x/day
Severe Persistent
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continuous symptoms
limited physical activity
frequent exacerbations
frequent night time sx
PEFR ,60% but >30%
daily anti-inflammatory; high dose
bronchodilator up to 3x/day
Status Asthmaticus
• severe, unrelenting respiratory distress with
bronchospasm
• persists despite medication and supportive
interventions
• medical emergency requiring endotracheal
intubation with assisted ventilation
Lower Airway Disorders
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Bronchopulmonary Dysplasia
Bronchiolitis
Pneumonia
Cystic Fibrosis
Foreign body aspiration
Bronchopulmonary Dysplasia:
Patho
• acute lung injury with abnormal xray
findings and persistent oxygen need beyond
36wks gestational age.
• Seen more often in preterms and those
treated with long term ventilatory support
• results in fibrosis and edema of the
bronchioles with smooth muscle
hypertrophy
BPD: clinical manifestations
• sx resp distress: tachypnea, wheezing,
crackles/rales, irritability, F/G/R, pulmonary
edema, FTT, barrel chest.
• Cyanosis if severe or accompanied by
cardiac anomalies
• Normal activities such as feeding, playing
or a mild URI, increases oxygen demands
and therefore can precipitate respiratory
distress
BPD: medical management
• symptomatic treatment and support
• humidified 02 to keep sats 90-92% even
during feeding and sleeping
• CPT 3-4x/day or as needed, preceeded by
bronchodilator nebs (Albuterol,Xopenex),
diuretics (Lasix, Aldactone), Antiinflammatories(steroids:Dexamethasone,Me
thylprednisolone, Prednisone/Prednisolone),
inhaled steroids (Pulmocort, Flovent).
FIGURE 25–14 Many children with BPD are cared for at home, with the support of a home care program to monitor the family’s ability
to provide airway management, oxygen, and support. This premature infant girl, who is now 4 months old but weighs only about 5 pounds,
requires respiratory support with oxygen.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
BPD: nursing management
• promote respiratory function, nl G+D.
• preparing the family for home care needs
• close monitoring of RR, HR, color, behavior
changes, and how the family unit is coping
with caring for this child with special needs.
• Clear parameters for follow up in an acute
exacerbation:readmission to the hosp is
common and become ill very quickly.
Bronchitis
• inflammation of the trachea and bronchi
• usually follows a URI esp in children <4yr.
• Usually viral but can be bacterial: xray may
be indicated
• treatment usually supportive with close
monitoring for worsening of symptoms.
• Coarse breath sounds, wheezing, hacking
cough, worse at night, fatigue, decreased
appetite and interest in play.
Bronchiolitis
• variation of severity of respir distress
• <2mo hospitalized; ,6mo more severe
disease than older infant
• inflammation and destruction of smaller
airways
• caused by viruses: Influenza type A & B,
Parainfluenza, RSV.
• Can also be caused by bacteria or
mycoplasma (but less likely).
Respiratory Syncytial Virus: RSV
• transmitted through close or direct contact
• viruses act like parasites and invade the
mucosal cells
• cells die, bursts and the resultant debris
clogs and obstructs the bronchioles
• in response, airways swell, produce excess
secretions causing obstruction and
bronchospasm.
• Apnea and pulmonary edema may occur
RSV: clinical manifestations
• URI, fever, clear rhinitis progressing to
wheezing/coarse breath sounds, increased
work of breathing, F/G/R.
• Appear progressively more ill as sx of resp
distress develop
• less po intake, less energy/activity, incr
sleepiness or irritability.
RSV: clinical therapy
• chest xrays are not specific unless the child
has a pneumonia as well
• viral cultures are done on the nasal
secretions and child is put on contact
precautions until cultures come back neg (if
positive, precautions continue)
• respirations are supported with humidified
02 to keep sats by oxymetry >93%
• CPT, sx VS, contact prec, hand washing.
RSV: medical management
• Ribavirin:only antiviral drug available
.Questionable effectiveness; reserved for
severe, life-threatening cases.
• Evidence that RSV in early childhood
increases the risk of asthma in later
childhood and COPD later in life.
• Recomm premies and children with
underlying medical conditions during their
first RSV season (Oct-Mar) with Synagis.
Synagis for children at risk
• passive immunity with monoclonal
antibody specific to RSV
• IM inj given 1x/mo Oct-April to those born
<37 wks, and/or have cong heart disease,
asthma, BPD, or immunosuppression (and
other chronic diseases).
• Day care, shelters, high density group living
and older siblings also increase the risk of
the child contracting RSV.
Pneumonia
• inflammation or infection of the bronchioles
and alveolar spaces of the lungs
• viral, bacterial or mycoplasma in
origin(latter two are treated with A/B)
• end result from all causes is exudate that
fills alveolar spaces, creating areas of
plugging and consolidation that can
interfere with gas exchange.
Pneumonia:clinical
manifestations and nursing
management
• similar to bronchiolitis
• in addition, use of Tylenol or Ibuprofen for
fever and pain control
• frequent persistent coughing can cause
muscle strain and interrupted sleep for both
child and parent.
• Cough suppressants are not routinely
advised for young children
• supportive therapy: fluids/nutr/02 if indic.
Cystic Fibrosis
• common inherited autosomal recessive
disorder
• involves the exocrine glands which excrete
a thick fluid that affects functioning of the
respiratory, GI, endocrine, skin and
reproductive systems.
• Predominantly seen in the white population
• equal distribution among gender
• median life span is 30yrs.
FIGURE 25–20 Cystic fibrosis is an inherited autosomal recessive disorder of the exocrine glands, so it is not uncommon to see siblings
with it such as this brother and sister.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
CF: clinical manifestations
• 600 mutations with variation of severity
• all types affect multiorgan systems:
• lungs become plugged with thick mucous
that can not be expectorated, causing
atelectasis and air trapping. Secondary
infections are common and are combatted
by scheduled hosp. admissions for “clean
outs”
CF: clinical manifestations
• pancreatic ducts become blocked: enzymes
can’t adequately digest food
– poor absorption of nutrients; weight loss, FTT,
resulting in foul smelling, frothy, floating and
fat containing stools.
– Insulin dependent diabetes is not uncommon as
the child ages (adolescence).
• Sterility or decreased fertility is common
due to increased mucous secretions
CF: Primary presentation and
diagnosis
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•
•
•
•
meconium ileus in the new born
small bowel obstruction as a young infant
fecal impaction and/or intussusception
steatorrhea (fatty stools)
productive cough, frequent URI’s, weight
loss
• elevated Chloride on a Sweat Test (>50-60)
FIGURE 25–21
Rectal prolapse.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
FIGURE 25–22
Digital clubbing.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
FIGURE 25–23 The parent may hold and reassure the infant or small child being evaluated for cystic fibrosis with a sweat chloride test.
Sweat is being collected under the wrappings for later analysis of the amount of sodium and chloride.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
CF: Clinical Therapy
• maintaining respiratory function: nebs/CPT
TID/PD/vibration/expectoration
• supportive 02 as needed
• managing infection:maintenance A/B, then
clean outs and high dose antibiotics when
hospitalized.
• Avoid colonization and cross contamination
with other Cystic Fibrosis kids.
• Optimal GI absorp and avoid obstruction
FIGURE 25–24 Postural drainage can be achieved by clapping with a cupped hand on the chest wall over the segment to be drained.
This action creates vibrations that are transmitted to the bronchi so that secretions are loosened and drain by gravity to the bronchi. A, If the
obstruction is in the posterior apical segment of the lung, the nurse can do this with the child sitting up. B, If the obstruction is in the left
posterior segment, the child should be lying on the right side. Several other positions can be used depending on the location of the
obstruction. See the Skills Manual.
A
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Foreign Body Aspiration
• at risk: infants>6mo, toddlers, preschoolers
during exploration and experimentation
• schoolage and teens d/t activity while
eating, too much in the mouth or eating too
fast.
FIGURE 25–6 An aspirated foreign body (coin) is clearly visible in the child’s trachea on this chest radiograph. Courtesy of Rockwood
Clinic, Spokane, WA.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
FBA: clinical manifestations
• coughing, choking, gagging, dyphonia and
wheezing; decreased breath sounds on one
side, stridor and possible respiratory
distress.
• FB in bronchus is better tolerated; in trachea
is life threatening
• can migrate to R main stem bronchus to R
lung d/t anatomical slope.
FBA: clinical management
• in air way obstruction: chest thrusts and
back blows in the infant.
• Abdominal thrusts in the child over 8 yrs.
• if partially obstructed: xray indic of chest
(A/P & lateral) and lateral film of the neck.
• Bronchoscopy under sedation may be
necessary to remove object or sometimes,
surgery.
• Best therapy is prevention.