Transcript CLED40505_RespiratoryDiseasesMay2007

Respiratory Disorders
Pat Volker, RN, BSN
May 2007
Objectives
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The learner will be able to:
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State the functions and components of the respiratory tract.
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Understand the effect of respiratory disorders on cardiac status.
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Recognize age-specific concerns in caring for children with
respiratory illnesses.
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State the signs and symptoms of respiratory distress.
Objectives
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Describe disorders involving the upper airway
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Croup
Epiglottitis
Foreign body airway obstruction
Describe disorders involving the lower airway
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Bronchiolitis (RSV)
Asthma (RAD)
Pneumonia
Cystic Fibrosis
Review of Respiratory Tract
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What is the function of the respiratory system?
To distribute air and exchange gases so that cells are
supplied with oxygen for body metabolism while
carbon dioxide is removed.
Components of Respiratory Tract
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Upper Airway
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Nose – passageway that
moistens and filters air.
Pharynx – passageway
for entry and exit of air.
Role in vocalization.
Tonsils located here.
Larynx- Glottis and
epiglottis located here.
Cricoid cartilage
Upper trachea
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Lower Airway
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Lower trachea
Mainstem bronchi – right
more vertical than left
Bronchioles – distribute
air to alveoli
Alveoli – gas exchange
occurs by simple
diffusion between
inspired air and the
bloodstream
Thoracic Cavity
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Right three-lobed lung
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Left two-lobed lung
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Mediastinum
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Esophagus
Trachea
Large blood vessels
Heart
Age-Specific Considerations
“Children are not small adults!”
The anatomical differences and the immaturity of the respiratory and immune
systems are primarily responsible for increased susceptibility of the child to
respiratory infections and obstruction.
are nose breathers – nasal congestion or trauma may result in
severe respiratory distress.
Infants
ribs are horizontal and cartilaginous - ↓ chest diameter and
abdominal breathing
Infant
Epiglottis
is U-shaped, higher and anterior leaving it more prone to
infection and trauma.
Lower
airway cartilage is soft and compressible.
Age-Specific Considerations
“Children are not small adults!”
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Alveolar surface is decreased (24 million vs. 300 million in adults) –
children breathe faster than adults. Respiratory rates increase further
with distress. Alveoli more prone to collapse.
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Infant head is large in proportion to body.
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Infant tongue is large in proportion to oral cavity and can block
airway.
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Larynx is anterior and high – may cause increased risk for aspiration.
Age-Specific Considerations
“Children are not small adults!”
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Airway structures are smaller and more easily obstructed.
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Cricoid cartilage is the narrowest part of the airway and
provides natural cuff until 8 yrs. Also a frequent site for
foreign-body obstruction.
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Smaller and thinner chest wall.
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RLL and LLL should be assessed posteriorly for children
< 8 yrs.
Age-Specific Considerations
“Children are not small adults!”
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Tidal volume – 10 ml/kg vs. 500 ml/kg in adults.
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Diaphragm is the major muscle of breathing in children <
7 yrs.
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Increased metabolic rate and O2 consumption.
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Hgb is 75% of the adult – cyanosis develops when 5 gms
of Hgb are desaturated or as much as 50% of blood is
deoxygenated making cyanosis a late sign of distress.
Age Groups
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Neonate
Infant
Toddler
Preschool
School Age
Adolescent
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Birth - 1 month
1 Month - 1 Year
1 - 3 Years
3 - 6 Years
6 - 11 Years
11 - 18 Years
Normal Age Variations
Neonates are periodic breathers – periods of rapid breathing followed
by short (< 15 seconds) periods of apnea without color changes are
normal up to six weeks of age.
Infants are obligate nose breathers – simple upper respiratory
infections may cause severe problems.
Normal Age Variations
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Children < 6-7 years are abdominal
breathers – gastric distention, bowel
obstruction and major abdominal surgery
can effect respiratory status.
Children over age 7 have a more adult-like thorax and are chest
breathers.
Respiratory Assessment
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Normal Respiratory Rates
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Neonate
Infant
Toddler
Preschooler
School Age
Adolescent
40 - 60
30 - 40
28 - 32
24 - 28
22 - 24
12 - 18
Respiratory Assessment
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Respiratory disorders account for approximately ½ of
illnesses in children under 5 years of age. A complete
respiratory assessment should include the following:
Visual Assessment
Inspection
Auscultation
Palpation
Visually Assess: Across the Room
Visual assessments should be completed before disturbing the
child, if possible.
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Rate/ Depth/ Symmetry of respirations should be
assessed for one full minute
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Work of Breathing: Look for:
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Nasal Flaring
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Retractions
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Level of Consciousness
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Color
Location of Retractions
What signs do you see
of increased work of
breathing?
Nasal Flaring
Apprehensive
look
Retractions
Pectus
excavatum
Inspect
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Note respiratory rate
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Depth
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Use of accessory muscles
Is there paradoxical chest and abdominal movement?
Nail Beds
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Color
Clubbing
Inspect
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Shape of Thorax
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Infants – rounded, gradually changes to a more
flattened anterioposterior diameter (rounded or barrel
chest indicates chronic lung disease).
Sternum
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Protuberant – Pectus Carinatum
Depressed – Pectus Excavatum
Pectus Carinatum
Auscultate
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Are breath sounds equal?
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Do you hear adventitious breath sounds?
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Is aeration adequate?
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Are there any abnormal heart sounds?
Breath Sounds
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Stridor – inspiratory sound usually due to an upper airway obstruction
from a narrowing or partial narrowing of the airway
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Wheezing – can be inspiratory or expiratory, usually due to a
narrowing of the airway related to asthma, foreign body or tumor.
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Grunting –can be a sign of pneumonia, pulmonary edema or
respiratory distress syndrome.
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Absent or Diminished
Breath Sounds
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Rales (Crackles) – can be coarse or fine depending on the size of the
airway. Caused by air passing through fluid.
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Rhonchi ( Rattles) – caused in large upper airways by thick
secretions. Usually continuous sounds.
Palpate
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Assess for:
 Respiratory excursion – symmetry of movement
 Tenderness
 Crepitus - peculiar crackling, crinkly, or grating feeling or
sound under the skin, around the lungs, or in the joints.
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Subcutaneous emphysema - occurs when air gets
into tissues under the skin covering the chest wall or neck.
This can happen due to stabbing, gun shot wounds, other
penetrations, or blunt trauma
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Bony deformities
Respiratory Distress and Failure
Respiratory Distress
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Clinical state characterized by increased work of
breathing.
Respiratory Distress
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Early
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Tachypnea
Tachycardia
Use of accessory muscles
Nasal Flaring
Anxiety / Irritability
Diminished breath sounds
Tripod Position
Respiratory Distress
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Late Phase
Decreased level of consciousness
 Head bobbing
 Decrease in muscle tone
 Cyanosis
 Decrease in respiratory rate - ominous sign
 Fatigue
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Respiratory Distress
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Clinical manifestations of respiratory distress can
be subtle and are often not recognized early!
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Excellent assessment skills can prevent the
progression of respiratory distress to respiratory
failure.
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One of the major causes of cardiac arrest in
children is respiratory failure!!!!
Respiratory Failure
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Clinical diagnosis resulting from inadequate
elimination of CO2 and inadequate oxygenation
of the blood.
Respiratory Failure
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A child who progresses to respiratory failure
needs critical interventions – use your ABC’s!
Support
the airway – open and clear the airway
breathing – O2, pulse oximetry, may need
intubation
Support
circulation – monitor heart rate, establish
vascular access
Support
Respiratory Disorders
Respiratory Disorders
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Can be:
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Acute
Chronic
Life Threatening
Early detection and intervention is vital!
Upper Airway Disorders
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Croup (Laryngotracheobronchitis)
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Inflammation and narrowing of larynx, trachea, bronchi
and bronchioles. Obstruction is caused by swelling and
increased secretions leading to increased work of
breathing
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Affects
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Etiology
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6 months – 3 yrs; greater incidence in males
Usually viral, most commonly parainfluenza
Seasonal Considerations
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Late autumn – early winter
Upper Airway Disorders
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Croup (Laryngotracheobronchitis)
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Clinical Picture
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Preceded by cold symptoms, barking cough, inspiratory
stridor, worse at night and with agitation, low grade fever,
anorexia, malaise
Severe cases may have cyanosis, retractions
Can proceed to obstruction
Treatment
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Cool humidified air, keep child calm, nebulized racemic epi,
dexamethasone, pulmocort, fluids
May rebound after 4 hours
Position of comfort
Upper Airway Disorders
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Epiglottitis
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Rapidly progressive bacterial infection of the epiglottis and
surrounding tissue.
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Affects
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Unvaccinated children, adults
Etiology
Almost always caused by H flu, type B
 Incidence in children greatly decreased
due to HIB vaccine
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Seasonal Considerations
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None
Upper Airway Disorders
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Epiglottitis
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Clinical Picture
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Sudden onset high fever, respiratory distress, appears sick,
drooling, severe dysphagia, stridor, little or no cough, cherry
red epiglottis, severe sore throat
Treatment
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REQUIRE IMMEDIATE ATTENTION!!!
Emergency airway management, avoid agitation, place in
position of comfort, oxygen, IV antibiotics
Point of airway
obstruction –
epiglottitis vs.
croup
Upper Airway Disorders
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Foreign Body Airway Obstruction
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Affects
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Most common in older infants and children 1 –3 yrs.
Clinical Picture
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Gagging, refusal to eat, vomiting, cough, stridor, drooling
Severity determined by location and type of object and
extent of obstruction
Upper Airway Disorders
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Foreign Body Airway Obstruction
Universal Choking
Sign
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Treatment
Heimlich
 Back blows/chest thrusts
 Best treatment – PREVENTION!
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Avoid hotdogs, hard candy, nuts, grapes, balloons
Lower Airway Disorders
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Asthma ( RAD)
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Most common chronic disease in kids
Classified by severity (based on symptom frequency,
use of medications, nighttime symptoms, peak
flows):
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Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
Affects
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All ages
Lower Airway Disorders
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Asthma (RAD)
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Seasonal Considerations
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Weather changes can trigger exacerbation
Clinical Picture
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Expiratory wheezing, cough (worse at night), difficulty
breathing, chest tightness, sinusitis, allergic rhinitis, atopic
dermatitis, symptoms that worsen with airborne allergens or
exercise
Worsening Symptoms
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Dyspnea, productive cough, tachypnea, use of accessory
muscles, nasal flaring, prolonged expiration, decreased LOC
Lower Airway Disorders
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Asthma (RAD)
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Treatment
Allergen control
 Medications
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Bronchodilators (inhaled or po)
Anticholinergics
Anti-inflammatory
 Corticosteroids
Albuterol
Atrovent
Prednisone
Lower Airway Disorders
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Asthma (RAD)
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ER Treatment
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Oxygen therapy
Inhaled Albuterol or in combination with Atrovent- may be
continuous
IV corticosteroids
Terbutaline
Magnesium Sulfate – PICU admit
Ketamine – PICU admit
Education
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Reinforce disease process, symptom management, peak flow
meter usage, medication usage and avoidance of
allergens/triggers
Lower Airway Disorders
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Bronchiolitis (RSV)
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Affects
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Etiology
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Primarily infants 2 – 6 months, up to 2 years; greater
incidence in males and infants with bronchopulmonary
dysplasia (BPD)
Respiratory syncytial virus (RSV)
Seasonal Considerations
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Late fall/winter/early spring
Lower Airway Disorders
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Bronchiolitis (RSV)
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Characterized by:
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Inflammation of the bronchioles
Airway edema
Increased mucous production
Small airway obstruction
Air trapping
Atelectesis – produces ventilation perfusion mismatch,
leading to hypoxemia and hypercarbia
Lower Airway Disorders
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Bronchiolitis (RSV)
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Clinical Picture
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Present with cough, rhinorrhea, nasal congestion, slight
intermittent fever over 3 –5 days
Progresses to wheezing, ↑ respiratory rate, dyspnea, nasal
flaring,
↑ heart rate, retractions, irritability, poor feeding, vomiting
Treatment
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Cool mist humidification, hydration (small amounts,
frequent intervals), ↑ HOB, O2
Severe – symptomatic hospital management
Lower Airway Disorders
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Bronchiolitis (RSV)
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Transmission
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Droplets or direct contact with secretions
Infectious before symptoms appear and for 1 – 3 weeks
Prevention
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Education of family and staff regarding careful and frequent
handwashing, good hygiene, disposal of tissues, cleaning
and disinfection of toys,
Lower Airway Disorders
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Pneumonia
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Affects
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Etiology
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All ages
Bacterial, viral or fungal
Seasonal Considerations
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May be more prevalent in fall/winter
Lower Airway Disorders
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Pneumonia
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Clinical Picture
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Acute onset fever, productive cough, pleural pain, rales, ↓
breath sounds. May see lethargy, vomiting, diarrhea, poor
feeding.
Treatment
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Viral – symptomatic
Bacterial – O2 therapy, CPT, antipyretics, fluids, cool mist,
antibiotics
Lower Airway Disorders
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Cystic Fibrosis
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Affects
All ages, diagnosis
made by sweat test
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Etiology
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Inherited genetic disease. Causes obstruction of and
abnormal secretions from sweat glands. Pulmonary
symptoms are caused by thick, tenacious mucous and
infection.
Lower Airway Disorders
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Cystic Fibrosis
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Seasonal Considerations
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Careful infection control, especially during cold and flu
season
Clinical Picture
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Half initially present with pulmonary symptoms – productive
cough
GI symptoms – rectal prolapse, malabsorption, can develop
diabetes, cirrhosis
GU symptoms – infertility
Lower Airway Disorders
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Cystic Fibrosis
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Treatment
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Pulmonary
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CPT, antibiotics, medications to decrease
viscosity of secretions, oxygen therapy,
hospitalization for IV antibiotics
Heart/lung transplant
GI
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Replacement of pancreatic enzymes, high
protein/high calorie diet
Question
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You are caring for a 6 month old infant. He has a 2 day history of
fever, cough and runny nose. The child is alert and active. His O2
mask is lying on the bed. Upon assessing the child you notice a
frequent barky cough, stridor, moderate retractions and crackles in
both lung bases. His skin is warm with good pulses and capillary
refill of 2 seconds. His HR is 170/min, respirations are 50. What
interventions should be initiated for this child?
Notify House Officer
Keep child calm
Notify Respiratory Therapy for treatment
Reassess, reassess, reassess!
Administer O2 via mask.
Question
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Because an infant’s tongue is large in proportion to their oral cavity,
it may be the cause of a blocked airway.
True or False?
True
Question
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An inspiratory sound usually due to an upper airway obstruction from
a narrowing or partial narrowing of the airway is called:
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Stridor
Wheezing
Crackles
Rhonchi
Stridor
Question
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You are caring for a 16 year old asthmatic. She calls you into the
room and says, “I can’t breathe”. Your assessment reveals an anxious
looking teen with pursed lips. She is pale. Respiratory rate is 36. She
has suprasternal retractions and looks distressed. You initial responses
should include:
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√
Apply O2
Have her call her mother on the phone to try and calm her down
Obtain pulse ox √
Offer her a drink of water
Assess breath sounds
√
Run for help
Question
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The child from the previous slide continues to deteriorate. Her
respiratory rate decreases to 8. She has severe retractions and no
wheezing. Your response now should include:
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√
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Call the ER for assistance
Call the Rapid Response Team or a Code Blue, begin ventilation
support
Ask your Nurse Manager for one-to-one care for this patient
Send the NA for a meal for this patient
References
Whaley/Wong, Nursing Care of Infants and Children.
Seventh Edition.
http://medlineplus.gov