Respiration

Elisa A. Mancuso RNC, MS, FNS Professor of Nursing

•

Respiratory Alterations

↑ Risk < 3 years



Smaller upper and lower airways

 

Underdeveloped supporting cartilage



ineffective clearing of organisms Immature immune systems Compensatory Mechanisms

• Lungs-

↑ or ↓ RR

• Kidneys- retain or filter H+ affects pH

Blood buffer system: H+, HgB, Na Interact to maintain pH

Interpreting ABG’s

• Know your normal values!

• PH 7.35-7.45

< 7.35 = Acidosis > 7.45 = Alkalosis • PaCo2 35-45 < 35 = Alkalosis > 45 = Acidosis • HCO3 22-26 < 22 = Acidosis > 26 = Alkalosis PaO2 90-100% < 90 = Hypoxia

Respiratory or Metabolic?

ROME

Respiratory opposite (pH & CO2) Metabolic even (pH & HCO3)

Respiratory reflects PaCO2 ↓

CO2 = alkalosis

↑

CO2 = acidosis

Metabolic reflects HCO3 and BE ↓ ↑

HCO3 = acidosis HCO3 = alkalosis

Respiratory Alterations

•

Respiratory Acidosis

↓ PH and ↑ PaCO2

• Causes –

↓ RR

– Neuromuscular problems: BPD, RDS, CF • Respiratory depression and

↑ CO2 Respiratory Alkalosis

• • –

↑ PH and ↓ PaCO2

Causes

↑

RR

↑

Fever Stress

Metabolic Alterations

•

Metabolic Acidosis ↓ PH and ↓ HCO3

• Causes – Renal failure, diarrhea, ketoacidosis •

Metabolic Alkalosis ↑

–

High PH and Diuresis ↑ HCO3

• Causes – Vomiting, Meds for ulcers, NaHCO3, –

NGT = HCL loss & ↑ HCO3

Case Study

Mariska, 4 years old presents with following: RR = 54 C/O Chest tightness Bilateral expiratory & inspiratory wheezing Frightened appearance.

ABG pH of 7.27, PaO2 88, PaCO2 48 and HCO3 24. What is her acid – base status?

• Identify each component. •

Find the cause

•

Answer????

Upper Respiratory Infections URI

Acute pharyngitis and nasopharyngitis

• Children get 7-10 colds/year! • Majority is viral = Rhinovirus

Signs and symptoms

• low grade fever • sore throat • spontaneous recovery – Self limiting 7-10 days

URIs

Bacterial

• Group A beta-hemolytic strep (GABHS)

Signs and symptoms

• Abrupt onset • Fever >102, chills • Fatigue, HA • Nasal congestion • Abdominal pain & Anorexia • Vomiting, diarrhea •

Halitosis

• •

Fire red throat & petechiae Exudative

Treatment of Strep Pharyngitis

• Throat culture IN and OUT. – Rapid antigen detection test 60-95% sensitive. • Antibiotics

Prevents serious complication = Rheumatic fever PEN-VK BID-TID drug of choice x 10 days

• Amoxicillin

40-45mg/kg/day ÷ BID

–

↑ tasting and ↓ dosing needed

–

↑ better compliance!

• Zithromax – 5mg/kg day 2-5 • Cefdinir

10mg/kg/day 1 (Omnicef) 14 mg/kg/day

• Cefixine

(Suprax) 8mg/kg/day

Treatment (cont)

• Bed rest • Tylenol 10-15mg/kg every 4 hours – √ Infant vs. Child concentration! • Saline gtts and cool mist humidifier • Hydration • Decongestants > 6 months. • Contagious: Separate from others! – Need meds x 24 hours – Then return to school –

Feel better in 24-48 hours!

–

Must Complete all meds!

Tonsils

• • Lymphoid tissue in pharyngeal cavity • Filter and protect respiratory and GI tract

↑ Antibody formation

– until 3 years & immune system mature •

↑ ↑ size in children until puberty

• Inflamed with infections • If chronically enlarged 3+ – Obstructive Sleep Apnea (OSA) –

→ 4+ Difficulty breathing and eating

Tonsillitis

• Persistent cough • Dry mucous membranes • White patchy exudate • Secondary OM from blocked

Eustachian tubes

• Viral-

Self- limiting

•

Palliative measures

•

Pain & Hydration

Tonsillectomy

• • • • Most common indication today is OSA • 4 strep infections/season • Peri-tonsilar Abscess

Post-op care ↑

• (1

HOB with pt prone or on side

• Encourage fluids PO -No straws! • Medicate for pain (no ASA) and N/V • Ice pack to anterior neck

√ Hemorrhage (5-20%) Go to OR!

st 48 hours and then 5-7 days) ↑ ↑ swallowing/vomiting bright red blood ↑↑ RR ↑↑ HR Normal Eschar forms ↑↑ Restlessness

Epiglottitis

• Medical Emergency – –

↑ @ 3-6 years

• Haemophilus influenza type B (HIB) (50% pre-vaccination) – Dramatic

↓↓ since HIB vaccine

• Strep pneumoniae, staph aureous.

• Rapid & severe inflammation – of epiglottis and surrounding areas

Complete airway obstruction

Signs and symptoms

• Abrupt onset of sore throat • Fever 102-104 - toxic appearing • 4 D’s – Dysphonia (muffled voice) – Dysphagia (

↓ swallowing)

– Drooling – Distress/Dyspnea • Inspiratory stridor • Retractions

↑ RR ↑HR Pallor

• Tripod position

Thumb sign on soft tissue x-ray

Treatment

MEDICAL EMERGENCY

• Establish Airway • Respiratory Isolation! • Humidified O2 • Hydration

: ANESTHISIA STAT!!

• DO NOT INSPECT THROAT! • LIMIT UPSETING PROCEDURES! • Antibiotics

(Meningitic doses)

– Ampicillin 200-400 mg/kg/day ÷ q6H – Chloramphenicol 75-100mg/kg/day ÷ q6H • –

Steroids Methylprednisolone 2mg/kg/day ÷ q6H

Croup Laryngotracheobronchitis

• • Acute spasmodic laryngitis – Upper airway •

↑ 3 months to 5 years

– peak @ 2 years • Paroxysmal laryngeal edema – Attacks @ night • Parainfluenza virus or allergic reaction •

↑ in fall and winter months Precipitated with nasopharyngitis

Clinical signs

• Awakes suddenly with barking cough • Inspiratory stridor • Hoarseness • Restlessness • Anxious • Retractions, •

↑ ↓↓O Temp 101-102 2

• Stridor @ rest = severe croup • Duration few hours, Repeat x 2 nights • Symptoms improve with change in temp

Treatment

• Maintain airway • Position upright • Cool mist humidified O2 • Steam shower or expose to cold night air • Decadron 0.6mg/kg IM/PO x 1 dose • Racemic epinephrine 2.25% nebulizer • – for inspiratory stridor at rest • Induce vomiting = stops laryngospasm Hospitalize only when: – ↑ Stridor ↓ O2 ↓ LOC

Otitis Media (OM)

• Acute inflammation & effusion of middle ear • •

Common pathogens

• Strep pneumonia (50%) –

↓ incidence with Prevnar vaccine

• Haemophilus influenza (30%)-not type B! • Moraxella catarrhalis (20%) –

↑↑ incidence with resistance Viruses Food Allergies

Pathophysiology

Eustachian tube dysfunction

• < 5 years = shorter, wider and straighter • Acute – bacteria/purulent exudates •

Signs and symptoms ↑ ↑ Pain, ↑ ↑

• Tugging on ears • Fever >102

irritability

• Rhinorrhea, cough and congestion • Anorexia, vomiting and diarrhea • Tympanic membrane

Red & bulging Tympanogram No movement of TM Hearing loss

To treat or not treat?

AAP guidelines to ↓ resistant organisms

• < 6 months: – with S/S of illness

→ Treat!

• 6 mos -2 years: – certain diagnosis

→ Treat!

– Uncertain & no s/s of severe illness = Observe • > 2 years: –

certain diagnosis & no S/S of severe illness

–

Observation & Pain Relief AMERICAN ACADEMY OF PEDIATRICS, Guidelines for Acute Otitis Media, 2004

Treatments

• Amoxicillin • Augmentin • Ceclor 40-45mg/kg/day ÷ BID – Now recommending high dose: – 80mg/kg- 90mg/kg/day ÷ BID 40-45mg/kg/day BID for resistance to amoxicillin 40 mg/kg/day • Bactrim/Septra 8mg/kg/day • Rocephin for resistant OM’s Myringotomy Tubes Frequent infections Prolonged fluid

Bronchiolitis (RSV)

•

Disease of lower airways

• Respiratory syncytial virus (RSV) = common cause • Can be fatal in <2 months/premature • 90% of infants <1 year get RSV

↑ incidence winter/spring • ↑ Contagious via direct contact & inhalation

– Use alcohol based hand rubs.

Pathophysiology

• RSV affects epithelia cells of lungs • Bronchioles become edematous • Lumen filled with mucous - green thick exudate • Bronchioles infiltrated with inflammatory cells –

Air trapping

•

Severe cases mucous plugging & apnea= death

RSV Clinical signs

• Nasal Aspirate Culture = – (+) ELISA • enzyme-linked immunosuppressive assay – (+) RSV Ag • Peak @ 72 hours after onset

secretions or rapid fluorescent antibody

• Rhinorrhea with thick, tenacious, green •

 RR, retractions & cyanosis

• Coughing, wheezing • CXR – Hyperinflation (obstructive emphysema) – Atelectasis =

↓ Breath sounds (PN)

• Hypoxia

→ apnea and even death

Therapy

• Respiratory Isolation • Cool mist humidified O2 – √ O2 sats! >95% is nl • ↑ Hydration • Antibiotics for PN • Bronchodilators • Steroids • Severe Cases – Racemic epinephrine – Mechanical ventilation

Prophylactic Approach

• Respi Gam (RSV Immune Globulin) $600/vial • Synagis – – – (Monoclonal AB) 15 mg/kg IM Binds with RSV to ↓ infection. @ beginning of RSV season Oct - Nov total of 5 monthly doses; Need ↑ titers to be effective

Asthma

• Inflammation & Hyperactivity • Abrupt onset after URI or allergen • RAD= Reactive Airway Disease • 1 – Reversible bronchospasm • 8 million kids/year

st

attack usually @ 3-8 years

Pathophysiology

• Inflammation – Histamine release to allergen/trigger (stimulus). –

Edema→ Mucous Production → Bronchial Obstruction & Spasm

• Bronchoconstriction – Hyper-responsiveness of stimuli: • Allergens: – Cigarette smoke

Dust mites Exercise

– Cold air

Stress Drugs (ASA/NSAID)

• • – –

Urban factors: #1 Cockroach droppings Diesel fumes

Early & Subtle Clinical signs

• Irritable • Itchy • Tired • Dry mouth • Dark circle under eyes • Chronic cough worse @ night

Clinical Signs Older child

• SOB and Dyspnea • Expiratory wheeze bilaterally • Chest pain or tightness • Mild Intermittent • – <2 days/week

→ ↑ HR

• Spasmodic or tight cough @ night • Abdominal pain and nausea

Severe Persistent

–

Constant/daily

Warning signs

• Retractions

↑

RR and Hypoxia<92% (Admit to hospital)

• As symptoms progress

→

– Expiratory & Inspiratory wheeze •

↑

HR

• Breathlessness • Anxious & Restless • Absent breath sounds –

No air movement

–

Respiratory arrest!

Status Asthmaticus

• Limited or no response to therapy • Respiratory distress

→ arrest

• ICU – IV Hydration & Intubation • Medications: – Steroids – Magnesium Sulfate IV –

Bronchodilators Nebulizer RX

–

Antibiotics

Diagnostic Tests

• Allergy testing- – 4-8% have a food allergy • Pulmonary Function Test (PFT) – Forced exhalation – √ before and after neb – Reliable when • age > 5 years • good effort

Peak Expiratory Flow Rate (PEFR)

• Assess asymptomatic lung changes

and function.

• Based on child’s height

Ex: 47”=PEFR=200

• Peak flow zones – Visual =

↑ manage

– Early interventions – Maintain control

Asthma Therapy

The National Asthma Education and Prevention Program (NAEPP) 2002

4 components of asthma management:

• Measures of assessment and monitoring • Control factors that contribute to severity • Education for a partnership in asthma •

Pharmacologic therapy

Bronchodilators “Rescue meds”

Inhaled Beta 2 Agonists Albuterol (Proventil,Ventolin) 0.15-5 mg/kg/dose Levalbuterol (Zopenex) > 6 years 0.31mg/kg/dose SE = Tremors ↑ HR Hyperactivity Bronchospasm = Overdose!

• Anticholinergic

Ipratropium (Atrovent) MDI 1-2 puffs q6-8H SE = Dizzyness HA Cough ↓ BP

• Methylzanthines

Theophylline (PO) Aminophylline (IV) √ serum levels (10-20) SE = ↑ HR Arrhythmias Systemic B2 agonists SC Epinephrine 1:1000=bronchodilation x 3doses Caution CARDIAC DOSE 1:10,000 SE = ↑ BP ↑ HR Tremors Terbutaline (Brethine) SQ/IV SE = Restlessness cardiac arrthymias Stops pre-term labor

Anti-Inflammatory meds

Systemic Corticosteroids

• onset - 3 H

Peaks in 6-12 H

• Loading dose 2mg/kg and taper slowly • No need to taper if short term use

Short-Acting (use 5-7 days ↓ SE)

• Hydrocortisone (Solu-Cortef) 0.25-2 mg/kg/day • Methylprednisolone (Solu-Medrol) 1-2 mg/kg/dose • Prednisone PO 1-2 mg/kg/dose • Prednisolone (Orapred, Pediapred) PO 1-2 mg/kg • Dexamethasone (Decadron) 0.6-1.5 mg/kg/day •

SE = Hyperglycemia GI distress ↓ Growth Cushing Syndrome = ↑ Wt. ↑ Infection Mood Lability

Controller Meds

Inhaled corticosteroids-

• Budesonide (Pulmicort) 2-4 puffs tid • Fluticasone (Flovent) • Triamcinolone (Azmacort, Kenalog) • Advair discus

Not rescue drug

– Synergistic effect with B2agonists – SE = Oral & pharyngeal irritation

Non-steroidals-

• Cromolyn Na (Intal) – Stabilizes mast cells & prevents attack. • Leukotriene Receptor Antagonists-(LRA) – Leukotrienes cause inflammation (capillary permeability) – Use at night when leukotrienes are highest. – Montelukast (Singulair) 5-10 mg PO/day –

Zafirlukast (Accolate) 10-20 mg PO/day

–

Zileuton (Zyflo) 300-600 mg PO/day SE = HA Vasculitis Flu like symptoms

Other Treatments

•

↑ Fluids

– Dilute mucous & mobilize secretions • May need allergy shots • Zyrtec or Clarinex

= ↓ allergy symptoms. Singulair

–

now indicated for allergy use as well as asthma maintenance

• Nasal Lavage • Treat cold symptoms>7-10 days – 60-80% pt with allergic asthma have

sinusitis

• •

Parent Teaching

• Remove allergens – Identify precipitating factors –

↓ Rugs, heavy drapes, pets, foods (eggs, milk)

– Mattress & pillow covers • Dehumidifier - AC • Review – Signs/symptoms of asthma – PEAK Flow daily – Meds SE & toxicity – Nebulizer use

↓ Antihistamines

–

May exacerbate wheezing Swimming = Best Exercise

Cystic Fibrosis

Dysfunction of exocrine glands

– –

↑↑ ↑↑ Na++

• CC • Cf

= ↑ Cl- in sweat & saliva

– (2- 5x normal levels)

Viscosity of secretions

– GI & Pulmonary systems

Autosommial Recessive

– 1/25 whites carry gene. • Chromosome # 7

Healthy = Carrier

• ff = Disease

Mom Dad → C f ↓ C CC Cf

• •

25% risk = healthy / disease 50% risk = carrier f Cf ff

Pathophysiology

Pulmonary

•

↑ Leukocyte DNA in sputum

– Long, thick strands •

↑↑ Thick mucous (yellow/grey)

•

↓↓ Diffusion of gases → ↓ O2 hypoxia ↑ CO2

•

↑↑

• Obstruction = – Fibrotic and stiff lobes –

↓ Respiratory distress & Pseudomonas PN compliancy & ↓ function

Pancreas

• Thick secretions block ducts • Fibrosis =

↓↓ pancreatic enzymes

• Malabsorption Syndrome – Only 50% of food is absorbed – Inability to digest & absorb proteins & fats – “

Steatorrhea ” foul smelling bulky stools

–

↓↓ fat soluble vitamins A,D,E and K.

• Bile ducts – Occluded: biliary cirrhosis & portal

↑ BP

Hallmark – CF Signs

• Meconium Ileus (newborn) – No mec passed in 1

st 24 hours

– Abdominal distention – 10-15% &

1 st sign of CF

• Skin - “Infant tastes salty” – Sweat Test (Pilocarpine Ionophoresis) – > 1 month old –

Cl> 60 mEq = (+) CF

Respiratory Signs

• Frequent sinus & respiratory infections. • Bronchitis & PN • Recurrent pneumothorax • SOB, wheezing, hemoptysis • Dyspnea, Hypoxemia • Barrel shaped chest – AP>lateral • Clubbed fingers

Gastrointestinal Signs

• Steatorrhea – Excretion of undigested fats and proteins – Bulky, frothy, foul smelling stool • Abdominal Distension – 3

rd spacing & edema RT ↓↓ protein & albumin

• Prolapsed rectum • Voracious appetite – only 50% of food absorbed • Failure to thrive

RT starving

–

↓↓ drop on growth chart 10-25% = short stature

Diagnosis

• Genetic testing – DNA analysis: Chromosome # 7 – Prenatal screen (

↑↑ mutations exist)

– F508 mutation in 70% of pt with CF • Sweat Test – Cl>60meq strongly suggests CF • Stool specimen – 5 day collection √ fat content • Duodenal Enzymes –

↓↓ trypsin and chymotrypsin

–

(absent in 80% of CF pt’s)

– Immunoreactive Trypsin Test • >140 = CF (+)

Therapy

• Goals –

↑ Life Expectancy > 30

–

↑

–

↓ Quality of life Sequella of CF

• Nutrition – –

↑ ↑ protein ↑ calories and moderate fat

– Need 150% of daily requirements to replace losses

Na intake in hot weather

• Medications

Pancrelipase (Pancrease, Pancrease MT4) PO

–

(10,000u lipase/36,000u protease & amylase)

– – –

Enteric coated & must give before all meals!

↑ digestion of fats, proteins and carbs. SE: diarrhea and abdominal cramping

Therapy

• Supplements – Fat Soluble Vitamins • A, D, E & K (2x dose) – H2O Soluble Vitamins • C, B, B2, B6 (B-C complex) • Niacin, B12, Folic Acid • Pulmonary – 1 – Nebulizer treatments then PD & C. –

st Assess breath sounds and O2!

CPT x 15-20 minutes in trendelenburg.

– Vibrate all lung fields =mobilize secretions

Inhalation Therapy

• Dornase Alfa-Pulmozyme – Recombinant DNAse 2.5 mg – Breaks down DNA in sputum – –

↓↓ viscosity of sputum

– SE- laryngitis – Administer via neb before PD&C • Proventil • Thoracic expansion exercises

Stretching & Breathing

–

Swimming ( ↑ mobility)

Family Support

• Educate – Disease process and S/S of illness – Meds and diet • Pulmonary care ATC – Need

↑ support group to assist q 3-4 H

– Breathing exercises – Antibiotics only for documented infections! • Encourage verbalization of fears – Numerous Hospitalizations – Invasive Procedures (CT) lung transplants – Anticipatory Grieving -Fatal Illness – Support group • •

CF Foundation www.cff.org

www.cysticfibrosis.com

Foreign Body Aspiration

•

↑ R isk @ 1-3 years of age

– Developmental stage

↑ curious and

– hand–to-mouth or nose – 4 • Food

th cause of accidental death < 5 years

– Acute and dramatic onset

Common Objects

• Small toys • Buttons • Paper clips • Batteries (Acid leaks = chemical PN)

↑

– –

in size as absorbs H2O ↑ Edema = ↑ Obstruction Hotdogs Grapes Nuts Seeds

Clinical Signs

Laryngeal

• Choking & Coughing • Aphonia = No cry or speaking • Rapid color change

→ blue

• Inspiratory stridor •

↓ O2 → Change in LOC → Collapse/Unconscious Bronchial # 1 site = R main stem bronchus

• Wheezing

Lung

• Persistent respiratory infections – Cough & congestion –

Purulent secretions

• –

Foul smelling breath Acute or chronic pulmonary lesions

Interventions

• Immediate Intervention (Death in 4 mins!) • CPR – Obstructed Airway – Infants • alternate 5 back blows with 5 chest thrusts – Kids >1 year • Heimlich • CXR – Identify object & location • Bronchoscopy – Removal of object ASAP!

• Post removal – Humidity – – • Steroids ↓ Edema & ↓ inflammation Antibiotics

Pneumonia

• Classified according to agent or location: – Viral (RSV) most common – Bacterial (strep pneumoniae, pseudomonas) – Fungal (candida) – Chemical/Aspiration (Oil, lotion, cleaners)

Pathophysiology

• Inflammation of lung parenchyma • Consolidation - aveoli fill with exudate • Bronchial Obstruction –

RT ↑ restriction of lung

–

↓ Impaired gas exchange ↓ O2 & ↑ CO2

Primary Atypical Pneumonia Mycoplasma pneumoniae

• • Most common pathogen in older

children 5-12 years of age

↑

incidence in Fall and Winter

•

↑

–

Highly populated areas

• Diagnosis: – CBC & Differential – BC or Tracheal aspirate

CXR

–

ELISA test

•

Clinical signs

• Sudden or gradual onset – could be a 7-10 day duration of symptoms • Fever - low grade • Chest pain • Flushed cheeks with generalized pallor • Hacking cough • Pharyngitis • Coarse Crackles or rhonchi • •

↓ Breath sounds with dullness (consolidation)

• Hypoxemia

Anorexia Malaise

Therapy

• • O2 √ Pulse oximeter

↑↑ Hydration PO/IV

• Humidity • CPT – Blow Bubbles •

↑↑ HOB & Rest Medications

• Azithromycin (Z-Pack)

(10 mg/kg day 1 then 5 mg/kg day 2-5)

• Erythromycin –

30-50 mg/kg/day PO/IV ÷ q 6-8 x 14 -21 days No IM causes tissue necrosis!

• Acetaminophen (Tylenol)

10-15 mg/kg/dose √ (infant vs. children)

• –

↓ Pain & Fever Expectorants only No cough suppressant!

Bacterial Pneumonia

•

↑ R isk @ birth-5 years

• Strep pneumoniae (90%)

Clinical signs/symptoms

• Abrupt onset

after viral illness - URI

• High fever 104-105 • Retractions, tachypnea, hypoxia • Rales/rhonchi • Chest Pain with deep inhalation – Pleural effusion

→ Shallow respirations & ↑ CO2

• –

↓↓ immune system

–

Abdominal pain Lower lobe infiltrate

Therapy

• Similar to Mycoplasma • Maintain patent airway! • Isolate with same pt if hospitalized • Lying on affected side

↓ pleural rub/pain

• CT for thoracentesis

Medications

• Antibiotics- appropriate drug for the bug! – High dose

Amoxicillin or Augmentin (40mg/kg/day PO)

– Ceftriaxone (Rocephin)

(50-75 mg/kg/day)

– – •

↑ WBC or based on S/S Cefotaxime (Claforan) Ceftiazidine (Fortaz) 100-200 mg/kg/day 150 mg/kg/day

• Tylenol • Expectorants