Transcript Document 7155020
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