The Child with Respiratory Dysfunction

1. The Child with Respiratory Dysfunction Chapter 23

2. General Aspects of Respiratory Infections • Upper respiratory tract • Nose, pharynx • Lower respiratory tract • Bronchi and bronchioles • Croup syndromes • Infections of epiglottis, larynx

3. Infectious Agents • Viruses • RSV • Others • Group A ß-hemolytic streptococcus • Staphylococci • Chlamydia trachomatis, mycoplasma, pneumococci • Haemophilus influenzae

4. Age • Infants <6 months: maternal antibodies • 3-6 months: infection rate increases • Toddler and preschool ages: high rate of viral infections • >5 yrs: increase in mycoplasma pneumonia and ß-strep infections • Increased immunity with age

5. Size • Diameter of airways • Distance between structures is shorter, allowing organisms to rapidly move down • Short eustachian tubes

6. Resistance • Immune system • Allergies, asthma • Cardiac anomalies • Cystic fibrosis • Day care

7. Seasonal Variations • Most common during winter and spring • Mycoplasmal infections more common in fall and winter • Asthmatic bronchitis more frequent in cold weather • RSV season considered winter and spring

8. Clinical Manifestations • Vary with age • Generalized signs and symptoms and local manifestations differ in young children • Fever • Anorexia, vomiting, diarrhea, abdominal pain • Cough, sore throat, nasal blockage or discharge, ear pain or nonverbal signs, halitosis • Adventitious lung sounds • “allergic salute”, nasal crease, “allergic shiners”

9. Nursing Care • Assessment—S/S, VS, heart and lungs, lymphadenopathy, skin color, inflamed mucous membranes, nasal d/c, sputum characteristics, S/S dehydration • Interventions—warm shower mist, cool mist vaporizer, quiet and rest, nose drops or spray, throat gargles, cold or warm compresses, reduce fever, handwashing, tissue isolation, covering moth and nose, staying away from others, FF, support nutrition, antibiotics prn

10. Tonsillitis (795) • Infection and inflammation of tonsils. Usually involved palatine and adenoids • May be viral or bacteria • Dx by throat culture because viral can look as bad as bacterial • Tx for viral is palliative, but bacterial (GABHS) is tx with PCN, unless allergic, then azithromycin. Repeated cases or sleep apnea warrant tonsillectomy

11. Tonsillectomy • MD may do just tonsils or may do T&A • Postop nursing care: • Observe for hemorrhage • HOB up • Routine VS • Ice collar • Non-red full liquids to soft bland diet • Antibiotics, analgesics • Home care p. 797

12. Otitis Media (OM) (797) • Infection of middle ear behind eardrum with inflammation of canal and eardrum • Purulent and fluid collection causes bulging and pain • Loss of light reflex and bony landmarks • Usually caused from dysfunctioning eustachian tube • Bacterial infection from strep, haemophilus, or moraxella is usually preceded by RSV or influenza

13. OM cont’d • Risk factors include • Family hx • Second-hand smoke • Day care or other crowded settings • Hx allergies • Bottle feeding in supine position

14. OM cont’d • Treatment includes • Antibiotic tx for all children < 6 months because of immature immunity • Antibiotic tx for all children < 2 years if fever and severe pain is present • “Watchful waiting” x 72h for all others • If antibiotics are used, amoxicillin 80-90 mg/kg x 10d • If allergic—azithromycin, cephalosporins

15. OM cont’d • For repeated and resistant cases, myringotomy with placement of tympanostomy tubes • Parental education includes • Causes of infection • S/S of infection • Prevention of recurrence • Med administration • Complications (meningitis, mastoiditis, hearing loss)

16. Croup Syndromes (800) • Characterized by hoarseness, “barking” cough, inspiratory stridor, and varying degrees of respiratory distress • Croup syndromes affect larynx, trachea, and bronchi • epiglottitis—life-threatening* • spasmodic laryngitis • laryngotracheobronchitis (LTB)—most common* • tracheitis

17. Acute Epiglottitis • Usually caused by Haemophilus. • Clinical manifestations include sore throat, pain, tripod positioning, drooling, protruding tongue, agitation, restlessness, retractions, inspiratory stridor, mild hypoxia, distress, can progress to airway obstruction (exam can cause obstruction) • Need aggressive antibiotic tx, IV fluids, steroids, and intubation equipment available • Prevention: Hib vaccine

18. Acute LTB • Primarily viral • Most common of the croup syndromes • Generally affects children <5 yrs • Organisms responsible • RSV, parainfluenza virus, Mycoplasma pneumoniae, influenza A and B

19. Manifestations 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 • Stages—p. 802. Stage 1 can be treated at home, but progression to stage 2 warrants medical intervention

20. Therapeutic Management • Airway management • Maintain hydration—PO or IV • High humidity with cool mist • Nebulizer treatments • Epinephrine • Steroids

21. Respiratory Syncytial Virus (RSV) (804) • Acute, highly contagious, viral infection causing 80% of cases of bronchiolitis • Causes inflammation, mucus production, edema, partial obstruction, and air trapping • S/S—Box 23-8 • CXR shows hyperinflation with consolidation • Dx by antibody detection from nasal washings

22. RSV cont’d • Most treated at home with high humidity, adequate fluid intake and rest • Hospitalization is recommended for child with • Chronic illness • Inadequate caregiver • Apnea • Marked retractions • Listlessness • Poor fluid intake

23. RSV cont’d • In-hospital treatment includes • Assessments, O2 sats, ABGs, oxygen therapy, IVF (po may be restricted due to fatigue) • Contact precautions with handwashing, gloves, gowns, masks, goggles. Need separate room and nurses not caring for hi-risk patients • Respiratory treatments with Ribavirin is controversial—toxic & teratogenic. Need special mask • Prevention with RSV immune globulin IV or palivizumab IM for children with CLD, heart defects,and preemies.

24. Asthma (813) • Chronic airway disorder characterized by inflammation, edema, spasm, and tenacious mucus production • Bronchial hyper-responsiveness to triggers in environment (Box 23-14) • Clinical manifestations—Box 23-15. Can progress to hypoxemia, respiratory acidosis, and respiratory failure.

25. Asthma Severity Classification in Children 5 yrs and Older • Step I: mild, intermittent asthma • Step II: mild, persistent asthma • Step III: moderate, persistent asthma • Step IV: severe, persistent asthma • Clinical features of each classification are found in Box 23-13

26. Asthma cont’d • Diagnostics include: • CXR—shows hyperinflation in acute episodes • PFT—shows decreased forced expiratory volume. • PEFR measures the maximum flow of air that can be forcefully exhaled in one second and is interpreted on p. 815 in Guidelines. Families use this as a way of assessing the child’s status on a daily basis. • Eosinophilia is usually present

27. Drug Therapy for Asthma • Long-term control meds—corticosteroids, bronchodilators (albuterol), mast cell stabilizers (Cromolyn), and leukotriene modifiers (block inflammation and bronchospasm) usually given by MDI or HHN • Quick relief meds—bronchodilators given by inhalation, orally, or IV (albuterol, Theophylline)

28. Asthma Interventions • Exercise—use of albuterol or cromolyn can prevent exercise induced asthma • Chest physiotherapy (CPT)—includes breathing exercises and physical training to help learn more effective breathing methods, stregthen respiratory muscles, and promote relaxation. • Hyposensitization—limited to those that cannot be controlled

29. Goals of Asthma Management • Avoid exacerbation • Avoid allergens—see p. 816 “Family Home Care” • Relieve asthmatic episodes promptly • Monitor function with peak flow meter—see p. 822 • Self-management of inhalers, devices, and activity regulation—see p. 822

30. Cystic Fibrosis (CF) (824) • Exocrine gland dysfunction that produces multi-system involvement • Most common lethal GENETIC illness among white children • Approximately 3% U.S. Caucasian population are symptom-free carriers. CF is inherited as autosomal recessive trait—child has to inherit defective gene from both parents to have disease

31. Pathophysiology of CF *Multisystem disease with most devastating effects on respiratory and GI systems • Mucous glands produce thick mucus which causes glands and their ducts to clog, enlarge, and harden, obstructing small passages in the pancreas and bronchioles

32. Diagnostics • Basis of the most reliable diagnostic procedure—sweat chloride test. Sodium and chloride will be 2-5 times greater than the controls • Parents say that child tastes “salty” • 72 hour fecal fat test • Liver functions • CXR, sputum cultures, PFTs • Meconium ileus may be first diagnostic clue • Many children are diagnosed by symptoms—poor growth, greasy stools, frequent respiratory infections. 50% by 6 mos; 90% by 8 yrs

33. Respiratory Manifestations • Present 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

34. Respiratory Manifestations (cont’d) • Decreased O2/CO2 exchange results in hypoxia, hypercapnea, acidosis • Respiratory infection spreads to bronchial tissues, weakening walls, and destroying bronchial epithelium. • Peribronchial fibrosis results • Compression of pulmonary blood vessels and progressive lung dysfunction lead to pulmonary hypertension, cor pulmonale, respiratory failure, and death

35. Infectious Pathogens • Pseudomonas aeruginosa • Burkholderia cepacia • Staphylococcus aureus • Haemophilus influenzae • Escherichia coli • Klebsiella pneumoniae

36. GI Tract • Thick 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

37. GI Tract (cont’d) • 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

38. Other Manifestations • Rectal prolapse • Excretion of undigested food in stool—increased bulk, frothy, and foul • Delayed puberty in females • Sterility in males • Dehydration • Hypoalbuminemia

39. Goals • Prevent/minimize pulmonary complications • Adequate nutrition for growth • Assist in adapting to chronic illness

40. Respiratory Management • CPT • Bronchodilator medication • Forced expiration thru mucus clearing device • Aggressive treatment of pulmonary infections • Home IV antibiotic therapy • Aerosolized antibiotics and D-Nase (decreases viscosity)

41. GI Management • Replacement of pancreatic enzymes will increase absorption of nutrients and decrease abnormal stools. • High protein high calorie diet as much as 150% RDA. More fat in diet requires more capsules • Salt supplementation • Tube feedings or TPN if FTT

42. Prognosis of CF • Estimated life expectancy for child born with CF in 2003 is 40-50 years • Maximize health potential • Nutrition and good skin care (thin) • Prevention/early aggressive treatment of infection • Pulmonary hygiene • New research—hope for the future • Gene therapy • Bilateral lung transplants • Improved pharmacologic agents

43. Family Support • Coping with emotional needs of child and family • Child requires treatments multiple times/ day • Frequent hospitalization • Implications of genetic transmission of disease