Alteration in Respiratory Function

1. Alteration in Respiratory Function Jan Bazner-Chandler RN, MSN, CNS, CPNP

2. Allergic Rhinitis

3. Assessment • Itching of nose, eyes, and throat • Sneezing and stuffiness • Watery nasal discharge / post nasal drip • Watery eyes • Swelling around the eyes

4. Assessment Allergic Shiner Allergic Salute eMedicine.com

5. Rhinitis Interdisciplinary Interventions • Avoid offending allergen – smoke / pets • Pharmacologic management: • Oral or nasal antihistamines - Benadryl • Leukotriene modifiers - Singulair • Mast cell stabilizers – cromylin – nasal / ophthalmic / inhaled • Allergen-specific immunotherapy • Do not use combination OTC medications especially those that contain pseudoephedrine • No OTC Antihistamines for children under 6 years of age.

6. Sinusitis Adam.com

7. Assessment • Fever • Purulent rhinorrhea • Nasal congestion • Pain in facial area • Malodorous breath • Chronic night-time cough Children more prone to sinusitis: children with asthma and cystic fibrosis.

8. Interdisciplinary Interventions • Normal saline nose drops • Warm pack to face • Acetaminophen for pain • Increase po fluid intake • Antibiotics • Recent studies question their effectiveness

9. Tonsillitis • Tonsils and adenoids are important to the normal development of the body’s immune system. • Serve as part of the body’s defense against infection • Can become the site of acute or chronic infection • Repeated acute infections cause the tonsil tissue to swell • Enlarged tonsils and adenoids impinge on the pharyngeal opening of the eustachian tube

10. Assessment • Child may refuse to drink • Fever • Reddened pharynx and tonsils • Most common causative agent = group A beta-hemolytic stretococci • Chronic tonsillitis may result in snoring due to enlarged tonsils and adenoids

11. Tonsilitis “Kissing tonsils” occur when the tonsils are so enlarged they touch each other.

12. Interdisciplinary Interventions • Throat culture to determine causative agent • Antibiotics for ten days if throat culture positive for beta strep • Acetaminophen for pain • Cool fluids • Saline gargles • Antiseptic sprays • Viral throat infections will not get better faster with antibiotics.

13. Tonsillectomy • Done if child’s respiratory status is compromised • Post operative care: • Side lying position • Ice collar • Watch for swallowing • Cool fluids / soft diet

14. Croup • Most common acute respiratory condition seen in early childhood. • Highest incidence from 6 months to about 3 years • Respiratory symptoms are caused by inflammation of the larynx and upper airway, with resultant narrowing of the airway. • Severity depends on the area of the upper airway that is inflamed and narrowed. • Most often viral – antibiotics are not needed

16. Assessment • Symptoms: • Hoarseness • Inspiratory stridor • Barking cough • Afebrile • Often worsens at night

17. Interdisciplinary Interventions • Home care: • Cool mist • Fluids • Hospital care: • Racemic epinephrine inhalant • Mist tent – not used much anymore • Dexamethasone • IV fluids if not taking po fluids

18. Epiglottitis Bowden & Greenberg Tripod position

19. Acute Epiglottitis • Acute inflammation of supraglottic structures, the epiglottis and aryepiglottic folds. • True pediatric emergency • Delayed treatment may result in complete airway obstruction • Most often seen in children 2 to 7 years • Most common causative agent – H. influenzae type B

20. Assessment • Sudden onset • High fever – 102.2 or greater • Dysphasia and drooling • Agitation, irritability and restlessness • Epiglottis is cherry red and swollen • Note: Do not look into the mouth – diagnosis often made by presenting symptoms or lateral neck x-ray

21. Interdisciplinary Interventions • Keep child quiet in a controlled medical environment with emergency airway equipment readily available. • Do not put tongue blade in mouth to look in the throat – may cause epiglottis to spasm and shut • Assess respiratory status • Give humidified oxygen by mask and keep HOB elevated. • Mild sedation may help the child relax

22. Apnea • Apnea is cessation of respirations lasting longer than 20 seconds. • Monitor in hospital for underlying problems • Discharge home with monitor

23. Foreign Body • Severe inspiratory stridor • Symptoms depend on location • Unilateral chest movement • Chest x-ray • Bronchoscope to remove object

24. Coin in Trachea

25. Teaching • No small hard candies, raisins, popcorn or nuts until age 3 or 4 years • Cut food into small pieces • No running, jumping, or talking with food in mouth • Inspect toys for small parts • Keep coins, earring, balloons out of reach

26. Influenza • Associated with community epidemic • Febrile, URI, achy joints • Management: • Acetaminophen for fever • Fluids • Keep away from others • Watch for signs of pneumonia • Hypoxia, high fever, increase work of breathing

27. Bronchiolitis • Acute obstruction and inflammation of the bronchioles. • Most common causative agent: Respiratory Syncytial Virus (RSV) • Bronchioles become narrowed or occluded as a result of inflammatory process, edema, mucus and cellular debris clog alveoli

29. Assessment • Harsh dry cough • Low grade fever • Feeding difficulties • Wheezing • Respiratory distress with apnea • Thick mucus

30. Interdisciplinary Interventions • Oxygen to maintain oxygen saturation >than 95% • Pulse oximeter • Nasal suction as needed • Chest percussion to mobilize secretions • Inhalation therapy – not sure if it is beneficial • Mechanical ventilation as needed if increased work of breathing is seen • Increased heart rate, poor peripheral perfusion, apnea, bradycardia and hypercarbia

31. RSV Positive - Isolation • Respiratory Syncytial Virus is spread from respiratory secretions through close contact with infected persons or contact with contaminated surfaces or objects. • Hospitalized patients should be on contact and respiratory isolation • Can be placed with other RSV + patients • Family members: use hand washing to decrease spread

32. Pneumonia • An inflammatory condition of the lungs in which alveoli fill with fluid or blood resulting in poor oxygenation and air exchange. • Can be primary illness or develop as a complication of another illness. • Incidence: 34 to 40 cases per 1000 children younger than 5 years • Most likely to develop when the body is unable to defend against infectious agents.

34. Typical X-ray

35. Assessment • High fever • Thick green, yellow, or blood tinged secretions • Grunting respirations • Rales, crackles, diminished breath sounds • Cough and cyanosis • Increased work of breathing • Hypoxia: oxygen saturations less than 92 % on room air • Diagnostic tests: Infiltrate seen on x-ray

36. Interdisciplinary Interventions • Assess for respiratory distress • NPO (respiratory rate > 60 = high risk for aspiration) • IV fluids for hydration • Supplemental Oxygen to keep oxygen saturation equal to or > 92% • Chest percussion • Nasal suctioning as needed • Acetaminophen for fever • Antibiotics – Ceftriaxone (3rd generation cephaloporin)

37. Pneumonia Isolation • Respiratory isolation • May be taken off isolation if RSV negative and on antibiotics for 24 hours.

38. Cystic Fibrosis • Inherited autosomal recessive disorder of the exocrine glands • Gene responsible for CF is located on chromosome 7 • Life span is about 37 years • Complex disease requiring a holistic approach

39. CFTR Gene • Mutation of the CFTR gene disrupts the function of the chloride channels, preventing them from regulating the flow of chloride ions and water across cell membranes. As a result cells that line the passage ways of the lungs, pancreas and other organs produce mucus that is thick and sticky

40. Cystic Fibrosis

41. Cystic Fibrosis

42. Assessment • History of Meconium ileus at birth • Foul smelling, greasy, bulky stools / constipation • Voracious appetite with poor weight gain • Recurrent respiratory infections • Persistent chronic cough • Salty tasting skin

43. Diagnosis • Positive sweat test – Gold standard • Genetic marker

44. Medications • Pancreatic enzymes to help digest food • Inhaled antibiotics – antimicrobial for lung treatment • Aerosol bronchodilators to open airways • Mucolytic enzyme – to thin mucus • H2 blocker – alters gastrointestinal acidic environment • Tagamet • Prokinetic agents – enhances gastrointestinal motility • Reglan • Vitamin C to improve absorption of other meds • Vitamins E, A, D, K / fat soluble vitamins • Oral and IV antibiotics – S. aureus, H. influenzae, P aeruginosa

45. Long Term Complications • Nasal polyps • Sinusitis • Rectal polyps / rectal prolapse • Hyperglycemia / diabetes • Infertility - male

46. Asthma • Asthma is a chronic, inflammatory lung disease involving recurrent breathing problems. • Third leading cause of hospitalization among children younger than 15 years. • Most common, chronic health problem in children

47. Pathophysiology • Reversible changes in airway that lead to bronchoconstriction, airway hyper-responsiveness and airway edema. • At the cellular level mast cells release histamine causing smooth muscle contraction and bronchoconstriction. • Increased mucous secretion by goblet cells causes epithelial damage • Increased mucus secretion results in airway edema, mucus hypersecretion and plugging, airway narrowing, leading to airway obstruction

48. Assessment • Wheezing • Cough • Tightness of chest • Prolonged expiratory phase

49. Assessment • Hypoxemia – universal in child with moderate to severe symptoms • Hypercarbia – carbon dioxide retention from air trapping in the alveoli and ventilation – perfusion mismatch • Monitor blood gases – PaCO2 level more than 50 mm Hg indicated ventilatory failure • Diagnostics: chest x-ray = hyper-expansion of lungs

50. Asthma Attack