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• Health promotion, restoration, and maintenance of the family: Eye, ear, and respiratory dysfunction.

Anatomy and Physiology Review

• Upper respiratory tract diseases include croup/epiglottitis, nasopharyngitis, pharyngitis, tonsillitis, and otitis media
• Lower respiratory tract diseases include asthma, cystic fibrosis, respiratory syncytial virus, as well as croup/epiglottitis.

Trachea: Adult versus Infant

• 1 mm of circumferential edema causes a 50% reduction of the diameter and radius of an infant's trachea, increasing pulmonary resistance by a factor of 16.
• 1 mm of circumferential edema causes a 20% reduction of the diameter and radius of an adult's trachea, increasing pulmonary resistance by a factor of 2.4.

Respiratory Illnesses in Children

• Most acute illnesses in children are caused by respiratory conditions.
• Children are at a higher risk due to age, low income, and chronic disorders.
• Seasonal factors include higher incidence of viruses in winter, and allergens in spring and fall.
• Late recognition of the severity of illness in children is also a risk factor

Respiratory Assessment

• Inspection and observation can determine if the patient looks sick or not sick
• Assess skin color (pale, circumoral vs central cyanosis), behavior (alert, playing, anxious), and vital signs (tachypnea, retractions, tachycardia, fever, SaO2)
• Assess the nose for obstruction, nasal flaring a discharge (amount, color, viscosity, odor)
• Inspect the conjunctivae for discharge, redness, eye rubbing, presence of tears.
• Inspect the ears for otitis media signs such as ear pulling, headache, lethargy, discharge, mastoid tenderness, and enlarged cervical lymph nodes.
• Inspect the oral cavity, paying attention to the tonsils and pharynx (swelling, redness, white areas), uvula, oropharynx, mucous membranes, bubbles/saliva, and halitosis.
• Assess the type of cough (productive, non-productive, barky), grunting, stridor, and audible wheezes.
• Assess the chest by its size, shape, depth, quality, symmetry of movement bilaterally, pain, and work of breathing.
• Assess WOB by the respiratory rate and presence of retractions (suprasternal, supraclavicular, intercostal, substernal, subcostal), paradoxical (seesaw) breathing, nasal flaring, and head bobbing.

Lung Sounds

• Stridor presents as a high-pitched whistling sound during inspiration and is associated with airway obstruction from a foreign body, mechanical issues, abscess, tumor, tracheomalacia, and edema.
• Rales/crackles involve soft, fine crackles (↑ pitched) or loud, coarse crackles (↓ pitched), and are related to pneumonia, fibrosis, and CHF.
• Wheezes are ↑ pitched musical whistling sounds usually associated with asthma, COPD, bronchiolitis, or CF.
• Rhonchi has ↓ pitched, snoring quality and are associated with secretions in the large airways.
• A prolonged expiratory phase is associated with bronchiolitis, asthma, pulmonary edema, and foreign body aspiration (FBA).

Nursing Interventions

• A focused respiratory status assessment should be made before and after treatments and interventions
• This includes assessment of work of breathing (respiratory effort), lung sounds, oxygenation saturation levels, vital signs and trends.
• Administer prescribed medications and assess the response
• Monitor the child's behavior, especially pain and activity level
• Administer pulmonary toilet procedure: Suction nares & oral cavity, CPT, position with the head of bed ↑
• A focused assessment of hydration and nutrition status should be made
• Monitor intake and output, and assess PO intake and nutrition
• Teach patients and family members hand hygiene practices to prevent illness
• Explain the disease process and treatment being undertaken

Asthma

• Defined as a chronic inflammatory disorder of the lower airway, considered the "reactive" portion of the lower respiratory tract, including both bronchi and bronchioles
• It is the most common chronic childhood illness, that is episodic and has triggers.
• Airflow can be limited or obstructed, reversing spontaneously or with treatment.
• Acute complications include status asthmaticus and respiratory failure.
• Etiology can be influenced by genetic predisposition, air pollution, allergens, and viral infections.

Asthma Pathophysiology

• Airway hyperresponsiveness-bronchospasm: severe, producing impaired respiratory function caused by spasmodic smooth muscle contraction in response to an irritant, causing airway edema to develop.
• Airway edema - bronchoconstriction: decreases the diameter of bronchi/bronchioles, increasing resistance that leads to air trapping, which makes it difficult to inspire/expire sufficient air. Respiratory difficulty is more pronounced in the expiratory phase.
• Mucus production: tenacious secretions from mucous glands cause airways to plug and X-ray findings show hyperinflation

Asthma Diagnostic Evaluation

• Diagnosis is made based on subjective and objective signs and symptoms
• Includes H&P, presence of dyspnea, chronic cough in the absence of infection, and wheezing during the expiratory phase of respiration.
• Pulmonary function tests (PFT's) and peak expiratory flow meter (PEFM) readings are also important.
• An X-ray may show infiltrates and hyperinflation of airways.
• A physical exam may reveal an increased anteroposterior diameter (barrel chest).
• Skin testing for allergens and pulse oximetry readings can be helpful
• Arterial blood gas tests may show carbon dioxide retention leading to respiratory acidosis and hypoxia

Clinical Manifestations of Asthma

• Hacking, nonproductive to productive cough
• SOB, prolonged expiratory phase, audible wheeze, may not be able to speak in full sentences, chest tightness or pain
• Inspiratory and expiratory wheezes throughout lung fields are also manifestations of asthma.
• Note the specific lobes where wheezing is heard and if air movement is present in all lobes.
• Increased WOB: accessory muscle use, tachypnea, and tachycardia.

Therapeutic Management of Asthma

• Prevention
• Bronchodilators (adrenergics, anticholinergics, xanthines)
• Long term maintenance medications (corticosteroids, leukotrienes, mast cell stabilizers, combination meds)

Asthma Exacerbation Prevention

• Exercise is important
• May need quick acting medications for prophylactic treatment to prevent exercise-induced bronchospasm
• Consistent use of maintenance treatment, with regular follow up with a provider (LIP)
• Hyposensitization to allergens with weekly to monthly injections, for a minimum of 3 years.
• Prognosis: asthma can continue into adulthood, and is rarely deadly but can cause hypertension and CHF if untreated, adolescents are more vulnerable.

Bronchodilators: Quick Acting Medications

• Short-acting B₂- adrenergic agonists, such as albuterol, epinephrine, metaproterenol, and terbutaline, are rescue medications to use for quick relief for acute asthma symptoms and exacerbations.
• These are available as metered dose inhalers (MDI), inhalation nebulizers, or can be administered orally, Sub-Q, or IV.
• Action: binds to beta-2 receptors to relax smooth muscle in the airway which can cause S/E: cardiac and CNS stimulation

Bronchodilators: Anticholinergics

• Ipratropium bromide and tiotropium are used for long term asthma management and/or combined with a rescue med (albuterol). They are ineffective by themselves for acute bronchospasm.
• Action: inhibits bronchoconstriction and mucus production
• Can cause side effects such as cough, nervousness, nausea, GI upset, dry mouth, constipation, headache, and dizziness.

Bronchodilators: Xanthines

• Theophylline (aminophylline) is classified as a long-term treatment for asthma, but is a second line drug due to its narrow therapeutic range of 5-15 mcg/ml.
• Action: relaxes bronchial smooth muscle promoting bronchodilation
• Common side effects are N/V, agitation, tachycardia, and seizures. Quickly becomes toxic outside of therapeutic range.

Long-Term Maintenance Medications: Corticosteroids

• Beclomethasone (Beconase), fluticasone aerosol (Flovent), budesonide (Pulmocort Turbuhaler), prednisolone (Prelone), methylprednisolone (Solu-Medrol), triamcinolone acetonide (Azamacort), and prednisone are types of corticosteroids.
• Use: prophylactic management of asthma and chronic asthma
• Are available as MDI, inhalation neb, PO, and IV.
• S/E in children: long term use can cause = decreased adrenal function, which must be weaned and needs lowest dose to control symptoms, can cause decreased growth and bone mass, and oral fungal infection.
• Action: decreases edema, increasing effectiveness of B₂-adrenergic medications.

Long-Term Maintenance Medications: Leukotriene Modifiers

• Montelukast (Singulair)
• Use: Prevention and chronic treatment of asthma, allergic rhinitis, exercise-induced bronchoconstriction.
• Route : PO
• Action: leukotriene receptor antagonist, decreases the inflammatory process
• S/E: headache, nausea, diarrhea, infection.

Long-Term Maintenance Medications: Mast Cell Stabilizers

• Cromolyn (NasalCrom)
• Use: mild, persistent asthma, exercise-induced asthma
• Preparation: MDI or inhalation neb for asthma, PO route for allergic rhinitis
• Action: prevents release of histamine, decreases inflammation and bronchoconstriction.
• S/E: cough, nausea, nasal and throat irritation
• Goal: Reduce dosage of bronchodilators and steroids

Long-Term Preventive/Maintenance Medications: Combo Meds

• Combination medications (bronchodilator and inhaled steroid) includes fluticasone/salmeterol (Advair), budesonide/formoterol (Symbicort), and ipratropium/albuterol (Combivent, DuoNeb).
• Preparation: MDI and inhalation neb
• Goal: smaller doses of each class of drug can be given

Status Asthmaticus

• Defined as a condition when respiratory distress continues despite vigorous therapeutic measures,
• Is a medical emergency that can result in respiratory failure and death if untreated
• Concurrent infection can be a factor

Goals of Asthma Management

• Avoid exacerbations and allergies/triggers
• Relieve asthmatic episodes and bronchospasm promptly
• Monitor respiratory function with a peak expiratory flow meter
• Prevent sick visits and decrease hospitalizations, and school absences
• Proper self-management of inhalers and equipment
• Education and follow up is critical

Cystic Fibrosis

• To understand this, reference the Cystic Fibrosis Foundation videos: "How CF Affects the Body."

General Pathophysiology of Cystic Fibrosis (CF)

• CF is the most common inherited genetic disorder that affects Caucasians.
• It is inherited as an autosomal recessive trait.
• If both parents have the defective gene:
  • There is a 25% chance (1 in 4) the child will have CF.
  • There is a 50% chance (1 in 2) the child will be a carrier.
  • There is a 25% chance (1 in 4) the child will not be a carrier.
• Exocrine gland dysfunction causes the production of a thick mucoprotein, resulting in the mechanical obstruction of the mucus secreting glands and dilated ducts in multiple systems.
• Chloride secretion is decreased and sodium absorption is increased, decreasing water flow across cells.

Diagnostic Evaluation of Cystic Fibrosis (CF)

• Family history
• In utero dx can be made by examining DNA for CF genes.
• Universal newborn screening.
• Barium enema to dx meconium ileus in infants
• The sweat chloride test is the most a reliable diagnostic procedure.

  • 60 mEq/L is diagnostic

• Stool fat or enzyme analysis
• X-ray = atelectasis & obstructive emphysema as the disease progresses

Symptoms of Cystic Fibrosis (CF)

• Respiratory Symptoms: persistent cough with productive thick mucus, wheezing & shortness of breath, frequent chest infections, sinusitis, nasal polyps
• Digestive Symptoms: bowel disturbances, weight loss, obstruction, constipation
• Other symptoms: osteoporosis, arthritis
• Reproductive Problems: 95% of men & 20% of women are infertile

Treatment for Cystic Fibrosis

• Therapeutic management of cystic fibrosis aims to minimize pulmonary complications, maximize lung function, and prevent infection so to facilitate growth.
• Chest physiotherapy (CPT) with postural drainage to mobilize secretions from the lungs
• Recombinant human DNase (Pulmozyme) via nebulizer to decrease sputum viscosity and help clear secretions
• Inhaled bronchodilators and anti-inflammatory agents
• Pancreatic enzymes and supplemental fat-soluble vitamins to promote adequate digestion/absorption of nutrients and optimize nutritional status
• Increased-calorie, high-protein diets
• A lung transplant may be an option if there is failure of other treatments

Bronchiolitis - Respiratory Syncytial Virus (RSV)

• A highly contagious acute inflammatory process of the bronchioles & small bronchi
• Common between September through May
• Affects infants and toddlers with a peak age of 6 months
• Transmission occurs through exposure to contaminated secretions
• RSV can survive on fomites for several hours and on hands for 30 minutes

Diagnostics and Signs & Symptoms of RSV

• Diagnostics are performed by completing an: ELISA or DFA from direct aspiration of nasal secretions.
• Symptoms: low-grade fever, poor feeding, and viscous clear rhinorrhea.
• Other possible symptoms: OM, conjunctivitis, wheezing, grunting, accessory muscle use, cough, air hunger, tachypnea (>60 breaths/min with retractions), cyanosis, listlessness, and apnea
• ABG results may show ↑ and PaCO2 , resulting in respiratory acidosis & hypoxemia

Therapeutic Management of RSV

• Admit patients with pulmonary/cardiac disease and premature infants
• Maintain patent airway by pulmonary interventions and if that is not effective, intubate
• Administer O2 & humidity via nasal cannula (NC) or high flow NC
• Continuously monitor pulse oximetry and their cardiac rate
• If the respiratory rate decreases, this could indicate a life-threatening situation
• Maintain a balanced nutritional intake via PO & IV fluids
• Use of bronchodilator (albuterol) is not effective but can trial it

RSV Bronchiolitis - Nursing Considerations

• Assessment: focused respiratory assessment, reassess frequently
• Placement: private room or cohort patients
• Precautions: Contact & Droplet
• Encourage hand washing!
• Complete pulmonary toiletry using suction of the nares with a bulb syringe & perform CPT before feeds and sleep.
• Monitor hydration, fluid balance, and the infants daily weight.

Prevention of RSV

• Handwashing
  • Palivizumab (Synagis) monthly IM for high risk groups only

Pharyngitis

• Viral (self-limited) or bacterial
• A streptococci infection (strep throat) for 15-25% of cases

Complications of group A streptococci

• Sinusitis, paraphrayngeal, peritonsillar or retropharyngeal abscess
• Head ache, abdominal pain, sore throat, difficulty swallowing
• Anterior cervical lymphadenopathy with tender nodes
• Patients may have redness, exudate and white “strawberry” tongue coating
• At risk for rheumatic fever & acute glomerulonephritis

Pharyngitis Diagnostic and Treatment

• Diagnostic Evaluation: rapid strep test or throat culture for sensitivities
• Management for group A strep:
  • Penicillin (PCN) for 10 days or Erythromycin if the patient has PCN allergy
• Incision & drainage may be indicated for abscesses

Tonsillitis

Pathophysiology

• Swelling and infection of lymphoid tissue in pharyngeal cavity: filter & protects respiratory & alimentary tracts from organisms
• Has a role in antibody formation
  • Palatine tonsils are removed during tonsillectomy
  • Pharyngeal (adenoids) tonsils removed during adenoidectomy
  • Tubal & adenoid tonsils are located near the eustachian tubes

Etiology

• Often occurs with viral or bacterial pharyngitis

Clinical Manifestations

• Edema and difficulty swallowing & breathing
• “Kissing tonsils” (touch at midline): can lead to a medical emergency d/t airway obstruciton

Nursing Considerations

• Assess, assess & reassess
• Offer a soft liquid diet
• Use a cool-mist vaporizer
• Salt water gargles
• Throat lozenges
• Analgesic/antipyretic drugs

Therapeutic Management

• Treat viral symptomatically & bacterial with antibiotics
• Indications for a tonsillectomy & adenoidectomy (T & A):
  • Malignancy, recurrent peritonsillar abscess, adenoiditis, sinusitis, otitis media with effusion.
  • Airway obstruction or sleep apnea

Post-op T & A Cares

• IV fluids until tolerating PO intake
• Cool/cold liquids, no straws & Ice collar, analgesics
• Facilitate drainage of secretions, position side lying or prone
• Avoid careful suctioning, coughing, throat clearing, blowing nose or using straws
• Blood tinged mucus or dark old blood in emesis or nose is common
• Observe for Post-op hemorrhage for up to 10 days
• Assess back of throat Increase in pulse, skin pallor , frequent swallowing or clearing of the throat, restlessness, vomiting, all can indicate hemorrhage Monitor for decreased BP as is a late sign of shock.

Croup, Laryngotracheobronchitis

• Inflammation and edema of the larynx & trachea, and bronchi; parainfluenza is the main pathogen
• Common age is 3 months - 3 years, self-limited (3-5 days)
• Clinical manifestations: Usually sudden onset at night, audible inspiratory stridor, hoarseness, barking cough, steeple sign on x-ray is diagnostic
• Management is usually at home with humidified air and the use of dexamethasone (a corticosteroid) and racemic epinephrine
• Complications are rare but include worsening respiratory distress, hypoxia, or bacterial tracheitis

Acute Epiglottitis

• Life threatening for two to seven year olds
• Inflammation and edema of epiglottis often caused by Haemophilus influenzae
• Hallmarks include the the absence of spontaneous cough, drooling, agitation, irritability, dysphagia, significant respiratory distress, inability to lay flat, and tripod positioning.
• Abrupt onset with severe respiratory distress. A presumptive dx is a medical emergency.

Acute Epiglottitis treatment

• Diagnostic: lateral X-ray of the neck film
• Must avoid examining throat with a tongue blade (contraindicated)
• Provide: patent IV access, fluids, and 100% oxygen
• Be prepared for respiratory emergency: intubation or tracheostomy
• Need to administer antibiotics for seven to ten days as well as corticosteroids when needed

Acute epiglottitis nursing considerations

• Decrease in anxiety + position for optimal comfort
• Assess respiratory status, pulse ox, blood gases, maintenance IVF
• Prevention: Incidence has declined with Hib vaccine

Acute Otitis Media (AOM)

• Often the results of a viral (most common cause) or bacterial infection of fluid in the middle ear.
• Most common prevalence in the winter season.
• Characteristics are: fever, possible pain, possible ear canal drainage Risk factors include:
  • Eustachian tube dysfunction & upper respiratory infection

Therapeutic Management

• Treatments can range from antivirals if viral in nature or antibiotics
• Antibiotics administration should be used wisely because it can increase resistances for superinfections.
• There is generally a period of observation prior to giving antibiotics depending on patient presentation.
• Anti-Infective: amoxicillin, ciprofloxacin
• Anti-Infective/Glucocorticoid: neomycin-polymyxin B-hydrocortisone, ciprofloxin-hydrocortisone
• Always remember to treat discomfort with fever reducers.

Otitis Media with Effusion (OME)

• This is fluid in the middle ear.
• Risk Factors: exposure to passive smoking, bottle feeding, frequent URI, young age, male, adenoid hypertrophy, or Eustachian tube dysfunction. -Symptoms may be asymptomatic and can be fullness behind the ear drum, typically resolves over time.
• For DX: Confirm via tympanometry. Complications: can vary between AOM, hearing loss and deafness too.

OME and Hearing Loss

• Hearing evaluation needed with follow up All children with persistent OME lasting 3 months or longer
• When hearing loss, speech, language or learning difficulties are suspected School nurses provide screenings
• Communication with a hearing impaired child:
• Turn off all background noise
• Face the child at a distance of 3 feet or closer
• Speak clearly and slightly louder using facial expression.
• Evaluate with questions to assess hearing deficits.

Surgical Procedures - Ear

• Myringotomy which is the surgical incision of the eardrum to alleviates pain: requires insertion of pressure-equalizing tubes into the tympanic membrane to facilitate drainage of fluid in the middle ear & provided adequate hearing.
• This is a minimally invasive procedure done as outpatient by an ENT specialist.
• Post Education:
• Administration of ear drops
• Earplugs when in water
• Contact MD if ear drainage noted
• *Tubes does not prevents infection it only allows fluid to drain through the middle ear.
• Adenoidectomy: can decrease recurrent AOM that comes with obstruction or/chronic sinusitis and/or adenoidities.

AOM - Patient Education

• AOM = treat the discomfort Use of Antipyretic, analgesic medications and/or numbing eardrops Can use warm or cool compresses to the ear to alleviate pain Take all prescribed medications per MD orders Breastfeed for 1st 6 to 12 months to promote immunity Decrease exposure to 2nd hand smoke when applicable
• T each prevention methods for future infections

Tips

• Try to hold and feed infants in an upright position during feeds
• DO not Prop bottles to feed because this can lead to bacteria stasis in the Eustachian tube
• If possible, please seek to eliminate smoking from the home enviroment or at least reduce exposure.*

Otitis Externa (Swimmer's Ear)

• Is the infection and swelling in the external ear canal
• Common Causes: can be from exposure of the ear canal to Pseudomonas bacteria, staphylcoccus bacteria, or fungus
• Moist ear canal with retained water typically promotes infection
• Some common findings are itching, pain (especially on the tragus with palpation), ear drainage, feeling of fullness, and possible hearing difficulty.
• Treatment will include: Analgesics like acetaminophen and/or antibiotics. It all depends on the infection found in otoscopic exam.
• Prevention Tips: Keep ear canals dry at all times, wear ear plugs in swimming scenarios, or when showering.

Conjunctivitis

Conjunctivitis and characterized as the inflammation of the conjuctiva in one or both eyes. Causes can vary across all age groups.

• Caused from virus, bacteria, allergy, and exposure from the environment
• Common to also be found in newborns from clamydia and/or neisseria gonorrhoeae Those at risk of contracting this are folks in close clusters like school settings , frequent viral infections, and/or sensitivity to some allergens. Some signs and symptoms may include eye(s) pain, itchiness, redness, edema, tearing, and discharge ranging from clear to purulent

Conjunctivitis Treatments

Bacterial infectious: wash hands, back to school after 24 to 48 hours after start of antibiotics per medical order Viral: symptom relief, compresses for comfort. Allergic reactions: can seek to sooth redness, swelling, tearing with medication.

Non-Infectious Disorders

• Strabismus is diagnosed by a misalignment of the eyes. Can include: Exotropia: eyes turned outward from midline of the face Esotropia: eyes turned inward
• Vision may be impaired which can cause diplopia -Hallmark findings are: Misaline ment of one or both eyes, reported double or blurry vision, turning of/tilting head to see objects near or far. -Treatment: Patching of one eye or the other, corrective lenses to help alignment, surgical intervention to correct deficits.

Foreign Body Aspiration (FBA)

• Is very common for risk ages between 6 months to 4 years
• Hallmarks: are choking, gagging, wheezing, coughing after an incident or exposure to small toy parts and/or round items.
• A child will be in absolute distress, as they may display cyanosis and inability to speak after a significant obstruction.

Diagnostics and Treatment

• DX with endoscopy to dx & remove the FB
• Fluoroscopy to assess full inspiration vs collapsed tissue. -Treatments: Basic Life Support that can dislodge the object with chest compresssions. and potential surgery interventions
• ** prevention methods are always appropriate with this***

Aspiration Pnuemonia

A condition where the lining of the lungs become irritated due to entry of pathogens and/or chemicals that will damage the tissue.

• High risk groups are with patients who has hx of feeding difficulties and/or significant gastrointestinal reflux.
• This will cause increased inflammation in the respiratory tract. The primary goal is the prevention of aspirations -Proper feeding techniques with upright positioning of the patient during feeds. -NGT/GT feeds may be indicated if tachypnic or unable to safetly swallow without aspiration
• Make sure to do a full assessment of placement for NG/GT tubes for safety factors. -Positioning: elevate HOB ↑ during and after feeds to reduce chance of regurgitation or reflux.

Safety

• Avoid administering oily medications through nasal route
• Safe use and precautions for solvents Caution patient regarding Talcum powders