Child Anatomy: Nose, Throat, and Respiratory System

Anatomy and Physiology of the Child's Nose and Throat

• Infants are obligate nose breathers.
• Infants produce very little mucus.
• Infants are more susceptible to infections.
• Sinuses are not developed in infants.
• Newborns have very small nasal passages.
• Newborns are more prone to obstruction.
• Children have an increased risk for airway obstruction in the throat.
• Infants' tongues are larger in relation to oropharynx.
• Children have enlarged tonsillar and adenoid tissue.

Lower Respiratory Structures

• The trachea bifurcates at the level of the third thoracic vertebra.
• Tracheal bifurcation is important when suctioning or intubating children.
• Infants and children have narrower bronchi and bronchioles.
• Narrower airways lead to an increased risk for lower airway obstruction.
• Children have smaller numbers of alveoli.
• Fewer alveoli lead to a higher risk of hypoxemia.

Inspection and Observation

• Anxiety and restlessness can indicate respiratory distress.
• Color changes like pallor or cyanosis can indicate respiratory distress.
• Hydration status should be assessed.
• Clubbing of fingers can be a sign of chronic respiratory issues.
• It's important to assess breath sounds.
• Assess the rate and depth of respirations, tachypnea indicates increased respiratory rate.
• Assess respiratory effort and if they are struggling to breath.
• Inspect the nose and oral cavity.
• Note any cough and other airway noises like stridor.

Adventitious Breath Sounds

• Wheezing is a high-pitched sound on inspiration or expiration.
• Wheezing may be indicative of lower trachea or bronchioles obstruction.
• Wheezing may be indicative of viral infections or asthma.
• Rales are crackling sounds heard when alveoli become fluid filled.
• Rales may be indicative of pneumonia.

Laboratory and Diagnostic Tests for Respiratory Issues

• Pulse oximetry can show decreased oxygen saturation.
• Chest radiograph might reveal hyperinflation and patchy areas of atelectasis or infiltration.
• Blood gases might show carbon dioxide retention and hypoxemia.
• Nasal-pharyngeal washings can identify RSV or other viral illness using ELISA or IFA testing.
• Rapid strep testing can aid in diagnosis, via throat swab.

Pneumonia: Laboratory and Diagnostic Tests

• Pulse oximetry: oxygen saturation might be decreased significantly or within a normal range.
• Chest x-ray results vary depending on age and causative agent.
• Sputum culture can help determine the causative bacteria in older children and adolescents.
• White blood cell count might be elevated in bacterial pneumonia cases.

Cystic Fibrosis: Laboratory and Diagnostic Tests

• A sweat chloride test is completed
• A level of chloride in collected sweat above 50 mEq/L is suspicious.
• A level of chloride in collected sweat above 60 mEq/L is diagnostic.
• Pulse oximetry reveals that oxygen saturation might be decreased, particularly during a pulmonary exacerbation.
• Chest radiograph reveals hyperinflation, bronchial wall thickening, atelectasis, or infiltration.
• Pulmonary function tests reveal a decrease in forced vital capacity and forced expiratory volume, with increases in residual volume.

Common Medical Treatments for Respiratory Illnesses

• Oxygen administration is a common treatment.
• High humidity can help with respiratory issues.
• Suctioning can help clear airways.
• Chest physiotherapy and postural drainage can help mobilize secretions.
• Saline gargles or lavage can help soothe irritation.
• Mucolytic agents can help thin secretions.
• Chest tubes can help drain fluid or air from the chest cavity.
• Bronchoscopy can help visualize and clear the airways.

Risk Factors for Respiratory Disorders

• Prematurity is a significant risk factor.
• Chronic illnesses such as diabetes, sickle cell anemia, cystic fibrosis, congenital heart disease, or chronic lung disease increases likelyhood.
• Developmental disorders like cerebral palsy are a risk factor.
• Passive exposure to cigarette smoke is a risk factor.
• Immune deficiency is a risk factor.
• Crowded living conditions or lower socioeconomic status are risk factors.
• Daycare attendance can increase risk.

Risk Factors for Tuberculosis

• HIV infection
• Incarceration or institutionalization
• Positive recent history of latent TB infection
• Immigration or travel to endemic countries
• Exposure at home to HIV-infected or homeless persons and illicit drug users.
• Also at risk are recently incarcerated, migrant farm workers, or nursing home residents.

Pneumothorax

• Risk factors include chest trauma or surgery, intubation and mechanical ventilation, or chronic lung disease such as cystic fibrosis.
• Signs and symptoms include chest pain and signs of respiratory distress.
• Respiratory distress can include tachypnea, retractions, nasal flaring, and grunting.

Acute Infectious Disorders

• Common cold, sinusitis
• Influenza
• Pharyngitis, tonsillitis, and laryngitis
• Croup syndromes
• Respiratory syncytial virus (RSV)
• Pneumonia and bronchitis

Bronchiolitis (RSV) Signs and Symptoms

• Onset of illness includes a clear and runny nose (sometimes profuse).
• Pharyngitis
• Low-grade fever
• After 1-3 days of illness, a cough develops, followed by a wheeze.
• Poor feeding

Pharyngitis

• Signs and symptoms include petechiae on the palate, a fine, red, sandpaper-like rash on trunk or abdomen, and a strawberry tongue.
• These signs often accompany Streptococcus A infections
• Diagnosis includes rapid identification test kits , and throat culture.
• Nursing care is supportive and directed toward parent education.
• Parents are instructed regarding medication administration.
• Education includes instructions to administer the full dose of antibiotic prescribed, fluid administration, and prevention of dehydration.

Tonsillitis

• Inflammation of the tonsils, located within the pharynx
• Symptoms of acute tonsillitis include fever, chills, foul breath, dry throat, dysphagia (difficulty swallowing), referred otalgia (pain in the ears), and headache.
• Other symptoms include malaise (fatigue), muscular pains, enlarged cervical nodes.
• Enlarged tonsils can touch at the midline, called "kissing tonsils": 4+ in size
• Airway obstruction and mouth breathing may be results from enlarged tonsils .
• Diagnosis is based on presenting symptoms and inspection of the throat.
• Nursing care includes using a cool-mist humidifier, warm saline gargles, throat lozenges, and antipyretics .
• It is best to maintain a soft or liquid diet.
• Tonsillectomy is used for recurrent or chronic tonsillitis.
• Monitor for postoperative bleeding after tonsillectomy, excessive swallowing, elevated pulse, decreasing blood pressure, signs of fresh bleeding, vomiting bright red blood, and restlessness not associated with pain.
• Education/discharge instructions after tonsillectomy is needed: Keep child away from highly seasoned food and “sharp" foods (e.g., chips) for period of 2 weeks, the scab is most likely to be dislodged at 8–12 days, have child avoid gargling and vigorous teeth brushing, and instruct child not to cough or clear throat and limit child’s activities that may result in bleeding.

Croup

• Croup is a generic term for a heterogeneous group of illnesses affecting the larynx, trachea, and bronchi.
• Croup lateral walls of the trachea below the level of the vocal cords are marked by swelling and erythema.
• Acute laryngotracheitis is when it is usually viral (parainfluenza, adenovirus, RSV), peak age: 3-36 months, has a gradual, acute onset during the night and a URI symptom.
• Croup often begins at night.
• Croup sudden onset includes harsh, metallic, barky cough; sore throat; inspiratory stridor; hoarseness Use of accessory muscles to breathe, frightened appearance, agitation, cyanosis and a low grade Fever.
• DO NOT attempt to visualize throat with tongue blade, this may cause laryngospasm and immediate airway occlusion.
• Plan for tracheal intubation if direct laryngoscopy is ordered.
• Nursing care focuses on maintaining the airway, promoting rest, providing humidification, monitoring fluid balance.
• Nursing care also includes administering medications as prescribed and observing level of consciousness.

Epiglottitis

• Cardinal symptoms include drooling, dysphagia (difficulty swallowing, dysphonia (difficulty talking) and distressed respiratory efforts
• DO NOT leave child unattended if epiglottitis is suspected
• DO NOT Examine or attempt to obtain culture without airway support as any stimulation by tongue depressor or culture swab could trigger airway obstruction

Asthma

• Asthma is a chronic inflammatory airway disorder
• Airways are hyperresponsive to allergens.
• Asthma is characterized by airway edema and mucus production.
• Leads to airway obstruction that is reversible or partially reversed.
• Allergen triggers include dust mites, cockroaches, mice, mold, pollens (trees, grass, weeds), and pet dander.
• Irritant triggers include smoke, cold air, air pollution, strong odors and sprays, upper respiratory infections/colds, exercise and stress/laughing/crying.
• A tachypnea is shortness of breath.
• Increased work of breathing is also symptomatic.
• Emergency situations include worsening wheeze, cough, or shortness of breath, difficult breathing, not improving after using a bronchodilator, trouble with talking or walking, discontinuing play, listlessness and cyanosis.
• Asthma sign and symptoms include wheezing, chest tightness, coughing early morning or cough and increases respiratory rate as well as decreases the ability to breath.

Asthma Management

• Goal is to determine the severity with a tier system of therapy and treatment.
• Utilize rescue medicine with short-acting bronchodiliators for immediate relief
• The uses of leukotriene modifiers, inhaled corticosteroids and long-acting bronchodilators can help with maintenance.
• Nursing care includes administering quick-relief medications.
• Asthma also needs administering medications with correct time.
• Providing adequate hydration to liquefy secretions.
• Proper positioning (head of bed elevated 30°) helps with comfort and lung expansion.
• Education for asthma includes identifying environmental factors that trigger attacks and follow up.
• It is important to know to use and clean inhalers, spacer devices, or aerosol equipment as needed.
• Peak Flow Meters should be a part of asthma care - it identifies how well a child can blow out of lungs.
• Asthma testing also needs the eosinophil count to monitor.
• A personal Peak Flow Meter is important to have and read on a daily basis.
• Used for patients greater than 6 years old.
• Used to manage asthma at home and prevent ER/hospital admits.
• Setting of zones includes Green set at 80% above - and Yellow set at 50-80% and Red is <50% of personal best for danger.

Asthma Implications

• Asthma Action Plan is to be given to each family/patient
• The asthma Action plan has 3 zones: Daily Medicine, Yellow Zone (when sick), Red Zone (danger zone)
• Smoking needs to be assessed in the house hold
• Avoid outdoors as much as possible during seasons of increased pollen and stay indoors during the midday and afternoons when counts are high
• Avoid sources of mold which includes (wet leaves, lawn mowing and sand boxes)

Cystic Fibrosis

• Cystic Fibrosis is a autosomal recessive disorder.
• Cystic fibrosis transmembrane conductance regulator (CFTR) mutation results in problems in exocrine glands.
• Cystic Fibrosis: Excess thick, tenacious mucus lining airways causing decreased resistance to infection and air trapping Decreased pancreatic enzymes and hypersecretion of gastric acids.
• Cystic Fibrosis can be treated with chest physiotherapy, Inhaled dornase alfa which a pulmonary enzyme, Inhaled antibiotics for exacerbation an Pancreatic enzyme supplementation while maintaining an ADEK vitamin supplementation along with a Well-balanced, high-calorie, high-protein diet.

Cystic Fibrosis Facts for Diagnosis

• Perform a medical history and a physical exam with screening or lab tests.
• Need Two positive sweat tests on different dates while maintaining a
• Positive genetic blood results with An abnormal nasal potential difference

Alternatives to Traditional Mechanical Ventilation

• Use High-frequency oscillators to Provide respiratory rates up to 1200 bpm with low tidal volume.
• Nitric oxide inhalation(INO): Inhaled nitric oxide gas, causes vasodilation to increase blood flow to alveoli.
• Perfluorocarbon liquid Acts likes a surfactant which provides improved gas exchange.
• Extracorporeal membrane oxygenation (ECMO): Blood is removed from the body, warmed, oxygenated and returned to the patient via pump.

Nursing Management of Epiglottitis

• AVOID: Attempting to visualize/ assess the throat
• AVOID: Leaving the child unattended
• AVOID: Placing the child in a supine position.
• DO: Provide 100% oxygen in the least invasive manner.
• DO: Ensure tracheostomy tray and emergency equipment is readily available.
• Provide 100% oxygen in the least invasive manner.
• Ensure tracheostomy tray and emergency equipment readily available.

Nursing Care Posttonsillectomy

• Promote airway clearance, place the child in side-lying prone position.
• Discourage coughing.
• Encourage fluids but avoid citrus, brown, or red fluids.
• Relieve pain with an ice collar and analgesics (with or without narcotics).
• A sign of Frequent swallowing may indicate bleeding.

Acute Noninfectious Respiratory Disorders

• Occasional Epistaxis
• Foreign body aspiration
• Acute respiratory distress syndrome
• Pneumothorax.

Interventions to Minimize Psychosocial Impact of Chronic Respiratory Conditions

• Promoting child's self-esteem through education and support and give Allow a school-age child to take control of managing the disease such as Providing culturally sensitive education and interventions.
• Promote the family coping through education and encourage them.
• Provide culturally appropriate education and intervention.