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Airway Components

• The upper airway is composed of the nasopharynx, oropharynx, and epiglottis.
• The upper airway allows for gas exchange and ventilation.
• The larynx separates the upper and lower airways.
• The lower airway allows for oxygenation and gas exchange.
• The lower airway consists of the bronchi, bronchioles, alveoli, lungs, and trachea.

Pediatric Airway Variations

• Pediatric upper airways are shorter and narrower than adult airways.
• Children have smaller oral cavities and larger tongues.
• Pediatric epiglottises are longer and floppier.
• The larynx and glottis are positioned higher in the neck.
• Cartilage in the neck is more flexible, leading to increased airway resistance.
• In children, the mainstem bronchi separates higher at T3 versus T6.
• Children younger than 6 years primarily use the diaphragm for inspiration.
• Pediatric lower airways have fewer immature alveoli, narrower bronchioles, smaller lungs, and immature intercostal muscles.

Differences in Respiratory Assessment

• Pediatric respiratory systems have different characteristics and reserves compared to adults.
• It's best to observe respirations when the child is at rest.
• Auscultation of pediatric lungs allows for hearing more due to less tissue and muscle between the stethoscope and lungs.

Signs and Symptoms of Respiratory Distress

• Compensatory mechanisms, restlessness, tachypnea/tachycardia, and diaphoresis are common signs.
• Children under 5 years tend to be belly breathers.
• Upper body use for breathing, including tugging and retractions, indicates respiratory distress.
• A decreased respiratory rate can indicate the child is becoming apnic.

Moderate vs. Severe Distress

• Moderate distress presents as severe intercostal retractions, with possible substernal or subcostal retractions.
• Severe distress presents as deep suprasternal, sternal, or supraclavicular retractions.
• When retractions are present, look for other signs of respiratory distress.

Respiratory Failure

• Respiratory failure is often preceded by hypoventilation in the alveoli.
• It happens suddenly when compensatory mechanisms fail and, if untreated, leads to respiratory arrest.
• Signs include cyanosis or gray color, tachypnea followed by bradypnea, severe retractions and apnea, altered mental status, inability to maintain O2 levels, and acidotic pH.

Oxygenation

• Newborns are obligatory nose breathers, needing oxygenation through the nose.
• Mouth breathing typically begins around 4 months of age.
• A nasal cannula should be used when oxygenating through the nose.
• Select the oxygen device based on age, situation, and required flow rate.
• Oxygen saturation should be monitored when using supplemental oxygen.
• Position the patient to increase oxygenation.

Oxygen Options

• Nasal cannula delivers 24% to 35% oxygen at 0.25-6 L/min.
• A simple oxygen mask delivers 35% to 50% oxygen at 5-10 L/min.
• A non-rebreather mask delivers 70% to 100% oxygen at 10-15 L/min.
• Bilevel positive airway pressure (BiPAP), continuous positive airway pressure (CPAP), or a ventilator is needed if positive airway pressure is required.

Types of Airway Obstructions

• Retractions with stridor or snoring indicate an upper airway obstruction.
• Retractions with expiratory wheezing indicate a lower airway obstruction.

Croup

• Croup involves inflammation of the upper airway, including the epiglottis, larynx, trachea, and possibly the bronchi.
• Cough, hoarseness, and stridor are the most common symptoms.
• There are many “croup syndromes” or “croup disorders,” which can be viral or bacterial
• Croup is characterized by a distinctive bark cough.

Viral Croup Disorders: Laryngotracheobronchitis (LTB)

• Viral croup disorders do not require antibiotics.
• LTB is the most common croup disorder, occurring in children aged 3 months to 8 years.
• It is caused by a viral infection in the upper airway.
• Symptoms include a brassy cough, dyspnea, stridor, and low-grade fever, with a gradual onset and slow progression.
• Treatment includes steroids, fluids, and racemic epinephrine.

Spasmodic Laryngitis

• Spasmodic laryngitis occurs in children aged 3 months to 3 years.
• It occurs suddenly, often at night, and typically has an unknown or possibly viral cause.
• Signs include barking cough, afebrile state, and mild respiratory distress.
• Treatment involves cool mist and is self-limiting and transient.
• This happens fast, like SPAZ- FAST MIDDLE OF NIGHT

Croup Nursing Interventions

• The main goals are close observation for respiratory distress caused by obstruction, relief of anxiety, and reduction of edema and inflammation.
• Implement corticosteroid therapy, humidifier, and elevate the head of the bed (HOB).

Epiglottitis

• Epiglottitis is bacterial.
• This involves swelling/inflammation of the epiglottis.
• This is a medical emergency that can shut off the airway.
• It is a bacterial croup disorder with a rapid onset of 2-6 hours.
• This condition has a high mortality rate if not treated quickly.

Epiglottitis Signs and Symptoms

• These worsen rapidly over 2-4 hours.
• Dysphasia, stridor (aggravated when supine), drooling, high fever, toxic appearance, rapid pulse and respiration, muffled voice, mouth breathing, and hyperextended neck (tripod position) all indicate the condition.
• A hallmark sign is a cherry-red epiglottis.
• Immediate actions include intubation and sedation to protect the airway.

Epiglottitis Treatment

• Keep the patient calm and avoid anxiety and crying.
• Immediate endotracheal intubation is done for airway patency.

Tracheitis

• Can be viral or bacterial, more common in the fall and winter.
• Typically a bacterial croup disorder.
• More common in males than females.
• Clinical manifestations include a toxic appearance, croupy cough, dysphonia, hoarseness, high fever without drooling, stridor that doesn't improve with positioning, and thick, purulent secretions.
• Treatment includes antibiotics, fluids for rehydration, maintaining a patent airway, oxygenation, and mucolytics.

Lower Airway Respiratory Disorders

• Includes Bronchiolitis, RSV, Pneumonia, Bronchitis, and Asthma

Bronchiolitis- RSV

• Commonly leads to RSV as RSV progresses.
• Cells in the bronchioles die, accumulate, and obstruct.
• Mild cough, rhinorrhea, and congestion are included.
• Symptoms worsen after 2 days.
• Treatment is symptomatic and self-limiting.
• The affected can take air in but struggle to expel air, causing air trapping, which interferes with a normal exchange of gases.
• Transmission is direct.

RSV Signs and Symptoms

• Mild and wet cough, rhinorrhea, and congestion, with or without fever.
• There is difficulty eating with nasal congestion.
• Symptoms worsen after 2 days, which starts respiratory distress.
• Hallmark: worse on day 2, the worst at day 3.

RSV Treatment

• Isolation.
• Hydration while NPO if RR>60.
• IV fluids
• May try saline nebs and bronchodilators.
• The most critical time is 48-72 hours after onset of cough and dyspnea, with rapid and complete recovery.
• Synagis (palivizumab) for preemies less than 35 weeks that have BPD.
• Vaccine for premies.

Bronchitis

• Inflammation of the trachea, bronchi, and bronchioles.
• Usually viral
• Symptoms: coarse barking cough, chest pain, and thick sputum.
• Treatment: self-limiting; treat symptomatically (humidification).
• May vomit thick mucus
• Barking cough- more croup

Pneumonia

• Infection or inflammation of lower airways, bacterial, viral, community, or hospital-aquired.

Pneumonia Clinical Manifestations

• Fever
• Tachypnea
• Cough
• Nausea and vomiting
• Irritable, restless, and lethargic
• Pallor
• Treat with monitoring for respiratory distress, encourage coughing and deep breathing, and antibiotics.

Tuberculosis

• A lung infection with acid-fast bacilli.
• Risk factors are environmental or immune-related.
• Spreads by airborne droplets.
• Primary and secondary forms can occur.
• Manifestations include Persistent cough, Night sweats, and Fevers.
• Tuberculin skin testing, Chest x-ray, and QuantiFERON gold testing are used for diagnostic testing.
• Treat with long-term antibiotics.

Non-Infectious Respiratory Disorders

• Includes Foreign Body Aspirations, Acute Respiratory Distress Syndrome, Pneumothorax, and BPD.

Foreign Body Aspiration

• Inhalation of object into the respiratory tract.
• Manifestations: cough, dyspnea, stridor, and hoarseness.
• Causes sever respiratory distress.
• Prevent with anticipatory guidance; scans may not pick up plastic on X-rays.
• Use camera- bronchoscopy.

Acute Respiratory Distress Syndrome (ARDS)

• Acute, diffuse, inflammatory lung injury
• Causes noncompliant lungs
• Can be direct/undirect injury
• Bilateral opacities on x-ray
• Intubation, positive pressure mechanical ventilation (PPV), antibiotics, diuretics, and vasodilators happen in the ARDS ICU.
• Decrease pulmonary vascular resistance.
• Provide gastric ulcer prophylaxis.

Pneumothorax

• Accumulation of air in the pleural space.
• Can be spontaneous, traumatic, or tension-related.
• Manifestations: tachypnea, dyspnea, respiratory distress, hypoxemia, and tracheal deviation.
• Treatment: chest tube placement, supplemental oxygen, and monitoring respiratory status.
• Tension requires emergent needle aspiration.

Bronchopulmonary Dysplasia (BPD)- COPD in Baby

• Chronic obstructive pulmonary disorder.
• Occurs from prolonged use of supplemental oxygen and positive pressure ventilation after premature birth.
• There is a reduced surface area for gas exchange.
• Manifestations: tachypnea, tachycardia, nasal flaring, grunting, retractions, wheezing, crackles, failure to thrive, and increased oxygen demands.
• Treatments: positioning, humidified supplemental oxygen, chest physiotherapy, bronchodilators, and suction.
• Cluster and organize nursing care.
• Diuretics prevent fluid overload.
• The cause stems from being born prematurely.
• Treatment depends on positioning, humidified supplemental oxygen, chest physiotherapy, bronchodilators, and suction.
• Cluster and organize nursing care.
• Administer Diuretics to prevent fluid overload.
• May require tracheostomy.

Asthma

• Most common chronic condition in kids
• Chronic Inflammation in airways
• Intermittent bronchoconstriction, increased mucus, and airway remodeling
• Environmental, secondhand smoke exposure, or being a smoker, maternal smoking during pregnancy, chronic stress, obesity, obstructive sleep apnea, rhinitis/sinusitis, allergies, ethnicity, and low BW are comorbid conditions that may affect asthma.
• Treatment involves medications and education.
• Triggers include pollen, mold, pet danger, tobacco smoke, anxiety, and dust mites
• Intervention is based on peak-flow results

Subjective Assessment Data for Asthma

• Age of Onset, Triggers, Atopic vs. Non-atopic, Natural History, Severity, Exacerbation Prone, Response to Therapy, Treatment Adherence, Environmental Exposures, Psychosocial Issues, Reflux, Lung Function

New Asthma Assessment

• Identification of phenotypes has clinical relevance
• Pattern of inflammation
• Eosinophilic
• Neutrophilic
• allergic eosinophilic disease – T2 inflammation factor
• EOS >400 cell/u associated with increased rates of severe exacerbation and decreased rate of control
• Asthma is a heterogeneous condition

Assessment and Management of Asthma Severity and Control

• Monitor signs and symptoms of asthma
• Spirometry recommended for patients > 5 years of age
• PCP should see the patient at least every 2-6 weeks until control is achieved-chronic asthma visits
• Refer to asthma specialist
• Required hospitalization or 2 rounds of oral prednisone indicates uncontrolled asthma
• Not reaching goals of treatment in 3-6 months
• Co-morbidities that complicate asthma (nasal polyps) may necessitate additional diagnostic testing

Education for Asthma Care

• Partnership between patient/parent and provider
• Ensure effective and repeated education
• Review basic facts and medication use at every visit
• Ensure adequate self-monitoring
• Use the asthma action plan to determine daily actions to control asthma
• Adjust meds and seek medical care as needed

Medications for Asthma

• Quick relief: Used in acute episodes; short-acting beta2 agonists (albuterol)
• Long-term control: Taken daily over a long period; reduces inflammation, relax airway muscles, and improve symptoms and lung function (inhaled corticosteroids-prednisone)
• Long-acting beta2-agonists
• Leukotriene modifiers should also be perscribed.

Inhalers, Spacers, and Nebulizers

• Spacers help patients who have difficulty with inhaler use, which reduces potential for adverse effects.
• Nebulizers produce a mist of the medication
• Nebulizers are for small children or those with severe episodes

Cystic Fibrosis (CF)

• Autosomal recessive genetic disorder: abnormalities in body's salt, water, and mucus-making cells
• Can be carried without symptoms.
• Thick, sticky mucus builds up in lungs, sinuses, liver, pancreas, intestines, and reproductive organs.
• Manifestations include steatorrhea, failure to thrive, tachypnea, wheezing, retractions, and recurrent pneumonia
• Diagnose with sweat chloride testing
• Treat and manage affected systems, pancreatic enzyme replacement, percussion and drainage, mucolytics, and a high protein, high calorie, high fat diet.

CF Genes

• CFTR – cystic fibrosis transmembrane conductance regulator – a protein in the cells that line various organs (lungs, pancreas)
• CFTR controls the movement of sodium and chloride in and out of these cells
• CF = defective CFTR (4 main mutations)
• Salt balance is disturbed (too little salt and water on the outside of the cells causing thick mucous)
• Without CFTR, the airway surface is depleted, mucociliary clearance is reduced, mucous viscocity is increased and Failure to resorb NaCl

CF Pathophysiology

• Mucous secreted by the exocrine glands is abnormally viscous, sticky, and tenacious, adhering to the walls of glandular ducts, eventually obstructs them, and causes fibrosis of glands themselves
• This affects the respiratory and GI tracts
• Viscous mucus leads to infection and chronic inflammatory processes
• COPD and clubbing might occur with barrel chest
• Thick mucus in the obstructs the pancreatic ducts eventually becomes fibrotic so it does not make and release enzymes needed for digestion- MALABSORPTION- NO INSULIN which leads to decreased absorption of nutrients.
• The sweat glands produce sweat containing four times the NaCL concentration, with the sweat test diagnostic
• Patients are not retaining salt.

CF Nursing Interventions

• NEBS- albuterol, DNASE- break up mucus, PD&C, inhaled saline, vest, flutter valve, chest PT
• IV antibitics
• Nutrition – possible G tube
• Pancreatic enzymes
• Exercise is key
• Tobramycin nebs are an antibiotic.

CF Precautions

• Limit the time that two people spend in one place and maintain a minimum of 6 feet should be maintained
• Separate classrooms, bathrooms, and drinking fountains
• Have different times in gathering areas
• Assign lunch tables and lockers far apart