Respiratory Function & Disorders in Children - WEEK 2 NOTES PDF

Chapter 20 Alterations in Respiratory Function Learning Objectives Recognize the symptoms as a result of the above disorders. Recognize the impact that genomics have on the chronic respiratory illnesses of asthma and cystic fibrosis. Formulate nursing diagnoses for children with the above disor...

Chapter 20 Alterations in Respiratory Function Learning Objectives Recognize the symptoms as a result of the above disorders. Recognize the impact that genomics have on the chronic respiratory illnesses of asthma and cystic fibrosis. Formulate nursing diagnoses for children with the above disorders. Establish appropriate goals and outcomes working with children who are experiencing the above disorders. Formulate nursing interventions relative to children with respiratory dysfunction Airway Components - Upper airway: Nasopharynx and oropharynx Epiglottis Pathway for gas exchange Allows for ventilation - Larynx separates the upper and lower airways. - Lower airway: Allows for oxygenation and gas exchange Bronchi and Bronchioles Alveoli Lungs Trachea Pediatric Upper Airway Variations Shorter and narrower Small oral cavities and larger tongues Long, floppy epiglottises Larynx and glottis higher in the neck Cartilage in neck more flexible Increased airway resistance Pediatric Lower Airway Variations Mainstem bronchi separates higher (T3 versus T6) Fewer, immature alveoli Narrower bronchioles Diaphragm for inspiration in children younger than 6 years Smaller lungs Immature intercostal muscles Respiratory System Variations Respiratory Assessment Respiratory Assessment #2 Respiratory Assessment #3 Differences in Assessment Respiratory system and reserve different than adults Best to observe respirations while at rest - Auscultate lungs: hear more than in adults, so much less tissue and muscle between stethoscope and lungs Ask to blow out candles Signs and Symptoms of Respiratory Distress - Compensatory mechanisms (work to breathe) restlessness- tachypnia/tachycardia- diaphoresis - BELOW 5- BELLY BREATHERS - USING UPPER BODY TO BREATHE- TUGGING- BAD BAD BAD- UPPER RETRACTIONS BAD BAD BAD - - RR MAY DECREASE- BECOME APNIC Moderate v Severe Distress - Moderate distress: Severe intercostal retractions or accompanied by substernal or subcostal retractions - Severe distress: Deep suprasternal, sternal or supra clavicular retractions. When retractions are present, need to check for other signs of respiratory distress Respiratory Failure Preceded by hypoventilation in the alveoli Occurs suddenly when compensatory mechanisms fail Followed by respiratory arrest if not treated Signs and Symptoms of Respiratory Failure - Cyanosis, gray color - -tachypnea then bradypnea - Seere retractions and apnea - -altered MSE - Unable to maintain O2 lvels - Acidotic Ph Oxygenation ❖ Newborns are obligatory nose breathers: OXYGENATE THROUGH NOSE ❖ -PROBE ON FINGER o Mouth breathing begins at 4 months of age. o Use nasal cannula due to nose breathing. ❖ Select the device based on age, situation, and required flow rate. ❖ Monitor O2 saturation while on supplemental oxygen. ❖ Position to increase oxygenation. Oxygen Options ❖ Nasal cannula (24% to 35% oxygen; 0.25-6 L/min). ❖ Simple oxygen mask (35% to 50% oxygen; 5-10 L/min). ❖ Non-rebreather mask (70% to 100% oxygen; 10-15 L/min). ❖ Bilevel positive airway pressure (BiPAP), continuous positive airway pressure (CPAP), or ventilator if positive airway pressure needed. Types of Airway Obstructions - Retractions w stridor or snoring- upper airway obstruction - Retractions w expiratory wheeze- lower airway obstruction Croup Inflammation of upper airway: epiglottis, larynx, trachea, maybe bronchi Most common cause of cough, hoarseness, and stridor There are many “croup syndromes” or “croup disorders,” which can be viral or bacterial -BARK COUGH Croup Viral Croup Disorders = NO ANTIBIOTICS Laryngotracheobronchitis (LTB): o Most common croup disorder; occurs in 3 months to 8 years. o Viral infection in the upper airway. o Gradual onset and slow progression. o Signs: brassy cough, dyspnea, stridor, low-grade fever. o Treatment: steroids, fluids, and racemic epinephrine.  o STEROIDS (decrease inflammation), reciemic epi (nebulizer) Spasmodic laryngitis: o Occurs in children 3 months to 3 years. o Occurs suddenly; often at night. o Unknown cause; maybe viral. o Signs: barking cough, afebrile, mild respiratory distress. o Treatment: cool mist; self-limiting and transient, taking bby outside o TODDLERS AND BABIES o LIKE SPAZ- FAST MIDDLE OF NIGHT Croup Nursing Interventions Main goals: Close observation for resp distress caused by obstruction Relieve anxiety Decrease edema/inflammation Corticosteroid therapy Ease respiratory effort – Humidifier HOB elevated Epiglottitis- BACTERIAL -SWELLING/INFLAMATION OF EPIGLOTTIS -inflamation and swelling -MEDICAL EMERGENCY- SHUTS OFF AIRWAY -bacterial croup disorder -rapid onset 2-6 hrs -RARE but dangerous Epiglottitis Signs and Symptoms: - Rapid progressive sx- worsen 2-4 hrs - -dysphasia, stridor- aggravated when supine, drooling, high fever, toxic looking, rapid pulse and resp, muddled voice, MOUTH BREATHING AND HYPEREXTENDED NECK- tripod position - Hallmark sx- cherry red epiglottis - INTUBATE, SEDATE TO PROTECT AIRWAY - TX WHILE INTUBATED Treatment of Epiglottitis Treatment: Keep calm and avoid anxiety and crying. Immediate endotracheal tube for airway patency.  Antibiotic administration. Tracheitis ❖ Viral or bacterial; more common in fall and winter. ❖ Typically Bacterial Croup Disorder (the viral leads to bacterial anyways) ❖ More common in males than females. ❖ Clinical manifestations: o Toxic appearance o Croupy cough, dysphonia, and hoarseness o High fever but no drooling o Stridor that does not improve with positioning o Thick, purulent secretions ❖ Treatments: o Antibiotic administration o Fluids for rehydration o Maintain patent airway and oxygenation o Mucolytics o Lower Airway Respiratory Disorders Bronchiolitis RSV Pneumonia Bronchitis Asthma Bronchiolitis- RSV Commonly caused by RSV as RSV progresses Cells in bronchioles die and accumulate and obstruct. Mild cough, rhinorrhea, and congestion Worsening symptoms after 2 days Symptomatic treatment; self-limiting Able to take air in But difficult to expel air- causing air trapping Interferes with normal exchange of gases in the lungs. Transmission- direct contact with respiratory secretions In adults- viral cold In kids- extremely serious RSV Signs and Symptoms Mild and wet cough, rhinorrhea, and congestion With or without fever Difficulty eating d/t nasal congestion Worsening symptoms after 2 days, can begin signs of respiratory distress Lethargy Respiratory Distress - HALLMARK- worse on day 2, THE WORST at day 3 RSV Problems and Interventions RSV Treatment 1. Supportive – isolation 2. Hydration, NPO if RR>60 4. Fluids 5. Saline nebs- may try bronchodilators 4. Most critical time 48-72 hours after onset of cough and dyspnea, usually rapid and complete recovery ØIn preemies less than 35 weeks, that have BPD Synagis (Palivizumab) - Can room rsv kids together - Vaccine for premies for RSV Bronchitis Inflammation of trachea, bronchi, and bronchioles Usually viral Coarse barking cough, chest pain, and thick sputum Self-limiting; treat symptomatically (humidification) May vomit thick mucus Barking cough- more croup Pneumonia - Infection or inflammation of lower aiways- bacterial, viral, community or hosp aquired Pneumonia Clinical Manifestations Fever Tachypnea Cough Nausea and vomiting Irritable, restless, and lethargic Pallor Treatment for Pneumonia Monitor for respiratory distress. Encourage coughing and deep breathing. Antibiotics? Tuberculosis Lung infection with acid-fast bacilli Risk factors can be environmental or immune-related Spreads by airborne droplets Primary and secondary forms Manifestations: o Persistent cough o Night sweats o Fevers o KIDS CAN HAVE IT W NO SX Diagnostic testing: Tuberculin skin testing Chest x-ray QuantiFERON gold testing Long-term antibiotic treatment Non-Infectious Respiratory Disorders Foreign Body Aspirations Acute Respiratory Distress Syndrome Pneumothorax BPD Foreign Body Aspiration Inhalation of object into respiratory tract Manifestations: cough, dyspnea, stridor, and hoarseness Severe respiratory distress Foreign body removal Prevent with anticipatory guidance -scan may not pick up plastic! On x-ray - use camera- bronchoscopy Acute Respiratory Distress Syndrome - Acute, diffuse, inflammatory lung injury - -NONCOMPLIENT LUNGS - Direct/undirect injury - Bilateral opacities on x-ray ARDS ICU Care Intubation Positive pressure mechanical ventilation- PPV Antibiotics, diuretics, and vasodilators Decrease pulmonary vascular resistance Gastric ulcer prophylaxis - Prone position not necessary Pneumothorax Accumulation of air in pleural space Spontaneous, traumatic, or tension Manifestations: tachypnea, dyspnea, respiratory distress, hypoxemia, and tracheal deviation Treatment: chest tube placement, supplemental oxygen, and monitor respiratory status Open: cover with airtight seal Tension: emergent needle aspiration TRACHIAL DEVIATION, UNEQUAL CHEST RISE, ABSENT LUNG SOUNDS, CHEST TUBE Bronchopulmonary Dysplasia (BPD)- COPD IN BABY Chronic obstructive pulmonary disorder. Occurs from prolonged use of supplemental oxygen and positive pressure ventilation after premature birth. 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 to prevent fluid overload. May require tracheostomy.- to get over rough period trying to figure out how to breathe CAUSE- born prematurely, excensive time in NICU Treatment for BPD Positioning, humidified supplemental oxygen, chest physiotherapy, bronchodilators, and suction. Cluster and organize nursing care. Diuretics to prevent fluid overload. May require tracheostomy. PP2 Asthma and CF Asthma - Most common chronic condition in kids - Chronic inflammation in airways - Intermittent bronchoconstriction, increased mucus, airway remodeling Co-Morbid Conditions that may Affect Asthma Environmental Secondhand smoke exposure or being a smoker Maternal smoking during pregnancy Chronic stress and/or depression Obesity or over-weight Obstructive Sleep Apnea Rhinitis/sinusitis Allergies Ethnicity (African American at greater risk) Low BW Asthma Pathway Asthma Treatment -tx- meds, control triggers, education -triggers- pollen, mold, pet danger, tobacco smoke, anxiety, dust mites -intervention based on peak-flow results Subjective Assessment Data to Collect 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 Assessment- Identification of phenotypes has clinical relevance Pattern of inflammation Eosinophilic Neutrophilic Determine if Allergic Eosinophilic Disease – T2 inflammation factor (increased exhaled FeNO, eosinophil count, IgE level) 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 the signs and symptoms of asthma Spirometry recommended for patients > 5 years of age PCP seeing patient at least every 2-6 weeks until control is achieved Chronic asthma visits Referral to asthma specialist Required hospitalization or 2 rounds of oral prednisone Not reaching goals of treatment in 3-6 months Co-morbidities that complicate asthma (nasal polyps) Additional diagnostic testing Education for a Partnership in Care Partnership between patient/parent and provider Effective and repeated patient/parent education Review basic facts about asthma at every visit Review use of meds at every visit Ensure meds are being taking correctly at every visit Ensure adequate self monitoring Asthma Action Plan Use to determine daily actions to control asthma Adjust medications in response to symptoms Seek medical care as needed Medications to Treat Asthma: Quick Relief Used in acute episodes Generally short-acting beta2 agonists- albuterol Medications to Treat Asthma: Long-Term Control Taken daily over a long period of time Used to reduce inflammation, relax airway muscles, and improve symptoms and lung function Inhaled corticosteroids- prednisone Long-acting beta2-agonists Leukotriene modifiers Inhalers and Spacers Spacers can help patients who have difficulty with inhaler use and can reduce potential for adverse effects from medication. Nebulizers Machine produces a mist of the medication Used for small children or for severe asthma episodes No evidence that it is more effective than an inhaler used with a spacer Asthma Action Plan Cystic Fibrosis Autosomal recessive genetic disorder: abnormalities in body’s salt, water, and mucus- making cells Can asymptomatically carry the gene. Thick, sticky mucus builds up in lungs, sinuses, liver, pancreas, intestines, and reproductive organs. Manifestations: steatorrhea, failure to thrive, tachypnea, wheezing, retractions, recurrent pneumonia Sweat chloride testing Treat and manage the affected systems: Pancreatic enzyme replacement Percussion and drainage Mucolytics Diet: high protein, high calorie, high fat CF Genes CFTR – cystic fibrosis transmembrane conductance regulator – protein found 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: Airway surface is depleted Mucociliary clearance is reduced Mucous viscosity is increased Failure to resorb NaCl CF patients do not make more mucus than non-CF CF Pathophysiology The mucous secreted by the exocrine glands is abnormally viscous, sticky and tenacious. Mucous adheres to the walls of glandular ducts and eventually obstructs them. Obstruction causes fibrosis of glands themselves. This process occurs in many parts of the body, most affected are... Respiratory Tract- viscous mucus lead to infection and chronic inflammatory process. COPD and clubbing eventually occur with barrel chest CF Affecting Respiratory viscous mucus lead to infection and chronic inflammatory process. COPD and clubbing eventually occur with barrel chest CF Affecting GI thick mucous obstructs the pancreatic ducts- eventually becomes fibrotic so does not make and release enzymes needed for digestion- (lipase, amylase and tryptase- MALABSORPTION- NO INSULIN ). Leads to decreased absorption of nutrients. CF Affecting Integumentary Causes sweat glands to produce sweat containing 4 times the concentration of NaCL- this is most consistent observation for all children with CF. Sweat test is the diagnostic tool for CF -NOT RETAINING SALT GET RID OF IT 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- antibiotic med CF Precautions Minimize the time that 2 people with CF spend in one place, minimum of 6 feet should be maintained Separate classrooms, bathrooms, drinking fountains Different times in gathering areas – gym, cafeteria, nurse office  Assign lunch tables, lockers as far away from each other Notify staff id student with CF goes to another room to make sure another person with CF is not present What about siblings??