The Child with Respiratory Dysfunction

Abdulmahdi A. Hasan*
*Ph,D, pediatric & psychiatric Mental Health Nursing

The Child with Respiratory Dysfunction

? Acute Respiratory Infections
Common
Virus- respiratory syncytial virus upper resp. passages.
B-hemolytic streptococcus
Staphylococcus aureus,
Homophiles influenza
Chlamydia trachomatis
And pneumococci
DX:-
Clinical manifestation
Physical examination
Radiographs
Lab cultures

? Acute Upper Respiratory Infections
Nasopharyngitis
Viral infection, rhinovirus.
Like common cold in adults, or rhinitis
Complications more often otitis media, sinusitis
Pharyngitis:
Site is pharyngitis, including the tonsils
Uncommon before 1 year
Peak incidence betw. 4 and 7 years of age.
Cause: viruses or A B-hemolytic streptococcus
Complication; otitis media, acute cervical adenitis, tertopharyngeal abscess, and lower resp. tract infection.
Streptococcal infection sometimes triggers a response in the heart (rheumatic fever) or kidneys (acute glomerulonephritis).

? Tonsillitis
Are masses of lymphoid tissue encircling the pharyngeal cavity.
Palatine or faucial tonsillis, pharyngeal, lingual, tubal (found near the posterior nasopharynx opening of the Eustachian tubes).
filtering function-protection from pathogens
Bigger in children than adults.

? Tonsillitis
Viral, symptomatic treatment
Antibiotic for bacterial
Strep. Abt. for 10 days
Tonsillectomy, (palatine) controversial,
? Should not be removed before 3-4 years of age.
? Indicated for massive hypertrophy that cause difficulty eating or breathing.
Adenoidectomy: removal of adenoids, indicated for recurrent otitis media, to prevent hearing loss and may be done before 3 years of age.

Nursing consideration
Providing comfort.
Soft liquid diet.
Cool-mist vaporizer
Warm saline gargles, throat lozenges, and analgesic/antipyretic as acetaminophen
are useful to promote comfort.

? Otitis Media (OM)
Middle ear infection.
Most prevalent disease of early childhood.
The incidence is highest in children age 6 months to 2 years. small increase at 5- 6 years. uncommon after 7 years, highest winter months, around smokers.
Breast fed lower risk
Bacterial, inflammation block Eustachian tube.
Dysfunction of Eustachian tube, trapped secretions in middle ear and air, air get absorbed by mucosa, creating negative pressure, and when it opens it pulls bacteria to the middle ear leading to infection.

? Terminology for OM:-
Acute OM (AOM): s/sy lasting for 3 weeks
OM with effusion (OME): OM with collection of fluids in middle ear.
Subacute OM: OM lasting for 3 weeks to 3 month
Chronic OM with effusion: OM beyond 3 months.

? OM
Dx – otoscopy
Culture
RX-Antibiotic ampicillin or amoxicillin improve within 48 to 72 hours.
Myringotomy- surgical incision of the ear drum for children with suppuration
Tympanoplasty insertion of venting tubes, under general anesthesia, tympanostomy remain in the ear average 6 months before spontaneous rejection (controversial).
Ice back to affected ear for Myringotomy
Ear plugs when swimming or taking shower
Heating pad to affected side may reduce discomfort.

If draining, clean external canal with sterile cotton swab.
Teach parents about possible complications:
1 - Conductive hearing loss,
2- A perforated and scared eardrum
3 - Mastoiditis, inflammation of the mastoid air cell system
4 - Cholesteatoma, cyst like lesion that can invade and destroy surrounding auditory structures
5 - Intracranial infections such as meningitis
OM can be reduced by sitting child upright when feeding, gentle nose blowing esp. when cold, removing smoking and allergen from surroundings

? Cystic Fibrosis
Most common serious pulmonary and gastric disorder of children, is a multi system disorder primarily affecting the exocrine (mucous producing) glands and accounts for a large percentage of lung disease in children
It appears in varying severity.
Inherited, Autosomal-recessive trait, need both parents to give him the gene
Incidence 1 in 1600 births in predominantly white populations, equal sex distribution
Basic defect unknown
Unrelated clinical feature;
Increased viscosity of mucous gland secretion.
Increase of sweat electrolytes
Increased organic and enzymatic constituents of saliva
Possible abnormalities in autonomic nervous system.

Earliest sign, meconium ileus
Pancreas, fibrosis, impaired digestion-frothy undigested stools
GI: prolapsed rectum, intestinal obstruction from undigested or impacted feces.
Pulmonary complication: most serious and threat to life. Retain thick viscous mucous.

DX:
1 - Family history
2 - No pancreatic enzymes
3 - Increased electrolyte concentration
4 - Chronic pulmonary involvement salty skin important sign.
RX: good nutrition, prevent pulmonary Infections, help psychological adjustment

Pulmonary therapy

Chest PT, and drainage
PT not after meals
Breathing exercise
Oxygen as needed
Mucolytic & expectorants
Antibiotic

Exercise
GI:
- Replacement of pancreatic enzymes with meals
- Balanced diet, high in calories, restriction of fat not indicated, multivitamins
prescribed
- Salt supplementation esp. in hot weather
With Rx many are reaching adulthood, depending on severity of disease

? CROUP
Croup is a general term applied to a symptom complex characterized by hoarseness, a resonant cough (barking), varying degrees of respiratory distress resulting from swelling or obstruction in the larynx.
Croup affect larynx, trachea, bronchi, larynx dominate due to clinical manifestations on voice and breathing.
LTB: Laryngotracheobronchitis (3month-8 years), in very young children, while epiglottitis is more in older children (1-8 yrs)

? Acute Epiglottitis
Or acute supraglottitis: serious obstructive inflammatory process occur btw. 3-7 years.
Organism: H. Influenza
LTB & Epiglottitis do not occur together.
Abrupt rapid & progressive, the child may go to bed asymptomatic to wake up later to C/O sore throat, pain, swelling, fever, & looks toxic, insist to sit upright & leaning forward, mouth open and tongue protruding, drooling. Agitation and deteriorated breathing and retraction, and cyanosis.

? Acute Epiglottitis
Quick diagnosis is an emergency and life saving.
Contraindicated tongue depressor until proper personal and availability of Endotracheal intubation (E.T.T.) and ventilation or tracheotomy.
Decrease after 24 hours of IV antibiotic
Corticosteroids for 7 to 10 days
Immunization is recommended at 2 months for H. Influenza.


? LTB
Mostly viral
Airway management
Humidity
ETT if needed.
Hydration adequate, severe resp distress are kept NPO, and use IVs
Nursing: observation, resp. and cardiac assessment, oxygen saturation or ABGs, readiness for intubation and ventilation,

? Acute Spasmodic Laryngitis
Characterized by paroxysmal attacks of laryngeal obstruction that occur mainly at night.
May involve child with allergy, or psychogenic factors
The attack subside in a few hours and the child appears well the next day.
Nursing: cool mist, or warm mist, may need racemic epinephrine

? Infection of Lower Airways
Bronchitis: inflammation of large airways usually associated with upper respiratory infections.
Primarily viral cause-dry nonproductive cough, worse at night and becomes productive in 2-3 days
Limited dz, symptomatic treatment-analgesics, antipyretics, & humidity
Recovery 5-10 days

? Bronchiolitis
Viral infection at the bronchiolar level
Mainly in winter & spring
Rare in children over 2 years
RSV virus is responsible for over half of all episodes
Inflammation, inspiration dilates bronchioles and air go to alveoli, but narrowing on expiration of air passages lead to progressive over inflation and emphysema.

Rx:
symptomatically, with adequate hydration, high humidity, and rest
Mostly Rx at home but hospital if needed.
Lasts 3-10 days, prognosis is good
Pneumonias: inflammation of pulmonary parenchyma
Lobar pneumonia: One or more lobes is involved
Bronchopneumonia: terminal bronchioles

? Pneumonias
Interstitial pneumonia
Pneumonitis - localized acute inflammation of the lung without toxemia related to lobular pneumonia
Viral pneumonia: occur more than bacterial
A typical pneumonia, caused by M. Pneumonia
10 -20% of hospital admission
More in crowded living condition
Recover in 7-10 days followed by 1 wk of convalescence
Hospitalization is rare.

? Bacterial Pneumonia
Abrupt and generally preceded by viral infection.
Local and general sy.
Malaise, fever, cough, shallow respirations, chest pain exaggerated by deep breathing, pain may be refereed to the abd. And confused with appendicitis, rapid deterioration .
Rx: abt., bed rest, liberal oral intake, antipyretic, antitussive for dry cough.
Hospitalization when pleural effusion or empyema and staphylococcal pneumonia.
Thoracentesis: if fluid is suspected in pleural cavity
Good prognosis with early treatment.


? Foreign Body (FB) Aspiration
Small children explore with their mouth.
Examples: seeds, nuts, piece of carrot, popcorn, balloons
DX: based on Hx
Initially Chocking, coughing, wheezing
A FB is always a possibility in acute or chronic pulmonary lesions
Usually when secondary sy. Appear the parents have forgotten the initial episode & cause
CXR: opaque foreign objects

RX:
Instrumental removal of object if needed ASAP.
High humidity after object removal
Antibiotics
Nursing: calm & quiet child, ready to deal with choking.
Chocking ; cannot speak, cyanotic, pointing at neck or chest, collapse- 2 back blows and Heimlich maneuver.
Prevention

? Aspiration Pneumonia
From fluids and foods, secretion, amniotic fluids aspiration, vomitus, hydrocarbons, lipids, talcum powder.
Rx as Pneumonia

? Asthma
Revisable obstructive process characterized by increased responsiveness and inflammation of the airway,
Sy.;
Expiratory wheezing, prolong expiration, tight cough,
Can be very mild to sever cyanosis and fatal asphyxia
Most common cause of school absence
Major portion of admissions at pediatric hospital and ER.
Single most important cause of morbidity in childhood
? Cause:
allergic hyper sensitivity to foreign substances in the air as plant pollens, sometimes no allergic process can be detected, can be caused also by bronchial compression from external pressure, FB, heredatry tendancy,
Many stimuli can provoke an asthma, including viruses, allergens, smoking, cold air, exercise,


? Pathophysiology:
Inflammation & edema of mucous membranes
Accumulation of tenacious secretions from mucous glands
Spasm of the smooth muscles of the bronchi and bronchioles, which decrease the caliber of the bronchioles
Dx: based on clinical Sy., hx, Physical examination, cxr to role out other diseases.

RX:
Allergen control
Drug therapy- bronchodilators, aminophylline, metered dose inhaler, ventolen inhaler, douned, antihistamine, corticosteroids.
Exercise
Chest physiotherapy
Hyposensitization

?Status Asthmaticus
Continue resp. distress (asthma attack) despite vigorous therapy and Rx,
Medical emergency, can lead to resp. failure and result in death if not treated.
Require continuous nursing and cardiovascular monitoring
Agitation due to hypoxia, or sitting up and refusing to lie down, Sy. Of the dz.