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Respiratory Disorders Pat Volker, RN, BSN May 2007.

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2 Respiratory Disorders Pat Volker, RN, BSN May 2007

3 Objectives The learner will be able to: State the functions and components of the respiratory tract. Understand the effect of respiratory disorders on cardiac status. Recognize age-specific concerns in caring for children with respiratory illnesses. State the signs and symptoms of respiratory distress.

4 Objectives Describe disorders involving the upper airway Croup Epiglottitis Foreign body airway obstruction Describe disorders involving the lower airway Bronchiolitis (RSV) Asthma (RAD) Pneumonia Cystic Fibrosis

5 Review of Respiratory Tract What is the function of the respiratory system? To distribute air and exchange gases so that cells are supplied with oxygen for body metabolism while carbon dioxide is removed.

6 Components of Respiratory Tract Upper Airway Nose – passageway that moistens and filters air. Pharynx – passageway for entry and exit of air. Role in vocalization. Tonsils located here. Larynx- Glottis and epiglottis located here. Cricoid cartilage Upper trachea Lower Airway Lower trachea Mainstem bronchi – right more vertical than left Bronchioles – distribute air to alveoli Alveoli – gas exchange occurs by simple diffusion between inspired air and the bloodstream


8 Thoracic Cavity Right three-lobed lung Left two-lobed lung Mediastinum Esophagus Trachea Large blood vessels Heart

9 Age-Specific Considerations “Children are not small adults!” The anatomical differences and the immaturity of the respiratory and immune systems are primarily responsible for increased susceptibility of the child to respiratory infections and obstruction. Infants are nose breathers – nasal congestion or trauma may result in severe respiratory distress. Infant ribs are horizontal and cartilaginous - ↓ chest diameter and abdominal breathing Epiglottis is U-shaped, higher and anterior leaving it more prone to infection and trauma. Lower airway cartilage is soft and compressible.

10 Age-Specific Considerations “Children are not small adults!” Alveolar surface is decreased (24 million vs. 300 million in adults) – children breathe faster than adults. Respiratory rates increase further with distress. Alveoli more prone to collapse. Infant head is large in proportion to body. Infant tongue is large in proportion to oral cavity and can block airway. Larynx is anterior and high – may cause increased risk for aspiration.

11 Age-Specific Considerations “Children are not small adults!” Airway structures are smaller and more easily obstructed. Cricoid cartilage is the narrowest part of the airway and provides natural cuff until 8 yrs. Also a frequent site for foreign-body obstruction. Smaller and thinner chest wall. RLL and LLL should be assessed posteriorly for children < 8 yrs.

12 Age-Specific Considerations “Children are not small adults!” Tidal volume – 10 ml/kg vs. 500 ml/kg in adults. Diaphragm is the major muscle of breathing in children < 7 yrs. Increased metabolic rate and O2 consumption. Hgb is 75% of the adult – cyanosis develops when 5 gms of Hgb are desaturated or as much as 50% of blood is deoxygenated making cyanosis a late sign of distress.

13 Age Groups Neonate Infant Toddler Preschool School Age Adolescent Birth - 1 month 1 Month - 1 Year Years Years Years Years

14 Normal Age Variations Neonates are periodic breathers – periods of rapid breathing followed by short (< 15 seconds) periods of apnea without color changes are normal up to six weeks of age. Infants are obligate nose breathers – simple upper respiratory infections may cause severe problems.

15 Normal Age Variations Children < 6-7 years are abdominal breathers – gastric distention, bowel obstruction and major abdominal surgery can effect respiratory status. Children over age 7 have a more adult-like thorax and are chest breathers.

16 Respiratory Assessment Normal Respiratory Rates Neonate Infant Toddler Preschooler School Age Adolescent

17 Respiratory Assessment Respiratory disorders account for approximately ½ of illnesses in children under 5 years of age. A complete respiratory assessment should include the following: Visual Assessment Inspection Auscultation Palpation

18 Visually Assess: Across the Room Rate/ Depth/ Symmetry of respirations should be assessed for one full minute Work of Breathing: Look for: Nasal Flaring Retractions Level of Consciousness Color Visual assessments should be completed before disturbing the child, if possible. Location of Retractions

19 What signs do you see of increased work of breathing? Nasal Flaring Apprehensive look Pectus excavatum Retractions

20 Inspect Note respiratory rate Depth Use of accessory muscles Is there paradoxical chest and abdominal movement? Nail Beds Color Clubbing

21 Inspect Shape of Thorax Infants – rounded, gradually changes to a more flattened anterioposterior diameter (rounded or barrel chest indicates chronic lung disease). Sternum Protuberant – Pectus Carinatum Depressed – Pectus Excavatum Pectus Carinatum

22 Auscultate Are breath sounds equal? Do you hear adventitious breath sounds? Is aeration adequate? Are there any abnormal heart sounds?

23 Breath Sounds Stridor – inspiratory sound usually due to an upper airway obstruction from a narrowing or partial narrowing of the airway Wheezing – can be inspiratory or expiratory, usually due to a narrowing of the airway related to asthma, foreign body or tumor. Grunting –can be a sign of pneumonia, pulmonary edema or respiratory distress syndrome. Absent or Diminished

24 Breath Sounds Rales (Crackles) – can be coarse or fine depending on the size of the airway. Caused by air passing through fluid. Rhonchi ( Rattles) – caused in large upper airways by thick secretions. Usually continuous sounds.

25 Palpate Assess for: Respiratory excursion – symmetry of movement Tenderness Crepitus - peculiar crackling, crinkly, or grating feeling or sound under the skin, around the lungs, or in the joints. Subcutaneous emphysema - occurs when air gets into tissues under the skin covering the chest wall or neck. This can happen due to stabbing, gun shot wounds, other penetrations, or blunt trauma Bony deformities

26 Respiratory Distress and Failure

27 Respiratory Distress Clinical state characterized by increased work of breathing.

28 Respiratory Distress Early Tachypnea Tachycardia Use of accessory muscles Nasal Flaring Anxiety / Irritability Diminished breath sounds Tripod Position

29 Respiratory Distress Late Phase Decreased level of consciousness Head bobbing Decrease in muscle tone Cyanosis Decrease in respiratory rate - ominous sign Fatigue

30 Respiratory Distress Clinical manifestations of respiratory distress can be subtle and are often not recognized early! Excellent assessment skills can prevent the progression of respiratory distress to respiratory failure. One of the major causes of cardiac arrest in children is respiratory failure!!!!

31 Respiratory Failure Clinical diagnosis resulting from inadequate elimination of CO2 and inadequate oxygenation of the blood.

32 Respiratory Failure A child who progresses to respiratory failure needs critical interventions – use your ABC’s! Support the airway – open and clear the airway Support breathing – O2, pulse oximetry, may need intubation Support circulation – monitor heart rate, establish vascular access

33 Respiratory Disorders

34 Can be: Acute Chronic Life Threatening Early detection and intervention is vital!

35 Upper Airway Disorders Croup (Laryngotracheobronchitis) Inflammation and narrowing of larynx, trachea, bronchi and bronchioles. Obstruction is caused by swelling and increased secretions leading to increased work of breathing Affects 6 months – 3 yrs; greater incidence in males Etiology Usually viral, most commonly parainfluenza Seasonal Considerations Late autumn – early winter

36 Upper Airway Disorders Croup (Laryngotracheobronchitis) Clinical Picture Preceded by cold symptoms, barking cough, inspiratory stridor, worse at night and with agitation, low grade fever, anorexia, malaise Severe cases may have cyanosis, retractions Can proceed to obstruction Treatment Cool humidified air, keep child calm, nebulized racemic epi, dexamethasone, pulmocort, fluids May rebound after 4 hours

37 Position of comfort


39 Upper Airway Disorders Epiglottitis Rapidly progressive bacterial infection of the epiglottis and surrounding tissue. Affects Unvaccinated children, adults Etiology Almost always caused by H flu, type B Incidence in children greatly decreased due to HIB vaccine Seasonal Considerations None

40 Upper Airway Disorders Epiglottitis Clinical Picture Sudden onset high fever, respiratory distress, appears sick, drooling, severe dysphagia, stridor, little or no cough, cherry red epiglottis, severe sore throat Treatment REQUIRE IMMEDIATE ATTENTION!!! Emergency airway management, avoid agitation, place in position of comfort, oxygen, IV antibiotics

41 Point of airway obstruction – epiglottitis vs. croup


43 Upper Airway Disorders Foreign Body Airway Obstruction Affects Most common in older infants and children 1 –3 yrs. Clinical Picture Gagging, refusal to eat, vomiting, cough, stridor, drooling Severity determined by location and type of object and extent of obstruction

44 Upper Airway Disorders Foreign Body Airway Obstruction Treatment Heimlich Back blows/chest thrusts Best treatment – PREVENTION! Avoid hotdogs, hard candy, nuts, grapes, balloons Universal Choking Sign

45 Lower Airway Disorders Asthma ( RAD) Most common chronic disease in kids Classified by severity (based on symptom frequency, use of medications, nighttime symptoms, peak flows): Mild intermittent Mild persistent Moderate persistent Severe persistent Affects All ages

46 Lower Airway Disorders Asthma (RAD) Seasonal Considerations Weather changes can trigger exacerbation Clinical Picture Expiratory wheezing, cough (worse at night), difficulty breathing, chest tightness, sinusitis, allergic rhinitis, atopic dermatitis, symptoms that worsen with airborne allergens or exercise Worsening Symptoms Dyspnea, productive cough, tachypnea, use of accessory muscles, nasal flaring, prolonged expiration, decreased LOC

47 Lower Airway Disorders Asthma (RAD) Treatment Allergen control Medications Bronchodilators (inhaled or po)Albuterol AnticholinergicsAtrovent Anti-inflammatory CorticosteroidsPrednisone

48 Lower Airway Disorders Asthma (RAD) ER Treatment Oxygen therapy Inhaled Albuterol or in combination with Atrovent- may be continuous IV corticosteroids Terbutaline Magnesium Sulfate – PICU admit Ketamine – PICU admit Education Reinforce disease process, symptom management, peak flow meter usage, medication usage and avoidance of allergens/triggers

49 Lower Airway Disorders Bronchiolitis (RSV) Affects Primarily infants 2 – 6 months, up to 2 years; greater incidence in males and infants with bronchopulmonary dysplasia (BPD) Etiology Respiratory syncytial virus (RSV) Seasonal Considerations Late fall/winter/early spring

50 Lower Airway Disorders Bronchiolitis (RSV) Characterized by: Inflammation of the bronchioles Airway edema Increased mucous production Small airway obstruction Air trapping Atelectesis – produces ventilation perfusion mismatch, leading to hypoxemia and hypercarbia

51 Lower Airway Disorders Bronchiolitis (RSV) Clinical Picture Present with cough, rhinorrhea, nasal congestion, slight intermittent fever over 3 –5 days Progresses to wheezing, ↑ respiratory rate, dyspnea, nasal flaring, ↑ heart rate, retractions, irritability, poor feeding, vomiting Treatment Cool mist humidification, hydration (small amounts, frequent intervals), ↑ HOB, O2 Severe – symptomatic hospital management

52 Lower Airway Disorders Bronchiolitis (RSV) Transmission Droplets or direct contact with secretions Infectious before symptoms appear and for 1 – 3 weeks Prevention Education of family and staff regarding careful and frequent handwashing, good hygiene, disposal of tissues, cleaning and disinfection of toys,

53 Lower Airway Disorders Pneumonia Affects All ages Etiology Bacterial, viral or fungal Seasonal Considerations May be more prevalent in fall/winter

54 Lower Airway Disorders Pneumonia Clinical Picture Acute onset fever, productive cough, pleural pain, rales, ↓ breath sounds. May see lethargy, vomiting, diarrhea, poor feeding. Treatment Viral – symptomatic Bacterial – O2 therapy, CPT, antipyretics, fluids, cool mist, antibiotics

55 Lower Airway Disorders Cystic Fibrosis Affects All ages, diagnosis made by sweat test Etiology Inherited genetic disease. Causes obstruction of and abnormal secretions from sweat glands. Pulmonary symptoms are caused by thick, tenacious mucous and infection.

56 Lower Airway Disorders Cystic Fibrosis Seasonal Considerations Careful infection control, especially during cold and flu season Clinical Picture Half initially present with pulmonary symptoms – productive cough GI symptoms – rectal prolapse, malabsorption, can develop diabetes, cirrhosis GU symptoms – infertility

57 Lower Airway Disorders Cystic Fibrosis Treatment Pulmonary CPT, antibiotics, medications to decrease viscosity of secretions, oxygen therapy, hospitalization for IV antibiotics Heart/lung transplant GI Replacement of pancreatic enzymes, high protein/high calorie diet

58 Question You are caring for a 6 month old infant. He has a 2 day history of fever, cough and runny nose. The child is alert and active. His O2 mask is lying on the bed. Upon assessing the child you notice a frequent barky cough, stridor, moderate retractions and crackles in both lung bases. His skin is warm with good pulses and capillary refill of 2 seconds. His HR is 170/min, respirations are 50. What interventions should be initiated for this child? Administer O2 via mask. Notify House Officer Notify Respiratory Therapy for treatment Keep child calm Reassess, reassess, reassess!

59 Question Because an infant’s tongue is large in proportion to their oral cavity, it may be the cause of a blocked airway. True or False? True

60 Question An inspiratory sound usually due to an upper airway obstruction from a narrowing or partial narrowing of the airway is called: Stridor Wheezing Crackles Rhonchi Stridor

61 Question You are caring for a 16 year old asthmatic. She calls you into the room and says, “I can’t breathe”. Your assessment reveals an anxious looking teen with pursed lips. She is pale. Respiratory rate is 36. She has suprasternal retractions and looks distressed. You initial responses should include: Apply O2 Have her call her mother on the phone to try and calm her down Obtain pulse ox Offer her a drink of water Assess breath sounds Run for help √ √ √

62 Question The child from the previous slide continues to deteriorate. Her respiratory rate decreases to 8. She has severe retractions and no wheezing. Your response now should include: Call the ER for assistance Call the Rapid Response Team or a Code Blue, begin ventilation support Ask your Nurse Manager for one-to-one care for this patient Send the NA for a meal for this patient √

63 References Whaley/Wong, Nursing Care of Infants and Children. Seventh Edition.

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