Presentation on theme: "Respiratory Disorders"— Presentation transcript:
1Respiratory Disorders Pat Volker, RN, BSNMay 2007
2Objectives 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.
3Objectives Describe disorders involving the upper airway CroupEpiglottitisForeign body airway obstructionDescribe disorders involving the lower airwayBronchiolitis (RSV)Asthma (RAD)PneumoniaCystic Fibrosis
4Review 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.
5Components of Respiratory Tract Upper AirwayNose – 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 cartilageUpper tracheaLower AirwayLower tracheaMainstem bronchi – right more vertical than leftBronchioles – distribute air to alveoliAlveoli – gas exchange occurs by simple diffusion between inspired air and the bloodstream
7Thoracic Cavity Right three-lobed lung Left two-lobed lung Mediastinum EsophagusTracheaLarge blood vesselsHeart
8Age-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 breathingEpiglottis is U-shaped, higher and anterior leaving it more prone to infection and trauma.Lower airway cartilage is soft and compressible.
9Age-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.
10Age-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.
11Age-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.
12Age Groups Neonate Infant Toddler Preschool School Age Adolescent Birth - 1 month1 Month - 1 YearYearsYearsYearsYears
13Normal Age VariationsNeonates 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.
14Normal Age VariationsChildren < 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.
15Respiratory Assessment Normal Respiratory RatesNeonateInfantToddlerPreschoolerSchool AgeAdolescent
16Respiratory 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 AssessmentInspectionAuscultationPalpation
17Visually Assess: Across the Room Visual assessments should be completed before disturbing the child, if possible.Rate/ Depth/ Symmetry of respirations should be assessed for one full minuteWork of Breathing: Look for:Nasal FlaringRetractionsLevel of ConsciousnessColorLocation of Retractions
18What signs do you see of increased work of breathing? Nasal FlaringApprehensive lookRetractionsPectus excavatum
19Inspect Note respiratory rate Depth Nail Beds Use of accessory muscles Is there paradoxical chest and abdominal movement?Nail BedsColorClubbing
20Inspect Shape of Thorax Sternum Infants – rounded, gradually changes to a more flattened anterioposterior diameter (rounded or barrel chest indicates chronic lung disease).SternumProtuberant – Pectus CarinatumDepressed – Pectus ExcavatumPectus Carinatum
21Auscultate Are breath sounds equal? Do you hear adventitious breath sounds?Is aeration adequate?Are there any abnormal heart sounds?
22Breath SoundsStridor – inspiratory sound usually due to an upper airway obstruction from a narrowing or partial narrowing of the airwayWheezing – 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
23Breath SoundsRales (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.
24Palpate Assess for: Respiratory excursion – symmetry of movement TendernessCrepitus - 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 traumaBony deformities
26Respiratory DistressClinical state characterized by increased work of breathing.
27Respiratory Distress Early Tachypnea Tachycardia Use of accessory musclesNasal FlaringAnxiety / IrritabilityDiminished breath soundsTripod Position
28Respiratory Distress Late Phase Decreased level of consciousness Head bobbingDecrease in muscle toneCyanosisDecrease in respiratory rate - ominous signFatigue
29Respiratory DistressClinical 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!!!!
30Respiratory FailureClinical diagnosis resulting from inadequate elimination of CO2 and inadequate oxygenation of the blood.
31Respiratory FailureA child who progresses to respiratory failure needs critical interventions – use your ABC’s!Support the airway – open and clear the airwaySupport breathing – O2, pulse oximetry, may need intubationSupport circulation – monitor heart rate, establishvascular access
33Respiratory Disorders Can be:AcuteChronicLife ThreateningEarly detection and intervention is vital!
34Upper 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 breathingAffects6 months – 3 yrs; greater incidence in malesEtiologyUsually viral, most commonly parainfluenzaSeasonal ConsiderationsLate autumn – early winter
35Upper Airway Disorders Croup (Laryngotracheobronchitis)Clinical PicturePreceded by cold symptoms, barking cough, inspiratory stridor, worse at night and with agitation, low grade fever, anorexia, malaiseSevere cases may have cyanosis, retractionsCan proceed to obstructionTreatmentCool humidified air, keep child calm, nebulized racemic epi, dexamethasone, pulmocort, fluidsMay rebound after 4 hours
38Upper Airway Disorders EpiglottitisRapidly progressive bacterial infection of the epiglottis and surrounding tissue.AffectsUnvaccinated children, adultsEtiologyAlmost always caused by H flu, type BIncidence in children greatly decreaseddue to HIB vaccineSeasonal ConsiderationsNone
39Upper Airway Disorders EpiglottitisClinical PictureSudden onset high fever, respiratory distress, appears sick, drooling, severe dysphagia, stridor, little or no cough, cherry red epiglottis, severe sore throatTreatmentREQUIRE IMMEDIATE ATTENTION!!!Emergency airway management, avoid agitation, place in position of comfort, oxygen, IV antibiotics
40Point of airway obstruction – epiglottitis vs. croup
42Upper Airway Disorders Foreign Body Airway ObstructionAffectsMost common in older infants and children 1 –3 yrs.Clinical PictureGagging, refusal to eat, vomiting, cough, stridor, droolingSeverity determined by location and type of object and extent of obstruction
43Upper Airway Disorders Foreign Body Airway ObstructionTreatmentHeimlichBack blows/chest thrustsBest treatment – PREVENTION!Avoid hotdogs, hard candy, nuts, grapes, balloonsUniversal Choking Sign
44Lower Airway Disorders Asthma ( RAD)Most common chronic disease in kidsClassified by severity (based on symptom frequency, use of medications, nighttime symptoms, peak flows):Mild intermittentMild persistentModerate persistentSevere persistentAffectsAll ages
45Lower Airway Disorders Asthma (RAD)Seasonal ConsiderationsWeather changes can trigger exacerbationClinical PictureExpiratory wheezing, cough (worse at night), difficulty breathing, chest tightness, sinusitis, allergic rhinitis, atopic dermatitis, symptoms that worsen with airborne allergens or exerciseWorsening SymptomsDyspnea, productive cough, tachypnea, use of accessory muscles, nasal flaring, prolonged expiration, decreased LOC
47Lower Airway Disorders Asthma (RAD)ER TreatmentOxygen therapyInhaled Albuterol or in combination with Atrovent- may be continuousIV corticosteroidsTerbutalineMagnesium Sulfate – PICU admitKetamine – PICU admitEducationReinforce disease process, symptom management, peak flow meter usage, medication usage and avoidance of allergens/triggers
48Lower Airway Disorders Bronchiolitis (RSV)AffectsPrimarily infants 2 – 6 months, up to 2 years; greater incidence in males and infants with bronchopulmonary dysplasia (BPD)EtiologyRespiratory syncytial virus (RSV)Seasonal ConsiderationsLate fall/winter/early spring
49Lower Airway Disorders Bronchiolitis (RSV)Characterized by:Inflammation of the bronchiolesAirway edemaIncreased mucous productionSmall airway obstructionAir trappingAtelectesis – produces ventilation perfusion mismatch, leading to hypoxemia and hypercarbia
51Lower Airway Disorders Bronchiolitis (RSV)TransmissionDroplets or direct contact with secretionsInfectious before symptoms appear and for 1 – 3 weeksPreventionEducation of family and staff regarding careful and frequent handwashing, good hygiene, disposal of tissues, cleaning and disinfection of toys,
52Lower Airway Disorders PneumoniaAffectsAll agesEtiologyBacterial, viral or fungalSeasonal ConsiderationsMay be more prevalent in fall/winter
54Lower Airway Disorders Cystic FibrosisAffectsAll ages, diagnosismade by sweat testEtiologyInherited genetic disease. Causes obstruction of and abnormal secretions from sweat glands. Pulmonary symptoms are caused by thick, tenacious mucous and infection.
55Lower Airway Disorders Cystic FibrosisSeasonal ConsiderationsCareful infection control, especially during cold and flu seasonClinical PictureHalf initially present with pulmonary symptoms – productive coughGI symptoms – rectal prolapse, malabsorption, can develop diabetes, cirrhosisGU symptoms – infertility
56Lower Airway Disorders Cystic FibrosisTreatmentPulmonaryCPT, antibiotics, medications to decrease viscosity of secretions, oxygen therapy, hospitalization for IV antibioticsHeart/lung transplantGIReplacement of pancreatic enzymes, high protein/high calorie diet
57QuestionYou 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?Notify House OfficerKeep child calmNotify Respiratory Therapy for treatmentReassess, reassess, reassess!Administer O2 via mask.
58QuestionBecause 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
59QuestionAn inspiratory sound usually due to an upper airway obstruction from a narrowing or partial narrowing of the airway is called:StridorWheezingCracklesRhonchiStridor
60QuestionYou 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 O2Have her call her mother on the phone to try and calm her downObtain pulse oxOffer her a drink of waterAssess breath soundsRun for help√√√
61QuestionThe 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 assistanceCall the Rapid Response Team or a Code Blue, begin ventilation supportAsk your Nurse Manager for one-to-one care for this patientSend the NA for a meal for this patient√
62ReferencesWhaley/Wong, Nursing Care of Infants and Children. Seventh Edition.