1. Elisa A. Mancuso RNC, MS, FNS Professor of Nursing
Respiration
Elisa A. Mancuso RNC, MS, FNS
Professor of Nursing

2. Respiratory Alterations
↑ Risk < 3 years
Smaller upper and lower airways
Underdeveloped supporting cartilage
ineffective clearing of organisms
Immature immune systems
Compensatory Mechanisms
Lungs- ↑ or ↓ RR
Kidneys- retain or filter H+ affects pH
Blood buffer system: H+, HgB, Na
Interact to maintain pH

3. Interpreting ABG’s Know your normal values! PH 7.35-7.45 PaCo2 35-45
< 7.35 = Acidosis > 7.45 = Alkalosis
PaCo
< 35 = Alkalosis > 45 = Acidosis
HCO
< 22 = Acidosis > 26 = Alkalosis
PaO %
< 90 = Hypoxia

4. Respiratory or Metabolic?
ROME
Respiratory opposite (pH & CO2)
Metabolic even (pH & HCO3)
Respiratory reflects PaCO2
↓ CO2 = alkalosis
↑ CO2 = acidosis
Metabolic reflects HCO3 and BE
↓ HCO3 = acidosis
↑ HCO3 = alkalosis

5. Respiratory Alterations
Respiratory Acidosis
↓ PH and ↑ PaCO2
Causes
↓ RR
Neuromuscular problems: BPD, RDS, CF
Respiratory depression and ↑ CO2
Respiratory Alkalosis
↑ PH and ↓ PaCO2
↑ RR ↑ Fever Stress

6. Metabolic Alterations
Metabolic Acidosis
↓ PH and ↓ HCO3
Causes
Renal failure, diarrhea, ketoacidosis
Metabolic Alkalosis
↑ High PH and ↑ HCO3
Vomiting, Meds for ulcers, NaHCO3,
NGT = HCL loss & ↑ HCO3
Diuresis

7. Case Study Mariska, 4 years old presents with following:
RR = 54 C/O Chest tightness
Bilateral expiratory & inspiratory wheezing
Frightened appearance.
ABG pH of 7.27, PaO2 88, PaCO2 48 and HCO3 24.
What is her acid – base status?
Identify each component.
Find the cause
Answer????
At this point her status is respiratory acidosis.
Decreased ability to ventilate appropriately, retained CO2 and lowered the pH.

8. Upper Respiratory Infections URI
Acute pharyngitis and nasopharyngitis
Children get 7-10 colds/year!
Majority is viral = Rhinovirus
Signs and symptoms
low grade fever
sore throat
spontaneous recovery
Self limiting 7-10 days

9. URIs Bacterial Group A beta-hemolytic strep (GABHS) Signs and symptoms
Abrupt onset
Fever >102, chills
Fatigue, HA
Nasal congestion
Abdominal pain & Anorexia
Vomiting, diarrhea
Halitosis
Fire red throat & petechiae
Exudative

10. Treatment of Strep Pharyngitis
Throat culture IN and OUT.
Rapid antigen detection test 60-95% sensitive.
Antibiotics
Prevents serious complication = Rheumatic fever
PEN-VK BID-TID drug of choice x 10 days
Amoxicillin mg/kg/day ÷ BID
↑ tasting and ↓ dosing needed
↑better compliance!
Zithromax 10mg/kg/day 1
5mg/kg day 2-5
Cefdinir (Omnicef) 14 mg/kg/day
Cefixine (Suprax) 8mg/kg/day

11. Treatment (cont) Bed rest Tylenol 10-15mg/kg every 4 hours
√ Infant vs. Child concentration!
Saline gtts and cool mist humidifier
Hydration
Decongestants > 6 months.
Contagious: Separate from others!
Need meds x 24 hours
Then return to school
Feel better in hours!
Must Complete all meds!

12. Tonsils Lymphoid tissue in pharyngeal cavity
Filter and protect respiratory and GI tract
↑ Antibody formation
until 3 years & immune system mature
↑ ↑ size in children until puberty
Inflamed with infections
If chronically enlarged 3+ → 4+
Obstructive Sleep Apnea (OSA)
Difficulty breathing and eating

13. Tonsillitis Persistent cough Dry mucous membranes White patchy exudate
Secondary OM from blocked Eustachian tubes
Viral-
Self- limiting
Palliative measures
Pain & Hydration

14. Tonsillectomy Most common indication today is OSA
4 strep infections/season
Peri-tonsilar Abscess
Post-op care
↑ HOB with pt prone or on side
Encourage fluids PO -No straws!
Medicate for pain (no ASA) and N/V
Ice pack to anterior neck
√ Hemorrhage (5-20%) Go to OR!
(1st 48 hours and then 5-7 days)
↑ ↑ swallowing/vomiting bright red blood
↑↑ RR ↑↑ HR ↑↑ Restlessness
Normal Eschar forms

15. Epiglottitis Medical Emergency
3-6 years
Haemophilus influenza type B (HIB) (50% pre-vaccination)
Dramatic ↓↓ since HIB vaccine
Strep pneumoniae, staph aureous.
Rapid & severe inflammation
of epiglottis and surrounding areas
Complete airway obstruction

16. Signs and symptoms Abrupt onset of sore throat
Fever toxic appearing
4 D’s
Dysphonia (muffled voice)
Dysphagia (↓ swallowing)
Drooling
Distress/Dyspnea
Inspiratory stridor
Retractions ↑ RR ↑HR Pallor
Tripod position
Thumb sign
on soft tissue x-ray

17. Treatment MEDICAL EMERGENCY: ANESTHISIA STAT!! DO NOT INSPECT THROAT!
LIMIT UPSETING PROCEDURES!
Establish Airway
Respiratory Isolation!
Humidified O2
Hydration
Antibiotics (Meningitic doses)
Ampicillin mg/kg/day ÷ q6H
Chloramphenicol mg/kg/day ÷ q6H
Steroids
Methylprednisolone 2mg/kg/day ÷ q6H

18. Croup Laryngotracheobronchitis
Acute spasmodic laryngitis
Upper airway
↑ 3 months to 5 years
2 years
Paroxysmal laryngeal edema
night
Parainfluenza virus or allergic reaction
↑ in fall and winter months
Precipitated with nasopharyngitis

19. Clinical signs Awakes suddenly with barking cough Inspiratory stridor
Hoarseness
Restlessness
Anxious
Retractions, ↓↓O2
rest = severe croup
↑ Temp
Duration few hours, Repeat x 2 nights
Symptoms improve with change in temp

20. Treatment Maintain airway Position upright Cool mist humidified O2
Steam shower or expose to cold night air
Decadron 0.6mg/kg IM/PO x 1 dose
Racemic epinephrine 2.25% nebulizer
for inspiratory stridor at rest
Induce vomiting = stops laryngospasm
Hospitalize only when:
↑ Stridor ↓ O2 ↓LOC

21. Otitis Media (OM) Acute inflammation & effusion of middle ear
Common pathogens
Strep pneumonia (50%)
↓ incidence with Prevnar vaccine
Haemophilus influenza (30%)-not type B!
Moraxella catarrhalis (20%)
↑↑ incidence with resistance
Viruses
Food Allergies

22. Pathophysiology Eustachian tube dysfunction
< 5 years = shorter, wider and straighter
Acute
bacteria/purulent exudates
Signs and symptoms
↑ ↑ Pain, ↑ ↑ irritability
Tugging on ears
Fever >102
Rhinorrhea, cough and congestion
Anorexia, vomiting and diarrhea
Tympanic membrane
Red & bulging
Tympanogram
No movement of TM
Hearing loss
preventing organism drainage into nasopharygeal cavity leading to back-up of fluid and organisms in middle ear

23. To treat or not treat? AAP guidelines to ↓ resistant organisms
< 6 months:
with S/S of illness → Treat!
6 mos -2 years:
certain diagnosis → Treat!
Uncertain & no s/s of severe illness = Observe
> 2 years:
certain diagnosis & no S/S of severe illness
Observation & Pain Relief
AMERICAN ACADEMY OF PEDIATRICS, Guidelines for Acute Otitis Media, 2004

24. Treatments Amoxicillin 40-45mg/kg/day ÷ BID 80mg/kg- 90mg/kg/day ÷ BID
Now recommending high dose:
80mg/kg- 90mg/kg/day ÷ BID
Augmentin 40-45mg/kg/day BID for resistance to amoxicillin
Ceclor 40 mg/kg/day
Bactrim/Septra 8mg/kg/day
Rocephin for resistant OM’s
Myringotomy Tubes
Frequent infections
Prolonged fluid

25. Bronchiolitis (RSV) Disease of lower airways
Respiratory syncytial virus (RSV) = common cause
Can be fatal in <2 months/premature
90% of infants <1 year get RSV
↑ incidence winter/spring
↑ Contagious via direct contact & inhalation
Use alcohol based hand rubs.
Pathophysiology
RSV affects epithelia cells of lungs
Bronchioles become edematous
Lumen filled with mucous - green thick exudate
Bronchioles infiltrated with inflammatory cells
Air trapping
Severe cases mucous plugging & apnea= death

26. RSV Clinical signs Nasal Aspirate Culture =
(+) ELISA
enzyme-linked immunosuppressive assay
(+) RSV Ag or rapid fluorescent antibody
72 hours after onset
Rhinorrhea with thick, tenacious, green secretions
 RR, retractions & cyanosis
Coughing, wheezing
CXR
Hyperinflation (obstructive emphysema)
Atelectasis =↓ Breath sounds (PN)
Hypoxia → apnea and even death

27. Therapy Respiratory Isolation Cool mist humidified O2 ↑ Hydration
√ O2 sats! >95% is nl
↑ Hydration
Antibiotics for PN
Bronchodilators
Steroids
Severe Cases
Racemic epinephrine
Mechanical ventilation
Prophylactic Approach
Respi Gam (RSV Immune Globulin) $600/vial
Synagis (Monoclonal AB) 15 mg/kg IM
Binds with RSV to ↓ infection.
@ beginning of RSV season Oct - Nov
total of 5 monthly doses; Need ↑ titers to be effective

28. Asthma Inflammation & Hyperactivity Abrupt onset after URI or allergen
RAD= Reactive Airway Disease
Reversible bronchospasm
8 million kids/year
1st attack 3-8 years
# 1 Chronic illness= 8 million kids, 1 cause of hospitalization
10 million missed school days/year

29. Pathophysiology Inflammation
Histamine release to allergen/trigger (stimulus).
Edema→ Mucous Production → Bronchial Obstruction & Spasm
Bronchoconstriction
Hyper-responsiveness of stimuli:
Allergens:
Cigarette smoke Dust mites Exercise
Cold air Stress Drugs (ASA/NSAID)
Urban factors:
#1 Cockroach droppings
Diesel fumes
Histamine is a vasoactive amine.
Vasodilation → mucosal edema → nasal stuffiness → rhinorrhea → itchy → erythema

30. Early & Subtle Clinical signs
Irritable
Itchy
Tired
Dry mouth
Dark circle under eyes
Chronic cough night

31. Clinical Signs Older child
SOB and Dyspnea
Expiratory wheeze bilaterally
Chest pain or tightness → ↑ HR
Spasmodic or tight night
Abdominal pain and nausea
Mild Intermittent
<2 days/week
Severe Persistent
Constant/daily

32. Warning signs Retractions ↑ RR and Hypoxia<92% (Admit to hospital)
As symptoms progress →
Expiratory & Inspiratory wheeze
↑ HR
Breathlessness
Anxious & Restless
Absent breath sounds
No air movement
Respiratory arrest!

33. Status Asthmaticus Limited or no response to therapy
Respiratory distress → arrest
ICU
IV Hydration & Intubation
Medications:
Steroids
Magnesium Sulfate IV
Bronchodilators Nebulizer RX
Antibiotics

34. Diagnostic Tests Allergy testing- 4-8% have a food allergy
Pulmonary Function Test (PFT)
Forced exhalation
√ before and after neb
Reliable when
age > 5 years
good effort

35. Peak Expiratory Flow Rate (PEFR)
Assess asymptomatic lung changes and function.
Based on child’s height
Ex: 47”=PEFR=200
Peak flow zones
Visual = ↑ manage
Early interventions
Maintain control

36. Asthma Therapy
The National Asthma Education and Prevention Program (NAEPP) 2002
4 components of asthma management:
Measures of assessment and monitoring
Control factors that contribute to severity
Education for a partnership in asthma
Pharmacologic therapy

37. Bronchodilators “Rescue meds”
Inhaled Beta 2 Agonists
Albuterol (Proventil,Ventolin) mg/kg/dose
Levalbuterol (Zopenex) > 6 years 0.31mg/kg/dose
SE = Tremors ↑ HR Hyperactivity
Bronchospasm = Overdose!
Anticholinergic
Ipratropium (Atrovent) MDI 1-2 puffs q6-8H
SE = Dizzyness HA Cough ↓ BP
Methylzanthines
Theophylline (PO) Aminophylline (IV)
√ serum levels (10-20)
SE = ↑ HR Arrhythmias
Systemic B2 agonists SC
Epinephrine 1:1000=bronchodilation x 3doses
Caution CARDIAC DOSE 1:10,000
SE = ↑ BP ↑ HR Tremors
Terbutaline (Brethine) SQ/IV
SE = Restlessness cardiac arrthymias Stops pre-term labor

38. Anti-Inflammatory meds
Systemic Corticosteroids
onset - 3 H Peaks in 6-12 H
Loading dose 2mg/kg and taper slowly
No need to taper if short term use
Short-Acting (use 5-7 days ↓ SE)
Hydrocortisone (Solu-Cortef) mg/kg/day
Methylprednisolone (Solu-Medrol) 1-2 mg/kg/dose
Prednisone PO 1-2 mg/kg/dose
Prednisolone (Orapred, Pediapred) PO 1-2 mg/kg
Dexamethasone (Decadron) mg/kg/day
SE = Hyperglycemia GI distress ↓ Growth
Cushing Syndrome = ↑ Wt. ↑ Infection Mood Lability

39. Controller Meds Inhaled corticosteroids- Not rescue drug
Budesonide (Pulmicort) 2-4 puffs tid
Fluticasone (Flovent)
Triamcinolone (Azmacort, Kenalog)
Advair discus
Synergistic effect with B2agonists
SE = Oral & pharyngeal irritation
Non-steroidals-
Cromolyn Na (Intal)
Stabilizes mast cells & prevents attack.
Leukotriene Receptor Antagonists-(LRA)
Leukotrienes cause inflammation (capillary permeability)
Use at night when leukotrienes are highest.
Montelukast (Singulair) 5-10 mg PO/day
Zafirlukast (Accolate) mg PO/day
Zileuton (Zyflo) mg PO/day
SE = HA Vasculitis Flu like symptoms

40. Other Treatments ↑ Fluids May need allergy shots
Dilute mucous & mobilize secretions
May need allergy shots
Zyrtec or Clarinex =↓ allergy symptoms. Singulair now indicated for allergy use as well as asthma maintenance
Nasal Lavage
Treat cold symptoms>7-10 days
60-80% pt with allergic asthma have
sinusitis

41. Parent Teaching Remove allergens Dehumidifier - AC Review
Identify precipitating factors
↓ Rugs, heavy drapes, pets, foods (eggs, milk)
Mattress & pillow covers
Dehumidifier - AC
Review
Signs/symptoms of asthma
PEAK Flow daily
Meds SE & toxicity
Nebulizer use
↓ Antihistamines
May exacerbate wheezing
Swimming = Best Exercise

42. Cystic Fibrosis Mom→ Dad ↓ C f CC Cf ff Dysfunction of exocrine glands
↑↑ Na++ ↑ Cl- in sweat & saliva
(2- 5x normal levels)
↑↑ Viscosity of secretions
GI & Pulmonary systems
Autosommial Recessive
1/25 whites carry gene.
Chromosome # 7
CC = Healthy
Cf = Carrier
ff = Disease
25% risk = healthy/disease
50% risk = carrier
Mom→
Dad ↓ C f CC Cf ff

43. Pathophysiology Pulmonary ↑ Leukocyte DNA in sputum
Long, thick strands
↑↑ Thick mucous (yellow/grey)
↓↓ Diffusion of gases → ↓ O2 hypoxia ↑ CO2
↑↑ Respiratory distress & Pseudomonas PN
Obstruction =
Fibrotic and stiff lobes
↓ compliancy & ↓ function

44. Pancreas Bile ducts Thick secretions block ducts
Fibrosis = ↓↓ pancreatic enzymes
Malabsorption Syndrome
Only 50% of food is absorbed
Inability to digest & absorb proteins & fats
“Steatorrhea” foul smelling bulky stools
↓↓ fat soluble vitamins A,D,E and K.
Bile ducts
Occluded: biliary cirrhosis & portal ↑ BP

45. Hallmark – CF Signs Meconium Ileus (newborn)
No mec passed in 1st 24 hours
Abdominal distention
10-15% & 1st sign of CF
Skin - “Infant tastes salty”
Sweat Test (Pilocarpine Ionophoresis)
> 1 month old
Cl> 60 mEq = (+) CF

46. Respiratory Signs Frequent sinus & respiratory infections.
Bronchitis & PN
Recurrent pneumothorax
SOB, wheezing, hemoptysis
Dyspnea, Hypoxemia
Barrel shaped chest
AP>lateral
Clubbed fingers

47. Gastrointestinal Signs
Steatorrhea
Excretion of undigested fats and proteins
Bulky, frothy, foul smelling stool
Abdominal Distension
3rd spacing & edema RT ↓↓ protein & albumin
Prolapsed rectum
Voracious appetite RT starving
only 50% of food absorbed
Failure to thrive
↓↓ drop on growth chart 10-25% = short stature
Gastrointestinal Signs

48. Diagnosis Genetic testing Sweat Test Stool specimen Duodenal Enzymes
DNA analysis: Chromosome # 7
Prenatal screen (↑↑mutations exist)
F508 mutation in 70% of pt with CF
Sweat Test
Cl>60meq strongly suggests CF
Stool specimen
5 day collection √ fat content
Duodenal Enzymes
↓↓ trypsin and chymotrypsin
(absent in 80% of CF pt’s)
Immunoreactive Trypsin Test
>140 = CF (+)

49. Therapy Goals ↑ Life Expectancy > 30 ↑ Quality of life
↓ Sequella of CF
Nutrition
↑ protein ↑ calories and moderate fat
Need 150% of daily requirements to replace losses
↑ Na intake in hot weather
Medications
Pancrelipase (Pancrease, Pancrease MT4) PO
(10,000u lipase/36,000u protease & amylase)
Enteric coated & must give before all meals!
↑ digestion of fats, proteins and carbs.
SE: diarrhea and abdominal cramping

50. Therapy Supplements Pulmonary- Fat Soluble Vitamins
A, D, E & K (2x dose)
H2O Soluble Vitamins
C, B, B2, B6 (B-C complex)
Niacin, B12, Folic Acid
Pulmonary-
1st Assess breath sounds and O2!
Nebulizer treatments then PD & C.
CPT x minutes in trendelenburg.
Vibrate all lung fields =mobilize secretions

51. Inhalation Therapy Dornase Alfa-Pulmozyme Recombinant DNAse 2.5 mg
Breaks down DNA in sputum
↓↓ viscosity of sputum
SE- laryngitis
Administer via neb before PD&C
Proventil
Thoracic expansion exercises
Stretching & Breathing
Swimming (↑ mobility)

52. Family Support Educate Disease process and S/S of illness
Meds and diet
Pulmonary care ATC
Need ↑ support group to assist q 3-4 H
Breathing exercises
Antibiotics only for documented infections!
Encourage verbalization of fears
Numerous Hospitalizations
Invasive Procedures (CT) lung transplants
Anticipatory Grieving -Fatal Illness
Support group
CF Foundation

53. Foreign Body Aspiration
↑ 1-3 years of age
Developmental stage ↑ curious and
hand–to-mouth or nose
4th cause of accidental death < 5 years
Acute and dramatic onset
Common Objects
Small toys
Buttons
Paper clips
Batteries (Acid leaks = chemical PN)
Food
↑ in size as absorbs H2O
↑ Edema = ↑ Obstruction
Hotdogs Grapes Nuts Seeds

54. Clinical Signs Laryngeal Choking & Coughing
Aphonia = No cry or speaking
Rapid color change → blue
Inspiratory stridor
↓ O2 → Change in LOC → Collapse/Unconscious
Bronchial
# 1 site = R main stem bronchus
Wheezing
Lung
Persistent respiratory infections
Cough & congestion
Purulent secretions
Foul smelling breath
Acute or chronic pulmonary lesions

55. Interventions Immediate Intervention (Death in 4 mins!)
CPR – Obstructed Airway
Infants-
alternate 5 back blows with 5 chest thrusts
Kids >1 year
Heimlich
CXR
Identify object & location
Bronchoscopy
Removal of object ASAP!
Post removal
Humidity
Steroids
↓ Edema & ↓ inflammation
Antibiotics

56. Pneumonia Classified according to agent or location:
Viral (RSV) most common
Bacterial (strep pneumoniae, pseudomonas)
Fungal (candida)
Chemical/Aspiration (Oil, lotion, cleaners)
Pathophysiology
Inflammation of lung parenchyma
Consolidation - aveoli fill with exudate
Bronchial Obstruction
RT ↑ restriction of lung
↓ Impaired gas exchange ↓O2 & ↑ CO2

57. Primary Atypical Pneumonia Mycoplasma pneumoniae
Most common pathogen in older children 5-12 years of age
↑ incidence in Fall and Winter
↑ Highly populated areas
Diagnosis:
CBC & Differential
BC or Tracheal aspirate
CXR
ELISA test

58. Clinical signs Sudden or gradual onset Fever - low grade Chest pain
could be a 7-10 day duration of symptoms
Fever - low grade
Chest pain
Flushed cheeks with generalized pallor
Hacking cough
Pharyngitis
Coarse Crackles or rhonchi
↓ Breath sounds with dullness (consolidation)
Hypoxemia
Anorexia
Malaise

59. Therapy O2 √ Pulse oximeter ↑↑ Hydration PO/IV Humidity CPT
Blow Bubbles
↑↑ HOB & Rest
Medications
Azithromycin (Z-Pack)
(10 mg/kg day 1 then 5 mg/kg day 2-5)
Erythromycin
30-50 mg/kg/day PO/IV ÷ q 6-8 x days
No IM causes tissue necrosis!
Acetaminophen (Tylenol)
10-15 mg/kg/dose √ (infant vs. children)
↓ Pain & Fever
Expectorants only No cough suppressant!

60. Bacterial Pneumonia ↑ Risk @ birth-5 years Strep pneumoniae (90%)
Clinical signs/symptoms
Abrupt onset after viral illness - URI
↓↓ immune system
High fever
Retractions, tachypnea, hypoxia
Rales/rhonchi
Chest Pain with deep inhalation
Pleural effusion→ Shallow respirations & ↑ CO2
Abdominal pain
Lower lobe infiltrate

61. Therapy Similar to Mycoplasma Maintain patent airway!
Isolate with same pt if hospitalized
Lying on affected side ↓ pleural rub/pain
CT for thoracentesis
Medications
Antibiotics- appropriate drug for the bug!
High dose Amoxicillin or Augmentin (40mg/kg/day PO)
Ceftriaxone (Rocephin) (50-75 mg/kg/day)
↑ WBC or based on S/S
Cefotaxime (Claforan) mg/kg/day
Ceftiazidine (Fortaz) 150 mg/kg/day
Tylenol
Expectorants