1.

) Anatomy and Physiology of the Respiratory System

The respiratory system can be separated into two divisions: the upper respiratory tract, composed of
the nose, paranasal sinuses, pharynx, larynx, and epiglottis; and the lower tract, composed of the
bronchi, bronchioles, and alveoli. Through inspiration (breathing in), the respiratory system delivers
warmed and moistened air to the alveoli, transports oxygen across the alveolar membrane to
hemoglobin-laden red blood cells, and allows carbon dioxide to diffuse from red blood cells back into
the alveoli. Through expiration (breathing out), carbon dioxide–filled air is discharged to the outside.

The respiratory center is located in the medulla of the brain. Peripheral receptors located in the aortic
arch and carotid arteries sense diminished PO2 levels and respond by increasing the respiratory rate.
Central respiratory receptors in the medulla sense increased PCO2 levels along with body acidity,
temperature, and blood pressure as another stimulus to respiration. Depth of respiration is influenced
by proprioceptors located in the lung periphery that register lung fullness. An inhibitory center in the
pons halts inspiratory impulses before the lungs become overextended. Often children with chronic lung
disease such as cystic fibrosis have adapted so well to a chronically high PCO2 level that central receptor
sites no longer register this as abnormal. In these instances, the main stimulus for respiration is a low
oxygen level. In such children, administering high levels of oxygen can be dangerous because it alleviates
oxygen want or their main respiratory stimulus.

Respiratory Tract Differences in Children

Because the respiratory tract continues to mature during childhood, children have several important
differences in respiratory anatomy and physiology than adults. The ethmoidal and maxillary sinuses are
present at birth; the frontal sinuses (the sinuses most frequently involved in sinus infection) and the
sphenoidal sinuses do not develop until 6 to 8 years of age. Due to rapid growth of lymphoid tissue,
tonsillar tissue is normally enlarged in early school-age children. Wheezing (the sound of air being
pushed through constricted bronchioles) may not be a prominent finding in infants even when the
lumen of the airway is severely compromised.

2.) Physical Assessment

Cough

A cough reflex is initiated by stimulation of the nerves of the respiratory tract mucosa by the presence
of dust, chemicals, mucus, or inflammation. The sound of coughing is caused by rapid expiratory air
movement past the glottis. Coughing is a useful procedure to clear excess mucus or foreign bodies from
the respiratory tract. It only becomes harmful and needs suppression when there is no mucus or debris
to be expelled and the amount of coughing becomes exhausting. This might occur with respiratory tract
inflammation. Paroxysmal coughing refers to a series of expiratory coughs after a deep inspiration.
Commonly, this occurs in children with pertussis (whooping cough) or those who have aspirated a
foreign body or a liquid they attempted to drink.

Although helpful in removing mucus, coughing increases chest pressure and so may decrease venous
return to the heart. This lowers cardiac output and can lead to fainting (syncope). Paroxysmal coughing
may increase the pressure in the central venous circulation to such an extent that bleeding into the
central nervous system (CNS) can result. Because young children often vomit after a series of coughs,
they may be suspected initially of having a gastric disturbance even though their main illness is
respiratory.

Rate and Depth of Respirations

Tachypnea (an increased respiratory rate) often is the first indicator of airway obstruction in young
children. When assessing respiratory rate, particularly in infants, try to count respiratory rate before
waking them, because crying distorts respiratory rate. Assess also the depth and quality of respiration,
as these also reveal anoxia or lack of oxygen in body cells.

Retractions

When children must inspire more forcefully than normally to inflate their lungs because of an airway
obstruction or stiff, noncompliant lungs (as in newborns with pulmonary dysplasia), intrapleural
pressure is decreased to the point that the nonrigid parts of the chest (the intercostal spaces) draw
inward, creating retractions. Retractions occur more commonly in newborns and infants than in older
children because the intercostal tissues are weaker and less developed in younger children. Retraction
of upper chest muscles (supraclavicular or suprasternal) suggests upper airway obstruction; retraction of
intercostal or subcostal muscles suggests lower airway obstruction.

Restlessness

When children or infants have decreased oxygen in body cells (hypoxia), they become anxious and
restless. Be careful not to interpret the excessive movements of infants with respiratory distress as a
sign that they are improving; anxious, restless stirring may be their only way of signaling that their
respiratory obstruction is becoming acute; it may be one of the first signs of airway obstruction.

Cyanosis

Cyanosis (a blue tinge to the skin) indicates hypoxia. It becomes apparent when the PO2 is under 40 mm
Hg or the level of unoxygenated hemoglobin increases to over 3 g/100 mL (because incompletely
oxygenated red blood cells in the circulation are what give blood a dark color). If children have a low red
blood cell count, cyanosis may not be apparent because there are not enough red blood cells to give the
arterial blood its blue tinge. This occurs at hemoglobin levels below 5 g/100 mL. The degree of cyanosis
present, therefore, is not always an accurate indication of the degree of airway difficulty. When children
have accompanying peripheral vasoconstriction caused by shock, cyanosis of the extremities also may or
may not be apparent.

As the PO2 drops and cyanosis results, children increase their respiratory effort in an attempt to supply
more oxygen to their tissues. When they do this, the difference in pressure between the intralumen of a
not yet fully developed trachea and the surrounding tissue becomes so great that the trachea may
collapse, compounding the obstruction problem.

Clubbing of Fingers

Children with chronic respiratory illnesses often develop clubbing of the fingers, a change in the angle
between the fingernail and nailbed because of increased capillary growth in the fingertips. The increased
capillary growth occurs as the body attempts to supply more oxygen routes (more capillaries) to distal
body cells.

Adventitious Sounds

Adventitious sounds (extra or abnormal breathing sounds) are caused by pathologic conditions and can
be heard on lung assessment in children with respiratory disorders. Normally, on chest auscultation, the
inspiratory sound is softer and longer than the expiratory sound. This is referred to as vesicular
breathing. If you listen over the trachea, this pattern in terms of the length of inspiration and expiration
is reversed. This is bronchial or tubular breathing. If you hear bronchial breath sounds in the periphery
of the lungs, where normally you would expect to hear a vesicular pattern, it indicates that gas exchange
in peripheral alveoli is so compromised (as in pneumonia) that you are listening to transmitted tracheal
sounds.

Accessory sounds of respiration result from the vibrations produced as air is forced past obstructions
such as mucus. If the obstruction is in the nose or pharynx, the noise produced is a snoring sound
(rhonchi). If the obstruction is at the base of the tongue or in the larynx, you will hear a harsh, strident
sound on inspiration. This is laryngeal stridor. It is often most marked when a child is in a supine position
and less marked when a child sits upright. If an obstruction is in the lower trachea or bronchioles, it is
most noticeable on expiration. An expiratory whistle sound (wheezing) occurs. If alveoli become fluid-
filled, fine crackling sounds (rales) are heard. Diminished or absent breath sounds occur when the alveoli
are so fluid-filled that little or no air can enter them.
Chest Diameters

With chronic obstructive lung disease, children may be unable to exhale completely, allowing air to be
chronically trapped in lung alveoli (hyperinflation). This produces an elongated anteroposterior diameter
of the chest, sometimes termed a “pigeon breast.” There is an accompanying tympanic or
hyperresonant (loud and hollow) sound heard on percussion over lung spaces.

3.) Therapeutic Techniques

Expectorant Therapy

Any irritation of the respiratory tract causes the production of large amounts of mucus. The amount
produced can become so great that the natural mechanisms for clearing it (coughing and upward cilia
action) are no longer adequate. If a child is breathing rapidly because of respiratory distress, the
frequent passage of air over the mucus tends to dry it and make it more viscid, compounding the
removal problem. Several measures may be used to liquefy dried mucus and help raise it.

Liquefying Agents

Pharmacologic agents (expectorants) such as guaifenesin (Robitussin), given orally, are designed to
liquefy mucus in the trachea and bronchi. Instilling saline nose drops or using saline nasal sprays can be
effective in moistening and loosening dried mucus in the nose.

Humidification

Humidification is the provision of moisture to the airway. Common methods of delivering moisture
include vaporizers and nebulizers.

Vaporizers

Vaporizers emit a stream of air moistened by fine droplets of water into a room, providing either a cool
or a warm mist to the entire room. Caution parents when using warm mist that a serious scald burn can
result if children accidentally pull a vaporizer over on themselves. To avoid this type of accident, they
should be certain the vaporizer is placed up, out of reach of the child. Although cool mist can create a
clammy atmosphere in a room, this can be advantageous for a child who also has a fever, helping to cool
and moisten the whole environment. Caution parents to clean vaporizers thoroughly after use to
prevent the growth of Pseudomonas or other pathogenic organisms.

Nebulizers
Nebulizers are mechanical devices that provide a stream of moistened air directly into the respiratory
tract. Most are hand-held masks that fit over the nose and mouth and are attached to an electrical
pump as a power source. Ultrasonic nebulization delivers such minuscule droplets into the respiratory
tract that even the smallest bronchioles can be moistened. Nebulizers also serve as an important means
for the delivery of respiratory tract medications. Drugs such as antibiotics or bronchodilators can be
combined with the nebulized mist and sprayed into the lungs.

Many children find nebulizer treatments uncomfortable because the feeling of the mist in their upper
respiratory tract can be frightening or irritating. Assure them that aerosol administration is the most
effective route for moisture and medication to reach and cause an effect in the respiratory tract.

During aerosol medication administration, watch carefully for signs of both local tracheal or bronchial
effect (spasm or edema) that might result from airway irritation as well as systemic symptoms that
might result from absorption of a medication by the membrane.

Coughing

As a rule, encourage coughing rather than suppress it in children because it is an effective method of
raising mucus. Changing a child’s position and suggesting mild exercise or deep breathing are helpful
techniques to initiate coughing. If a cough is caused by mucus dripping from the nose because of nasal
congestion, a decongestant such as pseudoephedrine (Sudafed) will best halt the draining mucus and
therefore the cough. Caution parents not to give cough syrup routinely to children. Several of these
contain codeine in doses that may be too high for a child’s weight. Others produce little effect and the
risk of overdose, incorrect dosing, and adverse events is greater than the benefit of the syrup. Because
of this, cough and cold remedies are no longer recommended for children under 2 years of age.

Mucus-Clearing Devices

A mucus-clearing device (a Flutter device) can be used to aid in the removal of mucus. This device looks
like a small plastic pipe. A stainless-steel ball inside the device moves when the child breathes out,
causing vibrations in the lungs. This vibration helps loosen mucus so that it can be moved up the airway
and expectorated. This device is used most frequently with children who have cystic fibrosis or
pneumonia to help remove mucus from the lungs.

Chest Physiotherapy

Simply changing a child’s position helps mucus to move, initiate a cough reflex, and be expelled. When a
child is positioned so the chest is lower than the abdomen, gravity aids in the removal of mucus from
the lower lobes and bronchi. When a child sits upright, gravity aids drainage from the upper lobes into
the bronchi. When lying supine, anterior alveoli drain; when prone, posterior alveoli drain. Frequent
changes of position are important, therefore, to prevent mucus from pooling in certain lung areas. If a
child has a localized mucus problem, lying predominantly in one position can encourage drainage of that
lung segment. When the child is repositioned and the mucus drains into new bronchi, this will often
cause a cough from irritation caused by this new drainage.

Three techniques are involved with chest physiotherapy (CPT) to further loosen mucus for
expectoration: postural drainage, percussion, and vibration. Each technique can be used alone, but they
are usually more effective at moving mucus toward the mainstem bronchus when performed together.

CPT is best scheduled before meals or at least an hour after a meal so the subsequent coughing does not
cause vomiting. Techniques are described in Box 40.5 and summarized below. Limit CPT to
approximately 30 minutes each time, because these techniques are tiring. Modifications in the
techniques or shortening of the time periods may be necessary, depending on a child’s ability to tolerate
the position changes and the techniques. For example, before breakfast, the upper right and the left
upper and lower lobes might be done; before lunch, the right lower lobe and right middle lobe might be
done; before supper or at bedtime, the upper and lower lobe on both sides might be done.

Common postural drainage positions for the infant are shown in Figure 40.8. An infant may be
positioned on your lap, whereas a slant board or other surface is needed for postural drainage with an
older child. Not all positions are tolerated well. Be ready to modify the positions used depending on the
child’s condition and tolerance.

Percussion involves striking a cupped or curved palm against the chest to determine the consistency of
tissue beneath the surface area. This technique causes a loud, thumping noise that sounds as if it hurts,
but you can assure parents it does not. In infants and some small children, a specialized device, a nipple,
or a small oxygen mask may be used as the palm of the hand is too big. These devices concentrate the
motion and may increase the amount of mucus removed.

Vibration is done by pressing a vibrating hand against a child’s chest during exhalation. Like percussion,
it mechanically loosens and helps move tenacious secretions upward. Vibration also may be
accomplished by a mechanical vibrator or a vibrating vest.

Position a child so the lobe of the lung to be drained is in a superior position. Apply vibration or
percussion. After each position, ask the child to cough. Children cough best if you demonstrate the
proper technique by taking a deep breath, blowing it out, taking a second deep breath, blowing that out,
taking a third deep breath, and then coughing. The irritation of mucus in the major airway by the third
breath makes a cough happen almost spontaneously. Formerly, CPT was done in hospital settings by
respiratory therapists. However, in today’s health care climate of managed care, nurses are now often
the health care provider who perform CPT and teach it to parents. One or both parents may need to
learn the technique before their child is discharged so that it can be continued conscientiously at home.
The technique is used most frequently with children with bronchiolitis or cystic fibrosis