CHAPTER 1: RESPIRATORY DISORDER

I. ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM

- Inspiration (breathing in)
- Expiration (breathing out)

II. ASSESSING RESPIRATORY ILLNESS IN CHILDREN

1. Physical Assessment
 Cough
- Cough reflex – initiated by stimulation of nerves of respiratory
system tract mucosa due to presence of dust, chemical, mucus, or
inflammation.
- Coughing – useful procedure to clear excess mucus or foreign
bodies from respiratory tract; or as a response to gastric contents
refluxed into the airway.
- Paroxysmal coughing – series of expiratory coughs after a deep
inspiration; occurs in children with pertussis (whooping cough); or in
those who have aspirated a foreign body or a liquid they attempted
to drink.
 Rate and Depth of Respirations
- Tachypnea – increased respiratory rate; first indicator of respiratory
distress in young children.
- Retractions – when children must inspire more forcefully than
normal to inflate their lungs; intercostal spaces draw inward.
- Restlessness – caused by hypoxia (decreased oxygen in body
cells)
- Cyanosis – can indicate hypoxia; blue, gray or purplish tinge to skin
or mucous membranes.
- Clubbing of fingers - happens because of increased capillary
growth in fingertips.
- Adventitious sounds – includes:
a. Rhonchi (a snoring sound) – vibrations produces as air is
forced past an obstruction, such as mucus in nose or pharynx
b. Stridor (a harsher, strident sound on inspiration) –
occurs if obstruction is at the base of tongue or in larynx.
c. Wheezing (an expiratory whistle sound) - occurs if
obstruction is in lower trachea or bronchioles.
d. Rales (fine crackling sounds) – if alveoli become fluid-filled
e. Diminished or absent breath sounds – occur when alveoli
are so fluid-filled that little or no air can enter them
 Chest diameter – accompanying tympanic or hyper resonant (loud
and hollow) sound heard on percussion over lung spaces.
- Pigeon breast – an elongated anteroposterior diameter of the
chest
2. Laboratory tests
  Pulse oximetry – a noninvasive technique for estimating arterial
oxygen saturation (SaO2); normal value is 95% or higher
 Nasopharyngeal culture – may provide information about etiology
of an illness from upper respiratory tract
 Sputum analysis – instruct older children on how to obtain or
produce sputum
3. Diagnostic procedures
 Chest radiograph – includes:
- Chest X-rays – will show areas of infiltration or consolidation in
lungs; limited in infant
- Other modalities:
 CT scan (computed tomohraphy)
 MRI scan (magnetic resonance imaging)
 Pulmonary function studies
- Process of ventilation include 3 main forces:
1. Inertial force to change speed and direction of air when lungs
change to exhalation to inhalation
2. Elastic force – help lungs expand with inhalation
3. Flow resistance force – resistance to movement of air through
bronchial tree
- Pulmonary function test – measure how much air in the lungs can
hold
 Alveoli – never completely empty at expiration; never
completely filled on inspiration
 Spirometry – most common test of lung function; measures
amount of air that can be forced out of lungs in a forceful
breath
 Peak flow – often measured by peak flow meter

III. HEALTH PROMOTION AND RISK MANAGEMENT

 Viral Upper Respiratory Infections

- Referred to as common colds (most frequent respiratory disorder in
children)
- Spread easily with droplets transmission
 Help avoid spreading infections by:
- Coughing or sneezing into a tissue or elbow
- washing their hands
- Use of alcohol based sanitizers
- properly disposing of tissues
- Yearly influenza vaccination
- reducing exposure to secondhand smoke

IV. THERAPEUTIC TECHNIQUES USED IN THE TREATMENT OF RESPIRATORY

ILLNESS IN CHILDREN

1. Home treatments
  Humidification
- Humidifiers – add moisture to a room by emitting stream of fine
droplets of water
 Inhalation devices
- Nebulizers – provide a stream of moistened air directly into
respiratory tract
- MDIs (metered-dose inhalers) – with spacers (valve holding
chambers) are as equally effective as nebulizers in delivery of
aerosolized medications.
- Ultrasonic nebulization – delivers miniscule droplets into
respiratory tract to moisten even the smallest bronchioles
 Coughing
 Airway-clearing devices
- Flutter device – used to aid in removal of mucus; used most
frequently with children who have cystic fibrosis or pneumonia
 Chest physiotherapy
- Three techniques:
1. Postural drainage – infant may be positioned on lap
2. Percussion - striking a cupped or curved palm against chest
3. Vibration – pressing a vibrating hand against a child’s chest
during exhalation
- Best used before meals or at least an hour after a meal

V. DISORDERS OF UPPER RESPIRATORY

1. CHOANAL ATRESIA
- Bilateral or unilateral congenital obstruction of the posterior nares
by an obstruction membrane or bony growth.
- Assessment: (Methods to confirm the condition)
 Passing a soft 8 Fr or 10 Fr catheter through the posterior nares
to the stomach
 Holding newborn’s mouth closed then gently compressing first 1
nostril then other
 Becoming cyanotic at feedings
- Therapeutic management
 IV fluid for glucose and fluid level maintenance
 Local piercing of obstructing membrane
 Surgical removal of bony growth

2. ACUTE NASOPHARYNGITIS (COMMON COLD)

- Common cold-causing viruses

 Rhinovirus
 Respiratory syncytial virus
 Adenovirus
 Influenza viruses
- Assessment:
  nasal congestion
 watery rhinitis
 a low-grade fever
- Therapeutic management
 Dos (Antipyretic; Saline nose drops or spray; Nasal mucus
removal via bulb syringe; Cool mist vaporizer)
 DON’Ts (Antibiotics; Aspirin; Cough and Cold Preps; Oral

Decongestants)

3. PHARYNGITIS

- Infection and inflammation of throat

a. Viral pharyngitis
- Assessment:
 sore throat, fever, rhinorrhea, cough, general malaise
 enlarged regional lymph node
 erythema in the back of the pharynx and the palatine arch
 exudate on tonsils
- Therapeutic management:
 Analgesic ( Acetaminophen, Ibuprofen)
 Gargling with a solution
 Enforce adequate oral hydration
b. Streptococcal pharyngitis (abscess formed in retropharyngeal
lymph nodes)
- Assessment:
 Erythematous posterior throat and palatine tonsils
 Enlarged tonsils
 White exudate in the tonsillar crypts
 Petechiae on the palate
 Fever, sore throat, headache, stomach ache, and difficulty
swallowing
- Therapeutic management:
 Antibiotics (Penicillin, Cephalosporin)
c. Retropharyngeal abscess
- Assessment:
 Fever
 Refusal to eat
 Drooling
 Snoring with respirations
- Therapeutic management:
 Hyperextend the head to allow more breathing space
 Tonsillectomy
 Adenoidectomy

4. EPISTAXIS (NOSE BLEED)

 - Nursing management:
 Place in an upright position with their head tilted slightly forward.
 Apply pressure to the cartilage on the sides of the nose with your
fingers for about 10 minutes.
 Help the child settle and stop crying.

5. SINUSITIS

- Infection and inflammation of sinus cavities

- Assessment:
 Fever
 Nasal discharge
 Cough
- Therapeutic management
 Analgesic
 Antibiotic

6. LARYNGITIS

- Inflammation of the larynx due to excessive use of voice

- Nursing management:
 Sipping of warm or cold liquid

7. CONGENITAL LARYNGOMALACIA / TRACHEOMALACIA

- Occurs when an infant’s laryngeal structure is weaker than normal

and collapses more than usual in inspiration
- Assessment:
 Stridor
 Retracted sternum and intercostal spaces on inspiration
- Nursing management:
 Stop sucking frequently during a feeding
 Feed infant slowly

8. CROUP (LARYNGOTRACHEOBRONCHITIS)

- Inflammation of the larynx, trachea and major bronchi occurring

between 6 months and 3 years old due to viral infection (e.g.,
Parainfluenza virus)
- Assessment:
 Normal or mildly elevated temperature
 Barking cough (croupy cough)
 Inspiratory stridor
 Marked retractions
- Nursing management:
 Cool moist air combined with a corticosteroid via nebulizer

9. EPIGLOTTITIS
 - Inflammation of the epiglottis (the flap of cartilage that covers the
opening to the larynx to keep food and fluid during swallowing)
- Assessment:
 severe inspiratory stridor
 a high fever
 hoarseness
 sore throat
 difficulty swallowing
 drooling
- therapeutic management:
 Oxygen administration
 IV Fluid
 Antibiotic
 Antiviral
 Establishment of Endotracheal Airway

10. ASPIRATION

- Aspiration of foreign object into airway

- Nursing management:
 Allow forceful coughing
 Series of back blows or subdiaphragmatic abdominal thrusts

11. BRONCHIAL OBSTRUCTION

- Obstruction of right main bronchus due to aspiration

- Assessment:
 Hemoptysis
 Fever
 Purulent sputum
 Leukocytosis
 Wheezing
- Therapeutic management:
 Bronchoscopy
 Assess signs of bronchial edema and airway obstructions
 Take VS frequently
 NPO for at least 1 hour
 Cool fluid
 Application of Ice Collar

VI. DISORDERS OF THE LOWER RESPIRATORY TRACT

1. INFLUENZA

- Involves inflammation and infection of the major airways

- Young children are at highest risk of complications from flu
 - Oseltamivir
- Influenza virus mutates yearly
- Symptoms:
 sudden onset of fever
 cough (usually dry)
 headache
 muscle and joint pain
 severe malaise (feeling unwell)
 sore throat
 runny nose

2. COVID-19 (NOVEL CORONAVIRUS)

- disease caused by SARS-CoV-2 coronavirus

- usually spreads between people in close contact.
- Children under 1 year and children with underlying conditions such
as asthma, diabetes, or metabolic conditions may be higher at risk
for severe illness.
- Pfizer-BioNtech Pediatric Vaccine
- Symptoms:
 fever
 cough
 nasal congestion
 new loss of taste or smell
 shortness of breath
 sore throat
 gastrointestinal symptoms

3. BRONCHITIS

- Inflammation of the major bronchi and trachea

- Causative agents include the influenza viruses, adenovirus, and
Mycoplasma pneumoniae, among others.
- Symptoms:
 fever
 cough usually with nasal congestion
 feeling short of breath.
 soreness or a feeling of tightness in the chest.
 wheezing (a whistling or hissing sound with breathing)
 headache
- Assessment:
 Children have mild respiratory infection for 1-2 days
 Fever, and dry, hacking cough
 Cough: coarse, mildly productive
 Auscultation: rhonchi and course crackles can be heard
 Chest x-ray reveals diffuse alveolar hyperinflation and some
markings at hilus of lung
 - Therapeutic management:
 Relieving respiratory symptoms
 Reducing fever
 Maintaining adequate hydration
 Antibiotic if bacterial infection is suspected.

4. BRONCHIOLITIS

- Inflammation and edema of the fine bronchioles and small bronchi,

usually due to a viral illness.
- The most common cause of bronchiolitis is RSV, although a number
of other viruses may also cause bronchiolitis.
- Symptoms:
 fast breathing
 noisy breathing that sounds wheezy.
 breathing that is hard work
 irritability and fever
 difficulties eating or drinking
 congestion
 rhinorrhea
 fever
- Therapeutic Management (for less severe symptoms) :
 Antipyretics
 adequate hydration
 nasal suctioning
 nasal saline
 avoidance of tobacco exposure
 home monitoring are adequate
- Therapeutic Management (for severe illness):
 apnea
 hypoxia
- dehydration

5. ASTHMA

- Chronic inflammatory disorder of the respiratory tract and is the

most common chronic illness in children.
- When an allergen invades, mast cells release histamine and
leukotrienes that result in diffuse obstructive and restrictive changes
in the airway because of a triad of inflammation,
bronchoconstriction, and increased mucus production.
- Most children with asthma have allergy triggers.
- A primary irritant is environmental tobacco smoke.
- The severity of asthma in a child is dependent on risk
factors:
 Allergens
 Stress
  Pollution
- Assessment:
 “Panting” – child distress
 Typically, an episode begins with a dry cough.
 Dyspnea and wheezing (the sound caused by air being pushed
forcibly past obstructed bronchioles) associated with the disorder
begin
- Physical Assessment
 In some children, initial wheezing is by stethoscope auscultation
 During an asthma attack, however, a child must work so hard to
exhale due to air trapping that the expiration phase becomes
longer than the inspiration phase.
 observe for retractions (the chest wall is drawn inward with
breaths).
 During attacks, children with asthma are generally more
comfortable in a sitting or standing position rather than lying
down.
- Therapeutic Management
 According to the Expert Panel report, the diagnosis and
management of asthma involves four com-ponents:
a) measure of asthma assessment and monitoring,
b) education for home self-management;
c) control of environmental factors that contribute to
symptoms (i.e., allergens); and
d) pharmacologic therapy.
 The primary goal in asthma management is the prevention of
airway inflammation.
6. STATUS ASTHMATICUS

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7. PNEUMONIA
8. ATELECTASIS
9. PNEUMOTHORAX
10. BRONCHOPULMONARY DYSPLASIA
11. TUBERCULOSIS
12. CYSTIC FIBROSIS