RESPIRATORY DISORDERS

BEATRICE NKOROI
 Respiratory conditions
• The common respiratory conditions include:
– Tonsillitis.
– Laryngo tracheobronchitis
– Bronchial asthma
– Pneumonia
 Anatomy and Physiology

• Developmental variations increase the pediatric

population’s risks for acquiring a respiratory system
dysfunction.
• Small airways, fewer alveoli, and increased chest
compliance are leading factors that predispose them
to respiratory alterations.
• Size of infant’s trachea and lower airways is smaller.
• Even small reductions in the lumen of an infant or
young child’s airway can significantly increase airway
resistance and the work of breathing.
• The negative impact of this structural difference
decreases after early childhood.
The diameter of an infant’s airway is approximately 4 mm
• Young child’s nose, nasopharynx, and pharynx are also
smaller and more vulnerable to obstruction.
• Infants are typically nose breathers.
• This causes them to have difficulty breathing when
their nasal passages become blocked by the edema
and mucus associated with URTIs.
• At birth the chest wall is soft and pliable and the
infant’s respiratory muscles are not fully developed.
• These factors lead to poor expansion of the chest,
decreased lung volumes at the end of exhalation, and
contribute to the respiratory distress infants
experience with respiratory alteration.
• The pliable chest walls of infants in respiratory distress
move inward instead of expanding.
Trachea Position
• Other developmental factors may increase the
pediatric population’s risk for acquiring a
respiratory alteration.
• Infants and young children have immature
immune systems that make them more
susceptible to a microorganism invasion.
• They also tend to be around other infants and
children with respiratory infections.
• Hand-to-mouth activity characteristic of infants
and young children may increase this
population’s opportunity for acquiring a
respiratory system infection or injury.
• Preterm infants lack sufficient surfactant for
effective lung functioning.
• Without adequate surfactant infants are at high
risk for developing respiratory distress syndrome
and broncho-pulmonary dysplasia.
• Metabolic demands are greater in infants and
young children than in adults.
• Infants and children have limited oxygen stores.
• For this reason, they tend to get hypoxic quickly
and develop respiratory distress when their
oxygen demand exceeds the supply.
 Children with a respiratory alteration Nursing
assessment
Color:
Children with respiratory problems may be pale or have
cyanosis due to decreased oxygenation.
• Particular notice should be made of perioral cyanosis,
a pale or bluish tinge around the lips and mouth.
Respiratory Effort:
• Observe the child’s breathing.
• Is the child having difficulty breathing or exerting
extra effort in breathing?
• Note if retractions or accessory muscles are used for
breathing, or if nasal flaring is present.
Vital Signs:
• Observe the respiratory rate.
• A child with a respiratory problem often displays tachypnea.
• Is the heart rate elevated?
• Tachycardia will occur in response to decreased oxygenation,
increased metabolic demand, infection or fever.
• Hyperthermia can indicate infection.
Auscultation of Lung Sounds:
• Is there good air flow in and out of all areas of the lungs?
• Are there any adventitious sounds? Wheezing? Crackles?
Rhonchi?
• Are these sounds heard on inspiration and/or expiration?
• Are abnormal sounds only heard in one area of the lungs or
are they scattered throughout the lung fields?
 TONSILLITIS AND PHARYNGITIS
• Tonsillitis and pharyngitis are common viral
infections in children.
• 20% of acute tonsillitis and pharyngitis are
caused by Group A β-hemolytic streptococci
(GABHS) and can lead to significant health
problems.
 PATHOPHYSIOLOGY

• Tonsillitis refers to an inflammation, and

frequently an infection, of the palatine tonsils.
• Adenoiditis refers to inflammation or infection of
the pharyngeal tonsils, or adenoids.
• Children are prone to tonsillitis due to:
– They have a large amount of lymphoid tissue in the
pharyngeal cavity,
– They tend to have frequent upper respiratory tract
infections
– They are around other children who may be infected.
 Assessment
• Child may refuse to drink or eat
• Fever
• Reddened pharynx and tonsils
• Chronic tonsillitis may result in snoring due to
enlarged tonsils and adenoids
 Signs and Symptoms

• Sore throat.
• Difficulty swallowing.
• Fever.
• Most manifestations are by inflammation.
• As the palatine tonsils enlarge with edema, they may meet midline
of the throat and cause the child to have difficulty swallowing and
breathing.
• Mouth breathing leads to offensive mouth odor.
• Persistent cough.
• Children with GABHS may experience
• Headache
• Abdominal pain
• Nausea
• Vomiting
• Diarrhea
“Kissing tonsils” occur when the tonsils
are so enlarged they touch each other.
• Throat cultures positive for GABHS infection warrant antibiotic
treatment.
Treatment
• Treatment of viral tonsillitis and pharyngitis is symptomatic.
• Warm saline gargles.
• Acetaminophen for pain
• Cool fluids
• Non aspirin analgesics and antipyretics.
• If a bacterial source is identified as the etiologic agent, the child
needs to be treated with an antibiotic such as penicillin or
amoxicillin.
• If allergic to penicillin, the next drug of choice is erythromycin
• If left untreated, GABHS infections can lead to
Scarlet fever
Otitis media
• Tonsillectomy is recommended for recurrent
streptococcal infections and massive hypertrophy.
• Tonsillectomies are reserved for children >3 years
of age due to excessive blood loss and a potential
for the tonsils to grow back.
Nursing Interventions
• Baseline assessment prior to the procedure.
• Postsurgical assessments include close
monitoring with high alert for bleeding and
infection.
• Frequent swallowing following a tonsillectomy is a
cardinal sign of bleeding at the surgical site.
 Tonsillectomy

• Preoperative laboratory tests include: clotting and

bleeding times as the operative site is considerably
vascular and prone to postoperative bleeding.
• Preoperative care also includes client and family
education.
• Nursing care following a tonsillectomy is centered
on supportive care and ensuring client safety.
• Postoperatively, the child is positioned on the side
to facilitate drainage of secretions.
• Once fully awakened, the child may sit up if so
desired.
 Tonsillectomy cont…
• The nurse reminds the child not to cough often or blow
the nose, as this can disrupt an operative clot and cause
bleeding.
• Secretions and emesis are examined for any sign of fresh
bleeding.
• The family should be taught the difference between fresh
and old blood.
• Old blood, dark-brown in color, is commonly in the mouth,
nose, and emesis.
• Bright red or fresh blood suggests active bleeding and
warrants further investigation.
• Postoperative hemorrhage is uncommon, the health care
provider is contacted if this is suspected.
 ACUTE LARYNGOTRACHEOBRONCHITIS

• Laryngotracheobronchitis (LTB) is the most

common type of croup and primarily affects
children <5 years of age.
• The disease process is an inflammation of the
mucosa lining the larynx and trachea causing a
narrowing of the airway.
• The typical patient with LTB is a toddler who
develops the classic “barking” cough and acute
stridor after several days of coryza.
Signs and Symptoms
• Brassy cough.
• Gradual onset of low-grade fever.
• The child struggles to inhale air past the
obstruction and into the lungs producing an
inspiratory stridor.
• The child may be in moderate respiratory distress
with mild wheezing.
• Symptoms of hypoxia and airway obstruction may
lead to respiratory acidosis and respiratory failure.
• Often worsens at night
• These organisms are responsible for LTB:
 Parainfluenza virus types 1, 2, and 3
 Respiratory Syncyctial Virus
 Influenza A and B
 Mycoplasma pneumoniae
Treatment
• The major objective for treatment is medical management of the
infectious process and maintaining an airway for adequate
respiratory exchange.
• Children with mild croup without stridor are managed at home.
• Dexamethasone and epinephrine inhalant
• High humidity with cool mist provides relief in most cases.
• Fluids are essentials for recovery.
• If the child is unable to take fluids, intravenous fluid therapy is
initiated.
 Nursing Interventions

• Vigilant observation and accurate of assessment

of the respiratory status.
• Non-invasive cardiac, respiratory, and blood gas
monitoring.
• Ensure intubation equipment is immediately
accessible to the patient.
• Keep the child comfortable.
• Allow the parent or caregiver to lie next to the
child in the mist tent to lessen anxiety.
• Modify treatment to cool moist mist blowing
directly toward the patient from the hose when
child will not tolerate mist tent.
 ACUTE EPIGLOTTITIS

• This is a serious obstructive inflammatory process

resulting from a bacterial infection that occurs
mostly in children between 2 and 7 years of age
but can occur from infancy to adulthood.
• The obstruction is supra glottic as opposed to sub-
glottic as in laryngitis.
• This disorder is a paediatric emergency.
• Delayed treatment may result in complete airway
obstruction
• Most common causative agent – H. influenzae
type B
 Signs and Symptoms
• Onset is abrupt without • Drooling.
cough. • Agitation.
• Can rapidly progress to severe • Fever.
respiratory distress. • Dysphagia.
• Asymptomatic the night prior • Suprasternal/Substernal
to onset. retractions.
• No spontaneous cough. • Respiratory obstruction
• Voice is muffled with a froglike develops quickly and may lead
croaking sound on inspiration. to
• Sore throat, reddened and  Hypoxia
inflamed.  Acidosis
• Epiglottis is cherry red and  Reduced level of
swollen consciousness
 Sudden death
 NOTE
• The key difference between
laryngotracheobronchitis (LTB) and epiglottitis
is the presence of a cough in LTB.
Tripod position in epiglottitis
 Diagnosis and treatment

Test Results
– Positive for Haemophilus influenzae
– Chest films
– WBC with differential count
Treatment
– Intensive observation by experience personnel.
– Endotracheal intubation.
Tracheostomy.
– All invasive procedures should be performed in the
operating room or areas equipped to initiate
immediate intubation.
– Antibiotic therapy.
Nursing Interventions
• Reassure the child and family to reduce anxiety.
• Allow the child to remain in the caregiver’s lap and in the
position that is most comfortable.
• Keep child quiet in a controlled medical environment with
emergency airway equipment readily available.
• Do not put tongue blade in mouth to look in the throat –
may cause epiglottis to spasm and shut
• Assess respiratory status-tripod position
• Give humidified oxygen by mask
• Mild sedation may help the child relax
NB:
• The onset of epiglottitis is abrupt and can rapidly progress
to severe respiratory distress.
• This disorder requires immediate attention.
 ACUTE LARYNGITIS

• Acute laryngitis is most common in older children and

adolescents.
• Viruses are usually the causative agents, and the
disease is almost always self-limited without extended
duration or sequelae.
Signs and Symptoms
• Hoarseness
• Coryza
• Sore throat
• Nasal congestion
• Fever
• Headache myalgia
• Malaise
Test Results
– Virus are usually the causative agent.
Treatment
– Treatment is supportive of the symptomatic
presentation; fluids and humidification highly
encouraged.
Nursing Interventions
– Assist the patient to expectorate secretions
adequately.
– Avoid the spread of infection.
– Maintain patent airway.
 PNEUMONIA

• Pneumonia is an acute inflammation of the

pulmonary parenchyma associated with alveolar
consolidation.
• Viruses such as the following are primary causative
agents:
– Cytomegalovirus
– Influenza
– Adenovirus
– RSV
• Bacterial pneumonia most often caused by
mycoplasma pneumonia occurs less frequently in
children.
 Pathophysiology
• In pneumonia a pathogen manages to invade a susceptible
individual and releases toxins that stimulate secondary and
tertiary defense mechanisms.
• The toxins and by products of the body’s defenses damage
pulmonary mucous membranes and cause the accumulation
of debris and exudate in the airways.
• The alveoli fill with fluid or blood resulting in poor
oxygenation and air exchange.
• These effects lead to ventilation perfusion ratio (the ratio of
alveolar ventilation to capillary perfusion) abnormalities.
• Can be primary illness or develop as a complication of
another illness.
• Incidence: 34 to 40 cases per 1000 children younger than 5
years
• Pneumonia can be classified as
– Lobar
– Interstitial
– Bronchial
• Lobar, involves a significant portion of the lung;
• Interstitial pneumonia includes the alveolar walls
and peri bronchial, and interlobular tissues.
• Bronchial pneumonia, as suggested by its name,
involves the bronchi and lung fields.
 Assessment
• High fever
• Thick green, yellow, or blood tinged secretions
• Grunting respirations
• Rales, crackles, diminished breath sounds
• Cough and cyanosis
• Increased work of breathing
• Hypoxia: oxygen saturations less than 92 % on
room air
• Diagnostic tests: Infiltrate seen on x-ray
 Signs and Symptoms
• Cough
• Malaise
• Fever
• Anorexia
• Wheezing
• Fine crackles
• Headache
• Tachypnea
• Gastrointestinal upset
Test Results
– Diagnosis is based on physical findings
and a sputum culture.
– Chest films demonstrate the extent and
location of the involvement.
– CXR can identify complicating factors
(pleural effusion, recurrence of disease in
one area of the lung.
Typical X-ray
 Treatment

• The course of treatment is managed according to

the etiology of the disease.
• Treatment for viral pneumonia is supportive to
relieve symptoms.
• The objective of treatment is effective ventilation
and prevention of dehydration.
• Oxygen therapy and chest physiotherapy may also
be required.
• Isolation is used as a precautionary measure when
patients hospitalized until the causative agent is
identified.
 Treatment
• Assess for respiratory distress
• NPO (respiratory rate > 60 = high risk for
aspiration)
• IV fluids for hydration
• Supplemental Oxygen to keep oxygen saturation
equal to or > 92%
• Nasal suctioning as needed
• Acetaminophen for fever
• Antibiotics – Ceftriaxone (3rd generation
cephaloporin)
 Nursing Intervention
• Assess and monitor for manifestations that
suggest increasing respiratory distress.
• Provide symptomatic relief through supportive
measures.
• Encourage adequate fluid intake to remove
secretions.
• Administer pain medication to encourage deep
breathing and respiratory therapy treatments.
• Antibiotic therapy.
 ASTHMA
• Asthma is a chronic inflammatory disorder of the
airways.
• It is characterized by chronic inflammation,
bronchoconstriction, and bronchial hyper
responsiveness.
• The primary manifestations of the disease—
wheezing, coughing, and dyspnea—are caused by
airway obstruction from edema, mucus, and
bronchoconstriction.
• Asthma is the most common chronic respiratory
illness in the childhood population.
 Pathophysiology
• The inflammatory response associated with
asthma is triggered by agents such as antigens,
irritants (e.g., pollution, tobacco smoke, cold
air), infection, medications (e.g., aspirin,
nonsteroidal anti-inflammatory drugs),
gastroesophageal reflux, foods and food
preservatives, physical and emotional stress,
and exercise.
• These triggers stimulate a cascade of events that
affect the entire respiratory tract.
 Pathophysiology cont…
• Allergens stimulate an increase in circulating IgE, mast
cells, and macrophages.
• These products cause the release of other substances
such as histamine, basophils, eosinophils, neutrophils,
platelets, T lymphocytes, and prostaglandins.
• The result of this inflammatory cascade is
bronchoconstriction, mucosal edema, and an increased
mucus production.
• These effects cause airway obstruction and air trapping,
which lead to ventilation-perfusion alterations, an
increased work of breathing, hypercapnia, and
hypoxemia.
• If left untreated, respiratory failure and death can result
Asthma Attack
Risk factors
• Past history, e.g. premature birth, mechanical
ventilation, bronchiolitis requiring hospitalization.
• Signs of atopy, e.g. atopic eczema, hay fever,
genuine food allergy, particularly to egg
Family history
• Parents or siblings with asthma, eczema, hay fever
• Smoking parents
 Signs and Symptoms
• Expiratory wheezing
• Chronic cough
• Dyspnea (shortness of breath or difficulty in
breathing)
• Non-productive cough
• Tachypnea
• Chest pain
• Irritability
• Restlessness
• Use of accessory muscles
• Orthopnea (an increase in difficulty breathing when
lying down)
 Diagnosis
• Physical assessment findings and client history
• Peak expiratory flow (PEF) rates
• Measurement of flow volume loops with spirometry,
Spirometry before and after exercise may also reveal
exercise-induced bronchospasm.
• Skin-prick testing for common aeroallergens (e.g.
grass and tree pollens, house dust mite, aspergillus
mould, cat and dog) will indicate atopic status
• A chest radiograph may exclude several diagnoses
and may show hyperinflation in more severe cases
• Response to anti-asthma therapy can be very useful
for confirming the diagnosis.
Chest Xray; Hyperinflation of lungs
 Treatment

• Prevent and minimize physical and psychologic

morbidity.
• Prevent and reduce exposure to airborne
allergens and irritants.
• Pharmacologic therapy to prevent and control
asthma symptoms:
• Reverse airflow obstruction
• Long-term control medications
• Quick-relief medications
Medications:
• Leukotriene modifiers
• Rescue drugs: short acting albuterol (beta 2
agonist )– used as a quick-relief agent for acute
bronchospasm and for prevention of exercise
induced bronchospasm.
• Anti-inflammatory or preventative: low-dose
inhaled corticosteroid: inhaled or oral prednisone
• Allergy: leukotrines such as Singulair or
montelukast
• High fowlers position / bed rest
• Pulse oximetry
• Nebulized albuterol – beta 2 agonist
• Chest percussion to mobilize secretions
• Methylprednisone / Solumedrol IV
• IV fluids / po fluids
• Oxygen to keep oxygen saturation > 95%
 Bronchodilators
• Bronchodilators rapidly relax the airway smooth
muscle cells, thus reversing the bronchospasm
until anti-inflammatory effect of steroids is
attained.
– Aerosols
• Via mouth piece 3 years and older
• Via facial mask for less than 3 years
Spacer
Nebulizer
 Corticosteroids
• Steroids reduce the inflammatory component of
bronchial obstruction, decrease mucus production
and mediator release, as well as the late phase
(cellular) inflammatory process.
• Methyl prednisone IV in severe cases
• PO prednisone – always give with food to decrease
GI upset
• Inhaled corticosteroids: Pulmicort, AeroBid, Flovent
– Infant: mask should fit firmly to prevent cataracts
– Older child: rinse and spit after treatment to prevent
thrush
 NURSING INTERVENTIONS

• Assess how asthma impacts everyday life.

• Assess child and family’s satisfaction with the
effectiveness of the treatment program.
• Assist the child and family to avoid allergens.
• Teach child and family to modify the
environment to relieve asthmatic episodes, (i.e.,
avoid excessive heat, cold, and other extremes
of the weather or wind).
• Educate parents on reading food labels.
• Avoid foods known to provoke symptoms, foods
such as monosodium glutamate (MSG), sulfites,
bisulfites, and metabisulfites.
• Avoid aspirin with children who are sensitive and
subject to aspirin induced asthma.
• Monitor for and alert caregivers to signs of status
asthmaticus, a life threatening complication.
• Teach how to use medication, when to use and
how often
• No OTC drugs
• Increase fluid intake
 BRONCHIOLITIS
• Bronchiolitis is an acute viral infection of the
bronchioles.
• The illness occurs most frequently in children <2
years of age during winter and spring.
• The respiratory syncytial virus (RSV) is
responsible for 80% or most cases.
• The inflammatory process leads to airway edema
and the accumulation of mucous and cellular
debris.
• The obstruction in the airways leads to over
inflation in some alveoli and atelectasis in others.
 Signs and Symptoms

• Symptoms of upper respiratory infection (URI),

such as sneezing, rhinorrhea, decreased appetite,
low-grade fever, and coughing.
• Wheezing, retractions, crackles,
• Nasal flaring, prolonged expiratory phase, and
intermittent cyanosis.
• Harsh dry cough
• Feeding difficulties
• Respiratory distress with apnea
• Thick mucus
 Diagnosis
• The physical examination and medical history are
the main diagnostic tools for bronchiolitis.
• It is difficult to identify the specific etiologic
agent by clinical criteria alone.
• Nasal and nasopharyngeal secretions are tested
by rapid immunofluorescent antibody (IFA) or
enzyme-linked immunosorbent assay (ELISA).
Treatment
• Most cases are treated at home with high humidity,
adequate fluid intake, rest, and medications.
• Children with complicating conditions should be
hospitalized.
• Mist therapy combined with oxygen by hood or tent are
sufficient enough to alleviate dyspnea and hypoxia.
• Ribavirin (Virazole) a specific aerosol antiviral
medication for RSV bronchiolitis and reserved for severely
ill infants and children
• Two drugs currently available for prevention of RSV
bronchiolitis:
• RSV immune globulin intravenous (RSV-GIV or
RespiGam)
• Palivizumab (Synagis)
 Nursing Intervention

• Conduct continuous and thorough respiratory

system assessments.
• Practice consistent handwashing and do not
touch the mucous-secreting areas such as the
nasal mucosa or conjunctiva.
• Assign isolation rooms to hospitalized patients.
• Nurses caring for patients with RSV bronchiolitis
should not care for other patients who are
considered high risk.
 CYSTIC FIBROSIS
• Cystic fibrosis (CF) is an inherited autosomal
recessive trait disorder that affects the exocrine
glands of the body.
• The condition is characterized by an alteration in
sweat, electrolytes, and mucus production that
leads to multisystem involvement.
• The white population experiences 95% of the
occurrences.
 Signs and Symptoms

• The clinical symptoms vary widely and changes as

the disease progresses.
• Chronic respiratory infections are persistently
associated with CF.
• The majority of the patients also have some
exocrine pancreatic insufficiency.
• Manifestations associated with gastrointestinal
dysfunction include:
• Steatorrhea
• Vitamin deficiencies A, D, E, and K
• Diabetes mellitus
• Manifestations associated with respiratory
infections:
• Cough
• Sputum production
• Hyperinflation of the alveoli
• Bronchiectasis
• Hemoptysis
• Pulmonary insufficiency
Diagnosis
• A quantitative sweat chloride test >60 mEq/L.
• Chest radiography
• Stool fat and enzyme analysis
Treatment
• Chest physiotherapy (CPT)
• Postural drainage and percussion
• Exercise, deep breathing, and coughing
• Antimicrobial agents
Inhaled antibiotics
Intravenous antibiotics
• Oxygen therapy
• Replacement of pancreatic enzymes
• High-protein, high-caloric diet
• Salt supplementation during hot weather
 Nursing Interventions
• Pulmonary and gastrointestinal assessments
• Aerosol therapy
• Family education to prevent exacerbation of
the disease
• Educating parents on chest physiotherapy and
breathing exercises
Chest Physiotherapy
cupping and clapping