Chapter 1

Chapter 28 The Child with

Respiratory Dysfunction
 Growth and the Respiratory
System
• Child’s respiratory tract grows until about age 12

Upper Airway
 Airway Diameter

• Inverse relationship between airway

diameter and airway resistance
 Upper Airway: Newborns

• Until 4 weeks of age, obligatory nose

breathers
• Nasal patency is critical
 Lower Airway

• Alveoli change size and shape, increase in

number
– Continues until puberty
– Increases area available for gas exchange
• Smooth muscles of bronchi & bronchioles
– Develop during first year of life
– Until developed, less able to trap invaders
 Lower Airway

• Intercostal muscles immature – diaphragm

primary muscle used to breathe

• Ribs are primarily cartilage and are very flexible

– retractions seen, especially during respiratory
distress
 Clinical Manifestations of Respiratory
Infections
 Vary with age
 Generalized signs and symptoms and local

manifestations differ in young children:

 Fever
 Anorexia, vomiting, diarrhea, abdominal pain
 Cough, sore throat, nasal blockage or discharge
 Respiratory sounds

Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 7
Nursing Interventions for Respiratory
Infections
 Ease respiratory effort
 Fever management
 Promote rest and comfort
 Infection control
 Promote hydration and nutrition
 Family support and teaching

Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 8
Changes in Eustachian Tube with
Growth
 Otitis Media

• Symptoms
– Ear pain (tugging on ear)
– Redness of tympanic membrane
– Middle ear effusion
 Otitis Media: Treatment

• Current recommendations about antibiotic use

• “High-dose amoxicillin (80 to 90 mg\kg\ day)
• Delayed treatment can lead to permanent
hearing loss
• Myringotomy
The most common complications of AOM include:

• Hearing loss
• Expressive speech delay
• Tympanosclerosis (scarring of the tympanic membrane)
• Tympanic membrane perforation (acute or chronic)
• Chronic suppurative otitis media (chronic drainage via
perforation or tympanostomy tubes)
• Acute mastoiditis (infection of the mastoid process)
• Intracranial infections, including bacterial meningitis and
abscesses
Tonsillitis and tonsillectomy
• Tonsils are masses of lymph-type tissue found in the pharyngeal
area. They filter pathogenic organisms viral and bacterial), which
helps to protect the respiratory & gastrointestinal tracts. In
addition, they contribute to antibody formation.
• Tonsils are highly vascular, which helps them to protect against
infection because foreign materials (viral or bacterial organisms),
enter the body through the mouth.
• Palatine tonsils are located on both sides of the oropharynx.
These are the tonsils removed during a tonsillectomy.
• Pharyngeal tonsils , also known as the adenoids are removed
during an adenoidectomy.
 Tonsillitis
• Enlarged tonsils
• In some instances, enlarged tonsils can block the nose and throat.
This can interfere with breathing, nasal and sinus drainage,
sleeping, swallowing, and speaking.

• Enlarged tonsils also can disrupt the function of the Eustachian

tube, which can cause otitis media or impede hearing.
• Acute tonsillitis occurs when the tonsils become inflamed and
reddened. Acute tonsillitis can become chronic.
 Tonsillitis
• RISK FACTORS
• Exposure to a viral or bacterial agent
• Immature immune systems (younger children)
• PHYSICAL ASSESSMENT FINDINGS
• Mouth odor
• Mouth breathing
• Snoring
• Nasal qualities in the voice
• Fever
• Tonsil inflammation with redness and edema
• Difficulty swallowing or eating
 Tonsillitis
• LABORATORY TESTS
• Throat culture for group A beta-hemolytic streptococci
(GABHS)
 Tonsillitis NURSING CARE

• Provide treatment for manifestations of viral tonsillitis (rest,

warm fluids, warm salt water gargles).
• Administer antibiotic therapy as prescribed for
bacterial tonsillitis
• Encourage the child to get plenty of sleep.
• Provide comforting foods beverage.
• Humidify the air.
• Offer lozenges.
• Avoid irritants. ...
• THERAPEUTIC PROCEDURES
Tonsillectomy
• PREOPERATIVE NURSING ACTIONS: Maintain NPO
status.
• POSTOPERATIVE NURSING ACTIONS
• Positioning
• Place in position to facilitate drainage.
• Elevate head of bed when child is fully awake.
• Assessment
• Assess for evidence of bleeding, which includes frequent
swallowing, clearing the throat, restlessness, bright red emesis,
tachycardia, and/or pallor.
• Assess the airway and vital signs.
• Monitor for difficulty breathing related to oral secretions,
edema, and/or bleeding.
• Therapeutic Procedures-
Tonsillectomy
• Comfort measures
• Administer liquid analgesics as prescribed.
• Provide an ice collar.
• Offer ice chips or sips of water to keep throat moist.
• Administer pain medication on a regular schedule.
• Diet
• Encourage clear liquids and fluids after a return of the gag
reflex, avoiding red colored liquids, citrus juice, and milk-
based foods initially.
• Advance the diet with soft, bland foods.
 Acute Streptococcal Pharyngitis

• GABHS: Infection of the upper airway (strep throat)

• EXPECTED FINDINGS
• Onset is abrupt and characterized by pharyngitis, headache, fever
and abdominal pain.
• Tonsils and pharynx can be inflamed and covered with exudate,
usually appears by second day of illness.

• LABORATORY TESTS
• Throat culture or rapid antigen testing to determine GABHS
infection
 Acute Streptococcal Pharyngitis
NURSING CARE

• Administer IV antibiotics as prescribed

 Oral penicillin in a dose sufficient to control the acute local
manifestations and is administered for at least 10 days.
 Amoxicillin once a day for 10 days is also effective
 IM penicillin G benzathine is also appropriate.
 Oral erythromycin for children allergic to penicillin.
• Administer antipyretics for fever.
• Clarithromycin, azithromycin, clindamycin, oral
cephalosporins and amoxicillin with clavulanic acid are
also effective to treat GABHS
1. Inflammation of the trachea and bronchi; may be
referred to as tracheobronchitis
2. Usually occurs in association with an upper
respiratory infection
3. Is usually a mild disorder; causative agent is most
often viral
Assessment
1. Fever
2. Dry, hacking, and nonproductive cough that is worse at
night and becomes productive in 2 to 3 days
• Interventions
1. Treat symptoms as necessary.
• Give antipyretics for fever.
• Provide increased humidity (cool mist vaporizer).
2. Monitor for respiratory distress.
3. Provide cool, humidified air to the child.
4. Encourage increased fluid intake; child may drink beverages that
he or she likes as long as the respiratory status is stable.
5. 6. A cough suppressant may be prescribed to promote rest.
 Bronchiolitis and Respiratory
Syncytial Virus (RSV)

1. Bronchiolitis is an inflammation of the bronchioles that

causes production of thick mucus that occludes bronchiole
tubes and small bronchi.

2. RSV causes an acute viral infection and is a common cause

of bronchiolitis (other organisms that cause bronchiolitis
include adenoviruses, para-influenza viruses, and human
meta-pneumo virus).

3. RSV, although not airborne, is highly communicable and is

usually transferred by direct contact with respiratory
secretions.
 Bronchiolitis and Respiratory
Syncytial Virus (RSV)
4. RSV occurs primarily in the winter and spring.

5. RSV is rarer in children older than 2 years, with a peak

incidence at approximately 6 months of age.

6. At-risk children include children older than 1 year of age

who have a chronic or disabling condition.

7. Identification of the virus is done via testing of nasal or

nasopharyngeal secretions.
 Bronchiolitis and Respiratory
Syncytial Virus (RSV)

Prevention measures include:

 Encouraging breastfeeding
Avoiding tobacco smoke exposure
 Using good hand-washing techniques
 Administering palivizumab, a monoclonal
antibody, to high-risk infants. Palivizumab is
administered via intramuscular injection monthly
for a 5- month period (usually from November to
March).
 Bronchiolitis and Respiratory
Syncytial Virus (RSV)
Assessment
Initial Manifestations
▪ Rhinorrhea
▪ Eye or ear drainage
▪ Pharyngitis
▪ Coughing
▪ Sneezing
▪ Wheezing
▪ Intermittent fever
 Bronchiolitis and Respiratory
Syncytial Virus (RSV)
Manifestations as Disease Progresses
▪ Increased coughing and wheezing
▪ Signs of air hunger
▪ Tachypnea and retractions
▪ Periods of cyanosis

Manifestations in Severe Illness

▪ Tachypnea more than 70 breaths/minute
▪ Decreased breath sounds and poor air exchange
▪ Listlessness
▪ Apneic episodes
Bronchiolitis- Nursing care
1. For a child with bronchiolitis, interventions are aimed at
treating symptoms and include airway maintenance, cool
humidified air and oxygen, adequate fluid intake, and
medications.
2. For a hospitalized child with RSV, isolate the child in a single
room or place in a room with another child with RSV.
3. Ensure that nurses caring for a child with RSV do not care for
other high-risk children.
4. Use contact and standard precautions during care; using good
hand-washing techniques and wearing gloves and gowns are
necessary.
5. Monitor airway status and maintain a patent airway.
 Bronchiolitis- Nursing care
6. For most effective airway maintenance, position the child at a
30- to 40-degree angle with the neck slightly extended to
maintain an open airway & decrease pressure on the diaphragm.

7. Provide cool, humidified oxygen as prescribed.

8. Monitor pulse oximetry levels.

9. Encourage fluids; fluids administered intravenously may be

necessary until the acute stage has passed.
 Bronchiolitis- Nursing care
10. Periodic suctioning may be necessary if nasal
secretions are copious; use of a bulb syringe for
suctioning may be effective. Suctioning should be done
before feeding to promote comfort and adequate intake.

11. Administer ribavirin, an antiviral medication, as

prescribed,

Cough suppressants are administered with

caution because they can interfere with the
clearance of respiratory secretions.
 Croup
• Broad term for upper airway illnesses –
• Affect large numbers of children: 3 months -3 years of
age
• Cause is usually viral
 Croup syndromes: Acute
laryngotracheobronchitis and
acute spasmodic.laryngitis
• Acute laryngotracheobronchitis: Causative agents
include RSV, influenza A and B, and Mycoplasma
pneumonia, parainfluenza types 1, 2, and 3.

• Acute spasmodic laryngitis

• Self-limiting illness that can result from allergens
• Characterized by paroxysmal attacks of laryngeal
obstruction that occur mainly at night
 Croup syndromes: Acute
laryngotracheobronchitis and
acute spasmodic.laryngitis
• EXPECTED FINDINGS
• Acute laryngotracheobronchitis
• Low-grade fever, restlessness, hoarseness, barky cough,
dyspnea, inspiratory stridor, and retractions
• INFANTS AND TODDLERS: nasal flaring, intercostal
retractions, tachypnea, and continuous stridor
• Acute spasmodic laryngitis: Croupy barky cough,
restlessness, difficulty breathing, hoarseness, and nighttime
episodes of laryngeal obstruction
 Croup syndromes: Acute
laryngotracheobronchitis and
acute spasmodic.laryngitis
NURSING CARE
•Provide humidity with cool mist.
•Administer oxygen if needed.
•Monitor continuous oximetry.
•Administer nebulized racemic epinephrine as prescribed.
•Administer corticosteroids: oral or IM (dexamethasone), or
nebulized (budesonide).
•Encourage oral intake if tolerated.
•Administer IV fluids as prescribed
Croup syndromes: Bacterial
epiglottitis (acute
supraglottitis)
• Inflammation of the epiglottis
• Potentially life-threatening
• Usually caused by H. influenzae type B (Hib) – Hib
vaccination now required for children
• Peak age: 2 to 8 years

Lateral neck radiograph of the soft tissues

 Signs and Symptoms
• Absence of cough, drooling, and agitation
• Sitting upright with chin pointing out, mouth opened, and
tongue protruding (tripod position)
• Dysphonia (thick, muffled voice & froglike croaking
sound)
• Dysphagia
• Inspiratory stridor (noisy inspirations)
• Suprasternal and sub-sternal retractions
• Sore throat, high fever, and restlessness
 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
NURSING CARE
•Protect airway.
•Avoid throat culture or using a tongue blade.
•Prepare for intubation.
•Provide humidified oxygen
•Monitor continuous oximetry.
•Administer corticosteroids, and IV fluids as prescribed
•Administer antibiotic therapy starting with IV, then transition to
oral to complete a 10-day course, as prescribed.
• Droplet isolation precautions for first 24hr after IV antibiotics
initiated
 Bacterial Tracheitis
 Infection of the mucosa of the upper trachea
 Distinct entity with features of croup and epiglottitis
 Clinical manifestations similar to “laryngo-treacho-
bronchitis” LTB
 May be complication of LTB
 Thick, purulent secretions result in respiratory distress

Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 41
 Pneumonia
1. Inflammation of the pulmonary parenchyma or alveoli or both,
caused by a virus, mycoplasma agents, bacteria, or aspiration of
foreign substances.
2. The causative agent usually is introduced into the lungs through
inhalation or from the bloodstream.
3. Viral pneumonia occurs more frequently than bacterial
pneumonia, is seen in children of all ages, and often is associated
with a viral upper respiratory infection.
4. Primary atypical pneumonia,
pneumonia usually caused by Mycoplasma
pneumonia or Chlamydia pneumonia, occurs most often in the fall
and winter months and is more common in crowded living
conditions; it is most often seen in children 5 to 12 years old.
 Pneumonia
5. Bacterial pneumonia is often a serious infection requiring
hospitalization when pleural effusion or empyema accompanies the
disease; hospitalization is also necessary for children with
staphylococcal pneumonia (Streptococcus pneumonia is a common
cause).
6. Aspiration pneumonia occurs when food, secretions, liquids, or
other materials enter the lung and cause inflammation and a chemical
pneumonitis. Classic symptoms include an increasing cough or fever
with foul-smelling sputum, deteriorating results on chest x-rays, and
other signs of airway involvement.
7. Prevention of viral and bacterial pneumonia includes
immunization of infants and children with heptavalent pneumococcal
conjugate vaccine
 Viral pneumonia
Assessment
a. Acute or insidious onset
b. Symptoms range from mild fever, slight cough, and
malaise to high fever, severe cough, and diaphoresis.
c. Nonproductive or productive cough of small amounts of
whitish sputum
d. Wheezes or fine crackles
 Viral pneumonia

Interventions
a. Treatment is symptomatic.
b. Administer oxygen with cool humidified air as prescribed.
c. Increase fluid intake.
d. Administer antipyretics for fever as prescribed.
e. Administer chest physiotherapy and postural drainage as
prescribed.
 Primary Atypical Pneumonia
Assessment
a. Acute or insidious onset
b. Fever (lasting several days to 2 weeks), chills, anorexia,
headache, malaise, and myalgia (muscle pain)
c. Rhinitis; sore throat; and dry, hacking cough
d. Nonproductive cough initially, progressing to production
of seromucoid sputum that becomes mucopurulent or blood-
streaked
Interventions
a. Treatment is symptomatic.
b. Recovery generally occurs in 7 to 10 days.
 Bacterial Pneumonia
• Streptococcus pneumonia is a common cause of bacterial
pneumonia in all ages of children.
• Bacterial pneumonia: Streptococcus pneumonia, Group
A streptococci, Staphylococcus aurous
 Pneumonia
EXPECTED FINDINGS
• High fever
• Cough that can be unproductive or productive of white sputum
• Tachypnea
•Retractions and nasal flaring
• Chest pain
• Dullness with percussion
• Adventitious breath sounds (rhonchi, fine crackles)
• Pale color that progresses to cyanosis
• Irritability, restless, lethargic
• Abdominal pain, diarrhea, lack of appetite, and vomiting
 Pneumonia
• LABORATORY TESTS

• Radiographic examination to detect presence of

infiltrates
• Gram stain and culture of sputum in older children
• Nasopharyngeal specimens
• Blood cultures
• Occasionally lung aspiration and biopsy
• Elevated anti-streptolysin titer if streptococcal
infection present.
 Bacterial Pneumonia
NURSING CARE
•Encourage rest.
•Administer IV antibiotics.
•Promote increased oral intake.
•Monitor I&O.
•Administer antipyretics for fever.
•CPT and postural drainage can be helpful.
•Administer IV fluids
•Administer oxygen.
•Monitor continuous oximetry
 Bacterial Pneumonia
COMPLICATIONS
•Pneumothorax
•Accumulation of air in the pleural space
•Pleural effusion
•Accumulation of fluid in the pleural space
 Asthma
• Asthma is a chronic childhood inflammatory disorder of the
airways that results in intermittent and reversible airflow
obstruction of the bronchioles.
• It causes school absences and is considered one of the leading
causes of hospitalizations among children.
• The obstruction occurs because the mast cells release
histamines and leukotrienes which causes inflammation or
airway hyper-responsiveness.
• Asthma diagnoses are classified into one of four categories
based on effects on the child: intermittent, mild persistent,
moderate persistent, and severe persistent.
Asthma
 Asthma

TRIGGERS TO ASTHMA
•Allergens
•Indoor: mold, cockroach antigen, dust, dust mites
• Outdoor: grasses, pollen, trees, shrubs, molds, spores, air
pollution, weeds
• Irritants: Tobacco smoke, wood smoke, odors, sprays
• Exercise
•Cold air or changes in weather or temperature
•Environmental change (new home or school)
 Asthma

TRIGGERS TO ASTHMA
•Infections/viruses (colds)
•Animal hair or dander
•Medications (Aspirin, nonsteroidal anti-inflammatory drugs,
antibiotics, beta blockers
•Strong emotions: Fear, anger, laughing, crying
•Conditions: Gastro-esophageal reflux, tracheoesophageal fistula
•Food allergies or additives
•Endocrine factors: Menses, pregnancy, thyroid disease
 Asthma Severity Classification in
Children 5 Years and Older
 Step I: mild, intermittent asthma
 Step II: mild, persistent asthma
 Step III: moderate, persistent asthma
 Step IV: severe, persistent asthma
 Clinical features of each classification

Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 56
 Asthma manifestations
• Dyspnea • Restlessness, irritability
• Cough • Anxiety
• Audible wheezing • Sweating
• Coarse lung sounds, • Use of accessory muscles
wheezing throughout • Decreased oxygen saturation
• possible crackles (low SaO2)
• Mucus production • Tripod positioning
• Sitting retractions
• Inaudible breath sounds or
crackles (severe obstruction)
 DIAGNOSTIC PROCEDURES
• LABORATORY TESTS
• CBC (increased WBC)
• Pulmonary function tests
• The most accurate tests for diagnosing asthma and its severity
• Baseline test at time of diagnosis
• Repeat testing after treatment is initiated and child is stabilized
• Test every 1 to 2 years
• Peak expiratory flow rates (PEFR)
• Uses a flow meter to measure the amount of air that can be
forcefully exhaled in 1 second
• Each child needs to establish personal best
 DIAGNOSTIC PROCEDURES
• Bronchoprovocation testing
• Exposure to methacholine, cold air, or histamine
• Exercise challenge
• Skin prick testing: Identify allergens that trigger asthma
• Chest x-ray: showing hyper-expansion and infiltrates
 Asthma
• NURSING CARE
• Assess airway patency, respiratory rate, symmetry, effort, and use
of accessory muscles
• Assess breath sounds in all lung fields
• Monitor for shortness of breath, dyspnea, and audible wheezing. An
absence of wheezing can indicate severe constriction of the alveoli.
• Monitor vital signs and oxygen saturation.
• Check CBC and chest x-ray results, possible ABGs.
• Position the child to maximize ventilation.
• Administer oxygen therapy as prescribed. Keep endotracheal
intubation equipment nearby.
 Asthma
• NURSING CARE
• Initiate and maintain IV access as prescribed.
• Maintain a calm and reassuring demeanor.
• Encourage appropriate vaccinations and prompt medical attention
for infections.
• Administer medications. The provider can prescribe antibiotics if a
bacterial infection is confirmed
• Teach the family and the child about when to use each of the
prescribed medications (rescue medications vs. maintenance
medications).
 Asthma
MEDICATIONS

• A stepwise approach is used for treatment based upon the severity.

1. Bronchodilators (inhalers)
 Short-acting beta2 agonists (SABA) (albuterol, levalbuterol,
terbutaline)
• Used for acute exacerbations
• Prevention of exercised-induced asthma
 Long-acting beta2 agonists (LABA) (formoterol, salmeterol)
• Used to prevent exacerbations, especially at night, and reduce use
of SABA.
• Must be used along with anti-inflammatory therapy
• Cannot be used to treat acute exacerbations
 Asthma
MEDICATIONS

 Cholinergic antagonists (anticholinergic medications; atropine,

ipratropium) block the parasympathetic nervous system, providing
relief of acute bronchospasms.
 Asthma
MEDICATIONS

2. Anti-inflammatory agents
•Decrease airway inflammation
•Corticosteroids can be given parenterally (methylprednisolone),
orally (prednisone), or by inhalation fluticasone
• Oral systemic steroids can be given for short periods (3 or 10 days).
• Inhaled corticosteroids are administered daily as a preventive
measure.
• Monitor child’s growth
•Leukotriene modifiers (Zafirlukast, montelukast)
• Decrease in airway resistance
 Asthma
MEDICATIONS

2. Anti-inflammatory agents
•Decrease airway inflammation
•Corticosteroids can be given parenterally (methylprednisolone),
orally (prednisone), or by inhalation fluticasone
• Oral systemic steroids can be given for short periods (3 or 10
days).
• Inhaled corticosteroids are administered daily as a preventive
measure.
• Monitor child’s growth
•Leukotriene modifiers (Zafirlukast, montelukast)
• Decrease in airway resistance
 Asthma
MEDICATIONS

• Mast cell stabilizers (cromolyn)

• Long term control
• Monoclonal antibodies (omalizumab) are used to treat
moderate to severe persistent allergic asthma uncontrolled by
inhaled corticosteroids in children 12-years-old and older.
• Combination medications contain an inhaled corticosteroid
and a LABA (Fluticasone/ salmeterol)
 Asthma
MEDICATIONS

3. Theophylline: Used in the Pediatric Intensive Care Unit

(PICU) when the child is not responding to therapy because of
increased risk for toxicity and frequent monitoring of blood
levels.

4. Magnesium sulfate: Potent medication used for moderate

to severe attacks. Administered IV (Emergency
Department/ICU).
 CLIENT EDUCATION

• Identify personal triggering agents.

• Avoid triggering agents.
• Provide the family and child with an asthma action plan.
• Properly self-administer medications (nebulizers, inhalers, and
spacer).
 CLIENT EDUCATION

• Use a peak flow meter. (use at the same time each day)
• Ensure the marker is zeroed.
• Have the child stand up straight.
• Remove gum or food from mouth.
• Close lips tightly around the mouthpiece (ensure the tongue is not
occluding).
• Blow out as hard and as quickly as possible.
• Read the number on the meter.
• Repeat these steps two more times for a total of three attempts (wait
at least 30 seconds between attempts.)
• Record highest number.
 CLIENT EDUCATION

• Keep a record of PEFR results. Readings over time show the child’s
best efforts, and provide a warning of increased airway impairment.
• Learn how to interpret PEFR results and what measures to take for
their zone. (18.2)
• Learn how to recognize an asthma exacerbation (decreased PEFR,
increased use of SABA, difficulty speaking or eating).
• Perform infection prevention techniques.
• Promote good nutrition.
• Reinforce importance of good hand hygiene.
• Reduce allergens in the child’s environment
 CLIENT EDUCATION

• Perform prompt medical attention for infections.

• Keep immunizations, including seasonal influenza and pneumonia
vaccines, up to date.
• Perform regular exercise as part of asthma therapy.
• Promotes ventilation and perfusion
• Maintains cardiac health
• Enhances skeletal muscle strength
• Children can require medication before exercise to prevent induced
spasms of the bronchus.
 Asthma
COMPLICATIONS
• Status asthmaticus
• A life-threatening episode of airway obstruction that is often
unresponsive to common treatment. It is considered a prolonged
severe asthma attack.
• MANIFESTATIONS include wheezing, labored breathing, nasal
flaring, lack of air movement in lungs, use of accessory muscles,
distended neck veins, tachycardia, tachypnea, hypoxia, diaphoresis,
and risk for cardiac and respiratory arrest.
• Emergency treatment: epinephrine 0.01 ml/kg SC (maximum dose
0.3 ml)
 Asthma
COMPLICATIONS
• NURSING ACTIONS
• Monitor oxygen saturations continuously.
• Place on continuous cardiorespiratory monitoring.
• Position the child sitting upright, standing, or leaning slightly
forward.
• Administer humidified oxygen
• Administer three nebulizer treatments of a beta2 agonist, 20 to 30
min apart or continuously.
• Ipratropium bromide can be added to the nebulizer to increase
Broncho- dilation.
• Obtain IV access.
• Monitor ABGs and blood electrolytes.
 Asthma
COMPLICATIONS
• NURSING ACTIONS
• Administer corticosteroid.
• Prepare for emergency intubation.
• Magnesium sulfate IV decreases in inflammation and improves
pulmonary function and peak rate among children who have
moderate to severe asthma when treated in the emergency
department or pediatric ICU.
• Heliox (a mixture of helium and oxygen) can be administered via a
non-rebreathing mask to decrease airway resistance and work of
breathing
• Ketamine: Smooth muscle relaxant that decreases airway resistance
 Asthma
COMPLICATIONS
• Respiratory failure
• Persistent hypoxemia related to asthma can lead to
respiratory failure.
• NURSING ACTIONS
• Monitor oxygenation levels and acid-base balance.
• Prepare for intubation and mechanical ventilation as indicated.
 CYSTIC FIBROSIS
• Cystic fibrosis is a chronic multisystem disorder primarily
affecting the exocrine (mucus-producing) glands (pancreas,
respiratory, gastrointestinal, and reproductive glands).
• It is inherited as an autosomal-recessive defect.
• It is the most common cause of lung disease in children.
• It occurs predominantly in whites as opposed to blacks or
Asians
 ETIOLOGY
• Genetic predisposition (autosomal-recessive)
• Family history
• A deletion occurring on the long arm of chromosome 7 at the
cystic fibrosis transmembrane regulator (CFTR) is the
responsible gene mutation.
 Pathophysiology
• In cystic fibrosis, the CFTR mutation causes alterations in
epithelial ion transport on mucosal surfaces, resulting in
generalized dysfunction of the exocrine glands.
• The epithelial cells fail to conduct chloride, and water
transport abnormalities occur.
• This results in thickened, tenacious secretions in the sweat
glands, gastrointestinal tract, pancreas, respiratory tract, and
other exocrine tissues.
• The increased viscosity of these secretions makes them
difficult to clear. The sweat glands produce a larger amount of
chloride, leading to a salty taste of the skin and alterations in
electrolyte balance and dehydration.
 Pathophysiology
• In cystic fibrosis, the CFTR mutation causes alterations in
epithelial ion transport on mucosal surfaces, resulting in
generalized dysfunction of the exocrine glands.
• The epithelial cells fail to conduct chloride, and water
transport abnormalities occur.
• This results in thickened, tenacious secretions in the sweat
glands, gastrointestinal tract, pancreas, respiratory tract, and
other exocrine tissues.
• The increased viscosity of these secretions makes them
difficult to clear. The sweat glands produce a larger amount of
chloride, leading to a salty taste of the skin and alterations in
electrolyte balance and dehydration.
 Clinical manifestations
• The pancreas, intrahepatic bile ducts, intestinal glands,
gallbladder, and submaxillary glands become obstructed by
viscous mucus and eosinophilic material.
• Pancreatic enzyme activity is lost and malabsorption of fats,
proteins, and carbohydrates occurs, resulting in poor growth
and large, malodorous stools.
• Excess mucus is produced by the tracheobronchial glands.
Abnormally thick mucus plugs the small airways, and then
bronchiolitis and further plugging of the airways occur.
• Boys have tenacious seminal fluid and experience blocking of
the vas deferens, often making them infertile
 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
 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 Process Elements
 Check for family history of cystic fibrosis
 Assess for SIGNS AND SYMPTOMS
 Provide pulmonary hygiene to clear air passage:
1. Daily postural drainage with percussion and vibration between
meals and HS
2. Avoid PD right before and right after meals
3. Follow PD with good oral hygiene and rest
4. Aerosol therapy as ordered
 Nursing Process Elements
 Check for family history of cystic fibrosis
 Assess for SIGNS AND SYMPTOMS
 Provide pulmonary hygiene to clear air passage:
1. Daily postural drainage with percussion and vibration between
meals and HS
2. Avoid PD right before and right after meals
3. Follow PD with good oral hygiene and rest
4. Aerosol therapy as ordered
5. Maintain mist tent
 Encourage physical exercise
 Breathing exercises
 Nursing Process Elements
 Administer bronchodilators, mucolytic agents, and expectorants as
ordered
 Prevent respiratory infection; treat vigorously if present
 Maintain adequate nutrition
1. Provide high-calorie, high-protein, normal-fat diet
2. Administer water-soluble preparation for fat-soluble vitamins such
as A, D, E, and K
3. Provide salt supplements during hot or febrile periods (soup, and
sports drink, salty pretzels)
4. Administer pancreatic enzymes immediately with each meal and
each snack.
 Nursing Process Elements

5. Increase intake of fluids with electrolytes

6. Provide emotional support for the child and family

 Allow verbalization of concerns and feelings

 Encourage age appropriate independence
 Suggest genetic counseling
 Refer family to cystic fibrosis association
 SUDDEN INFANT DEATH
SYNDROME (SIDS)
 No one cause has been identified for Sudden Infant
Death Syndrome (SIDS) though several risk factors
have been noted.
 The incidence of SIDS often peaks between 2-4
months of age with less than 5% of cases happening
after 6 months of age.
 Breast fed infants have lower incidence of SIDS
The risk factors of SIDS include:
• Sleeping on abdomen or with pillows or other soft materials
around that could suffocate an infant
• Low birth weight infants
• Infants with low Apgar scores
• Exposure to tobacco smoke
• Respiratory disorders such as bronchopulmonary dysplasia
• Maternal habits such as smoking or drug use during pregnancy
• Central Nervous system abnormalities
• Male gender
• Possibly higher incidence in siblings of SIDS victims
 Signs and Symptoms
• Unexplained death that occurs suddenly in an infant
younger than one year of age
• Blood-tinged frothy fluid in mouth and nose
• Wet diaper that is full of stool indicating a devastating
death experience
• Bedding may be greatly disturbed
 Test Results
• Intrathoracic hemorrhage and pulmonary edema noted
on autopsy
 Nursing Interventions

• Parent and family discharge teaching after the birth of a

child, particularly the birth of a sibling of a SIDS
victim, related to methods of decreasing the risk factors
for SIDS :
– Stress “Back to Sleep” for infants to reinforce
positioning of infant
– Encourage removing pillows and loose linen from
infant sleeping area
– Encourage smoking cessation prior to pregnancy,
during pregnancy, and after pregnancy in any area
that would allow newborn exposure to smoke
 Apparent life-threatening event
(ALTE)
formerly referred to as an aborted SIDS death or a near-miss SIDS,
generally refers to an event that is sudden and frightening to the
observer in which the infant exhibits a combination of apnea, change
in color (e.g., pallor, cyanosis, redness), change in muscle tone
(usually hypotonia), and choking, gagging, or coughing that usually
involves a significant intervention such as CPR provided by the
caregiver who witnesses the
 Apparent life-threatening event
(ALTE)
Diagnostic Evaluation
Reported diagnoses in infants with ALTE include
•neurologic events such as a seizures (10% to 20% of cases seen);
•GI problems, including GER (48%);
•respiratory conditions (20% to 30%);
•cardiac conditions (10% to 20%);
•ear, nose, and throat abnormalities;
•ingestions; and
•Munchausen syndrome by proxy or child abuse (each less than 5%)
Apparent life-threatening event
(ALTE)
• Therapeutic Management
The treatment of an infant with an ALTE depends on the underlying condition.
Several diagnostic tests may be carried out to determine the cause of the ALTE;
however, a cause may not be determined in up to 50% of the cases.
 Apnea of Infancy
 Pathologic apnea in infants >37 weeks of
gestation
 Clinical presentation of ALTE
 Therapeutic management:
 Theophylline, caffeine
 Home apnea monitors
 Family support
 CPR training

96
 Apnea Monitoring

FIG. 11-5 Placement of electrodes or belt for apnea monitoring. In small

infants, one fingerbreadth may be used.

97
 OBSTRUCTIVE SLEEP APNEA

• Defined as a disorder of breathing during sleep with prolonged partial upper

airway obstruction and/or complete obstruction that disrupts normal respiration
during sleep and normal sleep patterns.
• Adenotonsillar hypertrophy is a common cause of OSA
• Other causes of OSA include allergies associated with chronic rhinitis/nasal
obstruction, craniofacial abnormalities, gastroesophageal reflux, nasal septal
deviation, and cleft palate repair
• The diagnosis of OSA is made by an overnight sleep study (polysomnography),
which provides evidence of sleep disturbance, respiratory pauses, and changes
in oxygenation.
 OBSTRUCTIVE SLEEP APNEA

• Therapeutic Management
• Adenotonsillectomy is now recommended as the first-line treatment of children
with adenotonsillar hypertrophy
• CPAP (cycles between high and low pressure) may be helpful in older children
with OSA whose condition persists after surgical intervention or in children
who are not good candidates for surgical intervention.
• Surgical interventions such as tracheotomy or mandibular distraction may be
required for children with craniofacial syndromes
 Foreign Body Aspiration

1. Swallowing and aspiration of a foreign body into the air

passages
2. Most inhaled foreign bodies lodge in the main stem or lobar
bronchus.
3. Most common offending foods are round in shape and include
items such as hot dogs, candy, peanuts, popcorn, or grapes.
 Foreign Body Aspiration

Assessment
1. Initially, choking, gagging, coughing, and retractions are general
findings.
2. If the condition worsens, cyanosis may occur.
3. Laryngotracheal obstruction leads to dyspnea, stridor, cough,
and hoarseness.
4. Bronchial obstruction produces paroxysmal cough, wheezing,
asymmetrical breath sounds, and dyspnea.
5. If any obstruction progresses, unconsciousness and asphyxiation
may occur.
6. Partial obstructions may occur without symptoms.
7. Distressed child cannot speak, becomes cyanotic, and collapses.
 Foreign Body Aspiration

Interventions
1. Emergency care
a. Interventions for the removal of a foreign body (or relief of
choking) in a child (1 year of age or older) are the same as for the
adult client.
2. After instituting emergency care measures, removal by
endoscopy may be necessary.
a. After endoscopy, the child receives high humidity air.
b. Observe for signs and symptoms of airway edema