Abdulmahdi A. Hasan*

*Ph,D, pediatric & psychiatric Mental Health Nursing

The Child with Respiratory Dysfunction

Acute Respiratory Infections

  • Common
  • Virus- respiratory syncytial virus upper resp. passages.
  • B-hemolytic streptococcus
  • Staphylococcus aureus,
  • Homophiles influenza
  • Chlamydia trachomatis
  • And pneumococci

DX:-

  • Clinical manifestation
  • Physical examination
  • Radiographs
  • Lab cultures

Acute Upper Respiratory Infections

  • Nasopharyngitis
  • Viral infection, rhinovirus.
  • Like common cold in adults, or rhinitis
  • Complications more often otitis media, sinusitis
  • Pharyngitis:
  • Site is pharyngitis, including the tonsils
  • Uncommon before 1 year
  • Peak incidence betw. 4 and 7 years of age.
  • Cause: viruses or A B-hemolytic streptococcus
  • Complication; otitis media, acute cervical adenitis, tertopharyngeal abscess, and lower resp. tract infection.
  • Streptococcal infection sometimes triggers a response in the heart (rheumatic fever) or kidneys (acute glomerulonephritis).

Tonsillitis

  • Are masses of lymphoid tissue encircling the pharyngeal cavity.
  • Palatine or faucial tonsillis, pharyngeal, lingual, tubal (found near the posterior nasopharynx opening of the Eustachian tubes).
  • filtering function-protection from pathogens
  • Bigger in children than adults.

Tonsillitis

  • Viral, symptomatic treatment
  • Antibiotic for bacterial
  • Strep. Abt. for 10 days
  • Tonsillectomy, (palatine) controversial,

Should not be removed before 3-4 years of age.

Indicated for massive hypertrophy that cause difficulty eating or breathing.

  • Adenoidectomy: removal of adenoids, indicated for recurrent otitis media, to prevent hearing loss and may be done before 3 years of age.

Nursing consideration

  • Providing comfort.
  • Soft liquid diet.
  • Cool-mist vaporizer
  • Warm saline gargles, throat lozenges, and analgesic/antipyretic as acetaminophen

are useful to promote comfort.

Otitis Media (OM)

  • Middle ear infection.
  • Most prevalent disease of early childhood.
  • The incidence is highest in children age 6 months to 2 years. small increase at 5- 6 years. uncommon after 7 years, highest winter months, around smokers.
  • Breast fed lower risk
  • Bacterial, inflammation block Eustachian tube.
  • Dysfunction of Eustachian tube, trapped secretions in middle ear and air, air get absorbed by mucosa, creating negative pressure, and when it opens it pulls bacteria to the middle ear leading to infection.

Terminology for OM:-

  • Acute OM (AOM): s/sy lasting for 3 weeks
  • OM with effusion (OME): OM with collection of fluids in middle ear.
  • Subacute OM: OM lasting for 3 weeks to 3 month
  • Chronic OM with effusion: OM beyond 3 months.

OM

Dx – otoscopy

  • Culture
  • RX-Antibiotic ampicillin or amoxicillin improve within 48 to 72 hours.
  • Myringotomy- surgical incision of the ear drum for children with suppuration
  • Tympanoplasty insertion of venting tubes, under general anesthesia, tympanostomy remain in the ear average 6 months before spontaneous rejection (controversial).
  • Ice back to affected ear for Myringotomy
  • Ear plugs when swimming or taking shower
  • Heating pad to affected side may reduce discomfort.
  • If draining, clean external canal with sterile cotton swab.
  • Teach parents about possible complications:

1 - Conductive hearing loss,

2- A perforated and scared eardrum

3 - Mastoiditis, inflammation of the mastoid air cell system

4 - Cholesteatoma, cyst like lesion that can invade and destroy surrounding auditory structures

5 - Intracranial infections such as meningitis

  • OM can be reduced by sitting child upright when feeding, gentle nose blowing esp. when cold, removing smoking and allergen from surroundings

Cystic Fibrosis

  • Most common serious pulmonary and gastric disorder of children, is a multi system disorder primarily affecting the exocrine (mucous producing) glands and accounts for a large percentage of lung disease in children
  • It appears in varying severity.
  • Inherited, Autosomal-recessive trait, need both parents to give him the gene
  • Incidence 1 in 1600 births in predominantly white populations, equal sex distribution
  • Basic defect unknown
  • Unrelated clinical feature;
  • Increased viscosity of mucous gland secretion.
  • Increase of sweat electrolytes
  • Increased organic and enzymatic constituents of saliva
  • Possible abnormalities in autonomic nervous system.
  • Earliest sign, meconium ileus
  • Pancreas, fibrosis, impaired digestion-frothy undigested stools
  • GI: prolapsed rectum, intestinal obstruction from undigested or impacted feces.
  • Pulmonary complication: most serious and threat to life. Retain thick viscous mucous.

DX:

1 - Family history

2 - No pancreatic enzymes

3 - Increased electrolyte concentration

4 - Chronic pulmonary involvement salty skin important sign.

RX:good nutrition, prevent pulmonary Infections, help psychological adjustment

  • Pulmonary therapy

  • Chest PT, and drainage
  • PT not after meals
  • Breathing exercise
  • Oxygen as needed
  • Mucolytic & expectorants
  • Antibiotic

  • Exercise
  • GI:

- Replacement of pancreatic enzymes with meals

- Balanced diet, high in calories, restriction of fat not indicated, multivitamins

prescribed

- Salt supplementation esp. in hot weather

With Rx many are reaching adulthood, depending on severity of disease

CROUP

  • Croup is a general term applied to a symptom complex characterized by hoarseness, a resonant cough (barking), varying degrees of respiratory distress resulting from swelling or obstruction in the larynx.
  • Croup affect larynx, trachea, bronchi, larynx dominate due to clinical manifestations on voice and breathing.
  • LTB: Laryngotracheobronchitis (3month-8 years), in very young children, while epiglottitis is more in older children (1-8 yrs)

Acute Epiglottitis

  • Or acute supraglottitis: serious obstructive inflammatory process occur btw. 3-7 years.
  • Organism: H. Influenza
  • LTB & Epiglottitis do not occur together.
  • Abrupt rapid & progressive, the child may go to bed asymptomatic to wake up later to C/O sore throat, pain, swelling, fever, & looks toxic, insist to sit upright & leaning forward, mouth open and tongue protruding, drooling. Agitation and deteriorated breathing and retraction, and cyanosis.

Acute Epiglottitis

  • Quick diagnosis is an emergency and life saving.
  • Contraindicated tongue depressor until proper personal and availability of Endotracheal intubation (E.T.T.) and ventilation or tracheotomy.
  • Decrease after 24 hours of IV antibiotic
  • Corticosteroids for 7 to 10 days
  • Immunization is recommended at 2 months for H. Influenza.

LTB

  • Mostly viral
  • Airway management
  • Humidity
  • ETT if needed.
  • Hydration adequate, severe resp distress are kept NPO, and use IVs
  • Nursing: observation, resp. and cardiac assessment, oxygen saturation or ABGs, readiness for intubation and ventilation,

Acute Spasmodic Laryngitis

  • Characterized by paroxysmal attacks of laryngeal obstruction that occur mainly at night.
  • May involve child with allergy, or psychogenic factors
  • The attack subside in a few hours and the child appears well the next day.
  • Nursing: cool mist, or warm mist, may need racemic epinephrine

Infection of Lower Airways

Bronchitis: inflammation of large airways usually associated with upper respiratory infections.

  • Primarily viral cause-dry nonproductive cough, worse at night and becomes productive in 2-3 days
  • Limited dz, symptomatic treatment-analgesics, antipyretics, & humidity
  • Recovery 5-10 days

Bronchiolitis

  • Viral infection at the bronchiolar level
  • Mainly in winter & spring
  • Rare in children over 2 years
  • RSV virus is responsible for over half of all episodes
  • Inflammation, inspiration dilates bronchioles and air go to alveoli, but narrowing on expiration of air passages lead to progressive over inflation and emphysema.

Rx:

  • symptomatically,with adequate hydration, high humidity, and rest
  • Mostly Rx at home but hospital if needed.
  • Lasts 3-10 days, prognosis is good
  • Pneumonias: inflammation of pulmonary parenchyma
  • Lobar pneumonia: One or more lobes is involved
  • Bronchopneumonia: terminal bronchioles

Pneumonias

  • Interstitial pneumonia
  • Pneumonitis - localized acute inflammation of the lung without toxemia related to lobular pneumonia
  • Viral pneumonia: occur more than bacterial
  • A typical pneumonia, caused by M. Pneumonia
  • 10 -20% of hospital admission
  • More in crowded living condition
  • Recover in 7-10 days followed by 1 wk of convalescence
  • Hospitalization is rare.

Bacterial Pneumonia

  • Abrupt and generally preceded by viral infection.
  • Local and general sy.
  • Malaise, fever, cough, shallow respirations, chest pain exaggerated by deep breathing, pain may be refereed to the abd. And confused with appendicitis, rapid deterioration .
  • Rx: abt., bed rest, liberal oral intake, antipyretic, antitussive for dry cough.
  • Hospitalization when pleural effusion or empyema and staphylococcal pneumonia.
  • Thoracentesis: if fluid is suspected in pleural cavity
  • Good prognosis with early treatment.

Foreign Body (FB) Aspiration

  • Small children explore with their mouth.
  • Examples: seeds, nuts, piece of carrot, popcorn, balloons
  • DX: based on Hx
  • Initially Chocking, coughing, wheezing
  • A FB is always a possibility in acute or chronic pulmonary lesions
  • Usually when secondary sy. Appear the parents have forgotten the initial episode & cause
  • CXR: opaque foreign objects

RX:

  • Instrumental removal of object if needed ASAP.
  • High humidity after object removal
  • Antibiotics
  • Nursing: calm & quiet child, ready to deal with choking.
  • Chocking ; cannot speak, cyanotic, pointing at neck or chest, collapse- 2 back blows and Heimlich maneuver.
  • Prevention

Aspiration Pneumonia

  • From fluids and foods, secretion, amniotic fluids aspiration, vomitus, hydrocarbons, lipids, talcum powder.
  • Rx as Pneumonia

Asthma

  • Revisable obstructive process characterized by increased responsiveness and inflammation of the airway,
  • Sy.;
  • Expiratory wheezing, prolong expiration, tight cough,
  • Can be very mild to sever cyanosis and fatal asphyxia
  • Most common cause of school absence
  • Major portion of admissions at pediatric hospital and ER.
  • Single most important cause of morbidity in childhood

 Cause:

  • allergic hyper sensitivity to foreign substances in the air as plant pollens, sometimes no allergic process can be detected, can be caused also by bronchial compression from external pressure, FB, heredatry tendancy,
  • Many stimuli can provoke an asthma, including viruses, allergens, smoking, cold air, exercise,

Pathophysiology:

  • Inflammation & edema of mucous membranes
  • Accumulation of tenacious secretions from mucous glands
  • Spasm of the smooth muscles of the bronchi and bronchioles, which decrease the caliber of the bronchioles

Dx: based on clinical Sy., hx, Physical examination, cxr to role out other diseases.

RX:

  • Allergen control
  • Drug therapy- bronchodilators, aminophylline, metered dose inhaler, ventolen inhaler, douned, antihistamine, corticosteroids.
  • Exercise
  • Chest physiotherapy
  • Hyposensitization

Status Asthmaticus

  • Continue resp. distress (asthma attack) despite vigorous therapy and Rx,
  • Medical emergency, can lead to resp. failure and result in death if not treated.
  • Require continuous nursing and cardiovascular monitoring
  • Agitation due to hypoxia, or sitting up and refusing to lie down, Sy. Of the dz.