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Anatomy of the respiratory system

• The respiratory system is divided into two divisions; upper & lower airways.

• The uppers is consisting from: nose, pharynx, larynx & epiglottis.

• The larynx divides the upper from the lower airways.

• The lower airways consist of trachea, bronchi, bronchioles & alveoli.

• During respiration: respiratory system delivers warmed, moistened air to alveoli; gas exchange occur; then carbon dioxide filled air is transferred outside the lungs.

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Pediatric differences • The child’s respiratory system grows constantly &

changes until 12 years of age.

1- Upper & lower airway differences:

• Children have smaller nasopharynx which would occluded easily during infections.

• Children have small oral cavity & large tongue that would increase the risk of obstruction.

• Children have small nares that would be easily occluded.

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• Children have immature thyroid, cricoid and tracheal cartilages, which would be easily collapsed when neck is flexed.

• Children have fewer muscle functioning, which will leads lungs to not being able to compensate for edema, spasm & trauma.

• Newborns and infants until 2-3 month are nose breathers.

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• The child’s airway is shorter & narrower than an adults.

• The trachea diameter can be estimated by the child’s little finger; it increase in length rather than diameter in the first 5 years of life.

Child --- 4mm

Adult --- 8mm

• The bifurcation of the trachea is at T3 while in adults is at T6.

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Assessing respiratory illness in children

Position of comfort

Tripod position (sitting forward with arms on knee for support & extending the neck.

Lung auscultation

Diminished or absent breath sounds.

Presence of adventitious sounds ( wheezing, crackles).

Color Color of the mucus membrane (pink, cyanotic) with & without crying.

Clubbing nail Presence of clubbing nail.

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Retractions • Presence of visible appearance of the chest being drawn on inspiration.

• Retractions in the supraclavicle suggest upper airway obstruction.

• Retractions in intercostal’s musclesuggest lower airway obstruction.

Respiratory efforts

Presence of nasal flaring.

Presence of tachycardia.

Presence of paradoxical breathing

( chest & abdomen do not raise at the same time).

Cough Presence of cough; dry, productive, brassy (musical, noisy).

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Measure Normal value Clinical significance

P02 80-100 mmHg Decrease when child cannot inspire adequately

PCO2 35-45 mmHg Increase when the child cannot expire adequately

O2 saturation 95-100 % Decrease if O2 cannot reach RBC

pH 7.35-7.45 Decrease if CO2 is being retained as carbonic acid in blood

HCO3 22-26 mEq/L Increase in respiratory alkalosis; decreased in respiratory acidosis.

Base excess -2.5 or + 2.5

mEq/L

(+) = alkaline excess

(-) = alkaline deficit

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Disorders of the nose & throat

• Nose bleed is common in school-age child, commonly caused by irritation from nose picking, foreign bodies, low humidity, forceful coughing, allergies.

• Or it could be related to systemic disease(bleeding disorder).

• To stop the nosebleed the child must be sit upright with head tilted forward to prevent blood drip down the throat cause vomiting.

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• The nares should be squeezed just below the nasal bone & held for 10-15 minute, while the child breath from his mouth.

• If bleeding does not stop, cotton ball soaked with epinephrine or lidocaine may be inserted to the affected nares to provide topical vasoconstriction or anesthesia.

• Post the bleeding, the child may be vulnerable to other episodes, so child must avoid hot bathes, hot drinks, vigorous exercise, bending over for the next 2-3 days.

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To prevent epistaxis:

Educate parents to:

• Provide humidity in the child’s room.• Discourage the child from picking or rubbing the

nose or inserting foreign objects into nose.

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• Known as the common cold, it causes inflammation of the nose & throat.

• The most common viruses that cause the infection includes rhinovirus & coronavirus; and from bacteria is group A streptococcus.

• The organism incubate for 1-3 days and the infection is communicable for several hours before the symptoms occur for 1-2 days. Symptoms last for 10-14 days.

• Disease spread through direct or indirect contactwith the patient (air droplets).

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Clinical manifestations Infant < 3 months

Infant > 3 months

Older children

Lethargy

Irritability

Poor Feeding

Fever

Fever

Vomiting

Diarrhea

Sneezing

Restlessness

Dry, irritated nose.

Chills, fever

Headache, malaise,sneezing

• Nasopharyngitis does not need hospitalization or any medical interventions, just support therapy.

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Symptomatic Therapy • For children who cannot breath from mouth, nasal

drop of normal saline should administer every 3-4 hours especially before feeding.

• Administration of Antihistamines would be helpful (as doctor order).

• Administer Antipyretic to decrease the fever. • Aspirin is not recommended for children below 5

years, due its association with Reyes’ syndrome. • Hot fluide and vitamine C .• Room humidification would help in preventing

drying nasal secretions. • Encourage rehydration (increase oral intake).

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• Infection that affects the pharynx, including the tonsils. 80% of these infections are caused by viruses (most commonly enteroviruses).

• Bacterial pharyngitis is known as strep throat; because 20-40 % of bacteria is caused b group A beta-hemolytic streptococcus

• Throat culture is needed to identify the causative agent.

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Clinical manifestations Viral Bacterial

Nasal congestion

Mild sore throat

Cough

Hoarseness

Fever < 38 C

Minimal tonsillar exudates

Mild pharyngeal redness

Abrupt onset

Tonsillar exudates

Anorexia, nausea,vomiting.

Sever sore throat

Headache, malaise.

Fever > 38 C

Dysphagia

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• Pharyngitis is treated by giving oral Penicillin or injection if the child have no allergy to Penicillin.

• If he have allergy, Erythromycin is the second drug of choice.

• For viral infection, symptomatic treatment alone is used.

Nursing interventions:

• reduce the child pain & discomfort.

• Decrease fever.

• Increase oral intake.

• Gargling with warm salt water (1 tsp in 250 ml).

• Encourage bed rest.

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Complications of Pharyngitis:

• Otitis media.

• Cervical adenitis.

• Lower respiratory tract infection.

• Rheumatic fever.

• Glomerulonephritis.

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Tonsillitis & Adenoiditis • Tonsillitis is an infection of the palatine tonsils;

while adenitis refer to infection of the adenoid pharyngeal tonsils.

Different types of tonsils: • The palatine tonsils: are located on both sides of

the pharynx. • Adenoid: are in the nasopharynx. • Tubal tonsils: are located at the entrance to the

Eustachian tubes. • Lingual tonsils: are located at the base of the

tongue.

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Clinical manifestations All symptoms of sever pharyngitis:

• Sore throat• Difficult & painful swallowing. • High fever. • Lethargic. • Pharyngeal pain & edema. • Mouth breathing. • Sleep apnea that results from pharyngeal

obstruction ## throat culture will reveal viral cause in children <

3 and bacterial cause in children > 3 years.

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Treatment • Antipyretic for fever.

• An analgesia for pain.

• Full 10 days course for antibiotic, such as Penicillin.

• If the cause is virus, no therapy other than comfort measures or fever reduction are needed

Surgical treatment:

Which includes removal of the palatine tonsils. IF

-Tonsillitis is recurrent -3 or more times in one year- removal must mot be before 3-4 years.

- IF there is sleep apnia

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Why we should not remove tonsils before 3-4 years of age?

• Excessive blood loss in small children.

• The possibility of regrowth.

• Hypertrophy of lymphoid tissue.

Tonsillectomy: refer to removal of palatine tonsils.

Adenoidectomy: refer to removal of the pharyngeal tonsils.

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Nursing management for tonsillectomy

Preoperative preparations includes:

• Complete history.

• Physical examination.

• Pt, PTT.

• Complete blood counts.

• Urine analysis.

• Assessment if the child have loose teeth.

## Tonsillectomy must not be done if the organs are infected.

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Post operative interventions includes:

• place the child on prone position with the head on the side to reduce the pressure on the operative site & prevent obstruction. (the head must be lower than the body). Why??

• Monitor for bleeding, if bleeding is heavy, return the child to the operation room to make suture to halt bleeding.

• The most dangerous period is 24 hrs after operation, so observe V/S carefully.

• Assess for signs of bleeding ( increase in pulse or respiratory rate, frequent swallowing, feeling of anxiety)

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• If bleeding occur, elevate the head & turn the child to his side.

• Avoid red fluid or red Jell-O, that could vomiting being mistaken with bleeding.

• Offer frequent sips of clear cold liquid, popsicles (liquid ice cream).

• Start soft diet 9 mashed potatoes, soups, cooked fruits after 24-48 hrs, and soft food for the first weeks to prevent pharyngeal irritation.

• Apply an ice cooler around the neck.

• Having the child gargle with solution of baking soda & salt (0.5 tsp in 250 ml).

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Nursing Diagnosis

Related tonsillitis: • Acute pain related to inflammation of the pharynx. • Risk for ineffective breathing patterns related to

obstruction by enlarged tonsils.• Risk for deficit fluid volume related to inadequate

intake. • Impaired swallowing related to inflammation &

pain. • Deficit knowledge (parents) related to home care

following discharge.

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Otitis Media

• Is an inflammation of middle ear, it is one of the most prevalent disease of early childhood .

• 70% of child have one episode in the first year of life and 50% of them have 2-3 episode by 3 years of age .

• The highest incident at 6 months to 2 years .

• It caused by streptococcus pneumonia, hemophilia influenza, staphylococcus.

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Factors that increase risk

• Child with smoker person more risk for develop OM than those who live with no smoking , because tobacco smoke inhalation increase the risk of blocked Eustachian tube and congestion of soft nasopharyngeal tissue lead to OM.

• Bottle feeding during sleep

• Children who use pacifiers for several hours daily.

• More common in winter.

• Children with cleft lip or palate, Down syndrome.

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Causes of non infectious type is unknown , but many risk factors :-

• Blocked Eustachian tube. • Edema or infections of URT.• Allergic rhinitis .• Hypertropic adenoids .

• Methods of feeding ( breast feeding infant less like to develop OM because the breast milk have IgA that limits the exposure of the Eustachian tubes to microbial pathogens ) .

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Pathophysiology • All of the previous risk factors could lead to

obstruction of the eustachian tube, which will leads eustachian tube’s mucus membrane to become edematous.

• As result the normal air flow to middle ear is blocked. & the air in the middle air absorbed into the blood stream.

• Which will leads fluid to shifts into middle ear, and provides good area for rapid growth of pathogens.

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Definitionterms

General term for inflammation of the middle ear

OM

An acute onset of ear pain, redness of tympanic membrane lasting approximately 3 weeks .

Acute OM

Inflammation of the middle ear in which a collection of fluid is present in the middle ear space .

OM with Effusion

(OME)

OME persist beyond 3 months .Chronic (OME)

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Clinical manifestations In acute OM:

• Ear pain (Otalgia, earache), rapid onset, irritability, poor feeding, malaise, bulging tympanic membrane, poorly mobile tympanic membrane. Rolling the head from side to side

In OM effusion:

• Difficulty of hearing, signs of acute inflammation are not present, tympanic membrane is retracted,

• Feeling of fullness in ear, popping sensation during swallowing and feeling of motion in the ear if air present above level of fluid.

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Medical Treatment For acute otitis media: • Treatment with antibiotic for 10 days in children

under 6 years of age and for 5-7 days in children above 6 years.

• First line therapy is Amoxicillin at a dose of 80 -90 mg/kg/day. Second drug is Cefuroxime (second generation of cephalosporin), at dose of 10 mg/kg/day.

For OM with effusion: • Myringotomy (surgical incision of the tympanic

membrane) may be performed. • Tympoanostomy may be inserted to drain fluid

from the middle ear (pressure equalizing tube).

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Nursing interventions

• Application of heating pad may reduce the discomfort (over the ear).

• Put the child on lying down position will facilitate drainage.

• Give analgesia & antipyretic as order to reduce pain & fever.

• An ice bag placed over the affected ear may be helpful to reduce edema & pressure

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Nursing Diagnosis

• Risk for imbalanced body temperature, hyperthermia related to infectious process.

• Fatigue (child & parents) related to sleep deprivation.

• Disturbed Sensory Perception (auditory) related to chronic ear infections and altered hearing perception.