Peds Respiratory Jan11

8/14/2019 Peds Respiratory Jan11

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Surface area is about the size of 3 tennis courts research being

done in how to get meds converted to inhaled form to access those

capillaries of the alveoli

Bronchiolar smooth muscle has autonomic innervations

Congenital Malformations

TE Fistula (TEF)

Most common esophagus is just a pouch (EA esophageal

atresia - with distal TEF)! Lower esophagus connects to

stomach but is also continuous with trachea.

Hallmark is coughing, choking, cyanosis since gastric acid

refluxes into the trachea

High risk for aspiration

Must be corrected quickly & immediately

Diaphragmatic Hernia

Devastating defect


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Weakness in muscle wall of diaphragm so loops of bowel

ooze up into the chest & press on other organs poor

pulmonary development, an issue even if this is surgically

corrected.

Easy to see on US. Visualized post-birth as a flattened belly

& full chest area

Bronchopulmonary Dysplasia (BPD)

Chronic condition primarily in pre-term infant or full term on

prolonged O2 or ventilation high O2 conc can be toxic over

long periods of time -> affects retinas of eyes & pulmonary

tissue

Risk Factors: Preemies, RDS, no surfactant given at birth

(given intra-tracheally to premies after born, since not

present until 28 weeks gestation), no antenatal steriods

(transferred to baby to decrease initial inflammation), sepsis,

PDA

More prone to infxn & other long term complications, may

need O2 at home for awhile, but most kids grow out of BPD

Pathogenesis of BPD


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Many factors that influence postnatal lung development

Assessment Stand back and look first! Can get general sense of

Bad/Good

RR & Effort?

Shiny mucous membranes?

Skin Color? (Remember that cyanosis is a sign of early death / late

hypoxia

Position of comfort? informative in an older child

Appropriate Cry?

Interaction with caregiver & environment even if upset at least

they are engaging, we dont want to see a baby that just doesnt

care

Babies are belly breathers!

Lag on respirations - WOB

Seesaw respirations recruitment of accessory resp muscles

& loss of synchronized resp

Retractions

Subcostal & subxyphoid & sternal big areas of retractions

for kids


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Can also suck chest towards backbone

Pic of girl bad! Leaning forward, retractions, mouth hanging open

Auscultation

In lap of caregiver or at least when CALM

Auscultate in the mid axillary line & side to side chest wall is so

small, easy to hear other sounds if you listen too medially

Use appropriate size stethoscope

Tough to distinguish normal breath sounds from airway noise in

kids

LOC, RR, WOB & mechanics, skin & mucus mbne color according

to video these are the 4 key areas to assess for respiratory

**See slide re: where to listen!!

LATE signs of distress (Early Death)

Irritability

Bradycardia Get the Crash Cart Terminal Rhythm in pediatrics

5% chance of successful resuscitation. Peds have cardiac arrest for

much different reasons than adults do.

Cyanosis


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Slowing RR

Asthmatic who stops wheezing (b/c no air is moving)

Essential that nurses are vigilant about respiratory status &

intervene early

Airway

Current ability to protect the airway

Obtain the history

Assess SECRETIONS and childs ability to handle (or clear)

Consider the current situation Is the child at risk for airway

problems?

Risk of Development of Airway Problems

Discussion of damages to muco-ciliary fxn

Recent intubations, surgery or bronchoscopy

Acute inflammation

Anesthesia

Trauma or congenital malformation

Foreign body or chemical inhalation

Disease affecting mucociliary function


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The Common Cold (URI)

Vast majority are viral (adenovirus, parainfluenza, rhinovirus,

meta-pneumovirus)

Consider strep if positive contacts and > 2yo without

exudate in pharynx

Symptom relief (Hydration!) cold meds often do nothing!!

Culture positive: treatment with penicillin; erythromycin for

resistant

Big movement in pediatric world to get some cold meds

pulled from the market

Acute Otitis Media

Probably not seen in hospital unless they have something else

going on

Highest incidence in kids 6mo-2 years

More in homes with smokers

Usual causes are Strep and atypical H Flu H Flu a part of the

normal vaccine schedule - **should know pediatric

vaccination schedule for nclex!**

Dysfunctioning eustachian tubes


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Bright red bulging Tympanic Membrane, neg light reflex and

landmarks

Placement of tubes in membranes to help the gooey fluid

drain

Bottle in mouth w/kid lying supine can affect teeth (bottle

mouth) but also fluid is being pushed back up into eustatian

tubes prime area for bacterial growth

Acute risk meningitis infection can transfer from middle

ear to CNS/meninges

Chronic risk hearing loss

Management of AOM

Pain Management

Antibiotics where indicated will not help with a viral

infxn!!

Myringotomy

Tympanostomy tubes

Prevention!!!!

See slide w/algorhythm of when to treat

Pharyngitis


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Bacterial sore throat (acute) often without nasal Sx

CULTURE

Nodes? Mono? palpate nodes to see if mono could be

present caused by Epstein Barr virus

Group A- hemolytic strepusually Pen

Comfort and Hydration wont want to drink d/t sore throat

give cold liquids/popsicles etc.

Complications! Can develop Scarlet Fever, Rheumatic Fever,

Glomerulonephritis, Cardiac Issues

Foreign Body Aspiration

Acute onset with no prior sxs , esp if afebrile & fits with

developmental group (crawler, esp with older kids that have

tiny toys i.e. legos) different from URI

Assess the airway

Procedure for clearing the airway

Oxygen and Humidity

Age of patient

Consider in the differential diagnosis with acute croup /

epiglottitis


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Can be caused by Parainfluenza, RSV or rarely mycoplasma

Inflammation of mucosa at level of larynx

Manifestations

Low grade fever

Loud, barking , seal-like cough

STRIDOR

Inflammation can be severe enough to obstruct airway

Cold, moist environment good for the airways picture

of croup tent

Steeple sign on CXR/neck films upper part of trachea

steeples like a church

Treatment

Cool humidified air (its the COLD that helps reduce

swelling)

Racemic (nebulized) Epinephrine (topical

vasoconstrictor to the airways to reduce swelling)----be

alert for rebound effect with worse swelling than they

had to begin with, used to hold kids in ER for

observation 4 hours post-tx


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Airway monitoring

Upper Airway Problems

Bronchitis

Inflammation of the large airways associated with URIs

Dry, hacking, non-prod. (Night) cough, becomes productive

after 2-3 days

Usually viral

Treat with cough suppressants b/c cough is making kids

lose a lot of fluid & interferes w/sleep. Would not do this with

a productive cough

Can be distinguished from croup b/c croup tends to be littler

kids & croup also characterized by upper airway stridor

RSV Bronchiolitis

Acute inflammation & mucus production at the BRONCHIOLAR

level

Seasonal variations YOUNG kids


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Primary if not sole Cause: Almost exclusively Respiratory

Syncytial Virus common virus that can be gotten over &

over again.

High Risk: Preemies, 6-8 wks old, CHD, Chronic Lung

Disease, immuno-suppressed

Clinically this child looks v similar to asthmatic child have

expiratory wheezes

Also caused by parainfluenza and adeno viruses

Pathology: airway inflammation, epithelial necrosis long

term cough, epithelial lining is sloughing off & being coughed

up, plugging of airway lumen, hyper-inflation and atelectasis

Diagnosis: Clinically and Nasopharyngeal swabs ELISA or

IFA) positive for RSV

Course:

cough and rhinorrhea (clear) ~3d after exposure

low grade fever

severe resp. distress by day 5

resolution in 10+ days

Tends to occur within a season, but year-round in Hawaii


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Monthly injections throughout season (5 mo)

Infection Control in hospitalized patients!!!! RSV can

live on a hard surface for up to 24 hours!

RSV Season

Season in Region 9 (San Francisco) Mid November

Mid March, slight variation

Varies throughout the US and and world (RSV seen all

12 months in Hawaii!)

Tends to be worse every other year

H1N1

Some folks think another spike of H1N1 is coming in Feb

see slide with website tracking

Sickest tend to be the youngest 0-4 yrs

Pneumonia

Inflammation of the pulmonary parenchyma

Described by location

Primary or secondary disease

Viral (most) vs bacterial vs atypical vs aspiration


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Causes slide contains table 19.2 in book

Pathophysiology

Inflammation of the alveoli and terminal airspaces in

response to an infectious agent

Inflammation causes plasma leak and loss of surfactant,

resulting in consolidation and air loss b/c alveoli

collapse

PneumonITIS results from toxins or irritants

May originate from upper respiratory tract or

hematogenous

On Xray more whiteness seen since air is not visible:

lobes are socked in by exudate or fluid

Manifestations

Usually an antecedent URI

Fever

Cough

Tachypnea

Poor Feeding, vomiting, diarrhea

Abdominal pain in older kids

Some kids end up with trach


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Predisposing Factors

Prematurity

Exposure to cigarettes

Underlying chronic illness

Neurologic deficits (aspiration risk)

Low socioeconomic status

Malnutrition

Treatment

Majority are viral (no antibiotics), but can have

secondary bacterial invasion

Common Bacteria:

Streptococcus, Pneumococcus and staphylococcal,

Atypical (Mycoplasma)

Supportive Therapy!

Hydration

May necessitate IV fluids mouth breathing & rapid RR

O2 Saturation monitoring

Oxygen / suctioning as needed

Elevate HOB (infant seats)

Analgesics


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Parent / Family Education

What is the best way to give O2 to a child? Any way that they tolerate

it must be age appropriate & appropriate to the patient such that they will

comply/tolerate. Base effectiveness on clinical appearance & O2 sat (i.e. a

child w/NC who is mouth breathing probably needs more O2!)

Cystic Fibrosis

Autosomal Recessive disease affecting chloride metabolism

A white persons disease

Result is exocrine dysfunction; THICK secretions which affect

primarily the pancreas and lungs impede food digestion,

specifically the digestion & absorption of fat

Diagnosed by sweat chloride test (babies taste salty!) & poop

is really bulky stinky/smelly poop

Kids must take pancreatic enzymes with each meal

Effects

See slide

All that fluid/secretion buildup = risk for infection

Treatment


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Airway Clearance Techniques (Inhaled meds:

Pulmozyme, TOBI) P &PD, CPT (chest physical

therapy, percussion & postural drainage)

Antibiotics

Nutrition big deal since theyre not absorbing facts

Alternative Therapies (antioxidants, ibuprofen)

Continued Research

Gene Therapy many hopes for this

Lung Transplantation

Asthma

THE chronic disease of childhood

Affects between 6 and 7 million kids in US (22 million total!)

Incidence and Severity are increasing

Differences in SES/Ethnicity

NAEPP updated in 2007 (NHLBIsee posting for the

summary document)

Facts

Accounts for at least 15% of all pediatric hospital

admissions


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As many as 20% of children in US may have asthma

Highest incidence in children under 4 years; many DO

outgrow it

Much higher incidence in boys but in adults much higher

in women

Although death rate declined, incidence is climbing

Symptoms:

Coughing (worse at night)

Wheezing

Shortness of Breath

Atopy

tightness

Frequent URI

**Nclex loves asthma & lifespan diseases!!** -> most

little kids < 4 have atypical presentation: cough w/o

wheeze

Goal is to manage sxs so kids can be fully participatory,

esp. in exercise

Allergies & Environments


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Strongest predisposing factor for developing asthma is

atopy

Most common are inhaled allergensDUST MITES

(inner cities: cockroach dung)

Environmental Triggers

House dust mites

Tobacco smoke

Cockroach exposure / dung

Other Triggers

Foods

Exercise

Cold

Pollutants

Virus: biggest trigger in peds

Treatment

Rule of 2s are they using their Beta/rescue

meds/albuterol > 2x/week, sxs with night-waking >

2x/month, refilling asthma meds > 2x/year. If yes to

all of these, then asthma is poorly controlled.

Symptom Management


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Summary slide

Describe the essential components of the respiratory exam in

children.

Differentiate signs of respiratory distress in children from those

commonly seen in adults.

Compare clinical findings seen in the most common pediatric

respiratory conditions and propose a diagnosis for a given set of

findings.

Prioritize nursing actions for children in acute respiratory distress.

Identify preventive and treatment strategies for children with RSV

bronchiolitis, asthma and pneumonia.

Categorize asthma severity and propose appropriate treatment.


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01/11/2010

Peds Respiratory Jan11

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