S/S Resp Distress

Lethargy

Respiratory Assessment

Factors that Increase the Risk for Respiratory Infection

S/S of Resp Infection

General Nursing Care

Age and Infection

Infectious Disorders

Otitis Media - How it happens

S/S of Otitis Media

Ear pain - babies can pick at ear, rub side of face (once ear perforates, child will feel better)

Fever

Cold before hand

May not hear out of one ear

Dizziness - toddlers might walk like drunk, fall more, walk crooked

Can complain of sore throat instead of ear

Fussy when eating or lying down

May see drainage from ear (pus, bloody pus, bad odor)

Otitis Media Physical Findings

Inflammation of tympanic membrane

Decreased movement of tympanic membrane

Decreased visibility of landmarks

Otitis Media: Treatment

Antibiotics: those with tubes in ears use drops

who needs them: under age 1

who doesn't need them: those able to communicate feelings (preschoolers), doesn't seem bad

Analgesics

Tympanostomy Tubes

they work by equalizing pressure and ventilating the middle ear

if these kids get another OM, the pus drains from the ear

Tx with otic and oral antibiotics

OM Complications

Serous effusion: may cause bilateral hearing loss

Perforation of tympanic membrane

Mastoiditis (now rare)

infection of mastoid process (portion of temporal bone of skull) will have extreme swelling, pain especially when pulling on ear

Nursing Management for OM

Pain management

Monitor for speech difficulty

Monitor for balance problems

Monitor for difficulty hearing

If ear draining, keep canal clean

KEEP taking antibiotics until all gone, even if feeling better

PET care: Need special ear plugs when swimming or head submerged in water

Make sure not getting water in perforated ear

Otitis Externa

Infection external ear canal

Peak incidence: 7-12 years old

S/S of Otitis Externa

Ear pain

Itchiness

May have drainage

Bad smell around ear

Canal may appear swollen shut look

Cottage-cheese look

Treatment of Otitis Externa

Physical exam

Treatment: antibiotic ear drops that also have pain relievers and help with swelling

Prevention

Croup

Laryngeotracheitis

Viral: parainfluenza

Toddlers and preschoolers: peak 2nd year of life

5-6 Cases/100 children

Most common in late fall/early winter

Inflammation of mucosal lining of airway and causes a seal-like bark, dry harsh like cough

Often not an emergency, but d/t inflammation, can get stridor and retractions

S/S of Croup

starts with non-specific respiratory s/s such as running nose or low grade fever

voice will get hoarseness, stridor, barking cough

respiratory distress

s/s may seem worse at night

breathing cold air or humidification will often help with the inflammation

Tx of Croup

home tx

usually viral, so antibiotics not helpful

cool mist air

oral steroids to help with edema

hospital tx:

O2 with cool mist

Racemic epinephrine, oral or IV steroids

in infants, if resp's greater than 60, NPO (Eating is work!)

albuterol doesn't really help d/t not really in lungs

Bacterial Tracheitis

bacterial infection of the mucosa of the upper trachea

1 mo - 6 yr

staphylococcus aureas most common cause

Hx: previous URI, high fever, stridor, thick and purulent tracheal secretions (nasty, stinky)

resp difficulties d/t secretions

Tx for Bacterial Tracheitis

EMERGENCY

oxygen

antibiotics

often need intubated

constant resp assessment

Epiglottitis

EMERGENCY!

Bacterial: H flu, strep pneuo

2 - 7 y/o

Abrupt onset of s/s

difficulty breathing

S/S of Epiglottitis

shock (may occur early)

marked suprasternal, subcostal, and intercostal retractions

tender adenopathy

cyanosis, late in course, poor prognosis

extreme retractions, swollen lymph nodes

Drooling because cant swallow spit

Treatment of Epiglottitis

airway!

assess respiratory status

antibiotics (Rocephin) - IV - about 24 hours can see decrease in size of epiglottis

do not put anything in child's mouth if suspected DO NOT LOOK AT THE THROAT!

trach kit at bedside

steroids to help with edema

Pertussis (Whooping Cough)

caused by bordetella pertussis

june - september common times

adolescents & adults primary source of disease

spread by droplet

Stages of Pertussis

6 week disease

stage 1: catharral cold s/s, most infectious stage

stage 2: paroxysmal bouts of intense coughing, young children whoop, post-tussive emesis

stage 3: convalescent chronic cough lasting weeks

Pertussis care

culture diagnostic

prevention: stay up to date on vaccine (booster at 11 and every 10 years after)

supportive care: managing fever

antibiotics: macroglides, bactrim, zithromax, erythromycin

cough will persist LONG after contagious period is over

Respiratory Syncytial virus (RSV)

AKA Bronchiolitis

Peak age 2-8 months, young infants/children most severe complications

mortality: increased with chronic lung disease, congestive heart disease, preemies, any issues with airway, CF, cerebral palsy

Late fall, winter, early spring

What happens in RSV

bronchioles become swollen and filled with mucus - increased mucus production

bronchi and bronchioles become infiltrated with inflammatory cells

leads to hyperinflation, atelectasis

dilation of bronchial passages on inspiration, narrowing of passages on expiration

air can get in, but can't get out

poor gas exchange

difficulty breathing, O-sat drop off

spread by droplets: droplet precautions and contact precautions

someone close to infant present with cold, but in infant is RSV

sibling may have hx of cold or parents may have the cold, but when infant is infected, it becomes RSV

Bronchiolitis S/S, Dx

can turn into bacterial infections such as pneumonia, otitis media, sinus infections

dx by nasal swab, x-ray

often + hx of close family member with mild to moderate URI

s/s: low grade fever, cough (wet, congested, barky), inc resp rate, retractions, wheezing, coarse wet lung sounds, difficulty breathing, cloudy mucus from the nose

Bronchiolitis Treatment

labs: CBC (will indicate viral illness), electrolyte panel, nasal swab, x-ray

supportive care: O2, resp support, IV fluids, NEBS?

NPO if resp greater than 60/min

May need steroids, bronchodilators

hospitalization is not always necessary - depends on severity

some end up intubated and on the vent in severe cases

MANY levels of severity

Bronchiolitis Prevention

hand-washing, cleaning of surfaces, NO KISSY-FACE, stay away from crowds

immunoglobin products:

synagis 15mg/kg/dose IM qmonth during season

must qualify for it: 

less than 2 with chronic lung disease

32 weekers can ahve one season Tx

28 weekers can qualify for two seasons Tx

Pneumonia

viral 45%, bacterial 60%, and mixed 23%

children < 5 years old second highest hospital admission rate with pneumonia

start off viral end up bacterial

hx of asthma, chronic lung disease, cerebral palsy, CF, congenital heart disease will increase chance of hospitalization

Pneumonia s/s in Neonates

tachypnea, grunting, flaring, and retractions

lethargy

poor feeding

irritability

may or may not have fever: hypothermia/hyperthermia and temp instability

cyanosis

organisms: early-onset group B strept infection

Pneumonia s/s in Infants

cough is the most common presenting symptom

hx of antecedent UR symptoms week before

tachpnea, grunting, retractions

fever with bacterial, viral low-grade or none (around 101 or so)

wheezing or has noisy breathing

Pneumonia s/s in Toddlers and Preschoolers

hx of UR illness before onset of symptoms common

cough is the most common presenting symptom; can do until throw up

vomiting, particularly post-tussive emesis

chest pain is common - get out of breath easy

abdominal pain or tenderness (symptom of lower lobe pneumonia) - on lower level of body

fever

respiratory compromise in severe cases

Pneumonia s/s in Older children and Adolescents

same s/s as younger children

adolescents: headache, pleuritic chest pain, and vague abdominal pain

vomiting, diarrhea, pharyngitis, otalgia/otitis are other common symptoms

Pneumonia: Physical Exam

observe respirations - esp little ones for signs of distress

auscultation - crackles, rhonchi

good air exchange?

lung expansion

Pneumonia: Treatment

usually outpatient management

antibiotics: penicillins, erythromycins - zythromax for schoolage children

antiviral: acylovir

prevention: immunizations; Prevnar, Hib for younger kids

keep comfy, plenty of fluids, suctioning for infants if unable to clear on own

older kids - deep breathing exercises, incentive spirometry

Foreign Body

older infants & 1-3 y/o

severity of symptoms depends on

location of foriegn body

the foreign body

amount of obstruction

most lodge in R mainstem bronchus

toilet-paper roll rule

if the item can fall down center of toilet paper roll, then that toy or part is too small and can get caught in child's airway

S/S & Dx of foreign body obstruction

cough, gag, wheezing, stridor

strong odor

quick onset - "well-appearing wheezer"

often Dx incorrectly as asthma

do a chest x-ray

bronchoscopy

Aspiration Pneumonia

care is the same as with reg pneumonia

high risk - reflux, chronic disease (cerebral palsy, etc), tube feeders, weak gag reflex

no talcum powder or baby oil near baby - can inhale particles in air

force feeding can cause

if infant has paralysis

Respiratory Distress Syndrome

premature infants

severity inversely related to gestational age - the younger, the more likely to have

RDS Risk factors

male infants

infants bron to mother with DM

babies born via Csec before 20 week mark

second born twin

Hx of RDS

congenital anomalies - cleft palate

Higher risk factors

pneumonia (often B strep)

metabolic disorders (hypo/hyperglycemia)

anemia, polycythemia

transient tachypnea of newborn

aspiration

air leak

anomalies

RDS Patho

relative deficieny of surfactant results in

decreased lung compliance

decreased functional residual capacity and increased dead space resulting in

V/Q mismatch & R-L shunt (80% of co)

hypoxemia & hypercapnia

hypoxia, hypothermia, acidosis & hypotension decreases surfactant production

RDS Diagnosis

blood gases: acidosis, hypoxia

CXR

monitor if need on vent or not

RDS Treatment

prevention - carry baby as long as possible; C sec at 39th week

experienced resuscitation at delivery

surfactant replacement therapy

oxygenation, CPAP, ventilator

supportive therapy

Asthma

chronic, inflammatory disorder of the airways in which many cells (mast, eosinophils, T-lymphocytes) play a role

inflammation causes wheezing, breathlessness, chest tightness and cough (esp night or early morning)

most develop before age 5, 50% < 3 y/o

primary reason for school absences

Asthma classification

mild intermittent s/s <2 times a week; nighttime s/s <2 times a month

mild persistent s/s >2 times a week but not everyday; nighttime s/s >2 times a month, but not every week

moderate persistent s/s daily

daily use of inhaled short acting beta2 agonists

advair, discus, etc

severe persistent s/s frequent daily nighttime symptoms and limited physical activity

Asthma etiology

allergies are a major factor

with infants, a strong relationship between viral illness and asthma

genetics - if one or both parents had asthma/has asthma

multi-factoral

cigarette smoking

viral illness often at early age

other chronic impairments

Asthma Tiggers

Asthma patho

mechanisms responsible for obstructive symptoms:

inflammation and edema of the mucous membranes

accumulation of tenacious secretions from mucous glands

spasm of the smooth muscle of the bronchi and bronchioles

Asthma S/S

wheeze

cough

chest tightness (may complain of pain)

non-specific: recurrent bronchitis, pneumonia

night-time cough

Asthma DX

Dx is determined mainly on the basis of clinical manifestations (Hx, PE, labs)

PFT: pulmonary function tests. provide an objective and reporducible method of eval the presence and degree of lung disease

PEF: peak expiratory flow. max flow of air that can be forcefully exhaled in 1 second

Asthma Treatment

overall goal of asthma management is to prevent disability and to minimize physical and psychological morbidity

allergen control

drug tx: goal is to prevent and control symptoms, reduce frequency and severity of exacerbations and reverse airflow obstruction

Asthma: Quick relief meds

rescue meds

beta-adrenergic agonists

levalbuterol, albuterol, metproterenol, terbutaline

usually given inhalation, nebulizer

rapid onset of action

do not take more than 2-3 times a day when not sick

Asthma: Long-term control

prevention

budesonide (pulmicort)

fluticasone and salmeterol (Advair)

little steroid in these; SE may present - need to rinse out mouth after use to prevent thrush

montelukast sodium (singulair) - oral tablet (leukotrine inhibitor)

help reduce edema and inflammation

can be used in teens for exercise-induced asthma

not been studied in children 16 and under

Asthma treatment: step-down

mild intermittent

long term control: none

step up if use quick relief > 2 x's a week

mild persisten

long term control: anti-inflammatory or leukotriene antagonist

step up if use quick relief daily

moderate persistent

long-term control: daily medium dose steroid or low/med steroid & long-acting bronchodilator or leukotriene antagonist

severe persistent

long term: daily high dose corticosteroid &/or long-acting bronchodilator or leukotriene antagonist

Leukotrine Modifiers (Singular)

leukotrines are mediators on inflammation that cause increases in airway hyper responsiveness

modifiers block inflammatory and bronchospasm effects

given PO in combination with beta-agonists and steroids to provide long and short-term prevention and control

Exercise Induced Asthma

acute reversible self-terminating airway obstruction that develops during or after vigorous activity, reaches its peak 5-10 minutes after stopping the activity, and stops 20-30 minuts afterward

problem is rare in short-burst activities (gymnastics, sprinting, baseball)

common in those that involve endurance (soccer, cross country, basketball)

SWIMMING IS GREAT!

humidified environment

tx: 2 puffs albuterol 20-30 minutes before event if under 16 y/o (if over 16, singular is fine)

Asthma treatment:

status asthmaticus

MED EMERGENCY

extremely acute exacerbation of asthma that remains unresponsive to initial treatment with bronchodilators

treatment: oxygen, inhaled beta agnoist, corticosteroids, anticholinergics

PICU for resp status monitoring

Cystic Fibrosis

autosomal recessive (both parents carriers = 25% chance that child will have)

most common lethal inherited disorders in caucasians

progressive and incurable

CF Patho

defect in gene for cystic fibrosis transmembrane conductance regulator (CFTR)

defective CFTR results in decreased secretion of chloride and increased reabsorption of sodium and water across epithelial cells

thicker mucus

thicker/sticker mucus resulting in inflammation and infection

all through the body not just nose, mouth, etc.

CF: GI Manifestations

neonates: thick secretions (block ducts of pancreas), cant metabolize food, impairs digestion and reabsorption of nutrients, meconium-ileus

infants/children: intussusception, frequent stooling (steatorrhea), FTT, jaundice, gallstones, prolapsed rectum, DM development  (dec. in Isle of Langerhan)

pancreatic s/s: DM

liver: biliary obstruction

CF: Respiratory Manifestations

prolonged brochiolitis

chronic/recurrent cough

recurrent wheezing

recurrent pneumonia

dyspnea

pneumothorax

hemoptysis

CF: GU Manifestations

males usually sterile d/t increased mucus productions

females delayed puberty, decreased fertility, amenorrhea secondary to nutritional status

CF Diagnosis

sweat chloride

perform at least 2x's, few weeks between

>60 mEq/L diagnositc

x-ray: chest and sinus

genotyping

newborn screeing

skin usually has salty taste to it

CF Care

prevent or minimize pulmonary complications

ensure adequate nutrition

GT if unable to eat adequately during day for night time feedings

assist pt and family in adapting to chronic disorder

daily routine of chest physiotherapy, bronchodilators, exercise, pancreatic enzymes before meals to help with absorption, protein and high calorie diet about 1 1/2 times the RDA diet

CF Goals of Care

maintenance of growth and development

maintenance of as nearly normal lung function as possible

intervention and retardation of the progression of lung disease

clinical assessment to monitor GI tract involvement and presence of malabsorption and to provide enzyme and nutrition supplementation

monitoring for complications and their treatment

addressing psychosocial issues

dont want to room CF patients together, because they can colonize each other and increase infections