• obligatory nose breathers (til ~ 3 months)
• ribs are horizontal
• muscles for breathing and holding head underdeveloped
• lung tissue's ability to inflate and deflate
• higher RR and demand for O2 make hypoxia easy to occur

• > metabolic rate
• less muscle glycogen reserve
• > ECF
• only have passive immunity first
• cell-mediated immunity not fully developed so increase chance of infection
• 1st hepB vaccine in hospital
• 6wks-2mo 1st resp vaccine
• resp drive is less
• blunted ventilatory response to hypoxia
• immature chemoreceptor mechanisms and brain stem

• younger than 3mo: maternal antibodies
• 3-6mo: infection rate increase (toys in mouth, daycare)
• toddler/preschool: high viral infections
• >5mo: increase in mycoplasma pneumonia and b-strep infections
• increased immunity w/ age

• diameter of airways
• distance b/n structures is shorter, allowing organisms to rapidly move down
• short eustachian tubes

• Immune system
• allergies, asthma
• cardiac anomalies
• cystic fibrosis
• daycare

• most common during winter/spring (allergies)
• mycoplasmal infections more common in fall/winter
• asthmatic bronchitis more freq in cold weather
• RSV season considered winter/spring

• Predisposing conditions: Obstructive lung disease, restrictive lung disease, primary inefficient gas transfer

Nursing Interventions?

in general

1. Ease resp effort
2. fever management
3. promote rest & comfort
4. infection control (handwashing, immunizations)
5. promote hydration & nutrition
6. family support & teaching

• O2
• Meds
• Airway clearance techniques (IS)
• nutritional support
• artificial airways
• mechanical ventilation
• tracheostomy

• Preventive care
• Monitoring & early detection of symptoms (educate parents)
• Adequate management (home vs hospital)
• health education

• Measurement of lung volumes & flow rates (pul function tests, peak flow measurement)
• direct/indirect blood and body fluid analysis (ABG's, fluid cultures, sweat chloride test = CF!!!
• Imaging tech (radiographs, fluroscopy, bronchography, CT scan, scintigraphy, MRI)
• Direct visualization of the resp tree (laryngoscopy, bronchoscopy

• O2 (mask, nasal cannula, O2 hood, O2 tent, mech ventilation)
• Meds (oral, inhaled [nebulizer, MDE, space device], IV, SQ/IM0
• Other: postural drainage, Chest PT, artificial ventilation (bag/mask, oral/nasal airways, endo/orotracheal, +/- pressure, tracheostomy [chronic], ECMO [heart-lung machine is more permanent, last effort, usu waiting for transplant

• Hemorrhage
• Edema
• Subcut emphsema
• Pneumothroax (too much pressure & blow out lung)
• Accidental decannulation (careful w/ clearing)

Croup syndromes:

described according to the primary area of inflammation

Types: acute epiglottis, acute laryngitis, acute larynogotracheobronchitis(LTB), and bacterial tracheitis

• hoarseness, "barking" cough, inspiratory stridor and varying degrees of resp distress
• affect larynx, trachea, and bronchi

• type of croup
• caused by HIB bacteria (need Hib vaccine!)
• rare and emergent case
• sore throat, pain, tripod postioning, retractions, inspir stridor, mild hypoxia, distress
• Potential for resp obstruction!
• Nursing Considerations: decrease resp effort so maintain O2, quiet, low stimulation

acute larynigitis

(croup)

• more common in older and adolescents
• usu caused by virus
• hoarseness (sounds worse than is)
• loss of voice
• rest vocal cords, cough drops, fluids!
• self-limiting and w/o long-term sequelae

• MOST COMMON type, usu <5yr
• Organisms responsible: RSV, parainfluenza virus, Mco pn, influenza A&B
• Inspiratory stridor
• Suprasternal retractions
• barking or seal-like cough
• increasing resp distress & hypoxia
• can progross to resp acidosis, failure, and death
• usu in middle of night

Bacterial Tracheitis

(croup syndrome)

• can be secondary infection, may be complication of LTB b/c clinical manifestations similar
• infection of the mucosa of upper trachea
• thick, purulent secretions result in resp distress

uncommon but life threatening

Therapeutic Management

(Croup??)

1. Airway management
2. maintain hydration -po or IV
3. high humidity w/ cool mist (shower, outside on cool night)
4. Nebulizer treatments (epi, steroids)

• chronic inflammatory disorder of airways
• reactive airway disease can be precuror
• bronchial hyperresponsiveness (twitchy airways)
• episodic
• limited airflow or obstruction that reverses spontaneously or w/ treatment
• will not outgrow true, but control symptoms
• mechanical ventilation will not work (outer muscle layer contracts
• need epi or steriods long term control
• increased muscus secretions

• long-term control meds
• quick relief meds (albuterol- opens inner layers0
• metered-dose inhaler (MDI)
• Corticosteriods
• Cromolyn sodium (mast cell stablizer - precursor to histamine - prevent twitchiness)
• albuterol, metaproterenol, terbutaline (beta antagonists)

• resp distress continues despite vigorous therapeutic measure
• emergency treatment - epi subcut
• concurrent infection in some cases

• Exercise
• CPT (s/t contra b/c stimulate asthma attack)
• hyposensitization (controlled fashion, keep introducing allergery)
• Prognosis: Keep doc appts and checkups

• considered the "reactive" portion of the lower resp tract
• includes bronchi and bronchioles
• cartilaginous support not fully developed until adolescence
• constriction of airways

• Sudden onset: fever, dry cough, sore throat, muscle aches, HA, malaise
• treat the symptoms b/c is viral!
• VACCINATE for prevention
• Educate, vaccinate, prevent spread
• Management: humidifed O2, antipyretics, antibiotics, may require intubation

Bronchitis

(lower airway disorder)

• aka tracheobronchitis
• Viral (primary), bacterial (usu secondary)
• Fever, loose cough, rhonchi, wheezes
• larger airways (compared to bronchiolites & RSV)

• smaller airways
• Diagnostic: lab testing
• fever, wheezes (more), loose secretions, copious clear drainage (lots of stuff)
• Management: symptomatic, maintain airway
• Prevention of RSV - prophylaxis (synagis)
• Isolation precautions (highly infectious)

• Lobar pneumonia (classic - 1 of lobes)
• bronchopneumonia
• interstitial pneumonia
• pneumonitis

~Etiology: bacterial, viral, aspiration, histomycosis, coccidiomycosis & other fungi (harder to treat), "atypical" = mycoplasma, chlamydial (infants/neonates)

~usu put on antibiotic, x-ray to confirm type, decreased O2 sat

• risk for child w/ feeding difficulties
• feeding techniques, positioning important
• Avoid oily nose drips, solvents, talcum powder
• most common in children
• GERD - take precautions
• Can thicken feeds, elevate HOB 30 min after eating

• exocrine gland dysfunction that produces multisystem involvement
• most common lethal genetic illness among white children
• autosomal recessive trait
• inherits defective gene from both parents w/ and overall incidence 1:4 (25% chance every child will have it)

• results in mechanical obstruction
• thick inspissated mucoprotein accumulates, dilates, precepitates, coagulates to form concretions in glands and ducts
• resp tract and pancreas are predominantly effected

• basis of the most reliable diagnostic procedure = sweat chloride test
• Na & Cl will be 2-5x's greater than the controls

• present in almost all CF pt's, but onset/extent is variable
• stagnation of mucus and bacterial colonization result in destruction of lung tissue
• tenacious secretions are difficult to expectorate - obstruct bronchi/bronchioles
• decreased O2/CO2 exchange
• results in hypoxia, hypercapnea, acidosis
• compression of the pul blood vessels and progressive lung dysfunction lead to pul HTN, cor pulmonale, resp failure, and death

• gradual progression follows chronic infection
• bronchial epithelium is destroyed
• infection spreads to peribronchial tissues, weakening bronchial walls
• peribronchial fibrosis
• decreased O2/CO2 exchange
• chronic hypoxemai causes contraction/hypertrophy of muscle fibers in pul arteries
• pul htn, cor pulmonale, pneumothorax, hemoptysis

• pancreatic enzyme deficiency
• progressive COPD assoc. w/ infection
• sweat gland dysfunction
• failure to thrive (thin pt's)
• increased wt loss despite increased appetite
• gradual resp deterioration

• wheezing respiration, dry nonproductive cough
• generalized obstructive emphysema
• patchy atelectasis (blow out in lungs)
• cyanosis
• clubbing of fingers and toes (chronic)
• repeated bronchitis & pneumonia
• delayed puberty in females
• sterility in males
• parents report children taste "salty"
• dehydration
• hyponatremic/hypochloremic alkalosis, hypoalbuminemia (r/t dehydration)

#1 Quantitative sweat Cl test

• chest x-ray
• pul function tests
• stool fat and/or enzyme analysis
• barium enema

• CPT - daily
• bronchodilator meds
• forced expiration (IS, flutter device)
• aggressive treatment of pul infections (take out the big guns)
• Home IV antibio theraphy, aerosolized antibiotics

• Estimated life expectancy = 40-50
• Maximize health potential: nutrition, prevention/early aggresive treatment of infection, pul hygiene
• New research: gene therapy, bilateral lung transplants, improved pharm agents (hope for the futrure)

• Nasopharyngitis - "common cold"
• caused by numerous viruses (RSV, flu, etc)
• Fever - varies w/ age
• Home management - varies w/ age

Acute Streptococcal Pharynigitis

(strep throat)

• Group A B-hemolytic streptococci
• Risk for serious sequelae: acute rheumatic fever (should treat before!), acute glomerulonephritis
• easy to diagnosis and treat
• Large tonsils, exudate, hard to swallow

• various bacteria
• common in children
• can occlude airway
• can be secondary for lower resp infection

• Caused by Bordetella pertussis
• In US occurs most often in children not immunized
• Highly contagious!
• Vaccines!
• Booster shot 11-12yo b/c after 5 the immunity wanes

• peak incidence 3-4mo
• more common in males
• nighttime sleep usually
• winter
• preemies, LBW, siblings of prior SIDS
• low economic status, maternal education, sleeping arrangements (cobedding)
• Back to sleep, clutter free, cool temp, don't overdress
• maternal smoking
• learn CPR as a parent

• mom <19 or >34
• umemployed, medicaid, less than HS education
• single
• preconception wt <110
• substance abuse, smoking
• any febrile illness

LBW=

VLBW=

ELBW=

SGA:

AGA:

LGA:

Posterm:

• <2500g
• <1500g
• <1000g
• <10th percentile
• 10th-90th percentile
• >90th percentile
• >42 completed weeks, regardless of weight

Apnea of Prematurity (AOP)

• forget to breath
• lower age = higher incidence of AOP
• 1/3-1/2 are <30 weeks
• Orgins: Central, Obstructive, Mixed
• Pharm: Caffeine (helps HR & resp drive). dosage based on weight. "breakthrough" apneic events - eval
• Monitoring: hospital, home
• interventions: stimulate, resuscitate, document

• one of the last things to develop
• alveoli present in some infants as early as 32 wks GA, they are not uniformly present until 36 wks GA
• alveoli nec for sufficient exchange of O2 & CO2.
• inadequate numbers of alveoli result in hypoxemia

• lack of surfactant in lungs contributes to alveolar collapse
• affected lungs become stiffer and require more pressure to achieve expansion
• increased transudate of fluid is produced and further impairs gas exchange

• retractions (substernal, subcostal, intercostal)
• nasal flaring
• grunting (can sound like fussing, but rhythmic)

• ventilatory support
• conventional ventilation (complications - positive pressure ventilation)

Respiratory complications of RDS:

Bronchopulmonary dysplasia (BPD) & Chronic Lung Disease (CLD):

• secondary issues to RDS
• O2 requirements or mechanical vent after 36 weeks of age
• may be marker of long-term pul and neuro outcome
• Incidence: 15-40% of preemies. is inversely r/t birth wt and GA

• RR > 60
• can lead to progressive hypoxemia & dyspnea...irregular respirations & apnea..death
• assoc w/: expiratory grunting, nasal flaring, cyanosis, inter&subcostal retractions

Suffocation

• lack of O2-rich environment
• blockage of airways
• results in O2 failing to reach blood and tissues
• if not intervention = DEATH!

Danger signs after surgery: bleeding, freq swallowing b/c prob blood.

Position: side-lying or semi-prone b/c want secretions to drain out