7/15/2019

Alterations in
Respiratory
Functions
Common Upper Respiratory Alterations and Asthma
Cindy O. Bridges, RN, MSN
Summer 2019
Brunner & Suddarth
Chapter 22 p. 538-557 (stop at cancer)
P. 624-626 (meds only)
P. 637-649 (ASTHMA)

What we will cover today

• Upper Respiratory Disorders
– Allergic
– Viral/bacterial induced (including the common
cold)

• Airflow Disorders
– Asthma
– COPD (we will not talk about this today)
• Nosebleeds (epistaxis)

From Syllabus (page 3) of

addendum

– Sinusitis
– Influenza
– Rhinitis
– Pharyngitis
– Epiglottitis
– Tonsillitis
– Epistaxis
– Acute/Serous/Chronic Otitis Media
– Asthma
– Upper respiratory disorders
– Pharmacological Therapies ( from ATI and class)
– Pediatric Considerations (from class)

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Upper Respiratory Infections

• Upper Airway Infections
• Known as URI
– Most common and affect most people
– Some acute lasting several days
– Some chronic lasting weeks, months and years
• “Common Cold” is the most common URI

Some terms to know regarding URIs

• Sinusitis
• Influenza
• Rhinitis – inflammation (not necessarily infection) of nasal
cavity
• Rhinosinusitis – sinus infection, inflammation of sinuses
located around the nose
• Nasopharyngitis – commonly called the “common cold”
because of the area affected (think of where you feel a
common cold) – nares, pharynx, hypopharynx, uvula,
tonsils
• Pharyngitis – inflammation of pharynx, uvula and tonsils
• Epiglottitis – inflammation of upper portion of larynx or
epiglottis
• Tonsillitis

Causes of URI

• Generally by direct contact and invasion of

inner lining of the upper airway by a virus or
bacteria.
• We have natural barriers to try to protect us
(cilia, mucus membranes, etc.)
• We often confuse inflammation with infection

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URI’s

• Can affect the sinuses as well as pharynx,

larynx and trachea. (review that A&P)
• Most people average 2-3 URI per year!!
• Viral infection of the upper respiratory tract

URI’s and the older adult

• URI’s can be more serious in the older
adult
• Older people usually have other co-
morbid diseases and conditions
• The Flu can cause exacerbations of COPD
and other respiratory issues.
• Antihistamines and decongestants must
be used with caution due to systemic
effects
• Structure of nose changes can restrict
airflow and increase risk of URI
• GERD can cause laryngitis.

Rhinitis FACTS

• May be acute or chronic; Allergic or non-allergic

• Allergic
– Seasonal – usually from exposures to airborne particles such as dust,
pollen. Occurs mostly during pollen season
– Non-seasonal - can be from exposure to dust, pet dander and other
things. Food can also cause it (peanuts, etc.)
• Can also occur if person exposed to anything they are allergic to, such as
peanuts.
• Non-allergic – most common is from common cold
– Temperature, humidity, odors, infections, age and other diseases can
cause non-allergic rhinitis
• Those with compromised immune system, transplant patients, or
those that are taking immunosuppressant meds (or chemo) are at
higher risk for rhinitis and other infections.

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S/S Rhinitis
• Rhinorrhea,
nasal
congestion,
nasal
discharge,
sneezing,
pruritus,
headache
(especially if
sinuses
involved)

Medical Management of
Rhinitis
• USUALLY SYMPTOM MANAGEMENT ONLY...first!!
• Identify symptoms and severity of symptoms. Onset,
duration, alleviating factors, aggravating
factors…remember this!
• Medications given depend on origin of the problem
– Viral – meds to treat symptoms
– Allergic – allergy testing and symptom management
– Steroids may be an option
– If bacteria, antimicrobial may be given, but mostly with
rhinosinusitis
– Over the counter symptom medication most commonly
used

Medications for Rhinitis

• Medications for Rhinitis focus on relieving
symptoms.
• Rhinitis is usually caused by a virus or allergic
reaction and has to “run its course” but we can
help alleviate symptoms.
– If it is caused by a bacteria, then antibiotic therapy
would be appropriate
• Many OTC meds to treat Rhinitis will have
adverse interactions. Patients MUST read all OTC
labels carefully. OTC can be dangerous

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Medications for Rhinitis

• Symptom relief is primary
– Antihistamines – most common – many OTC
• Control sneezing, itching eyes, runny nose
– Decongestants – help with sinus pressure
– Combination drugs (antihistamines and
decongestants)
– Tussives – anti-cough
– Saline nasal sprays
– Some steroid nasal sprays (Flonase) now OTC
– Decongestant nasal sprays should be used with
caution, can cause dependence and rebound
congestion when stopped

Antihistamines
(Think “Anti H1”)
• Sedating Antihistamines- Older of two types
– Affect H1
– Used to treat motion sickness and as a sleep aid as well
• Non-Sedating Antihistamines
– Some can treat motion sickness as well

Sedating Antihistamines
Used for allergic
reactions as well.

• SEE PROTOTYPE: Benadryl (diphenhydramine);

Phenergan (promethazine) (rarely use Phenergan as
antihistamine, mostly for antiemetic)
• What do both of these drugs do?
• Bind to H1 receptors, blocking release of
histamine. Very effective in treating allergic
reactions. (What do H2 receptors do?)
• Mild cholinergic blockers. Watch for dry mouth,
blurred vision, constipation, urinary hesitancy.
BCTUX

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Non-sedating Antihistamines
Zyrtec, Claritin and Allegra are prototypes
• SEE PROTOTYPE
• Still cause some drowsiness, but not as sedating as the
older type.
• Now available OTC
• Allergic rhinitis and treatment for itching, rash and hives
• Bind to H1 receptors, blocking histamines.
• Can cause some drowsiness and fatigue
• Not for patients under 6 months of age or liver or kidney
impairment

Sympathomimetic Drugs-
(decongestants)
• SEE PROTOTYPE: Sympathomimentics phenylephrine
• For allergic rhinitis, sinusitis and common cold
• Prototypes –
– Neo-synephrine (nasal preparation)
• Phenylephrine (found in Sudafed PE) NOT SUDAFED
• Good to treat nasal congestion
• Side effects related to CNS stimulation (nervousness,
agitation anxiety insomnia tachycardia)
• Can have rebound nasal congestion with nasal
preparation

Pseudoephedrine
• Also known as Sudafed
• Great decongestant
– Can be used in the production of Methamphetamine
– Controlled substance in some states
– RX required in Mississippi
– Will show up on drug tests
• D = Decongestant (pseuDophed)
– Advil Cold and Sinus
– Claritin-D
– Allegra-D

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Antitussives

• SEE PROTOTYPE: Anti-tussives – opioid; non-

opioid
• Suppress chronic, non-productive coughing
related to allergies and upper respiratory
infections. Work on cough center
• Also called cough suppressants.
• Two prototypes
– 1. Opioid – Codeine
– 2. Non-opioid – dextromethorphan and Tessalon
• Must have good liver and kidney function

https://www.drugabuse.gov/videos/emerging-trends-syrup-
purple-dranksizzurp-lean

• “Purple Drank”
• “Lean”
• “Syrup”

Which cold medicine to take?

• https://www.drugs.com/slideshow/otc-cold-
remedies-1095#slide-1

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Expectorants
• See Prototype: Guaifenesin (Mucinex)
• Reduces surface tension of secretions, thinning mucus,
making it easier to cough up and/or drain out of sinuses.
• NSG: Need to drink plenty of fluids to thin secretions
• Not many side effects- drowsiness can occur.
• NSG: Give with full glass of water. Patent should drink as
much fluid as possible to help with thinning secretions.
• Caution if given with other cold medications
• NSG: Safety monitoring (dizziness).
• Contraindicated if patient on ACE inhibitor.
• Can inhibit platelet aggregation; NSG: Monitor bleeding

Two types cough medicine

• Good example of how you need to read labels
• May have just guaifenesin, just
dextromethorphan, or both

Mucolytics
• Will not cover these as mostly for more
serious respiratory issues such as cystic
fibrosis.

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Steroid Nasal Spray

• Prototype: Using prototype Glucocorticoids # 6
• fluticasone (FLONASE) Nasal Spray is indicated for
the management of the nasal symptoms of
perennial non-allergic rhinitis in adult and
pediatric patients aged 4 years and older.
• A steroid nasal spray. Reduces inflammatory
response. Can be used long term. Does not give
immediate relief like Neo-Synephrine
(sympathomimetic see prototype). Works
differently
• Learn about what steroids do

What do we do as nurses
• Teach patients about self care and prevention
• Teach people with allergies how to avoid
exposure
• Screen patients at higher risk (elderly,
immunocompromised and very young)
• Basic symptom management
• Proper use of OTC and RX medications
• Side effects to monitor for
• HAND HYGIENE very important
• Increasing fluids-thins secretions

Common Cold Viral Rhinitis-again

• Most common
• Self limiting
• An acute URI with usual URI symptoms
• Highly contagious due to viral infections
• Virus sheds for 2 days before symptoms appear and during
first part of symptoms.
• Early fall and spring time most common
• Approximately 200 types of virus cause this
• Common ones, rhino, coronavirus, adenovirus, RSV, flu
• Vaccination almost impossible due to large number of
causative viruses
• Person’s immune system plays big role

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Nursing and/or patient Management

of Common Cold
• Increase fluids
• Rest
• Temperature management
• Medications as indicated and ordered
• NSAIDS (avoid aspirin)-viral infection- we learned about these
already
• Antihistamines
• Anti-virals decrease length and severity-need RX-rarely given for
common cold (Tami-flu is example for flu caused by virus)
• Nasal sprays (nasal decongestants such as Afrin and Neo-
Synephrine) used with caution as are habit forming.
• Teach on prevention and transmission
• Infection control- to prevent secondary bacterial infection
• May have cough from nasal drainage down back of throat

Influenza (the FLU) FACTS

• Influenza (flu) is a contagious respiratory

illness caused by influenza viruses.
• It can cause mild to severe illness. Serious
outcomes of flu infection can result in
hospitalization or death.
• Some people, such as older people, children,
and people with certain health conditions are
at high risk for serious flu complications.
• Reference: www.cdc.org

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FLU S/S
•Fever or feeling feverish/chills
•Cough
•Sore throat
•Runny or stuffy nose
•Muscle or body aches
•Headaches
•Fatigue (very tired)
•Some people may have vomiting and diarrhea,
though this is more common in children than
adults

Complications of the FLU

• The very old, very young, immunocompromised
and those with other illnesses are at higher risk of
developing complications.
• Opportunistic secondary infections are a major
complication- what does that mean?
• Bacterial pneumonia, ear infections, sinus
infections, dehydration, and worsening of chronic
medical conditions, such as congestive heart
failure, asthma, or diabetes

Flu Vaccine
• Traditional flu vaccines are made to protect
against three different flu viruses (called
“trivalent” vaccines) are available. In addition, flu
vaccines made to protect against four
different flu viruses (called “quadrivalent”
vaccines) also are available.

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Who should get the flu vaccine

• SHOT
– 6 months or older
• Even pregnant women can get shot
• NASAL SPRAY
– 2 years or older
• What’s the difference?
– In effectiveness, not that much. LIVE virus in nasal
spray

WHO SHOULD NOT GET THE NASAL

PREPARATION OF FLU VACCINE?
• Children under 2
• Adults 50 and over
• Anyone with a history of severe allergic reactions to the vaccine or a
previous flu vaccine
• Children and teens who get aspirin therapy
• Children between ages 2 and 4 who have asthma or have had a
history of wheezing in the past year
• Pregnant women
• Anyone with a weakened immune system
• Anyone who has taken influenza antiviral drugs in the last 48 hours
• Anyone who cares for someone with a weakened immune system

• https://www.webmd.com/children/vaccines/flu-shot-nasal-
spray#1-3

Treating the Flu

• Symptom Management. Plenty of fluids.
• Tamiflu (antiviral) may be given within 48
hours of onset of symptoms.
• Anti-virals do not kill the virus, but stops
replication of the virus. Can minimize severity
of flu symptoms.
• It can only be obtained by a prescription.

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Alternative to Tami FLU

• Elderberry is showing great promise for those
choosing not to, or who cannot take TAMIFLU
• In England, TAMIFLU is not being prescribed as
much, especially to children
• Elderberry comes in many preparations
• Boosts the immune system
• Some are not prescribing TAMIFLU

Watch those PEDS closely

• Children with siblings at higher risk to spread.
• They can deteriorate very quickly.
• Require very close monitoring.

Rhinosinusitis

• Also called “sinusitis”. Caused by bacteria or

virus

Acute = less than 4 weeks

Sub-acute = 4-12 weeks
Chronic = more than 12 weeks

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Nursing care – acute sinusitis

• Patient education – symptoms, worsening
symptoms – systemic or “moving” infection to
neck, meninges, etc. (nuchal rigidity is example)
• Symptom management
• Avoid self treating
• Finishing antibiotics- if bacterial infection
• Especially monitor patients with invasive lines,
etc. to nose, or sinus cavity for sinus infections –
KNOW WHY

S/S Chronic Sinusitis

• Chronic – cough from mucus dripping backward into

nasopharynx
• Chronic hoarseness
• Chronic headaches in peri-orbital area
• Facial pain
• Mouth breathing
• Fatigue and nasal congestion
• Symptoms worse in am
• Nasal discharge (purulent if bacterial)
• Some fever-viral or bacterial
• Can spread to neuro involvement (optic nerve)

General Management of recurrent

acute and chronic sinusitis
• Similar to acute
• Surgery may be needed-sinus surgery
• OTC meds to control pain and fever
• Good hydration
• OTC nasal saline sprays
• Avoiding fumes and smoke; sleep HOB up-help
prevent post-nasal drip
• Antibiotics
• Steroid nasal sprays

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Pharyngitis- aka
“sore throat” FACTS
• Acute and Chronic classifications
• Acute – sudden; Chronic – persistent
• ACUTE: Peaks during winter and early spring
due to decreased ventilation (think patient
teaching here)
– Spreads in droplets of coughs and sneezes as well
as unclean hands. More prevalent in cold weather
due to heaters, less fresh air
– 11 people per year experience sore throat

Acute Pharyngitis – sore throat FACTS

• Viral and bacterial causes. Viral most common
– Viruses: adenovirus, influenza, Epstein-Barr,
herpes simplex.
– Bacteria – numerous, Strep very common (strep
throat)
• Body starts inflammatory response (pain,
fever, edema, swelling of tonsils, uvula and
soft palate).
• Viral self limiting in 3-10 days

S/S Pharyngitis
• Sore throat
• May have red throat
• May have swollen throat with or without
drainage
• Fever/cough
• May have nasal involvement
• Swelling

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Pharyngitis S/S
• Red throat and tonsils, sometimes with white
liquid or dried exudate.
• Enlarged lymph notes. Usually no cough
• Fever, malaise, sore throat, body aches, chills
• Headache
• May have flushing of face
• Abdominal pain with (Group A Strep) GAS
• Patient feels “bad”.
• Usually high fever that spikes

Treating Pharyngitis
• Antibiotics if caused by strep or other bacteria
• Symptom treatment if caused by virus
• NSG: Cool air and humidity
• NSG: Warm salt water gargles can help relieve pain and discomfort
• NSG: OTC pain reliever
• NSG: Rest
• NSG: Teach Hydration/avoid alcohol
• Try throat lozenges
• Increase fluids
• Liquid or soft diet.if severe dehydration, then IVF
• REST
• SYMPTOM MANAGEMENT is primary focus, followed by eradicating
organism causing it if possible.

Tonsillitis and Adenoiditis

• Tonsils = lymphatic tissue
– Common site of infection
– Acute and Chronic
– Acute often confused with
pharyngitis
– Chronic often confused
with allergy, sinusitis
• Adenoiditis often
accompanies tonsillitis
– Usually caused by bacteria
– Some viral (usually
immunocompromised
patient)

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Tonsillitis can lead to other

complications such as…..
• Recurrent ear infections
• Hearing loss
• Breathing problems due to obstruction
• Scarring and hypertrophy of tonsils. “Pitting”
• Peri-tonsillar abscess

Adenoiditis

Medical Management
• Supportive treatment (fluid, pain
management, gargles)
• Antibiotics if bacterial
• Tonsillectomy and adenoidectomy if becomes
chronic. Usually laser surgery now.

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Nursing actions after tonsillectomy

• After surgery – basic post/op monitoring
• Patient at increased risk of hemorrhage and airway
obstruction
• Patient will lie in prone position at first
• Do not remove the oral airway until gag reflex returns
• Monitor for pain and bleeding
• Vomiting common- watch for aspiration
• Difference if blood vomiting
– Small bright red/small dark brownish red (swallowed)
– Large amounts bright red/large amts.
• Monitor LABS – especially HGB, HCT and WBC. Very
important before patient discharged from hospital.
• Monitor for SHOCK (Increased HR, restlessness, fever, dec bp)
• Teach to avoid talking or strain on throat

Nursing actions
•Tonsillectomy/adenoidectomy usually
outpatient
•TEACH:
• Symptoms of hemorrhage
• Bleeding can occur for up to 8 days
• Pain management
• Warm saline mouthwashes
• Symptoms to seek immediate medical care
• Common discomforts
• Hydrate/Hydrate/Hydrate
• Humidify home air if possible

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Laryngitis

Laryngitis
• Inflammation of the larynx
• May be short term or chronic. Chronic is more
cause for concern
• Causes:
– Voice abuse, exposure to dust, chemicals, smoke,
or as part of URI. Temperature changes, dietary
deficiencies, part of immunosuppressed state
– Rarely vocal cords get isolated infection that is not
associated with URI
– Can also be caused by chronic GERD

S/S Laryngitis
• Hoarseness
• Weak voice or voice loss
• Tickling sensation and rawness of your throat
• Sore throat
• Dry throat
• Dry cough

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Treatment/Management Laryngitis
• Basic Treatment
– Limit speaking
– Fluids
– Warm water gargles
– Take prescribed antibiotics
• Emergency care needed if:
– Makes noisy, high-pitched breathing sounds when
inhaling
– Drools more than usual
– Has trouble swallowing
– Has difficulty breathing
– Has a fever higher than 103 F (39.4 C)

Croup Syndromes
• Laryngotracheolbronchitis affects mostly
younger children, and epiglottitis affects
mostly older children.
• https://www.youtube.com/watch?v=TxDf3DH
GGuE

Epiglottitis

Infectious epiglottitis is
very RARE. If it happens,
usually in 3-7 year old age
group

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Epiglottitis Causes
• Traditionally seen in pediatric patients,
especially before the Haemophilus Influenza
Type B vaccine
• Today, most epiglottitis is caused either by
trauma (crushing, burns or injury to epiglottitis)
or infection with other bacteria….because we
receive HiB vaccine as children…or we
should!!!!

Epiglottitis Signs and Symptoms –

Sudden onset esp. infectious
• CHILDREN S/S
• Fever
• Severe sore throat
• Abnormal, high pitched sound when breathing (stridor)
• Difficult and painful swallowing
• Drooling
• Inability to swallow
• Respiratory distress
• Anxious, restless behavior
• Greater comfort with breathing when sitting up or leaning
forward

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• When you see a child sitting up to breathe in a hospital

or clinic, (TRIPOD POSITION)having difficulty breathing,
wheezing or in stridor, TAKE NOTE and ACT QUICKLY!!

• https://www.youtube.com/watch?v=TxDf3DHGGuE

Otitis Externa
• Chapter 64-beginning on p. 1891
• I would review the anatomy of the ear as I study this content so you have a
better grasp of the disease processes and interventions provided!!
• Otitis externa is inflammation of the external
ear canal
• CAUSES: Water in the canal (trapped) allowing
overgrowth of bacteria
• Trauma to the skin of the ear, any type of
dermatitis such as eczema, psoriasis, that
cause irritation to the skin and subsequent
infection.

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Otitis Externa
• Fungus and bacteria are most common
organisms causing the problem
• S/S
– Pain (on manipulation of the ear, the outer ear, not
the inner ear), discharge from ear, aural
tenderness, itching and hearing loss as well as
sense of fullness in ear.
– The outer ear canal will look red and swollen on
examination with or without discharge.

Our role
• Teaching patients ways to decrease trauma to
the external ear
– No Q-tips, no hair pins in ear, avoid excessive
scratching, avoid getting ear wet when bathing
and swimming and try to keep wax from
accumulating in ear as it traps water behind the
wax.
• Assess external ear
• Administer/teach medications and symptoms
to monitor for

How are ear infections related to

respiratory infections?

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Otitis Media
• Chapter 64 page 1880 B&S
• Page 1892-1893

Acute OM
• Can be viral or bacterial
• Pathogens enter middle via Eustachian tube
• The anatomy of a child’s ear makes them
more prone to OM (Eustachian tube
straighter)

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Acute OM Causes/Risk Factors

• CAUSES: Infections such as adenoiditis, tonsillitis,
rhinitis, sinusitis, pharyngitis
• Cleft palate
• Trauma to tympanic membrane
• Head injury
• RISK FACTORS: age (less than 1 year), chronic
URI’s, Down syndrome, cystic fibrosis, cleft
palate, compromised immune systems,
exposure to secondhand smoke.

Acute OM Symptoms
• Earache/Ear pain
• Discharge from ear
• Hearing loss – from purulent drainage in middle
ear
• Fever
• Irritability
• Red tympanic membrane
• Elevated WBC
• Culture
• Ear tenderness; child may pull on ear

Medical Treatment of Acute OM

• Medications: Antibiotics, antihistamines, nasal
decongestants, humidifying air, anty-pyretics,
analgesics.
• Outcome of treatment depends on the virulence
of the infectious organism, the physical status of
the patient.
• Generally effective. If eardrum perforation
occurs, may take longer to treat
• Ear drops for pain/antibiotic may be given as well.

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Chronic Otitis Media S/S

• Symptoms vary. Some hearing
loss
• Persistent foul smelling
discharge
• Pain not usually experienced
due to the ruptured eardrum
allowing purulent drainage out
• Cholesteatoma may develop-
read up on this. If it is chronic,
could mean cancer. –page 1893

Treatment COM
• Local antibiotics usually used. Systemic only if acute
• Surgery may be needed
• Reconstruction of tympanic membrane
• Surgery on ossicles may be needed
• Ossiculoplasty needed in more severe cases.
Reconstruction of middle ear bones
• Mastoidectomy – Know risks and nursing measures for
all treatments-YOU May BE TESTED ON THE SURGICAL
PROCEDURES RELATED TO TREATING OTITIS MEDIA
BOTH ACUTE AND CHRONIC

Airflow Disorders
• These include Asthma and COPD
• We will only be talking about asthma today

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Asthma
page 637-Chapter 24 B&S
• Asthma is a chronic inflammatory disease
• Asthma cannot be cured but it can be managed and
treated
• Airways narrow and swell and produce extra mucus.
This can make breathing difficult and trigger coughing,
wheezing and shortness of breath.
• Patients with asthma experience episodes of cough,
chest tightness, wheezing and SOB – especially at night
and in the morning.
• Asthma can occur at any age, but onset is usually
detected in childhood

Pathophysiology of Asthma
• Acute brocho-spasms and
increased mucus
production
• Increase swelling of
airways
• Chest tightness
• Shortness of breath
• Fatigue
• Respiratory fatigue

Common Allergens that trigger asthma

• Grass • hormonal factors
• tree and weed pollens • Medications
• mold • viral respiratory tract
• Dust infections
• Roaches • GERD
• animal dander • foods
• air pollutants • Exercise
• cold, heat • Stress
• Smoke • strong odors
• weather changes • Perfumes

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• Read through Pathophysiology on page 637-

638

Diagnostic Evaluation for Asthma

• Classic Manifestations are
– Dyspnea -Chest tightness
– Wheezing
– Coughing
• Wheezing on expiration at first, but then may be on
inspiration as well.
• Some experience symptoms that range from acute
episodes of shortness of breath, wheezing and cough,
followed by a quiet period to a relatively continuous
pattern of chronic symptoms that fluctuate inn severity
• Lung function is evaluated by spirometry.

Spirometry

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Peak Flow Meter

Nursing Care

• Help patients to understand the disease and decrease their fear

• Help obtain history and identify factors that cause exacerbations
• Identify and teach patients on medications prescribed
• Administer prescribed medications and monitor the patent’s
response
• Administer fluids if patient is dehydrated
• Assist with intubation of patient in acute respiratory failure and
monitor patient’s response
• Teaching patients on home care

Note
• Asthma is generally considered a “reversible”
condition if it is acute, however, chronic
inflammation, especially as the disease
progresses can cause airway remodeling to
airway structures which cannot be prevented
by and is not respondent to medication or
other treatments.

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Shortness of breath with air

movement in the chest
restricted to the point of
absence of breath sounds
accompanied by a sudden rise in
respiratory rate is an ominous
sign indicating ventilator failure
and imminent respiratory arrest.

Status Asthmaticus
Treat with B2
(Albuterol)

• Occur with little or no warning

• Can progress rapidly to asphyxiation and death
• Many factors contribute to this. Read page 646
• Respiratory alkalosis occurs initially due to hyperventilation.
Progresses to respiratory acidosis as CO2 is retained.
• Increasing CO2 is a sign of impending respiratory failure

Basic Equipment Information

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RX
Beta Adrenergic Agonist - Albuterol

• Treatment for acute asthma attacks(rescue). Fast acting

RX Inhaled Anticholinergics – Atrovent

and Spiriva are prototypes
• Cannot be used as
EMERGENCY RESCUE- used
more for prevention of
bronchospasms
• Primarily used for COPD
• Provide relief of
bronchospasms in COPD
patients.
• Also used to treat allergen
induced and exercise induced
asthma.

RX
Methylxanthines- Theophylline
• Treats long term asthma
• Comes in extended release and
immediate release forms
• Relax smooth muscles in bronchi and
pulmonary blood vessels
• Few side effects at therapeutic blood
levels.
• Most side effects if reach toxic level.
Restlessness and insomnia from CNS
stimulation. Can lead to cardiac
dysrhythmias and seizures if too high.
• Theophylline blood levels taken
regularly.
• PO only. Taken at prescribed intervals.

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Glucocorticoids RX
• SEE PROTOTYPE 9
• Glucocorticoids ( prednisone)
• For long term management and short term after acute
exacerbation. (inhaled for long term management)
• Can be used to treat allergic rhinitis (nasal preparation –
Flonase)
• May be given
– Inhaled – Beclomethasone
– Oral – Prednisone- usually short term (3-5 days)- must be
tapered
• Patient may be put on anti-fungal prophylactically
• Watch for GI bleeding and adrenal function
• Monitor blood glucose levels
• Monitor for infection
• Can increase risk of hypokalemia if patient on loop
diuretic

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Mast Cell Stabilizers-Cromolyn (Intal)

RX
• Inhaled drug (nebulizer or
MDI)
• Suppress inflammation
• Keep WBC from
stimulating the
inflammatory response –
decreases edema of
airways
• Dry mouth and headache
and bitter aftertaste
common

Leukotriene Modifiers - Singulair

RX
• Oral Meds
• Used for long term management of chronic
asthma, for exercised induced bronchospasms
and for management of allergic rhinitis
• Suppress inflammation- inhibit release of
leukotrienes
• Monitor liver function. Can cause headache
• Usually once daily in evening

RX
Emergency Treatment
• Albuterol- discussed
previously
• Epinephrine (Adrenalin)-
adrenergic that may be
given subcutaneously in an
acute of
bronchoconstriction with
therapeutic rescue effects
in about 5 minutes and can
last with up to 4 hours.
– Cardiac stimulation is
severe adverse effect.

– ALSO USED TO TREAT

WHAT?

33
 7/15/2019

Let’s look at chart on page 640- daily

asthma med guide

Metered Dose Inhaler

http://www.bing.co
m/videos/search?q=
using+metered+dos
e+inhaler&FORM=H
DRSC3#view=detail&
mid=747A718718AD
F85DA2DD747A7187
18ADF85DA2DD

MDI with spacer- when is spacer

needed?

http://www.bing.com/videos/search?q=meter
ed+dose+inhaler+with+spacer&FORM=HDRSC
3#view=detail&mid=BADDA09C2ADF12141AF8
BADDA09C2ADF12141AF8

34
 7/15/2019

Dry Powder Inhaler

http://www.bi
ng.com/video
s/search?q=dr
y+powder+in
haler&FORM=
HDRSC3#view
=detail&mid=
32AD590140B
BD4BF56D432
AD590140BB
D4BF56D4

Nebulizer
• A nebulizer changes medication from a liquid
to a mist so that it can be more easily inhaled
into the lungs. Nebulizers are particularly
effective in delivering asthma medication to
infants and small children and to anyone who
has difficulty using an asthma inhaler.

Pediatric Considerations
• Generally the same assessment and
treatment
• Can deteriorate much faster than adult
• Have less respiratory reserve
• Medication adjustments must be made
• Accurate, timely assessment necessary
• Respiratory infections account for the
majority of acute illnesses in children

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Retractions
https://www.youtube.com/watch?v=bYso_Oz-35k

https://www.youtube.com/watch?v=bAkPyXVrTLQ
https://www.youtube.com/watch?v=42jJ18fkZ0Y
https://www.youtube.com/watch?v=TxDf3DHGGuE
(skip to 9:43)

Croup, Epiglottitis, RSV

• Any of these can cause serious, immediate
emergency situations in pediatric patients.
• RSV-common upper respiratory infection with
Respiratory syncytial virus. Affects epithelial cells
of respiratory tract.
– Best treatment is humidified oxygen and hydration
and symptom management.
– If child has underlying condition that will compromise
strength, may be hospitalized, or if child progresses to
severe illness with infection.

RSV- starts in upper resp but can move

to lower so we will briefly discuss
• Initial
– Rhinorrhea, Pharyngitis, coughing, sneezing, wheezing,
possible eye or ear drainage, intermittent fever
• With Progression of Illness
– Increased coughing and wheezing, Tachypnea, retractions
and cyanosis
• Severe Illness
– Tachypnea > 70 breaths/min
– Listlessness
– Apneic spells
– Poor air exchange and poor breath sounds

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Nosebleeds (Epistaxis)
• Page 554
• Here there are three major blood vessels that enter the nasal cavity

Risk factors associated with Epistaxis

 Local infections (vestibultis, rhinitis, rhinosinusitis)
 Systemic infections (scarlet fever, malaria)
 Drying of nasal mucosa membranes
 Nasal inhalation of steroids
 Illicit drug use (cocaine or other “snorted” drugs)
 Trauma (digital, blunt, fracture, forceful nose blowing, NG TUBE)
 Arteriosclerosis
 Hypertension
 Tumor
 Thrombocytopenia
 Use of aspirin
 Liver disease
 Redu-Osler-Weber syndrome (hereditary hemorrhagic
telangiectasia)

Treatment
• Depends on cause
• Minor nosebleeds are nothing to get alarmed
about
• All nosebleeds must be considered potentially
dangerous
• Basic – sit upright with head tilted forward to
prevent swallowing and aspiration – 5-10 minutes
of continuous pressure on septum
– If continues, nasal spray that causes vasoconstriction
such as phenylephrine can be used

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Next Level of Treatment for

Nosebleeds
• Complete assessment
• Packing with cotton based
gauze (or tampon like). A
balloon catheter may be used
• Packing remains in place for up
to 3 days
• Antibiotics may be given
prophylactically
• Nurses monitor vitals signs,
airway and bleeding pre and
post procedure, keep patient
calm and monitors labs.

38