The Child with

Respiratory Dysfunction
Part I
Respiratory Dysfunction: Part I

•General Aspects
•Assessing for S & S of Respiratory Distress
•General Nursing Interventions
•Procedures and Equipment
•Common Respiratory Disorders

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General Aspects of Respiratory
Infections
• Upper respiratory tract
• Nose, pharynx, larynx, upper trachea
• Lower respiratory tract
• Lower trachea, bronchi and bronchioles, alveoli
• Croup syndromes
• Infections of the epiglottis or larynx

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Infectious Agents

• Viruses
• Respiratory syncytial virus (RSV)
• Others
• Group A β-hemolytic streptococci (GABHS)
• Staphylococci
• Chlamydia trachomatis, Mycoplasma organisms, pneumococci
• Haemophilus influenzae

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 Age
• In infants younger than 3 months, maternal antibodies offer
protection
• In infants age 3 to 6 months, the infection rate increases
• In toddlers and preschoolers, there is a high rate of viral infections
• In children older than 5 years, there is an increase in GABHS and
Mycoplasma pneumoniae infections
• Increased immunity develops with age

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Size
• Diameter of airways is smaller
• Distance between structures is shorter, allowing organisms to
rapidly move down
• Short and open eustachian tubes

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Resistance

• Immune system deficiencies

• Allergies, asthma
• Cardiac anomalies
• Cystic fibrosis
• Exposure to infections in daycare
• Exposure to second-hand smoke

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Seasonal Variations

• Most common during winter and spring

• Mycoplasmal infections are more common in fall and winter
• Asthmatic bronchitis is more frequent in cold weather
• RSV season is typically winter and early spring

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Clinical Manifestations of Respiratory
Infections
• Vary with age
• Generalized signs and symptoms and local manifestations differ
in young children
• Fever

• Anorexia, vomiting, diarrhea, abdominal pain

• Cough, sore throat, nasal blockage or discharge

• Types of cough

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Assessing for Respiratory Distress

• Breathing rate. Increases with increased work of breathing.

• Increased heart rate. Low oxygen levels may cause an
increase in heart rate.
• Color changes. A bluish color seen around the mouth-
circumoral cyanosis, on the inside of the lips, or on the
fingernails due to low O2 saturations. The color of the skin
may also appear pale or gray.
• Grunting. A grunting sound can be heard each time the
baby/child exhales. This grunting is the body's way of trying
to keep air in the lungs so they will stay open.
• Nasal flaring. Sign of having to work harder to breathe.

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Respiratory Distress

• Retractions. Suprasternal, substernal, supraclavicular,

intercostal, subcostal- trying to bring more air into the lungs.
• Sweating. There may be increased sweat on the head, but
the skin doesn't feel warm to the touch. More often, the skin
may feel cool or clammy. This may happen when the
breathing rate is very fast.
• Wheezing. A tight, whistling or musical sound heard with
each breath usually on expiration but can be heard on
inspiration and expiration. The air passages are constricted
making it harder to breathe, also there may be air trapping.
• Stridor. An inspiratory high pitched sound heard in the
upper airway.
• Rales. Coarse crackling sound, note location

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Respiratory Distress

• Changes in alertness. Low oxygen levels may cause the

child to act restless, agitated or irritable Respiratory fatigue
can cause child to be very tired, sleepy or limp.
• Body positions. Low oxygen and trouble breathing may
force the child to thrust his or head backwards with the nose
up in the air (especially if lying down). Or, your child may
lean forward while sitting. A child automatically uses these
positions as a last attempt to improve breathing.
• Head Bobbing. Infant’s head moves forward with each
inspiration.

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Nursing Interventions for Respiratory
Infections
• Ease the respiratory effort
• Monitor O2 Saturation
• Administer O2 as ordered
• Manage fever
• Promote rest and comfort
• Control infection
• Administer AB as ordered
• Promote hydration and nutrition
• Provide family support and teaching

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Pulse Oximetry for infant

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Child with Pulse Ox

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O2 Therapy Administration

•Need MD order
•Correct device
•Appropriate amount of O2
•Humidification
•Patient response

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O2 via hood

c. 19
O2 via nasal cannula

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O2 via simple face mask

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O2 masks

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Upper Respiratory Tract Infections
(URIs)
• Acute nasopharyngitis (common cold)
• Caused by numerous viruses
• RSV, rhinovirus, adenovirus, influenza, and parainfluenza viruses
• Teach family home management & when to notify PCP
1. Treatment: antipyretics, fluids and rest, saline nose drops and suction
with bulb syringe before feeding.
2. Prevention of spread to other family members
3. Evidence of earache, tachypnea, fever >101, listlessness, increasing
irritability persistent cough>2d,wheezing, confusion, refusal to drink/eat,
limited sleep, diarrhea.

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Pharyngitis

• Causes: viruses, bacteria:streph

• Risks: Rheumatic fever, Glumerulous Nephritis
• Clinical manifestations
• Fever, gen malaise, anorexia, sore throat, headache
• Therapeutic management; Antipyretics, Fluid/rest, AB
• Diagnostics: Throat Culture to R/O streph
• Nursing Role-Teach family when to call PCP
• Not responding to antipyretics, extremely sore throat, refuses liquids,
no improvement 24hr after starting AB

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Pharyngitis (cont’d)

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Tonsillitis

• Pathophysiology and etiology

• Common illness in children, usually with Pharyngitis, may be bacterial
or viral. May involve tonsils and adenoids.
• Clinical manifestations
• Tonsils enlarging causes difficulty eating and breathing.
• Adenoids edema makes nasal breathing difficult and child snores.
• Therapeutic management
• Symtomatic tx for viral; AB for bacterial-streph
• Tonsilectomy for frequent infections: Adenoidectomy for sleep
disturbances and apnea.
• Nursing considerations: post-op care to address pain,nausea,
risk of bleeding, refusal to eat or drink,

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Nursing Considerations Post-Op Tonsillectomy

• For pain-Hydrocone/acetaminophen, Dose for >2yrs &>50kg: 0.01-

0.15mg/kg/dose PO every 4-6 hours. Side effect:constipation
• Maintain oral intake: manage pain, offer popsicles, and soft diet,
jello, yogurt.
• Monitor bleeding-avoid red popsicles
• Discharge teaching:
• Meds for pain
• Avoiding gargling,clearing of throat, vigorous teethbrushing
• Limiting of activity to decrease risk of bleeding
• Notify PCP for bleeding, refusal to drink/eat, persistent fever, earache, or
cough.

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Influenza

• Clinical manifestations: dry cough, fever, chills, general malaise

• Therapeutic management: Symptomatic, if symptoms severe or
complications occur-hospitalized. Naso-pharyngeal swab &
blood test for dx of flu type
• How to collect a nasopharyngeal swab using a developmental
approach.
• https://www.youtube.com/watch?v=ar2Grm_t8X8

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Flu (con’t)

• Prevention: Annual flu vaccine recommended for children

>6mos.
• Nursing considerations:
• Acetaminophen, Ibuprophen for pain/discomfort,fever
• Antivirals: Oseltamirvir (Tamiflu) for children >1yr, Zanamivir (Relenza)
for children>7yrs, both effective for types A & B.
• No ASA due to risk of Reyes Syndrome

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Otitis Media (OM)

• Pathophysiology and etiology, very common in children often

with URI, viral or bacterial, more frequent <24mos,
• Diagnosis: clinical Symptoms of ear pain, fever, & URI followed
by visual inspection of tympanic membrane-bulging yellow or
red.
• Therapeutic management
• Pharmacologic: AB after 72 hours; Amoxicillin 80-90mg/kg/day divided
in 2 doses. Acetaminophen for fever.
• Surgical: Ear tube placement and adenoidectomy for recurrent cases.
• Nursing considerations: Teach about risk of hearing loss.
• Prevention of recurrence: BF for at least 6mos, no propping of
bottle, and avoid exposure to smoke.

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Infectious Mononucleosis

• Principal cause is Epstein-Barr virus, Common among

adolescents
• Diagnostics: Serum Mono-spot
• Symptoms: Headache, malaise, fatigue, chills, low grade fever,
loss of appetite, puffy eyes, sore throat with excudate, cervical
adenopathy, tonsillar petechiae, macular eruption on truck, May
include splenomegaly and hepatic involvement
• Treatment: Self-limiting; no specific treatment, Rest as needed
for fatique, Medication for severe throat pain including opiods
such as hydrocone/acetaminophen, dose for 2yo and older,
>50kg, 2.5-10mg PO every 4-6 hrs. Significant SE:
constipation-Miralax, fluids, foods.

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Croup Syndromes

• Characterized by hoarseness, barking cough,

inspiratory stridor, and varying degrees of
respiratory distress
• Croup syndromes affect the larynx, trachea,
and bronchi
• Epiglottitis, laryngotracheobronchitis (LTB)

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Acute Epiglottitis

• Clinical manifestations
• Sore throat, pain, tripod positioning, retractions
• Inspiratory stridor, mild hypoxia, distress
• 4 D’s dysphagia, dysphonia, drooling, and distress
• Therapeutic management
• Potential for respiratory obstruction-medical emergency
• Nursing considerations
• Prevention requires Haemophilus influenzae type b (Hib)
vaccine

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Acute Laryngotracheobronchitis (LTB)

•Most common croup syndrome

•Generally affects children younger than 5
years of age
•Organisms responsible
•RSV, parainfluenza virus, Mycoplasma
pneumoniae, influenza A and B viruses

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Manifestations of LTB

• Inspiratory stridor
• Suprasternal retractions
• Barking or seal-like cough
• Increasing respiratory distress and hypoxia
• Can progress to respiratory acidosis, respiratory failure, and
death
• Child with Croup

• (https://www.youtube.com/watch?v=Qbn1Zw5CTbA)

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 Therapeutic Management of
LTB
• Airway management
• Maintain hydration (oral or
IV)
• High humidity with cool mist
• Nebulizer treatments
• Epinephrine (racemic)
• Steroids

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Infections of the Lower Airways

• Considered the “reactive” portion of the lower respiratory tract

• Includes bronchi and bronchioles
• Cartilaginous support is not fully developed until adolescence
• Constriction of airways

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Bronchitis

• Also known as tracheobronchitis

• Definitions: inflammation of the trachea and bronchi
• Causative agents: most commonly M.pneumomiae
• Clinical manifestations: dry hacking cough especially at night
that becomes productive after 2-3 days.
• Treatment: Analgesics, antipyretics and humidity

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Bronchiolitis and RSV

• Definitions: inflammation of
the bronchioles
• Respiratory syncytial virus
(RSV), cause in most cases
• Pathophysiology: The
ciliated cells swell, lose
cillia, infiltrated with
inflammatory cells,
increases mucus, air is
trapped and expiration
difficult.

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Bronchiolitis and RSV

• Diagnostics:NP swab, chest xray shows hyperinflation

• Therapeutic management:Hospitalization for resp distress and
dehydration. Humidified O2, regular suctioning, IV fluids.
Ribavirin for tx of high risk infants. Potential toxic effect to HCP
during pregnancy
• Prevention of RSV: prophylaxis Synagis IM given monthly,
indicated for premature infants 0-12 months.

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Nursing Considerations

• 2 babies with RSV

• https://www.youtube.com/watch?v=lIE_UElOk3c
• Note respiratory rate, retractions, oxygen therapy with rebreather
mask, Epi treatment & response to treatment
• Baby with RSV receiving nasal suctioning with olive-tip suction
catheter.
• https://www.youtube.com/watch?v=d-eqanD_WG8

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Pneumonia

• Causative organism varies greatly by age category

• The most useful classification is etiologic agent
• Viral, most commonly RSV
• Bacterial, most common S.Pneumoniae
• Mycoplasmal: these bacteria don’t have cell walls and therefore
Penicillin ineffective.
• Atypical (not caused by common bacteria) usually M. pneumoniae
• Aspiration of foreign substances

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Clinical Manifestations of Pneumonia

• Vary depending on
• Age, Etiology, Systemic reaction to infection,Extent of the
lesions,Degree of obstruction
• Include: Cough, dry or productive, Tachypnea, BS:Crackles or
diminished, Chest pain, Retractions, nasal flaring, pallor to cyanosis
• Dx. Chest x-ray showing infiltration; may do NP swab or sputum
cultures.
• Treatment:
• Rest, IV fluids, O2 humidified,Suctioning if needed, nebulized albuterol
tx, Monitor resp. distress and dehydration. AB, antipyretics.

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Nebulizer Treatments

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Pertussis (Whooping Cough)

• Caused by Bordetella pertussis

• In the United States, it occurs most often in children who have
not been immunized
• Highest incidence is in spring and summer
• Highly contagious
• Risk to young infants
• Effectiveness of vaccine (booster might be recommended age
10)
• Baby with pertussis cough
• https://www.youtube.com/watch?v=S3oZrMGDMMw

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Foreign Body Aspiration

• More common in children 1 to 3 years of age

• Diagnosis is based on the history and physical signs
• May result in life-threatening airway obstruction
• Nursing assessment must recognize the signs of foreign body
aspiration
• Prevention

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Aspiration Pneumonia

• Risk for a child with feeding difficulties

• Prevention of aspiration
• Feeding techniques and positioning

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Passive Smoking

• Impact on children
• Increased respiratory illnesses, linked to increase in asthma dx and
asthma flare-ups.
• Nursing considerations
• Education of risks to family
• Info on smoking cessation resources
• Discuss ways to reduce smoke exposure to those who refuse to quit.

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Question 1

Which of the following interventions would

be appropriate nursing intervention when
caring for a child with pneumonia?

A. Encourage rest and fluids

B. Instruct the child to avoid lying on the affected side.
C. Administer analgesics
D. Place the child in the Trendelenburg position.

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 The Child with
Respiratory Dysfunction

Part II
Asthma

•Chronic inflammatory disorder of the

airways
•Includes, inflammation, increased
mucus & bronchial constriction.
•Recurring episodic symptoms
•Wheezing
•Breathlessness
•Chest tightness
•Cough (especially at night)

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Asthma and Airway Obstruction

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Asthma Severity Classification in
Children 5 Years and Older
•Step I: Intermittent asthma
•Step II: Mild, persistent asthma
•Step III: Moderate, persistent asthma
•Step IV: Severe, persistent asthma

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Intermittent asthma
• Asthma is considered intermittent if without
treatment any of the following are true:
• Symptoms (difficulty breathing, wheezing, chest tightness,
and coughing):
• Occur on fewer than 2 days a week.
• Do not interfere with normal activities.
• Nighttime symptoms occur on fewer than 2 days a month.
• Lung function tests (spirometry and peak expiratory
flow[PEF]) are normal when the person is not having an
asthma attack. The results of these tests are 80% or more of
the expected value and vary little (PEF varies less than 20%)
from morning to afternoon.

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Mild Persistent Asthma

•Symptoms occur on more than 2 days a week

but do not occur every day.
•Attacks interfere with daily activities.
•Nighttime symptoms occur 3 to 4 times a
month.
•Lung function tests are normal when the person
is not having an asthma attack. The results of
these tests are 80% or more of the expected
value and may vary a small amount (PEF varies
20% to 30%) from morning to afternoon.

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 Moderate Persistent Asthma

•Symptoms occur daily. Inhaled short-acting

asthma medication is used every day.
•Symptoms interfere with daily activities.
•Nighttime symptoms occur more than 1 time
a week, but do not happen every day.
•Lung function tests are abnormal (more than
60% to less than 80% of the expected value),
and PEF varies more than 30% from morning
to afternoon.
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Severe Persistent Asthma

•Symptoms:
•Occur throughout each day.
•Severely limit daily physical activities.
•Nighttime symptoms occur often, sometimes
every night.
•Lung function tests are abnormal (60% or less
of expected value), and PEF varies more than
30% from morning to afternoon.

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Asthma
•Diagnostic evaluation
•Symptoms of wheezing and/or coughing
without infection
•Pulmonary Function Tests

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Peak Flow Meter

•Used to manage asthma

•Use when well for 2 weeks to achieve personal
best reading and baseline
•Use daily, especially when exposed to trigger or
during cold months to monitor approaching
flare
•Nurses teach child and family how to use Peak
Flow Meter and how to use of Asthma
Management
•https://www.youtube.com/watch?v=PtWg6iE
Q_u8

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Identify and avoid triggers
• Allergens
• Dust mites
• Cockroaches
• Mice
• Cat dander
• Dog dander
• Other pets: Rats, Bunnies
• Mold
• Pollutants: smoke, poor air quality
• Chemicals: cleaning supplies, pesticides, perfumes
• Irritants: Cold air
• Infection: respiratory infections
• Home Assessment Checklist

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Drug Therapy for Asthma

•Long-term control medications

•Preventive
•Quick relief medications
•Rescue
Burst medication
• Corticosteroids

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Long-term bronchodilators: Advair or Qvar
Diskus
• Fluticasone and salmeterol inhalation is a steroid and bronchodilator
combination medicine that is used to prevent asthma attacks.

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Teach child/family
•Supervise a young child
•Shake the Advair HFA inhaler for at least 5
seconds before each spray.
•Breathe out
•Put mouthpiece in mouth, keep level, breathe in
quickly and deeply through your mouth
•Remove from mouth and hold breath for 10
secs.
•Rinse your mouth with water without
swallowing after each use of your inhaler.
•Video instructions for children 63
Meter Dose Inhaler: MDI

• Used for Rescue Medication, Albuterol

• Use of spacer
• How to teach a child to use an MDI with spacer

• https://youtu.be/BbONuRXJdr0

• How to teach a child to use an MDI without spacer

• https://www.youtube.com/watch?v=Lx_e5nXfi5w&feature

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Inhaler

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Drug Therapy for Asthma (cont’d)

•Corticosteriods-Burst Medication
• May be given for short periods to gain
control of Flare
• Parenteral: Methylprednisolone,Solu-medrol
• Oral: Prednisolone, Predisone,comes in
oral suspension or tablets

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Asthma Interventions
•Exercise
•Evaluate for EIB (exercise induced
bronchospasms)
•Helpful exercise
•Breathing exercises
•Allergy Testing and Hyposensitization

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Flares

•Manage with Asthma Action plan

that describes yellow & red zones
•Rescue and Burst medications
•Hospitalization when rescue meds
not effective

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Acute Asthma Care in Hospitalized
Child
• Calm nursing presence
• Monitor O2 with pulse oximetry
• Allow older children to sit up if they are more
comfortable in that position
• Allow parents to remain with children
• Monitor and assess respiratory distress
• Report to MD as needed using SBAR

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Acute Asthma Care (cont’d)

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Asthma Interventions (cont’d)

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Asthma Flare Treatments requiring
Hospitalization
•Severe Respiratory Distress
• Monitor O2 Sats
• Continuous Albuteral nebulizer
• Parenteral Corticosteroids
• Oxygen Therapy
• Hydration with IV fluids

•Moderate Respiratory Distress

• Albuteral nebulizer q2-4 hours
• Corticosteroids, oral
• Concurrent infection treated
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Status Asthmaticus

• Respiratory distress continues despite vigorous

therapeutic measures
• Requires PICU admission
• Emergency treatment is epinephrine 0.01 mL/kg
subcutaneously (maximum dose, 0.3 mL)

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Goals of Asthma Management

•Avoid exacerbation, Flares

•Avoid allergens
•Relieve asthmatic episodes promptly
•Relieve bronchospasm
•Monitor function with a peak flow meter
•Self-management of inhalers, devices,
and activity regulation
•Support child, adolescent, and family
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You are caring for a 10yo with asthma and
providing education to their family about
managing their asthma in the green zone.
Which instructions do you include? (all that
apply).

A. Give rescue meds for flare-up

B. Use Peak Flow Meter
C. Rinse mouth with water after using Advair
D. Administer corticosteroid per MD
E. Avoid triggers
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 The Child with
Respiratory Dysfunction
Part III
Cystic Fibrosis (CF)

• Exocrine gland dysfunction that produces multisystem

involvement

• Autosomal recessive trait

• Child inherits a defective gene from both parents, with an overall
incidence of 1:4
• Approximately 3% of the U.S. Caucasian population are symptom-free
carriers

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Exocrine Gland Dysfunction in CF

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Diagnostic Evaluation of CF

Initial:
• Newborn Screening for CF
• Quantitative sweat chloride test

Later:
• Chest x-ray
• Pulmonary function tests (PFTs)
• Stool fat and/or enzyme analysis
• Barium enema

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Treatment Goals for CF

• Prevent or minimize pulmonary complications

• Adequate nutrition for growth
• Assist the child in adapting to a chronic illness

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Respiratory Manifestations of CF

• Present in almost all CF patients, but the onset and extent vary
• Viscous secretions are difficult to expectorate and obstruct
bronchi and bronchioles
• Cause atelectasis and hyperinflation
• Stagnant mucus leads to destruction of lung tissue
• Stagnant mucus provides a favorable environment for bacteria growth

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 Respiratory Management of CF
• CPT
• Vests

• Bronchodilator medication

• Aggressive treatment of pulmonary infections

• Home/Hospital IV antibiotic therapy

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Respiratory Management of CF
(cont’d)

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Gastrointestinal (GI) Tract

• Thick secretions block ducts, leading to cystic dilation,

degeneration, and diffuse fibrosis
• Prevents pancreatic enzymes from reaching the duodenum
• Impaired digestion and absorption of fat, or steatorrhea, occurs
• Impaired digestion and absorption of protein, or azotorrhea,
develops

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GI Tract (cont’d)

• Endocrine function of the pancreas is initially unchanged

• Eventually, pancreatic fibrosis occurs; may result in diabetes
mellitus
• Focal biliary obstruction results in multilobular biliary cirrhosis

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GI Management in CF

• Replacement of pancreatic enzymes

• High-protein, high-calorie diet, as much as 150% of the
recommended daily allowance (RDA)

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Prognosis of CF

• Estimated life expectancy for a child born with CF in

2015 was 40 years old.
• CF continues to be a progressive, incurable disease
• Organ transplantation has increased the survival rate
• Heart–lung and bilateral lung transplantation
• Liver and pancreas transplantation
• Maximize health potential
• Nutrition
• Prevention and early aggressive treatment of infection
• Pulmonary hygiene

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Family Support for the Child
with CF
• Coping with the emotional needs of the child and family
• Child requires treatments multiple times each day
• Frequent hospitalizations
• Implications of genetic transmission of disease

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Living with CF

• Family with young child with Cystic Fibrosis

• Dear Teacher: School age child explaining CF to teacher

• https://www.youtube.com/watch?v=QT583xpU8

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Palliative Care for Children

• Anna’s Story

• End of Life Care at George Mark’s Home in San Leandro, CA

• Palliative Care: The best possible quality of life possible for children
and their families living with or dying from a chronic, complex or life-
threatening condition.
• End of life care is a part of palliative care

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