NRSG 364

RESPIRATORY DISORDERS
 Introduction
• Respiratory disorders in paediatrics can be
categorized into:
– Common acute disorders.
– Common chronic disorders.
– Less common conditions.
– Others e.g. foreign body aspiration and smoke
inhalation injury.
 Pharyngitis
• This is an acute respiratory condition where
there is inflammation of the tissues and
structures in the child’s throat.
• It is caused by viruses or bacteria.
• The most common type of bacteria that cause
pharyngitis is group A streptococcus.
 Pharyngitis
• Clinical features:
– Pain during swallowing or hoarseness.
– Cough, runny or stuffy nose, itchy or watery eyes.
– A rash.
– Fever and headache.
– Whitish-yellow patches on the back of the throat.
– Tender, swollen lumps on the sides of the neck.
– Nausea, vomiting, diarrhoea or stomach pain.
 Pharyngitis
• Management:
– Paracetamol is administered to decrease pain.
– NSAIDs are given to help decrease swelling, pain
and fever.
– Antibiotics should be given to treat a bacterial
infection.
– Ensure bed rest for the child as much as possible.
– Give the child plenty of liquids so he/she does not
get dehydrated.
 Pharyngitis
• Management:
– Provide warm salt gargles to soothe the child’s
throat.
– Administer throat lozenges to help decrease
throat pain.
– Use a cool mist humidifier to increased air
moisture making the child breath easily and help
decrease his/her cough.
– Provide health education on management and
prevention of pharyngitis.
 Tonsillitis
• This an acute inflammation of the tonsils.
• It can be caused by viruses, bacteria, fungi or
allergens.
 Tonsillitis
• Clinical features:
– Sore throat.
– Painful swallowing.
– Enlarged, painful neck glands.
– Hoarseness or change in voice.
– Fever or chills.
– Headache.
– Ear pain.
 Tonsillitis
• Clinical features:
– Nausea and vomiting.
– Abdominal pain.
– General malaise.
– Red or swollen throat.
– Red or enlarged tonsils.
– Throat or tonsils may have a whitish discharge.
– Difficult breathing or snoring.
 Tonsillitis
• Management:
• Administer antibiotics.
• Administer analgesics.
• Encourage intake of plenty of fluids(reduces
spasms around the throat).
• Give smooth, cool foods.
• Gargling with salt water.
• Administer throat lozenges.
 Otitis Media
• Otitis media is an inflammation of the middle
ear without reference to etiology or
pathogenesis.
• It is one of the most prevalent diseases of
early childhood.
• The incidence is highest in children ages 6 to
20 months.
 Otitis Media
• Clinical features:
– Pain.
– Irritability.
– Pulling at the ear.
– Rolling the head from side to side.
– Fever of 40oC.
– Enlargement of postauricular and cervical lymph
glands.
 Otitis Media
• Predisposing factors:
– Short eustachian tube which is wide and straight
and lie in a relatively horizontal plane.
– The cartilage lining is undeveloped, making the
tubes more distensible and therefore more likely
to open inappropriately.
– Normally abundant pharyngeal lymphoid tissue
readily obstructs the eustachian tube openings in
the nasopharynx.
 Otitis Media
• Complications:
– Hearing loss.
– Poor speech, language and cognition development.
– Tympanic membrane retraction.
– Perforation of the thinned-out areas.
– Infection of pockets in tympanic membrane
retraction.
– Cholesteatoma.(abnormal growth of skin in the
middle ear)
 Otitis Media
• Management:
– Administer antibiotics.
– Monitor and manage fever.
– Monitor and manage pain.
– Myringotomy may be done.(small tube inserted in
the ear to promote drainage)
– Clean the external ear canal with sterile cotton
swab if there is drainage.
– Give health education on prevention.
 Croup syndrome
• This is a general term applied to a symptom
complex characterized by many respiratory
signs and symptoms.
• Clinical features:
– Hoarseness.
– Barking cough.
– Inspiratory stridor.
– Respiratory distress.
– Acute infections of the larynx.
 Croup syndrome
• Management:
– Provide steam inhalation.
– Administer humidified oxygen.
– Encourage intake of plenty of fluids.
– Administer corticosteroids.
– Administer antibiotics.
– Tracheostomy or intubation may be done.
– Take vital signs.
– Provide small frequent meals.
 Acute epiglottitis
• This is a serious obstructive inflammatory
process that occurs principally in children
between 2 and 5 years of age.
• Clinical features:
– Abrupt onset.
– Less often preceded by cough symptoms.
– More often preceded by sore throat.
– Can rapidly progress to respiratory distress.
 Acute epiglottitis
• Clinical features:
– Child prefer sitting upright and leaning forward.
– Chin thrust out.
– Mouth open.
– Tongue protruding.
– Drooling of saliva.
– Irritability.
– Restlessness.
 Acute epiglottitis
• Clinical features:
– Frightened expression.
– Thick voice with a froglike croaking sound on
inspiration.
– Substernal retraction.
– Cyanosis.
– Red, inflamed throat.
– Cherry red epiglottis.
 Acute epiglottitis
• Management:
– Intubation.
– Tracheostomy.
– Start an IVI.
– Take vital signs 4 hourly.
– Administer humidified oxygen.
– Administer antibiotics.
– Administer corticosteroids.
 Acute laryngitis
• A common illness in older children and
adolescents.
• Caused by viruses.
• Presents with hoarseness, sore throat, nasal
congestion, headache, fever, myalgia and
malaise.
• Managed symptomatically with fluid and
humidified air.
 Bronchitis
• Inflammation of the large airways frequently
associated with a URTI.
• Viruses are the primary causative agents.
• M. pneumoniae is a common cause in children
older than 6 years of age.
• Characterized by a dry, hacking and
nonproductive cough.
• Require symptomatic treatment.
 Pneumonia
• An inflammation of the pulmonary
parenchyma.
• Common in childhood.
• Classified into lobar, interstitial and
bronchpneumonia.
 Pneumonia
• Clinical features:
– Fever.
– Toxic appearance.
– Tachycardia.
– Tachypnea.
– Nasal flaring.
– Chest indrawing.
– Cyanosis.
 Pneumonia
• Clinical features:
– Crepitations.
– Diminished breath sounds.
– Bronchial breathing.
– Slight dullness on percussion.
 Pneumonia
• Complications:
– Abscess formation.
– Pleuritic involvement.
– Atelectasis.
– Cardiac failure.
 Pneumonia
• Management:
– Administer antibiotics.
– Administer humidified oxygen.
– Position in semi-fowlers position.
– Administer cough medication.
– Encourage plenty of fluids.
– Give soft food.
– Administer antipyetics.
– Administer analgesics.
 Pneumonia
• Management:
– Encourage bed rest.
– Cluster care.
– Administer IV fluids.
– Monitor vital signs 4 hourly.
– Suction PRN.
– Provide chest physiotherapy.
– Alley anxiety.
 Allergic rhinitis
• Allergic rhinitis affects as many as 20% to 40%
of the paediatric population.
• It is associated with numerous airway
disorders, including asthma, OME, and chronic
sinusitis.
• Seasonal allergic rhinitis (hey fever) is caused
by trees, grass and weed pollens.
 Allergic rhinitis
• Clinical features:
– Watery rhinorrhea.
– Nasal obstruction.
– Sneezing.
– Nasal pruritus.
– Itching eyes, palate, phanrynx and conjuntiva.
– Nasal stuffiness.
 Allergic rhinitis
• Clinical features:
– Snoring during sleep.
– Fatigue.
– Malaise.
– Poor school performance.
– Associated URI.
– Breaths through the mouth.
– Enlarged nasal turbinates.
– Loss of appetite.
 Allergic rhinitis
• Management:
• Remove allergen from the environment.
• Administer antihistamines.
• Administer nasal corticosteroids.
• Take vital signs.
• Give health education to the family.
 Asthma
• This is a chronic inflammatory disorder of the
airways in which many cells play a role, in
particular, mast cells, eosinophinls and T-
lympocytes.
• The inflammation also causes an associated
increase in bronchial hyper-responsiveness to
a variety of stimuli.
 Asthma
• Asthma is an intermittent airway obstruction
as a result of complicated interactions
between allergy, infection and emotional and
environmental factors.
• This is causes over-reaction of the airways,
bronchospasm and obstruction to the passage
of air through swelling of the smaller bronchi.
 Asthma
• Clinical features:
– Infantile eczema.
– Eosinophilia is often present.
– Reccurent attacks of “bronchitis” with prolonged
expiration.
– Attacks of dyspnoea.
– Marked wheezing.
– Coughing.
– Over-distended and rounded chest.
 Asthma
• Clinical features:
– Diminished breath sounds.
– Child is anxious.
– Restlessness.
– Cyanosis.
– Prefers half-sitting position.
– Heavy perspiration.
– History of URI.
 Asthma
• Management (in between attacks):
– Treat infection.
– Avoid the allergen causing the attack.
– Keep children away from any irritation by cold
environment and smoke.
– Administer sodium cromoglygate 10-20 mg four
times daily or as single dose before a severe
exercise.
– Administer beclomethasone dipropionate.
 Asthma
• Management (of an attack):
– At the first sign of symptoms, ephedrine
3mg/kg/day is given.
– In moderate or severe attacks, adrenaline (0.1%)
0.015ml/kg should be given subcutaneously,
repeated every ½ hour until the attack is over.
– If no response: aminophylline 3-6mg/kg slowly over
20 minutes I.V. is admininstered.
– In all severe attacks, start prednisolone 1mg/kg 12-
hourly.
 Asthma
• Management:
– Assist child and family to recognize factors that
trigger asthma symptoms.
– Assist child and family to recognize early signs of
asthmatic episodes.
– Educate the child and family on the use of inhaled
corticosteroids and bronchodilators.
– Educate child and family on disease process and
management.
 Asthma
• Management:
– Administer oxygen PRN.
– Take vital signs every 4 hours.
– Monitor the oxygen saturation 4 hourly.
– Give the child small frequent meals.
– Encourage intake of plenty of fluids.
– Alley anxiety.
– Reduce stressful situations.
 Cystic fibrosis
• This is a condition characterized by exocrine
glands dysfunction that produces multisystem
involvement.
• It is a genetic illness that is inherited from
both parents who have defective gene.
• It is inherited as an autosomal recessive trait.
 Cystic fibrosis
• Clinical features:
– The clinical manifestations vary widely and change
as the disease progresses.
– The most common symptoms are:
• Pancreatic enzyme deficiency because of duct
blockage.
• Progressive chronic obstructive lung disease associated
with infection.
• Sweat gland dysfunction resulting in increased sodium
and chloride sweat concentration.
 Cystic fibrosis
• Clinical features:
– Wheezing.
– Dry, nonproductive cough.
– Diffuse bronchial and bronchiolar obstruction.
– Dyspnea.
– Mucoid impactions within the small air passages.
– Patchy areas of atelectasis.
– Barrel-shaped chest.
– Bronchiectatic cysts and subpleural blebs.
 Cystic fibrosis
• Clinical manifestations:
– Cyanosis.
– Clubbing of the fingers and toes.
– Repeated episodes of bronchitis and
bronchopneumonia.
– Chronic nasal congestion.
– Rhinitis.
– Chronic sinusitis.
– Nasal polyps.
 Cystic fibrosis
• Management:
– Routine chest physiotherapy.
– Administer bronchodilators.
– Exercises are important.
– Administer antibiotics for infection.
– Administer oxygen PRN.
– Chest tube insertion in cases of pneumothorax.
– Allay anxiety.
– Take vital signs.
 Cystic fibrosis
• Management:
– Implement standard precautions with meticulous
hand washing.
– Ensure a well balanced diet is given.
• High caloric diet.
• Pancreatic enzymes are supplied for each meal.
• Adequate salt is provided.
– Encourage intake of plenty of fluids.
 Bronchopulmonary dysplasia
• This is a pathological process that may
develop in infant with respiratory distress
syndrome.
• Risk factors include:
– Assisted ventilation.
– Oxygen administration.
– Prenatal and postnatal infections.
– Fluid imbalances.
 Bronchopulmonary dysplasia
• Management:
– No specific treatment exist except to maintain
adequate arterial blood gases with the
administration of oxygen and to avoid progression
of the disease.
– Administer corticosteroids.
– Provide adequate rest by clustering care.
– Administer extra calories.
– Give small, frequent feedings.
 Bronchopulmonary dysplasia
• Management:
– Reduce environmental stimuli and subsequent
hypoxia.
– Hydrate the child adequately.
– Alley anxiety.
– Give health education to family.
 Sinusitis
• This is the infection of the sinuses, which are
the air spaces in the bones of the face
connected by passages to the nose.
• These passages become blocked by infection,
thus creating a closed cavity, which is an ideal
surrounding for bacterial growth.
• The condition occurs only in children over 4
years.
 Sinusitis
• Clinical features:
– Blocked nose.
– Purulent nasal discharge.
– Postnasal drip.
– Irritating cough.
– Fever and other general signs of infection.
– Pain.
– Tenderness in cheekbones.
– Headache over one or both eyes.
 Sinusitis
• Management:
– Administer 0.5% ephedrine nose drops for 5 days.
– Administer antibiotics.
– Take vital signs 4 hourly.
– Encourage the child to take plenty of fluids.
– Ensure adequate rest.
– Provide a balanced diet.
 Tuberculosis
• This is a respiratory condition caused by
mycobacterium tuberculi.
• The tubercle bacilli are spread in droplets by
adults, who cough them up in their sputum.
• Predisposing factors:
– Poverty.
– Overcrowding.
– Poor housing.
 Tuberculosis
• Clinical features:
– Fever.
– Malaise.
– Anorexia.
– Weight loss.
– Aching pain and tightness in the chest.
– Haemoptysis.
– Chronic cough.
 Tuberculosis
• Management:
– Ensure adequate nutrition.
– Administer anti-TB drugs.
– Help the family understand the rationale for
diagnostic procedures.
– Promote drug compliance.
– Contact tracing.
– Follow-up.
– Prevention.
 Foreign body aspiration
• Small children characteristically explore objects
with their mouths.
• So they are prone to aspirate foreign bodies
into the air passages.
• Aspiration of FB can occur at any age but is
most common in older infants and children
ages 1 to 3 years.
• Severity is determined by location, type of
object and extent of obstruction.
 Foreign body aspiration
• Clinical features:
– Choking, gagging or coughing.
– Dyspnea.
– Stridor.
– Hoarseness.
– Cyanosis.
 Foreign body aspiration
• Management:
– Apply abdominal thrusts for children over 1 year
of age.
– Apply back blows and chest thrusts for children
less than 1 year of age.
– Prepare the child for endoscopy.
 Smoke inhalation injury
• A number of noxious substances that may be
inhaled are toxic to humans.
• They are primarily products of incomplete
combustion and cause more deaths from fires than
flame injuries do.
• The severity of the injury depends on the nature of
the substances generated by the material being
burned, whether the victim is confined in a closed
space, and the duration of contact with the smoke.
 Smoke inhalation injury
• Possible inhalation injury is suspected when:
– There is a history of flames in a closed space.
– Whether or not burns are present.
– There is sooty material around the nose or in the
sputum.
– Presence of singed nasal hairs.
– Presence of mucosal burns of the nose, lips,
mouth or throat.
– There is a hoarse voice and cough.
 Smoke inhalation injury
• Three distinct stages:
– Pulmonary insufficiency, usually during the initial
12 hours.
– Pulmonary oedema, usually after 6 to 72 hours,
with an increase in the lung fluid and interstitial
oedema.
– Bronchopneumonia usually after 72 hours with a
resulting airway obstruction or atelectasis.
 Smoke inhalation injury
• Management:
– Treatment is symptomatic.
– Place the child on humidified 100% oxygen as
quickly as possible.
– Monitor for signs of respiratory distress and
impending failure.
– Blood gases are drawn to determine baseline
arterial blood gases and carboxyhemoglobin
levels.
 Smoke inhalation injury
• Management:
– Have intubation equipment readily available.
– Provide pulmonary care.
– Take vital signs.
– Chest physiotherapy is done.
– Provide mechanical ventilation PRN.
– Administer IV fluids.
– Monitor fluid intake and output accurately.
– Provide psychological care.
 Prevention of respiratory
infections
• Protection from cold and wet.
• Better housing with less overcrowding.
• Keep the child away from the source of smoke
as possible.
• Better nutrition, to increase resistance.
• Immunization.
• Early and appropriate treatment of respiratory
disease.