The Child With

Respiratory
Dysfunction

Chapter 26
 Pediatric vs Adult Airway

• Differences in anatomy
• airway higher in the
neck
• epiglottis sits behind
soft palate
• funnel shaped
• cricoid is the most
narrow component
• relatively larger tongue
• angled vocal cords
• differently shaped
epiglottis
 • Differences in anatomy
• airway higher in the neck
• epiglottis sits behind soft palate
Adult vs Pediatric •
•
funnel shaped
cricoid is the most narrow component
Airway •
•
relatively larger tongue
angled vocal cords
• differently shaped epiglottis
Function of
Airway

• Allows child to feed and

breathe at the same time
• Promotes obligate nasal
breathing
Pediatric
Assessment
• Tachypnea
• Retractions
• Nasal flaring
• Head bobbing
• Grunting
• Wheezing
• Stridor
Types of Stridor

• Upper airway blockage

• inspiratory
• expiratory
• biphasic
• high pitched
• harsh
 • Croup
When Will You • Subglottic stenosis
Hear a Stridor? • Laryngomalacia
 • Almost all of pediatric codes are due to respiratory origin
• 80% of pediatric cardiopulmonary arrest are primarily due to
Why does this respiratory distress
• Majority of cardiopulmonary arrest
matter? occur at <1 year old
Advanced
Airways
• Nasotracheal: facilitates oral hygiene, stable
fixation
• Oro/nasopharyngeal: temporary, emergent
• Orotracheal: ER; short term
• Tracheal: long term, decision made on
individual basis.
• Child can sometimes speak and eat.
• Suctioning:
• Saline or no saline?????
Airway
Options
Measuring
for the ET
tube
• Broselow tape-
Generally Emergency
Dept only
• ET formula: (age[yrs] +
16) / 4
• Pinky rule:
• The diameter of
the child’s pinky is
approx. size of that
child’s trachea
Respiratory failure

Airway obstruction (actual or

potential)

Intubation
Increased work of breathing

Inadequate ventilation or
oxygenation even with
supplemental oxygen
 • Goal: sedation and paralysis in rapid succession to for safe emergency
tracheal intubation.
Rapid Sequence • 1. Preoxygenation: 100% O2 for 3 min to prevent desaturation
• 2. Induction agent: sedative (ketamine, propofal, midazolam,
Intubation fentanyl)
• 3. Muscular relaxation (paralytics): Succinylcholine (bradycardia/pre-
treat with atropine), vecuronium, pancuronium
General Aspects of
Respiratory Tract
Infections
• Respiratory infections are cause of
majority of acute illnesses in children
• Upper respiratory tract
• Oronasopharynx, pharynx, larynx,
and trachea
• Lower respiratory tract
• Bronchi, bronchioles, and alveoli

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 Infants younger than 3 months—maternal
antibodies

3 to 6 months—infection rate increases

Age Toddler and preschool ages—high rate of viral

infections

Older than 5 years—increase in Mycoplasma

pneumonia and β-strep infections

Increased immunity with age

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 • Diameter of airways plays significant role in respiratory illnesses
• Distance between structures is shorter, allowing organisms to
Size rapidly move down
• Short eustachian tubes

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Resistance

• Immune system
• Allergies, asthma
• Cardiac anomalies
• Cystic fibrosis
• Daycare

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 Most common during winter
and spring

Mycoplasmal infections more

Seasonal common in fall and winter
Variation Asthmatic bronchitis more
s frequent in cold weather

RSV season considered

winter and spring
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Croup
Syndromes:
Table 26-4
• Know this ****
• Acute Epiglottitis
• Acute LTB
(laryngotracheobronchitis)
• Acute Spasmodic Laryngitis
• Acute Tracheitis
Croup
Syndromes: Characterized by hoarseness, “barking”
cough, inspiratory stridor, and varying
table 26-4 degrees of respiratory distress

Affect larynx, trachea, and bronchi

Described by anatomic area primarily

affected

Epiglottitis [or supraglottitis], laryngitis,

laryngotracheobronchitis [LTB], and
tracheitis

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Larynx—Normal and Showing Edema
of Croup

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Acute Laryngotracheobronchitis
(LTB):

• Most common type of croup

• Bacterial or viral
• Starts with URI, low grade fever
• Awakes with barky brassy cough, inspiratory
stridor
• Worse at night
• May produce resp distress/failure from airway
obstruction (Hypoxia, hypercapnia, resp acidosis)
• TX: cool mist, epi nebulizer, steroids,heliox

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Signs of Increasing
Respiratory Distress
in Children

• RESTLESSNESS
• Tachycardia
• Tachypnea
• Retractions
• Substernal
• Suprasternal
• Intracostal
• **KNOW SIGNS OF
IMPENDING AIRWAY
OBSTRUCTION!

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Acute Spasmodic
Laryngitis

• Also called spasmodic croup,

midnight croup
• Paroxysmal attacks of laryngeal
obstruction
• Occurs chiefly at night
• Inflammation—mild or absent
• Most often affects children ages
1 through 3
• Therapeutic management

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Acute Epiglottitis
• Serious obstructive, inflammatory process-
medical emergency!
• Clinical manifestations
• Abrupt onset
• Sore throat, pain, tripod positioning,
retractions
• Drooling, dysphagia, distress
• Fever
• Therapeutic management
• Antipyretics, fluids and abx
• Prevention: Hib vaccine

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Nursing Considerations
—Epiglottitis

• Position for comfort

• Decrease anxiety
• No tongue blade
• Keep suction at bedside
• Keep emergency respiratory
equipment at bedside

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 • Infection of the mucosa of the upper trachea
• Distinct entity, features of croup and epiglottitis in older children (5-7 yrs)

Bacterial • Clinical manifestations

• Thick, purulent secretions
• Respiratory distress

Tracheitis • Stridor
• May develop life-threatening obstruction or respiratory failure (ARDS,
MODS)

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Infections ** know this

of the lower • BRONCHITIS

• BRONCHIOLITIS
airways: • ASTHMA (See long-term)

table 26-5
Infections of
the Lower
Airways
• Considered the “reactive”
portion of the lower
respiratory tract
• Includes bronchi and
bronchioles
• Cartilaginous support not
fully developed until
adolescence
• Constriction of airways

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 • Also called tracheobronchitis
• Inflammation of the large airways: trachea and bronchi- that lead to the windpipe

Bronchitis •
•
•
Causative agents: Viral, M Pneumoniae (over 6 y)
Mild, self- limiting5-10 days
Tx: analgesics, antipyretics, humidity
• Worse at night

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 • Acute viral infection—RSV or other viruses in infants
• Occurs primarily at the bronchiolar level
• Results in lack of cilia cell function, bronchioles fill with mucus, obstruction from

Bronchiolitis inflammatory exudate, obstructive emphysema, air trapping

• May occur in older children with chronic illnesses
• Transmission: exposure to contaminated secretions

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Respiratory
Syncytial
Virus (RSV)
• S/S: mimics asthma
• Copious secretions
• Tachypnea
• Retractions
• Poor feeding
• Apnea (Box 28-6)
• Diagnostics – RSV antigen detection
• TX: Ribraviran
• Prevention: Monoclonal antibody for high
risk infants
• Droplet/contact precautions
• Severe – PICU for vent support, inotropes

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Acute Lung Injury
(ALI)/Acute
Respiratory
Distress Syndrome
(ARDS)
• Continuum of symptoms of
ALI, with ARDS the most
severe form
• Characterized as respiratory
distress and hypoxia within
72 hours after serious injury
or surgery in person with
previously normal lungs
• Pathophys and
management – same as
adult

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 • Kawasaki “Like” disorder, new distinct disorder associated with COVID-19 infection
Pediatric • Affects children under 6-15 years (1 in 1000 infected), 2-4 weeks after infection
Multisystem • Blood vessels become inflamed & swollen
Inflammatory • S/s: fever, rash, red eyes, redness on palms and soles, and swollen glands, abd pain, N/V diarrhea
syndrome in • Inflammation in intestine, heart and other organs’ --- > cardiac dysfunction, coronary artery aneurysms
Children (MIS-C) • ICU : IV Immunoglobulins, glucocorticoids, anti-tumor necrosis factor and interleukin 1, ECMO
 LONG-TERM
RESPIRATORY
DYSFUNCTION

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 • Chronic inflammatory disorder of airways
• Bronchial hyperresponsiveness
• Episodic
• Limited airflow or obstruction that reverses
Asthma spontaneously or with treatment
• Etiology and pathophysiology

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Pathology of Asthma
 Stage I mild, intermittent asthma

Asthma
Severity
Classification Stage II mild, persistent asthma

Children 5 Stage III moderate, persistent asthma

Years and
Older
Stage IV severe, persistent asthma

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 This Photo by Unknown Author is licensed under CC BY-ND

• Long-term control meds

• Inhaled corticosteroids, cromolyn
sodium and nedocromil, long-acting
Drug 2-agonists, methylxanthines, and
leukotriene modifiers
Therapy for • Quick-relief (“rescue”) medications
Asthma • Short-acting 2-agonists,
anticholinergics, and systemic
corticosteroids are used as quick-relief
(or rescue) medications

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Drug Therapy
for Asthma
(Cont.)
• Long-term bronchodilators
• Combination inhaled medications
• Theophylline—monitor serum levels
• Oral steroids
• Leukotriene modifiers
• Anticholinergics
• Epi-pen
• Magnesium sulfate
• Others

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Signs of SEVERE
Respiratory Distress in
Children with Asthma

• Remains sitting upright,

refuses to lie down
• Sudden agitation
• Agitated child who suddenly
becomes quiet
• Diaphoresis
• Pale

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Status Asthmaticus

• Respiratory distress continues despite

vigorous therapeutic measures
• Concurrent infection in some cases
• Therapeutic intervention
• Emergency treatment—epinephrine
0.01 ml/kg subQ (maximum dose 0.3
ml)
• IV magnesium sulfate
• IV ketamine
• IV corticosteroids
• Heliox

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reserved.
43
Asthma
Action
Plan

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Bronchopulmonary
Dysplasia (BPD)

• Usually occurs in
premature infants
• 30 wks or less or very
low birth weight
Multiple factors are
thought to be associative

• Oxygen
• Positive pressure ventilation
• Pulmonary hypertension,
interstitial fibrosis, smooth
muscle hypertrophy
• Recurrent pneumonia, sepsis,
meconium aspiration
• Diaphragmatic hernia and
lung hypoplasia
BPD
• Mild
• Breathing room air at 36
weeks or at discharge
• Moderate
• Needs less then 30%
supplemental Oxygen at 36
weeks or discharge
• Severe
• Needs greater then 30%
supplemental Oxygen and or
positive pressure ventilation
or nasal CPAP at 36 weeks or
at discharge

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BPD S&S
• Continuous increased respiratory effort
• Tachypnea, nasal flaring, grunting,
retractions
• Irritability
• Wheezing, crackles, pulmonary edema
• As the baby increases their work
(feeding) they have increased oxygen
demands, poor feeding, fatigue
• -> Leads to FTT
Treatment

• Treat the symptoms

• Support their respiratory needs and nutritional
needs
• Tracheostomy may be needed for long-term
airway management
• May need NG or G-tubes to assist in feeding
• Chest Physiotherapy, medications (diuretics,
bronchodilators, anti-inflammatories,
methylxanthines)
• Long term: developmental & learning issues
More •Resp distress in NB with subcostal retractions
•https://www.youtube.com/watch?v=NBA9iigiD

Resources
gk&list=PL7EA9354BC2DD8B67&index=1
•Stridor in child in upright postion – age 7
•https://www.youtube.com/watch?v=Zkau4yHsL
LM&list=PL7EA9354BC2DD8B67&index=2
•Distressed breathing – retractions in child
•https://www.youtube.com/watch?v=Hv68EQ3t
CBI&index=3&list=PL7EA9354BC2DD8B67
•Stridor in infant
•https://www.youtube.com/watch?v=sgJNTnhf8
v0&index=6&list=PL7EA9354BC2DD8B67
•Head bobbing
•https://www.youtube.com/watch?v=q0bHwMa
yCJY&list=PL7EA9354BC2DD8B67&index=5
•Bronchiolotis
•https://www.youtube.com/watch?v=RFwr_zbgJ
II&list=PL7EA9354BC2DD8B67&index=7
•