Chapter 48

The Child with Alterations

in Respiratory Function
 Growth and the Respiratory
System
• Child’s respiratory tract grows until about
age 12
 Upper Airway

• Short and narrow when compared to adult

airway
• Child’s little finger estimates his or her
airway diameter
Trachea Position
 Airway Diameter

• Inverse relationship between airway

diameter and airway resistance
 Upper Airway: Newborns

• Until 4 weeks of age, obligatory nose

breathers
• Nasal patency is critical
 Lower Airway

• Alveoli change size and shape, increase in

number
– Continues until puberty
– Increases area available for gas exchange
• Smooth muscles of bronchi and
bronchioles
– Develop during first year of life
– Until developed, less able to trap invaders
 Lower Airway

• Intercostal muscles immature – diaphragm

primary muscle used to breathe
• Ribs are primarily cartilage and are very
flexible – retractions seen, especially
during respiratory distress
 Croup
• Broad term for upper airway illnesses –
• Affect large numbers of children: 3 months to 3 years
of age
• Cause is usually viral
Clinical Manifestations of Croup

• Abrupt onset, usually at night

• Resolves by morning
• Afebrile
• Barking seal cough, noisy inspiration
• Hoarse voice
• Mild respiratory distress
Laryngotracheobronchitis (LTB)
• Type of croup illness
• Usually viral cause
• Peak ages: 3 months to 8 years
• Signs: Tachypnea, stridor, seal-like barking cough
Laryngotracheobronchitis (LTB)
 Epiglottitis

• Inflammation of the epiglottis

• Potentially life-threatening
• Usually caused by H. influenzae type B
(Hib) – Hib vaccination now required for
children
• Peak age: 2 to 8 years
• Signs and symptoms: Fever, drooling,
difficulty swallowing, tripod position
 Signs and Symptoms
• Onset is abrupt without cough.
• Can rapidly progress to severe respiratory distress.
• Asymptomatic the night prior to onset.
• No spontaneous cough.
• The child is apprehensive.
• Voice is muffled with a froglike croaking sound on inspiration.
• Sore throat, reddened and inflamed.
• Drooling.
 Signs and Symptoms
• Agitation.
• Fever.
• Dysphagia.
• Suprasternal & Substernal retractions.
• Respiratory obstruction develops quickly and may lead to
– Hypoxia
– Acidosis
– Reduced level of consciousness
– Sudden death
• The key difference between laryngotracheobronchitis (LTB) and
epiglottitis is the presence of a cough in LTB.
 Test Results

• Positive for Haemophilus influenzae

• Chest films
• WBC with differential count
 Treatment
• Intensive observation by experience personnel.
• Endotracheal intubation.
• Tracheostomy.
• All invasive procedures should be performed in the
operating room or areas equipped to initiate immediate
intubation.
• Antibiotic therapy.
 Nursing Interventions

• Reassure the child and family to reduce anxiety.

• Avoid assessment of the oral cavity with a tongue blade.
• Allow the child to remain in the caregiver’s lap and in the
position that is most comfortable.
• Do not examine the child’s throat or distress the
child as this may precipitate acute airways
obstruction.
 Bronchitis
• Inflammation of the trachea and bronchi
– Usually a viral cause
• Symptoms: dry, hacking cough that is worse at night,
painful chest and ribs
 Bronchiolitis

• RSV and other viruses are main cause

• Pathophysiology
• Symptoms: Nasal symptoms, cough, fever,
wheezing, tachypnea, retractions,
decreased activity level, decreased oral
intake, dehydration
 Pneumonia

• Inflammation or infection of bronchioles

and alveoli
• Viral, mycoplasmal, bacterial sources
 Pneumonia
• Respiratory viruses are the most common cause of pneumonia
in younger children and the least common cause in older
children.
• Viral pneumonia is usually better tolerated in children of all
ages.
• Children with bacterial pneumonia are more apt to present
with a toxic appearance, but they generally recover rapidly if
appropriate antibiotic treatment is instituted early.
 Pneumonia
• Streptococcus pneumoniae is a common cause of bacterial
pneumonia in all ages of children.
• Fungal infection may also result in pneumonia.
• Aspiration pneumonia may result from aspiration of foreign
material into the lower respiratory tract.
 Pneumonia
• Streptococcus pneumoniae is a common cause of bacterial
pneumonia in all ages of children.
• Fungal infection may also result in pneumonia.
• Aspiration pneumonia may result from aspiration of foreign
material into the lower respiratory tract.
Pneumonia Manifestations and
Diagnosis
• Manifestations
– Fever, malaise, cough
– Wheezing, diminished or absent breath
sounds
– Tachypnea and dyspnea
• Diagnosis
– Sputum cultures, chest x-ray
 Treatment

• The course of treatment is managed according to the etiology

of the disease.
• Treatment for viral pneumonia is supportive to relieve
symptoms.
• Bacterial pneumonia is treated with antibiotic therapy.
• The objective of treatment is effective ventilation and
prevention of dehydration.
• Oxygen therapy and chest physiotherapy may also be required.
• Isolation is used as a precautionary measure when patients
hospitalized until the causative agent is identified.
•
 Nursing Intervention
• Assess and monitor for manifestations that suggest increasing
respiratory distress.
• Provide symptomatic relief through supportive measures.
• Encourage adequate fluid intake to remove secretions.
• Administer pain medication to encourage deep breathing and
respiratory therapy treatments.
• Antibiotic therapy.
 Asthma
• Asthma is a chronic inflammatory airway disorder
characterized by airway hyperresponsiveness, airway edema,
and mucus production.
• Airway obstruction resulting from asthma might be partially
or completely reversed.
• It is the most common chronic illness of childhood
• Children with asthma are more susceptible to serious bacterial
and viral respiratory infections. Acute complications also
include status asthmaticus and respiratory failure.
 Asthma

• Asthma
– Chronic
inflammatory
disorder of
tracheobronchial
tree
– Caused by
allergens,
medication, fumes,
exercise, stress
 Asthma
 Immunologic/allergic reaction results in
histamine release, which produces three main
airway responses
a. Edema of mucous membranes
b. Spasm of the smooth muscle of bronchi
and bronchioles
c. Accumulation of tenacious secretions

 Status asthmaticus occurs when there is little response to

treatment and symptoms persist
 Asthma
Manifestations
• Manifestations
– Fast, labored breathing, productive cough
– Wheezing on expiration, chest tightness
– Nasal flaring, intercostal retractions, head
bobbing
– Anxious, suffocating-feeling
– Status asthmaticus
Laboratory and Diagnostic Tests

• Pulse oximetry: oxygen saturation may be decreased significantly or

normal during a mild exacerbation
• • Chest radiograph: usually reveals hyperinflation
• • Blood gases: might show carbon dioxide retention and hypoxemia
• • Pulmonary function tests (PFTs): can be very useful in determining
the degree of disease but are not useful during an acute attack.
Children as young as 5 or 6 years might be able to comply with
spirometry.
• • Peak expiratory flow rate (PEFR): is decreased during an
exacerbation
• • Allergy testing: skin test can determine allergic triggers for the
asthmatic child
 Treatment
• Prevent and minimize physical and psychologic morbidity.
• Prevent and reduce exposure to airborne allergens and irritants.
• Pharmacologic therapy to prevent and control asthma symptoms:
 Reverse airflow obstruction
 Long-term control medications
 Quick-relief medications
• Corticosteroids( prednisolon)
• Mast cell inhibitors (Cromolyn sodium)
 Treatment
• Metered-dose inhaler (MDI)
• Short acting Βeta 2 agonists( Albuterol)
• Long acting Βeta 2 agonists(Salmeterol (Serevent))
• Anticholinergics (Ipratropium)
• Xanthine-derivatives
1) Theophylline (oral)
2) Aminophylline (IV)
3) Used for status asthmaticus
• Physical therapy
• Exercise
 Nursing Management

• Initial nursing management of the child with an acute exacerbation

of asthma is aimed at restoring a clear airway and effective breathing
pattern as well as promoting adequate oxygenation and ventilation
(gas exchange).
 Nursing Management

• Assess how asthma impacts everyday life.

• Assess child and family’s satisfaction with the effectiveness of the
treatment program.
• Assist the child and family to avoid allergens.
• Teach child and family to modify the environment to relieve
asthmatic episodes, (i.e., avoid excessive heat, cold, and other
extremes of the weather or wind).
 Nursing Management

• Educate parents on reading food labels.

• Avoid foods known to provoke symptoms.
• Avoid aspirin with children who are sensitive and subject to aspirin
induced asthma.
• Monitor for and alert caregivers to signs of status asthmaticus, a life
threatening complication.
Nursing Interventions for Asthma
in Schools
• Develop individualized health plan
• Log of peak flow meter readings
• Administer quick relief medications as
needed and monitor for response
• Assess for signs of exercise-induced
asthma
Nursing Interventions for Asthma
in Schools
• Coordinate education about the disease
process
• Coordinate support groups for children
with asthma
 CYSTIC FIBROSIS
• Cystic fibrosis is a chronic multisystem disorder primarily
affecting the exocrine (mucus-producing) glands (pancreas,
respiratory, gastrointestinal, and reproductive glands).
• It is inherited as an autosomal-recessive defect.
• It is the most common cause of lung disease in children.
• It occurs predominantly in whites as opposed to blacks or
Asians
 ETIOLOGY
• Genetic predisposition (autosomal-recessive)
• Family history
• A deletion occurring on the long arm of chromosome 7 at the
cystic fibrosis transmembrane regulator (CFTR) is the
responsible gene mutation.
 Pathophysiology
• In cystic fibrosis, the CFTR mutation causes alterations in
epithelial ion transport on mucosal surfaces, resulting in
generalized dysfunction of the exocrine glands.
• The epithelial cells fail to conduct chloride, and water
transport abnormalities occur.
• This results in thickened, tenacious secretions in the sweat
glands, gastrointestinal tract, pancreas, respiratory tract, and
other exocrine tissues.
• The increased viscosity of these secretions makes them
difficult to clear. The sweat glands produce a larger amount of
chloride, leading to a salty taste of the skin and alterations in
electrolyte balance and dehydration.
 Clinical manifestations
• The pancreas, intrahepatic bile ducts, intestinal glands,
gallbladder, and submaxillary glands become obstructed by
viscous mucus and eosinophilic material.
• Pancreatic enzyme activity is lost and malabsorption of fats,
proteins, and carbohydrates occurs, resulting in poor growth
and large, malodorous stools.
• Excess mucus is produced by the tracheobronchial glands.
Abnormally thick mucus plugs the small airways, and then
bronchiolitis and further plugging of the airways occur.
• Boys have tenacious seminal fluid and experience blocking of
the vas deferens, often making them infertile
 DIAGNOSIS

• A quantitative sweat chloride test >60 mEq/L.

• Chest radiography
• Stool fat and enzyme analysis
 TREATMENT
• Chest physiotherapy (CPT)
• Postural drainage and percussion
• Exercise, deep breathing, and coughing
• Antimicrobial agents
– Inhaled antibiotics
– Intravenous antibiotics
• Oxygen therapy
• Replacement of pancreatic enzymes
• High-protein, high-caloric diet
• Salt supplementation during hot weather
 Nursing Process Elements
 Check for family history of cystic fibrosis
 Assess for SIGNS AND SYMPTOMS
 Provide pulmonary hygiene to clear air passage:
1. Daily postural drainage with percussion and vibration between
meals and HS
2. Avoid PD right before and right after meals
3. Follow PD with good oral hygiene and rest
4. Aerosol therapy as ordered
5. Maintain mist tent
 Encourage physical exercise
 Breathing exercises
 Nursing Process Elements
 Administer bronchodilators, mucolytic agents, and expectorants as
ordered
 Prevent respiratory infection; treat vigorously if present
 Maintain adequate nutrition
1. Provide high-calorie, high-protein, normal-fat diet
2. Administer water-soluble preparation for fat-soluble vitamins such
as A, D, E, and K
3. Provide salt supplements during hot or febrile periods (soup, and
sports drink, salty pretzels)
4. Administer pancreatic enzymes immediately with each meal and
each snack.
 Nursing Process Elements

5. Increase intake of fluids with electrolytes

6. Provide emotional support for the child and family

 Allow verbalization of concerns and feelings

 Encourage age appropriate independence
 Suggest genetic counseling
 Refer family to cystic fibrosis association