RESPIRATORY

SYSTEM
INTRODUCTION
*Respiratory diseases are more common during infancy and
childhood periods mostly in cold season .
*The infants and children are nasal breathers .
*The narrow respiratory trees of infants and children make
them more susceptible to respiratory obstruction and to
respiratory tract infection(RTI) .
*The infants and children are using the abdominal muscles as
assistant for respiration ,while the adults using the chest wall
muscles .
*The respiratory trees divided into:-
1- upper _ nose, paranasal sinuses, pharynx and larynx .
2- lower _ trachea, bronchi, bronchioles and alveoli .
UPPER RESPIRATORY TRACT
* Foreign body of the nose
- usually during childhood.
- symptoms _ local obstruction, sneezing, nasal discharge.
- type _ food, small toys, beads, beans and stones.
- diagnosis
1. unilateral nasal discharge.
2. bad odor.
3. lateral skull x-ray if the F.B. is metallic.
- treatment
to reduce the danger of aspiration and prevent tissue necrosis
by forceps or nasal suction.
- complication _ tetanus or infection.
* Epistaxis (Nasal bleeding)
- common in childhood.
- common causes
1. trauma
2. foreign body
3. dry air
4. inflammation _ sinusitis
5. allergy
6. nasal steroid sprays
- treatment
a. if not stopped spontaneously
b. the nose must be compressed, the child kept as quiet as
possible in an upright position and the head tilted forward
c. anterior nasal pack
d. send the child to otolaryngologist
* Tonsillitis
- Causes
1. viral
2. group A beta hemolytic streptococcus
- Clinical features
A. Acute infection
- dry painful throat
- malaise and weakness
- fever and headache
- painful swallowing
- enlarge cervical lymph nodes
- muscular pain
B. Chronic infection
- bad odor from the mouth
- chronic > 2wks sore throat
- foreign body sensation
- on examination there is debris on tonsils
C. Airway obstruction
1. day time symptoms
- chronic mouth breathing
- nasal obstruction and hyponasal speech
- decrease smell sensation and appetite
- rarely right sided heart failure symptoms
2. night time symptoms
- loud snoring, choking and gasping breathing
- abnormal and restless sleep
- enuresis(night time urination)
- Treatment
1. medical treatment
- antibiotic use for bacterial tonsillitis for 10 days
- antipyretic and analgesic agent
- gargling with warm salt water
- soft warm liquid diet
2. tonsillectomy _ indications
- recurrent infections
- upper airway obstruction
- failure to gaining weight
- speech abnormalities
- right sided heart failure
- enuresis
- Complication of tonsillitis
1. post-streptococcal nephritis or rheumatic fever
2. peritonsillar infection
- abscess
- cellulitis
3. chronic infection
4. chronic airway obstruction
5. complications of tonsillectomy
- bleeding
- swelling of the tongue
- dehydration from painful swallowing
- psychological problems
LOWER RESPIRATORY TRACT
* Indicators of serious respiratory tract disease
1. persistent fever.
2. limitation of activity.
3. failure to grow.
4. failure to gaining weight properly.
5. persistent rapid breathing.
6. chronic productive cough.
7. persistent cyanosis.
8. abnormal X-ray findings.
9. positive family history of inherited lung disease.
* Foreign bodies of airway
1. most victims are older infants and toddlers.
2. children < 3 years old account 73% of cases.
3. 1/3 of aspirated objects are nuts.
4. a positive history must never be ignored, but negative
history may be misleading.
5. choking or coughing attacks accompanied by wheezing
are highly suggestive of an airway F.B.
6. the most serious complication of F.B. aspiration is complete
blockage of airways.
7. common objects to be aspirated are nuts, grapes and
candies.
8. the treatment of choice is removal of F.B. by endoscope.
* Causes of wheeze in children
1. Infection
- viral
- bacterial
- tuberculosis
2. Asthma
3. Anatomical abnormalities of airways
- extrinsic airway anomalies _ mass or tumor
- intrinsic airway anomalies _ lung cyst
4. Inherited
- cystic fibrosis
- immunodeficiency
5. Aspiration syndromes
6. Foreign body
* Bronchiolitis
1. common disease of lower R.T. in infants.
2. commonly affect infants aged 1-3 months old.
3. causative agent is virus _ 50% respiratory syncytial virus (RSV).
4. it is more common in males.
5. common in cold season.
6. increased in bottle fed baby and in over crowded places.
7. clinical features include:-
- low grade fever.
- respiratory distress.
- wheezy cough.
- apnea specially in very young infants.
8. diagnosis:-
- clinical features.
- chest X- ray.
9. differential diagnosis:-
- asthma.
- foreign body aspiration.
- heart failure.
- whooping cough.
10. treatment:-
- hospitalization.
- cool humidified O2.
- sitting with head and chest elevated.
- small oral feedings with caution.
- if the infant is tired use fluid or nasogastric feeding.
- bronchodilators.
- steroid and antibiotics of no benefits.
- ribavirin _ antivirus.
 Nursing Care of bronchiolitis:
Nursing diagnosis for the infant with
bronchiolitis include the following :
1)Ineffective airway clearance, related to thick
mucus.
2)Impaired gas exchange, related to edema and
mucus of the bronchioles.
3)Deficient fluid volume, related to insensible fluid
loss from tachypnea and decreased fluid intake.
4)Anxiety, related to unfamiliar environment,
respiratory distress, and placement in croupette.
5)Knowledge deficit, related to disease process and
treatment.
 The child with bronchiolitis is monitored closely for signs and
symptoms of:
-Increasing respiratory distress .
-Breath sounds.
-Skin color.
-Depth and rate of respiration.
-Vital signs
-Changes in alertness.
-Anxiety can be signs of impending distress.
-Continuous or intermittent pulse oximetry my be use to monitor
the infant’s oxygen level.
-Infant with a respiratory rate of 60 breaths per minute should
have nothing by mouth.
-Intravenous fluid are monitored in the acutely ill child.

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-As the child improves, oral fluids are increased
and frequent small meals are offered.
-The child on intake and output recording.
-Daily weights are taken.
-The fontanel and the child’s skin turgor are also
assessed as indicators of hydration status.
-Breastfed infants should have more frequent
feeding with short time.
-Nasal secretions should be removed with a bulb
syringe before feedings.
* Childhood asthma
- 80% of cases < 6 years old.
- asthma is a chronic reversible inflammation of lung
airways resulting in intermittent or episodic airflow
obstruction (broncchospasm) .
- clinical features:-
1. dry cough.
2. expiratory wheeze.
3. chest tightness.
4. dyspnea.
5. these features increased by physical exertion and
airways irritants( cold, dry air or smoke ).
6. clinical features worse at night.
- causes of asthma:-
1. genetics.
2. environment:
_ viral infection of respiratory tract
_ tobacco smoke
_ air pollutants
_ cold dry air
_ strong odors
- differential diagnosis:-
1. foreign body.
2. recurrent aspiration _ gastro esophageal reflux.
3. congenital anatomic abnormality.
4. cystic fibrosis.
- diagnosis:-
1- clinically.
2- lung function tests ( spirometry ).
3- radiology _ chest X-ray or CT- scan of chest.
- treatment:-
1. regular assessment and monitoring.
2. control of factors that can worsen asthma _
a- environmental factors :
ex. Smoke, animal danders, dusts and strong odors.
b- treat the associated conditions :
ex. Rhinitis, sinusitis or gastro esophageal reflux.
3. asthma drugs and depending on severity :
- bronchodilators.
- anti-inflammatory drugs.
- theophylline.
- oxygen.
* Emergency department(E.D.) management of asthma
A. Close monitoring of general condition.
B. Given oxygen.
C. Inhaled bronchodilators by nebulizer every 20 min. for 1 hr.
D. Systemic anti-inflammatory(steroid) orally or IV.
E. Discharging patient on:
- inhaled bronchodilator every 3-4 hrs.
- oral steroid for 3-7 days.
* Criteria for discharging patient from emergency department
1. improvement in symptoms.
2. normal physical finding.
3. normal lung function tests.
4. O2 saturation > 92% .
5. no need to be kept on O2 .
* Adverse effects of chronic use of systemic steroids
1. growth suppression.
2. weight gain.
3. diabetes mellitus.
4. hirsutism and acne.
5. cataract and glaucoma.
6. increased the risk of infection _ tuberculosis
7. hypertension.
* Pneumonia
- pneumonia is an inflammation of lung tissues.
- it is significant cause of death in children.
- Causes of pneumonia:-
1. viral _ respiratory syncytial virus.
2. bacterial _ pneumococcus and staphylococcus.
3. mycoplasma pneumoniae.
- Risk factors for pneumonia:-
a- age _ children < 5 years old .
b- season _ specially cold season .
c- immunization status .
d- health status and crowdening .
e- presence of lung disease _ asthma .
f- recurrent aspirations _ gastro-esophageal reflux .
g- diseases affect the immune system of the child .
- Clinical features:-
- upper respiratory symptoms as flu .
- fever
- respiratory distress .
- nasal flaring .
- using accessory muscles .
- Diagnosis:-
- clinical features .
- chest X-ray .
- isolation of the micro-organism from blood,pleura or lung .
- Treatment:-
- O2 therapy .
- antibiotics _ amoxicillin or erythromycin .
- parenteral therapy _ fluid or antibiotics .