Child with Respiratory

Dysfunction

Dr. Nuhad Mohammed Q. Aldoori

Pediatric Nursing Department
 Objectives
Upon completion of the chapter, you will be able to:
 1. Distinguish differences between the anatomy and physiology of the

 respiratory system in children versus adults.

 2. Identify various factors associated with respiratory illness in infants and

 children.

 3. Discuss common laboratory and other diagnostic tests useful in the

diagnosis of respiratory conditions.
 4. Describe nursing care related to common medications and other
treatments used for management and palliation of respiratory conditions.
 Cont.
 5. Recognize risk factors associated with various respiratory disorders.
 6. Distinguish different respiratory disorders based on their signs and
symptoms.
 7. Discuss nursing interventions commonly used for respiratory
illnesses.
 Anatomy of the Lower Respiratory Tract

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Children are not just small adults….

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 VARIATIONS IN PEDIATRIC ANATOMY AND
PHYSIOLOGY
 Nose
 Newborns are obligatory nose breathers until at least 4 weeks of age. The young
infant cannot automatically open his or her mouth to breathe if the nose is
obstructed. The nares must be patent for breathing to be successful while
feeding. Newborns breathe through their mouths only while crying
 The tongue of the infant relative to the oropharynx is larger than in adults.
Posterior displacement of the tongue can quickly lead to severe airway
obstruction. Through early school age.

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 Cont.
 Trachea
 The airway lumen is smaller in infants and children than in adults. The infant's
trachea is approximately 4 mm wide compared with the adult width of 20 mm.
When edema, mucus, or bronchospasm is present, the capacity for air passage is
greatly diminished. A small reduction in the diameter of a child's airway Increased
work of breathing (effort or labor associated with respiration)

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 Metabolic Rate and Oxygen Need
 Children have a significantly higher metabolic rate than adults. Their resting
respiratory rates are faster and their demand for oxygen is higher.
 Adult oxygen consumption is 3 to 4 liters per minute, while infants consume 6 to 8
liters per minute.
 In any situation of respiratory distress, infants and children will develop hypoxemia
more rapidly than adults

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 Lower Respiratory Structures
 The bifurcation of the trachea occurs at the level of the third thoracic
vertebra in children, compared to the level of the sixth thoracic vertebra in
adults.
 This anatomic difference is important when suctioning children and when
endotracheal intubation is required This difference in placement also
contributes to risk for foreign material aspiration.
 The bronchi and bronchioles of infants and children are narrower in diameter
than the adult's, placing them at increased risk for lower airway obstruction.
Lower airway obstruction during exhalation often results from bronchiolitis
or asthma or is caused by foreign body aspiration into the lower airway.

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Differences between Children and Adults

Bifurcation of trachea Change in chest wall shape

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 Upper respiratory tract infections (URI or URTI)

are illnesses caused by an acute infection which involves the

upper respiratory tract including
the nose, sinuses, pharynx or larynx.

This commonly includes :

tonsillitis, pharyngitis, laryngitis, sinusitis,
and otitis media
 TONSILLITIS AND DENOIDITIS
 Lymphoid tissue normally enlarges progressively in childhood between the
ages of 2 and 10 years and shrinks during preadolescence.

 If the tissue itself becomes a site of acute or chronic infection,

 it may become hypertrophied and can interfere with breathing,

 may cause partial deafness, or may become a source of infection in itself.

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 Tonsillitis
 The tonsils are masses of lymphoid tissue located in the pharyngeal
cavity. They filter and protect the respiratory and alimentary tracts
from invasion by pathogenic organisms and play a role in antibody
formation.

 Causes: May be viral or bacterial usually associated with

pharyngitis. 20% of acute tonsillitis and pharyngitis are caused by
group A b-hemolytic streptococci (GABHS).
Tonsilitis
 Clinical Manifestations and Diagnosis

• The child with tonsillitis may have a fever of (38.4_C) or more

• Sore throat, often with dysphagia (difficulty swallowing)
• Hypertrophied tonsils
• Erythema of the soft palate.
• Exudates may be visible on the tonsils.
• The symptoms vary somewhat with the causative organism.
• Throat cultures are performed to diagnose tonsillitis and the causative
organism.
• Frequently the cause of tonsillitis is viral, although ßetahemolytic
streptococcal infection also may be the cause.

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 Treatment and Nursing Care

Medical treatment of tonsillitis consists of:

1. analgesics for pain
2. antipyretics for fever,
3. antibiotic in the case of streptococcal infection. A
standard 10-day course of antibiotics is recommended.
4. tress the importance of completing the full prescription of
antibiotic to ensure that the streptococcal infection is
eliminated.

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5. A soft or liquid diet is easier to swallow,
6. The child should be encouraged to maintain good fluid
intake.
7. A cool-mist vaporizer may be used to ease respirations.
8. Tonsillectomies generally are not performed unless other
measures are ineffective or the tonsils are so
hypertrophied that breathing and eating are difficult.
9. Tonsillectomies are not performed while the tonsils are
infected.

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 Adenoidectomy and Tonsillectomy
Treatment and Nursing Care

• The adenoids are more susceptible to chronic infection.

• An indication for adenoidectomy is hypertrophy of the tissue to the

extent of impairing hearing or interfering with breathing.

• Performing only an adenoidectomy if the tonsil tissue appears to be

healthy is an increasingly common practice.

• Tonsillectomy is postponed until after the age of 4 or 5 years, except in

the rare instance when it appears urgently needed.

• Often when a child has reached the acceptable age, the apparent need
for the tonsillectomy has disappeared.
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PREOPERATIVE ASSESSMENT

• preoperative preparation, include:

• complete blood count,
• bleeding and clotting time,
• urinalysis,
• Psychological preparation is often accomplished through preadmission
orientation play-nurse material helps the child develop security.
The amount and the timing of preparation
• before admission depend on the child’s age.
• The child may become frightened about losing a body part.
• Telling the child that the troublesome tonsils are going to be “fixed”
is a much better choice than saying that they are going to be
“taken out.”

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• Ask about any bleeding tendencies because postoperative bleeding
is a concern.
• Carefully explain all procedures to the child and
be sensitive to the child’s apprehension.
• Take and record vital signs to establish a baseline for postoperative
monitoring. The temperature is an important part of the data
collection to determine
• Observe the child for loose teeth that could cause a problem during
administration of anesthesia
• Document findings

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 Nursing Process for the Child
Having a Tonsillectomy
NURSING DIAGNOSES
1. Risk for Aspiration postoperatively related to impaired
swallowing and bleeding at the operative site
2. Acute Pain related to surgical procedure
3. Deficient Fluid Volume related to inadequate oral intake
secondary to painful swallowing
4. Deficient Knowledge related to caregivers understanding of
post discharge home care and signs and symptoms of
complications

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OUTCOME IDENTIFICATION
AND PLANNING
The major postoperative goals for the child include:
1. Preventing aspiration.
2. Relieving pain, especially while swallowing
3. Improving fluid intake.
4. The major goal for the family is to increase knowledge
and understanding of post discharge care and possible
complications.

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IMPLEMENTATION
• Preventing Aspiration Postoperatively
• Immediately after a tonsillectomy, place the child in a partially prone
position with head turned to one side until the child is completely
awake.
• Encourage the child to expectorate all secretions
• Discourage the child from coughing.
• Check vital signs every 10 to 15 minutes until the child is fully
awake, and then check every 30 minutes to 1 hour.
• Hemorrhage is the most common complication of a tonsillectomy.
Bleeding is most often a concern within the first 24 hours after
surgery and the 5th to 7th postoperative day.

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Indications of bleeding during the 24 hours after surgery:
• observe, document, and report any unusual restlessness
• anxiety, frequent swallowing, or rapid pulse that may indicate
bleeding.
• Vomiting dark, old blood may be expected, but bright, red flecked
emesis or oozing indicates fresh bleeding.
• Observe the pharynx with a flashlight each time
• vital signs are checked.
Bleeding can occur when the clots dissolve between the 5th and 7th
postoperative days if new tissue is not yet present. or due to
infection

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Providing Comfort and Relieving Pain

• Administer pain medication as ordered.

• Liquid acetaminophen with codeine is often prescribed.
• Rectal or intravenous analgesics may be used
Encouraging Fluid Intake
• When the child is fully awake from surgery, give small amounts of
clear fluids or ice chips.
• Synthetic juices, carbonated beverages that are “flat,” and frozen
juice popsicles are good choices.
• Avoid irritating liquids such as orange juice and lemonade.
• Milk and ice cream products tend to cling to the surgical site and
make swallowing more difficult

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 Providing Family Teaching

• The child typically is discharged on the day of or the day after

surgery if no complications are present.
• Instruct the caregiver to keep the child relatively quiet for a few days
after discharge.
• Recommend giving soft foods and nonirritating liquids for the first
few days.
• Teach family members that if at any time after the surgery they note
any signs of hemorrhage (bright red bleeding, frequent swallowing,
restlessness), they should notify the care provider.
• Provide written instructions and telephone numbers before
discharge.

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Ihsan Lash 28
Bronchiolitis

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 BRONCHIOLITIS:
Acute bronchiolitis is a common viral disease of
the lower respiratory tract of infants, resulting
from inflammatory obstruction at the bronchiolar
level.
Age group is: infants < 6 months up to 2 years.
Greater incidence in males.
Common in ‘Winter and spring

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 Causative agent:
• Respiratory syncytial virus RSV, common in infancy
and early childhood it affects epithelial cells of
respiratory tract they swell and lose their cilia, the
cells group together forming large multinuclear cells.
• Para influenza virus
• Influenza virus
• Adenovirus
• Mycoplasma pneumoniea

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Clinical manifestations:
• Occur several days after nasopharyngeal infection (5-8
days incubation period)
• Respiratory distress, characterized by:
1.Paroxysmal wheezy cough
2.Dyspnea and decreased breath sound
3.Irritability gradually becoming evident

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Cont. Clinical manifestations

• Increased respiratory rate (40-80)

causes difficulty to suck & breath at
the same time
• Fever some times
• Cyanosis
• Dehydration
• Shallow intercostals & subcostal
retraction

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Diagnosis:
• Chest X-ray shows over inflation of
the lungs with some consolidation
areas may be seen
• Pa02 decreases.
• Rapid immuno fluorescent antibodies
(IFS) or Enzyme-Linked Immun-
osrbent Assay (ELlSA) to detect the
virus

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Treatment and Nursing management:
• Antibiotics given until confirmation established
• Ribavirin antiviral agent for RSV with special precautions given as
aerosolized by hood, tent or mask 12-20 hrs for 1-7 days
• Respiratory syncytial virus Immune globulin used prophylactically
to prevent RSV infection in high risk infants
• I. V immunoglobin G provide neutralizing antibodies against sub
type A&B strains of RSV, given in epidemic season & monthly for
high risk infant's protection

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• High humidity & 02 relieves arterial hypoxia
• Monitoring ABGs & correction of acidosis
• Possible ventilator assistance.
• Maintain Acid -Base & fluid electrolyte and
nutrition balance
• N. G tube feeding or I. V for several days

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Cont. Treatment and Nursing management

• Keep nasal airway patent

• Position baby in infant seat inside
croupette and provide respiratory
assistance
• Continuous vital signs monitoring, and
observe for respiratory acidosis,
dehydration & cardiac failure
• Recemic Epinephrine via intermittent
positive pressure breathing (IPPB) may
relieve brochospasm
• Minimal handling to allow undisturbed
sleep & rest

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Complications:
• Exhaustion & anoxia
• Secondary bacterial infection
• Pneumothorax
• Apnoeic spells
• Circulatory collapse
• Increased predisposition to Asthma

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 Pneumonia

Definition:
 Inflammation of the lung tissue. Inflammation of the alveoli results in
atelectasis. Atelectasis is defined as a collapsed or airless portion of the
lung, so gas exchange becomes impaired. The inflammatory response
further impairs gas exchange.
Morphologically pneumonias are
recognized as:
1. Lobar pneumonia: all or a large segment of one or
more lobes is involved. When both lungs are affected
this known as bilateral pneumonia.
2. Bronchopneumonia: Begins in the terminal
bronchioles progressing to consolidated patches in near
by lobules also called lobular pneumonia
3. Interstitial pneumonia: Inflammatory process is
confined within the alveolar walls and the peribronchial
and interlobular tissues.

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Lobar pneumonia

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Bronchopneumonia

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Interstitial pneumonia

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Causative agent: viruses
• Bacteria
• Mycoplasma as in Primary Atypical Pneumonia
• and aspiration of foreign substances.
Clinical manifestations:
varies with the:
1. causative agent,
2. age of the child,
3. child's systemic reaction to the infection,
4. the extent of the lesions,
5. the degree of bronchial and bronchiolar obstruction

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 Viral pneumonia:
Causative agent:
• ++ RSV in infants,
• Influenza in older children,
• Para influenza,
• and Influenza adenovirus
Affects all ages
Associated with URTI then it progresses to Interstitial pneumonitis
Clinical manifestations:
• acute or insidious
• mild fever –
• slight cough and malaise
• then" high fever, sever cough & prostration with or without productive cough of
whitish sputum
• Treatment and prognosis:
Good prognosis but may become complicated by bacterial infection
Recovery within 7-10 days with symptomatic treatment,
one week rest for Convalescence is needed.

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 Primary Atypical Pneumonia
Causative agent:
Mycoplasma
Age incidence 5-12 years
Season: Autumn & winter More common in crowded
living conditions
Clinical manifestations:
Sudden or insidious
Systemic symptoms:
Fever & chills
Headache
Anorexia
Muscle pain
Rhinitis, sore throat
Dry hacking cough may be followed by cough of
seromucoid then mucopurilant or blood streaked
Treatment:
Erythromycin 2-3 weeks may be effective
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Bacterial pneumonia:
Causative agent :
1. Pneumococcus,
2. Group A streptococcus,
3. Staphylococcus
4. Enteric bacilli are most likely agents in infants
under 3 months of age ++
5. Chlamydia infection
6. Pneumococcal infection & influenza type B,
and staphylococcus aureus are common in 3
months to 5 years old children
7. Pneumococcus is 90% of all bacterial
infections in children above 5 years
8. Mycoplasma pneumonia affects children above
5 years of age
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 Clinical manifestations:
Acute cases:
• ++ fever with toxic appearance
• In older children: headache, abdominal pain or chest pain
some times with respiratory distress
• Meningism
• Cough initially dry & hacking
• In smaller children: Irritability poor feeding
• Sudden fever & seizures
• Respiratory distress with air hunger
• Tachypnea and circmuoral cyanosis
• Breathing sound tubular if there is consolidation, as infection
resolves coarse crackles & wheezing increase, cough becomes
productive & purulent sputum

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Diagnosis:
• High WBC but it is normal in infants with
staphylococcus infection
• Positive blood culture
• Positive antistreptolysin 0 titer (ASO)
Treatment:
• Penicillin G intramuscular injection for
Pneumococcus & streptococcal Pneumonia
• For staphylococcal type, semi synthetic penicillin
is given
• ++ fluids
• Antipyretics
• 02 if there is respiratory distress
• Hospitalization for young children & for
staphylococcal pneumonia & for complicated
condition with empayema or pleural effusion
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 Prognosis:
Good prognosis but with staph pneumonia it is
prolonged.
Complications:
• Staph pneumonia empayema, and tension
pneumothorax which may occur but pleural
effusion is common with lobar pneumonia
• Acute otitis media and pleural effusion are
common with pneumococcal pneumonia

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Pleural effusion

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 Nursing care of pneumonia:
• It is mainly supportive and symptomatic to meat
the needs of each child
• Rest and conservation of energy, encourage relief
of physical and psychological stress
• Disturb as little as possible Increase sleep and
rest.

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 Cont. Nursing care of pneumonia:

• Fluids IV during acute phase then oral fluids given

cautiously to avoid aspiration & decrease fatiguing
cough.
• 02 via tent, head box, or nasal catheter depending on the
child's tolerance & age.
Position: semi sitting or as the child prefers.
• For fever: cool environment & antipyretic drugs.
• Temperature & vital signs monitored regularly until
maintained at a normal level.

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 Cont. Nursing care of pneumonia:

• Chest sounds assessed to determine prognosis

• If there are ++ secretions & the child is unable to
get rid of them, then high humidity & postural
drainage & suctioning are needed.
• Psychological support to the parents and the child

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ASTHMA:
 ASTHMA
• Is a recurrent and reversible condition of the lung
where there is airway obstruction due to spasm of
the bronchial smooth muscle, edema of the mucosa,
and increased mucus secretions in the bronchi and
bronchioles that has been caused by various stimuli.
• It can occur at any age since birth
• More common in males up to adolescence then it is
reversed and females become more affected
• It is the most common cause of school absences and
form a major portion of admission to emergency
room and hospitals
 Etiology:
1. Hypersensitivity to foreign substances, plant pollens
2. Non allergic precipitating factor:
i. Bronchial compression from external pressure
ii. Foreign body in the air way
iii. Diffuse endobronchial inflammation
iv. Post exercise bronchial constriction
3. Family history of allergy suggest genetic basis
 Pathophysiology:
Mechanism that produce symptoms:
1. Inflammation and edema of the mucus membrane
2. Accumulation of tenacious secretions from mucus
glands
3. Spasm of the smooth muscle of the bronchi and
bronchioles which decrease the diameter of the
bronchioles
4. The sequence of these mechanisms is not the
same in all patients
5. These obstructive processes interfere with
ventilation and result in characteristic symptoms
of: coughing, shortness of 'breath and wheezing
6. Inspiration: normally the bronchi dilate and
elongate during inspiration
7. Expiration: bronchi contract and shorten.
4. Following an inflammatory process caused mostly
by allergens the obstruction will increase causing
forced expiration through the narrowed lumen
9. The air trapped in the lung increase (theobstruction
is between the alveoli and the lobar bronchi)
10.The obstruction forces the patient to breath at a
higher and higher lung volume
10.The patient fight to inspire leading to fatigue
11. Decrease respiratory effectiveness cause
increase 02 consumption
12. Also inspiration occur at higher lung volume that
lead to hyper inflate the alveoli
13. With increased obstruction C02 increase leading
to hypoxia, respiratory acidosis and ending in
respiratory failure
Factors contributing to the pathologic mechanisms
responsible for airway obstruction asthma:
• Internal triggers:
 Exercise
 Infection
 Stress

External triggers:
 Pollens
 Dust & Pollution
 Mold
 Dander
 Incidence:
• Common age 3 and above
• In young children incidence is high in males
• Equal sex incidence in adolescence
• Decrease in puberty
• 3% of school children have symptoms of asthma.
• in urban indwellers than rural.
 Clinical manifestations:
A. Onset may be gradual with nasal congestion,
sneezing and watery nasal discharge before the
attack
B. Attack may occur suddenly mostly at night with:
1. Wheezing primarily with expiration
2. Anxiety and apprehension
3. diaphoresis
1. Uncontrollable cough, dry at first then productive
(frothy, clear, gelatinous sputum)
2. Dyspnea with increased effort during expiration
3. Shortness of breath
4. Prolonged expiratory phase
5. Audible wheeze
6. Pale appearance - but may be flushed cheeks and
red ears, and lips deep red color
10.May progress to cyanosis of nail beds and
circumoral area
11.Restlessness - apprehension
12.Anxious facial expression
13.Sweating
14.May sit upright, shoulders in a hunched over
position hands on bed or chair
15.Speaks with short, panting broken phrases
16.Chest: hyper resonance on percussion
17.Coarse, loud breath sounds
18.Wheezing through out the lung field
19.Prolonged expiration
20.Crackles
21.Generalized inspiratory and expiratory wheezing
increasingly high pitched
 With repeated episodes:
• "Barrel (pigeon ) chest - elevated shoulders-Use
of accessory muscles of respiration
• Facial appearance: flattened molar bones, and
circles beneath the eyes
 Asthma: Risk Assessment
• Prior ICU admissions
• Prior intubation
• >3 emergency department visits in past year
• >2 hospital admissions in past year
• >1 bronchodilator used in past month
• Use of bronchodilators > every 4 hours
• Chronic use of steroids
• Progressive symptoms in spite of aggressive Rx
 Diagnosis:
1. History of symptoms. and physical examination
2. Barrel chest- Chest X-Ray shows hyper
expansion of airways
3. Pulmonary function tests show air trapping and
decreased expiratory flow measurement of
forced expiratory volume at one second (FEV1)
4. Respiratory volume (RV) and Total lung capacity
(TLC)
5. Blood: CBC
6. Routine skin and sputum testing may help
determine allergic causes
 Treatment:
Objective is to relieve symptoms and improve ventilation capacity:
1. Bronchodilators: I.V Aminophyline. S.C Epinephrine.
2. Corticosteroids reduce the inflammatory component of bronchial
obstruction, decrease mucus production and mediator release,
as well as the late phase (cellular) inflammatory process.
• Methyl prednisone IV in severe cases
• May need Reglan if experiencing GI upset
• PO prednisone – always give with food to decrease GI upset
3. Continuous assessment of respiratory status:
Blood gas studies
4. Maintain patent air way and oxygenation, suction
of viscous secretions, ensure humidity and position
correctly.
5. Re-establish and maintain fluid and electrolyte
balance
6. Cardiac monitoring (increased B/P & Rt sided
heart failure and arrhythmias may develop)
7. Maintain bed rest and physical comfort
8. Parental reassurance
9. Anti-inflammatory agents and expectorants
given as indicated
10. Intubations and ventilation if necessary
 Long term care:
Objective:
1. Prevention of acute attacks - Decrease
school absence
2. Minimal medications and treatment
3. Participation in normal activities
4. Normalization of pulmonary function tests
5. Promotion of normal growth and
development.
6. Removal of suspected stimuli
7. Desensitization to build the patient's
resistance to allergen
8. Drug therapy to control symptoms
9. Physiotherapy - Bronchial drainage -
Breathing exercises
10. Supportive treatment:
11. Hydration
12. Oxygen therapy when needed
13. Treatment of infection
14. Correcting Acid - Base balance
15. Relieve fatigue
 Nursing considerations:

1. Assessment of the respiratory system:

Observation - Inspection Palpation - Auscultation
- Percussion Some physical characteristics: Chest
configuration –
2. Posturing Breathing assessment and finger
clubbing
3. Psychological assessment: Assess the degree to
which the disorder interferes with every day living
activities.
4. Coping of the child and family with the condition
altered self concept
5. The comply to treatment?????????
 Nursing diagnosis:
• Ineffective breathing pattern RlT allergic
response in bronchial tree
• Activity intolerance RlT imbalance between
oxygen supply and demand
• Altered family process RlT having a child with
a chronic illness
 Thank You All
Any Question ??????