Chapter 23

The Child with

Respiratory Dysfunction

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Infectious Agents
 Viruses:
◦ Respiratory syncytial virus (RSV)
 Others:
◦ Group A β-hemolytic streptococci
◦ Staphylococci
◦ Chlamydia trachomatis, mycoplasma organisms,
pneumococci
◦ Haemophilus influenzae

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Age
 Infants <6 months: maternal antibodies
 3-6 months: infection rate increases (Why)
 Toddler and preschool ages: high rate of viral

infections
 >5 years: increase in mycoplasmal

pneumonia and Group A β- hemolytic

streptococcal infections
 Increased immunity with age

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Size
 Diameter of airways (smaller)
 Distance between structures is shorter,

allowing organisms to rapidly move down

 Short eustachian tubes

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Resistance
 Factors reduce the ability to resist infection
are
◦ Immune system deficiencies
◦ Allergies, asthma
◦ Cardiac anomalies
◦ Cystic fibrosis
◦ Daycare attendance (smoking)

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Seasonal Variations
 Most common during winter and spring
 Mycoplasmal infections more common in fall

and winter
 Asthmatic bronchitis more frequent in cold

weather
 RSV season considered winter and spring

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 Clinical Manifestations of
Respiratory Infections
Box 23-1 page 756

 Vary with age

 Generalized signs and symptoms and local

manifestations differ in young children:

◦ Fever
◦ Anorexia, vomiting, diarrhea, abdominal pain
◦ Cough, sore throat, nasal blockage or discharge
◦ Respiratory sounds

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Nursing Interventions for Respiratory
Infections
 Ease respiratory effort
 Fever management
 Promote rest and comfort
 Infection control
 Promote hydration and nutrition
 Family support and teaching

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9
Upper Respiratory Tract Infections
(URIs)
 Nasopharyngitis—“common cold”
 Caused by numerous viruses:

◦ RSV, rhinovirus, adenovirus,

influenza and parainfluenza viruses
 Fever—varies with the child’s age from

high to low grade fever

 Home management—varies with age

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 Acute Upper Respiratory Tract
Infections in Children:

 Most URTIs are caused by viruses & are

self-limited.

 Acute naso-pharyngitis & pharyngitis

(including tonsillitis) are extremely
common in pediatric age groups.

11
 Naso-pharyngitis: = Common cold.
Def:
 Viral infection of the nose & throat. Children
are more susceptible because they have not yet
developed resistance to many viruses
Assessment (S &S):
1. Younger child
Fever, sneezing, irritability, vomiting & diarrhea
2. Older child
Dryness & irritation of nose & throat, sneezing,
&muscular aches.

12
 Complications of nasopharyngitis:
 Otitis media
 Lower respiratory tract infection
 Older child may develop sinusitis

 Medication: Acetaminophen
(nursing alert box p. 758)

13
Antipyretics are prescribed for mild fever and discomfort
Rest is recommended until the child is free of fever for at least 1
day.
Decongestants may be prescribed for children and infants older
than 6 months of age to shrink swollen nasal passages.
Cough suppressants may be prescribed for a dry, hacking cough.
However, some cough preparations contain up to 22% alcohol, and
should not be administered to young children continuously and
must be stored securely away from the reach of
children.
Antihistamines are largely ineffective. These drugs have a weak
atropine-like effect that dries secretions, but they can cause
drowsiness or, paradoxically, have a stimulatory effect on children.
There is no support for the us of anti biotic

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 Most discomfort of nasopharyngitis is related to the nasal obstruction,
especially in small infants.
 Elevating the head of the bed or crib mattress assists with drainage of
secretions.
 Suctioning and vaporization may also provide relief.
 Saline nose drops and gentle suction with a bulb syringe before
feeding
 Maintaining adequate fluid intake is essential
 avoiding contact with affected persons.
 carefully disposing of tissues; not sharing towels, glasses, or eating
utensils; covering the mouth and nose with tissues when
 coughing or sneezing
 washing the hands thoroughly after nose blowing or sneezing

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 Pharyngitis: = Sore throat including tonsils.
 Uncommon in children under 1 yr. The peak
incidence occurring between 4 & 7 yrs of age.
 Causative organism: viruses or bacterial (group
A beta-hemolytic streptococcus).

16
Assessment (S &S) of pharyngitis:
1. Younger child
Fever, anorexia, general malaise, & dysphagea
2. Older child
Fever (40 c), anorexia, abdominal pain,
vomiting, & dysphagea.

17
 Complications of pharyngitis:
- Retro pharyngeal abscess.
- Otitis media.
- Lower respiratory tract infection.
 Complications of GABHS Infection:
Peritonsillar abscess; occurs in fewer than 1% of
patients
 Rheumatic fever
 Acute glomerulonephritis.
CNS involvement (Chorea disease)

18
 Management of pharyngitis:
 A throat culture: This test that may help to identify
the type of germ is causing the sore throat.
 Antibiotic medicine is needed if a germ called
streptococcus found to be the causative organism.
(Penicillin) or (Erythromycin) azithromycin,
clarithromycin, oral cephalosporins, amoxicillin,
and amoxicillin with clavulanic acid

 No special treatment is needed if your child's sore

throat is caused by a virus. Antibiotic medicine will
not help a sore throat caused by a virus.
Intramuscular benzathine penicillin G is an
appropriate therapy, but it is very painful and is
not the first choice for children.
19
Cold or warm compresses to the neck may provide relief.
In children who can cooperate, warm saline gargles
offer relief of throat discomfort.
Pain may interfere with oral intake, and children should not be
forced to eat. Cool liquids or ice chips are usually more acceptable
than solids.
Special emphasis is placed on correct administration of oral
medication and completing the course of antibiotic therapy
If injections are required, they must be administered
deep into a large muscle mass (e.g., vastus lateralis or ventrogluteal
muscle).
To prevent pain, application of EMLA over the injection

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 Tonsillitis:

What is tonsillitis?
 Tonsillitis is a viral or bacterial infection in the throat

that causes inflammation of the tonsils. Tonsils are

small glands (lymphoid tissue) in the pharyngeal
cavity. Figure (23-2 p. 763)

 In the first six months of life tonsils provide a useful

defense against infections. Tonsillitis is one of the
most common disorder in pre-school children, but it
can also occur at any age.

21
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.
children generally have much larger tonsils than adolescents or
adults.

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Tonsillitis and Pharyngitis

Courtesy Dr. Edward L. Applebaum, Head, Department of Otolaryngology, University of Illinois Medical Center, Chicago.

FIG. 23-1  Tonsillitis and pharyngitis. (Courtesy Dr. Edward L.

Applebaum, Head, Department of Otolaryngology, University
of Illinois Medical Center, Chicago.)

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Causes of tonsilitis
 Tonsillitis is caused by a variety of
contagious viral and bacterial infections.
 It is spread by close contact with other
individuals and occurs more during
winter periods.
 The most common bacterium causing
tonsillitis is streptococcus.

24
As the palatine tonsils enlarge from edema,
they may meet in the midline (kissing
tonsils),obstructing the passage of air or
food.
 The child has difficulty swallowing and

breathing. When enlargement of the adenoids

occurs, the space behind the posterior nares
becomes blocked, making it difficult or
impossible for air to pass from the nose to
the throat. As a result, the child breathes
through the mouth.

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Medical Management:
 Antibiotics for bacterial tonsillitis

 Tonsillectomy:
 Surgical removal of chronic tonsillitis
(tonsillectomy)
 Nursing observation for bleeding post
tonsillectomy

Nursing alert box p. 764

26
Nursing interventions :
 Encourage bed rest.
 Introduce soft liquid diet according to the

child's preferences.
 Provide cool mist atmosphere to keep the

mucous membranes moist during periods

of mouth breathing.
 Warm saline gargles & paracetamol are

useful to promote comfort.

 If antibiotics are prescribed, counsel the

child's parents regarding the necessity of

completing the treatment period

27
Tonsillitis

 Post operative care:

 Position (place child on abdomen or side).
 Discourage child from coughing frequency.
 Some secretion are common as dried blood.
 Crushed ice& ice water to relief pain.
 Analgesic may be rectally or IV, avoid oral
route.
 Avoid red or brown fluid, and citrus juice.

28
Tonsillitis

 Post operative care (cont.):

 Soft food, milk or ice cream not offered.

 Check post operative signs of Hemorrhage:

 Increase pulse more than 120b/min.
 Pallor.
 Frequent swallowing.
 Vomiting of bright blood
 Decrease blood pressure is late sign of shock.

** Note: use good light to look direct on site of

operation.
29
Otitis media
 Its incidence is highest in the winter months.
 The two viruses most likely to precipitate otitis
media are the RSV and influenza.
 Most episodes of acute otitis media (AOM) occur in
the first 24 months of life, increase at age 5 or 6
year especial in boys
 OM occurs infrequently in children older than 7
years of age.
 Children who have siblings or parents with a history
of chronic OM have a higher incidence of OM.
 Children living in households with many members
(especially smokers) are more likely to OM

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Otitis media:
Otitis media (OM) is the second most common disease of
childhood, after upper respiratory infection (URI).
 Otitis media (OM)—An inflammation of the
middle ear without reference to etiology or
pathogenesis
 Acute otitis media (AOM)—An inflammation

of the middle ear space with rapid onset of

the signs and symptoms of acute infection—
namely fever and otalgia (ear pain)
 Otitis media with effusion (OME)—Fluid in

the middle ear space without symptoms of

acute infection

31
 Streptococcus pneumoniae
 Haemophilus influenzae

 Moraxella catarrhalis

 A relationship between the incidence of OM and infant

feeding methods has been noted. Breast-fed infants

have a lower incidence than formula-fed infants.
Breastfeeding may protect infants against respiratory
viruses and allergy because breast milk contains
secretory immunoglobulin (Ig) A, which limits the
exposure of the eustachian tube and middle ear
mucosa to microbial pathogens and foreign proteins.
Reflux of milk up the eustachian tubes is also less
likely to occur in breast-fed infants because of the
semivertical positioning during breast-feeding.

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Anatomic position of
Eustachian tube in adult
33

33
Etiology of (O .M) :-
 Obstruction of Eust. Tube by edematous
mucosa during URI or enlarged adenoid.

Eustachian tube obstruction lead to high
–ve pressure in the middle ear cavity
lead to occurance of trasudative
middle ear (ME) effusion.
 Organisms contaminate the ME

effusion…..otitis media occur.

34
 Predisposing factors of developing otitis media in
children:

◦ Developmental alterations of the Eustachian

tube (short, wide, & straight),
◦ An immature immune system, and frequent
infections of the upper respiratory mucosa
◦ The usual lying-down position of infants
favors the pooling of fluids, such as formula.

35
1- Acute Otitis media (AOM):
2- Otitis media with effusion (OME):
 Is middle ear effusion (MEE) of any duration
that lacks the associated signs and
symptoms of infection (e.g., fever, otalgia,
irritability). OME usually follows an episode
of AOM.

3- Chronic otitis media:

 Is a chronic inflammation of the middle ear
that persists at least 6 weeks and is
associated with otorrhea through a
perforated TM
36
Otitis media
• Tympanostomy tube in
place.

37

Chronic OM
• Acute Otitis media with
purulent effusion behind
a bulging tympanic
membrane. 37
oral amoxicillin in high doses (80–90 mg/kg/day) is
the treatment of choice for initial episodes
Second-line antibiotics used to treat otitis media
include amoxicillin-clavulanate ,azithromycin, and
cephalosporins such as cefdinir, cefuroxime, and
cefpodoxime.
Intramuscular ceftriaxone is used when the
causative organism is a highly resistant
pneumococcus, and if the parents are noncompliant
with the therapy.
 The use of steroids, decongestants, and
antihistamines to treat acute AOM is
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Infectious Mononucleosis
 Characterized by increased mononuclear
elements of the blood; general symptoms of
infectious process
 Common among adolescents
 Principal cause is Epstein-Barr virus
 No specific treatment

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 Clinical Manifestation: Box 23-7. page 768
 Cardinal signs: Fever, Sore throat, cervical

adenopathy.

 Self Limited disease, disappear within 7 – 10

days.

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Croup Syndromes
 Characterized by hoarseness, “barking”
cough, inspiratory stridor, and varying
degrees of respiratory distress
 Croup syndromes affect larynx, trachea, and

bronchi:
◦ Epiglottitis, laryngitis, laryngotracheobronchitis
(LTB), tracheitis (Table 23-1 p. 769)

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Acute Epiglottitis
 Clinical manifestations:
◦ Sore throat, pain, tripod positioning, retractions
◦ Inspiratory stridor, mild hypoxia, distress
 Therapeutic management:
◦ Potential for respiratory obstruction
 Prevention: Hib vaccine

 (nursing alert boxes p. 769, 770)***

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Epiglottitis

Tripod position
43
Acute Laryngitis
 More common in older children and
adolescents
 Usually caused by virus
 Chief complaint is hoarseness
 Generally self-limiting and without long-term

sequelae
 Treatment: symptomatic

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Acute LTB
 LTB = laryngotracheobronchitis
 Most common of the croup syndromes
 Generally affects children <5 years
 Organisms responsible:

◦ RSV, parainfluenza virus, Mycoplasma pneumoniae,

influenza A and B

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Manifestations of LTB
 Inspiratory stridor
 Suprasternal retractions
 Barking or seal-like cough
 Increasing respiratory distress and hypoxia
 Can progress to respiratory acidosis,

respiratory failure, and death

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Therapeutic Management of LTB
 Airway management
 Maintain hydration (PO or IV)
 High humidity with cool mist
 Nebulizer treatments:

◦ Epinephrine
◦ Steroids

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Acute Spasmodic Laryngitis
 spasmodic croup, midnight croup
 Paroxysmal attacks of laryngeal obstruction
 Occur chiefly at night
 Inflammation: mild or absent
 Most often affects children ages 1-3 years
 Therapeutic management

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Bacterial Tracheitis
 Infection of the mucosa of the upper trachea
 Distinct entity with features of croup and

epiglottitis
 Clinical manifestations similar to LTB
 May be complication of LTB
 Thick, purulent secretions result in

respiratory distress

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Therapeutic Management of Bacterial
Tracheitis
 Humidified oxygen
 Antipyretics
 Antibiotics
 May require intubation

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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, which may cause

constriction of airways

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Bronchitis
 Also known as tracheobronchitis
 Definitions
 Causative agents
 Clinical manifestations

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Risk factors
 Un-cleanliness tops the list* * Improper care
of URI * Cold temperature / cold drinks *
beverages* Contaminated foods / beverages*
sufferers* Aerosol infection from sufferers*
environment* Dusty / smoky environment

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SYMPTOMS

 •Cough with expectoration

 •Mild breathlessness
 •Fatigue / Body pain
 Symptoms which can precede or follow are
 •Sore throat,
 •Fever with chills
 •Sinusitis headache
 •Post nasal drip
 •Wheeze

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MANAGEMENT
 rest, good amount of fluids, steam inhalation
and proper medications can help to clear off
the complaint at the earliest.

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Bronchiolitis and RSV
 Definitions
 RSV = respiratory syncytial virus
 Pathophysiology
 Diagnostics
 Therapeutic management
 Prevention of RSV: prophylaxis
 Nursing considerations

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Pneumonias
 Lobar pneumonia
 Bronchopneumonia
 Interstitial pneumonia
 Pneumonitis

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Etiology of Pneumonias
 Bacterial
 Viral
 Aspiration
 Histomycosis, coccidiomycosis, other fungi
 “Atypical pneumonias”

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Pertussis (Whooping Cough)
 Caused by Bordetella pertussis
 In United States it occurs most often in

children who have not been immunized

 Highest incidence in spring and summer
 Highly contagious
 Risk to young infants
 Vaccines

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Tuberculosis (TB)
 Caused by Mycobacterium tuberculosis,
human and bovine varieties
 Transmission modes
 Clinical manifestations

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TB Testing
 Recommended procedure is Mantoux test:
◦ Uses purified protein derivative (PPD)
◦ Standard dose and administration technique
 Positive reaction:
◦ 5-mm induration
◦ 10-mm induration
◦ 15-mm induration
 Recommendations for TB testing

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Therapeutic Management of TB
 INH
 Rifampin
 PZA
 6-month regimen
 Multidrug resistant—streptomycin IM
 Prophylaxis for high-risk patient: INH 9-12

months

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TB (cont’d)
 Prognosis
 Prevention
 Nursing considerations

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Foreign Body Aspiration
 Risk among children
 Diagnostic evaluation
 Therapeutic management
 Nursing considerations

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Aspiration Pneumonia
 Risk for child with feeding difficulties
 Prevention of aspiration
 Feeding techniques, positioning
 Avoid aspiration risks:

◦ Oily nose drops

◦ Solvents
◦ Talcum powder

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Acute Respiratory Distress Syndrome
(ARDS)
 AKA adult respiratory distress syndrome
 Characterized as respiratory distress and

hypoxia within 72 hours after serious injury

or surgery in person with previously normal
lungs

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ARDS (cont’d)
 Pathophysiology
 Treatment
 Prognosis
 Nursing care

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Inhalation Injury: Smoke and Carbon
Monoxide
 Severity depends on nature of substance,
environment, and duration of contact
◦ Local injury
◦ Systemic injury
 Therapeutic management
 Nursing considerations

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Passive Smoking
 Scope of the problem
 Impact on children
 Nursing considerations

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Asthma
 Chronic inflammatory disorder of airways
 Bronchial hyperresponsiveness
 Episodic
 Limited airflow or obstruction that reverses

spontaneously or with treatment

 Etiology and pathophysiology

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Asthma Severity Classification in
Children 5 Years and Older
 Step I: mild, intermittent asthma
 Step II: mild, persistent asthma
 Step III: moderate, persistent asthma
 Step IV: severe, persistent asthma
 Clinical features of each classification

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Asthma
 Diagnostic evaluation
 Therapeutic management
 Nursing considerations
 Implementation

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Drug Therapy for Asthma
 Long-term control medications
 Quick relief medications
 Metered-dose inhaler (MDI)
 Corticosteroids
 Cromolyn sodium
 Albuterol, metaproterenol, terbutaline

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Drug Therapy for Asthma (cont’d)
 Long-term bronchodilators (salmeterol
[Serevent])
 Theophylline—monitor serum levels
 Leukotriene modifiers
 Others

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Inhaler

FIG. 23-5  Child using metered-dose inhaler with spacer and face mask.

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Asthma Interventions
 Exercise
 Chest physical therapy (CPT)
 Hyposensitization
 Prognosis

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Status Asthmaticus
 Respiratory distress continues despite
vigorous therapeutic measures
 Emergency treatment: epinephrine 0.01

ml/kg SC (maximum dose 0.3 ml)

 Concurrent infection in some cases
 Therapeutic intervention

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Goals of Asthma Management
 Avoid exacerbation
 Avoid allergens
 Relieve asthmatic episodes promptly
 Relieve bronchospasm
 Monitor function with peak flow meter
 Self-management of inhalers, devices, and

activity regulation

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Cystic Fibrosis (CF)
 Exocrine gland dysfunction that produces
multisystem involvement
 Autosomal recessive trait
 Inherits defective gene from both parents,

with an overall incidence of 1:4

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Pathophysiology of CF
 Characterized by several unrelated clinical
features

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Increased Viscosity of Mucous Gland
Secretion
 Results in mechanical obstruction
 Thick inspissated mucoprotein accumulates,

dilates, precipitates, coagulates to form

concretions in glands and ducts
 Respiratory tract and pancreas are

predominantly affected

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Increased Sweat Electrolytes
 Basis of the most reliable diagnostic
procedure: sweat chloride test
 Sodium and chloride will be 2-5 times greater

than in the controls

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Other Factors in CF
 Increased organic-enzymatic constituents of
saliva
 Abnormalities of the autonomic nervous

system

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Respiratory Manifestations of CF
 Present in almost all CF patients but onset
and extent are variable
 Stagnation of mucus and bacterial

colonization result in destruction of lung

tissue
 Tenacious secretions are difficult to

expectorate, obstruct bronchi and

bronchioles

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Respiratory Manifestations of CF
(cont’d)
 Decreased O2-CO2 exchange
 Results in hypoxia, hypercapnia, acidosis
 Compression of pulmonary blood vessels and

progressive lung dysfunction lead to

pulmonary hypertension, cor pulmonale,
respiratory failure, and death

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Infectious Pathogens
 Pseudomonas aeruginosa
 Burkholderia cepacia
 Staphylococcus aureus
 Haemophilus influenzae
 Escherichia coli
 Klebsiella pneumoniae

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Respiratory Progression
 Gradual progression follows chronic infection
 Bronchial epithelium is destroyed
 Infection spreads to peribronchial tissues

weakening bronchial walls

 Peribronchial fibrosis

 Decreased O -CO exchange

2 2

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Further Respiratory Progression
 Chronic hypoxemia causes contraction and
hypertrophy of muscle fibers in pulmonary
arteries and arterioles
 Pulmonary hypertension
 Cor pulmonale
 Pneumothorax
 Hemoptysis

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Gastrointestinal (GI) Tract
 Thick secretions block ducts → cystic dilation
→ degeneration → diffuse fibrosis
 Prevents pancreatic enzymes from reaching

duodenum
 Impaired digestion and absorption of fat:

steatorrhea
 Impaired digestion and absorption of protein:

azotorrhea

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GI Tract (cont’d)
 Endocrine function of pancreas initially stays
unchanged
 Eventually pancreatic fibrosis occurs; may

result in diabetes mellitus

 Focal biliary obstruction results in

multilobular biliary cirrhosis

 Impaired salivation

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Clinical Manifestations of CF
 Pancreatic enzyme deficiency
 Progressive chronic obstructive pulmonary

disease (COPD) associated with infection

 Sweat gland dysfunction
 Failure to thrive
 Increased weight loss despite increased

appetite
 Gradual respiratory deterioration

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Presentation of CF
 Wheezing respiration; dry, nonproductive
cough
 Generalized obstructive emphysema
 Patchy atelectasis
 Cyanosis
 Clubbing of fingers and toes
 Repeated bronchitis and pneumonia

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Presentation of CF (cont’d)
 Meconium ileus
 Distal intestinal obstruction syndrome
 Excretion of undigested food in stool—

increased bulk, frothy, and foul

 Wasting of tissues
 Prolapse of the rectum

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Presentation of CF (cont’d)
 Delayed puberty in females
 Sterility in males
 Parents report children taste “salty”
 Dehydration
 Hyponatremic or hypochloremic alkalosis
 Hypoalbuminemia

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Diagnostic Evaluation of CF
 Quantitative sweat chloride test
 Chest x-ray
 Pulmonary function tests (PFTs)
 Stool fat and/or enzyme analysis
 Barium enema

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Treatment Goals for CF
 Prevent or minimize pulmonary complications
 Adequate nutrition for growth
 Assist in adapting to chronic illness

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Respiratory Management of CF
 CPT
 Bronchodilator medication
 Forced expiration
 Aggressive treatment of pulmonary infections
 Home IV antibiotic therapy
 Aerosolized antibiotics

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GI Management of CF
 Replacement of pancreatic enzymes
 High-protein, high-calorie diet,
 Reduction of rectal prolapse
 Salt supplementation

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Prognosis of CF
 Estimated life expectancy for child born with CF in
2003 is 40-50 years
 Maximize health potential:
◦ Nutrition
◦ Prevention and early aggressive treatment of infection
◦ Pulmonary hygiene
 New research—hope for the future:
◦ Gene therapy
◦ Bilateral lung transplants
◦ Improved pharmacologic agents

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Family Support for the Child with CF
 Coping with emotional needs of child and
family
 Child requires treatments multiple times each

day
 Frequent hospitalization
 Implications of genetic transmission of

disease

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