Chapter 40 Respiratory Dysfunction All Elsevier items and derived items 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc

Chapter 40

Respiratory Dysfunction

All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Upper respiratory tract Oronasopharynx, pharynx Larynx, upper trachea

Lower respiratory tract Lower trachea, bronchi Bronchioles, alveoli

Respiratory Infections

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Viruses Respiratory syncytial virus (RSV)

Others Group A β-hemolytic streptococci Staphylococci Haemophilus influenzae Chlamydia trachomatis, Mycoplasma organisms,

pneumococci

Infectious Agents


<3 Months: maternal antibodies 3-6 Months: infection rate increases Toddler and preschool ages: high rate of viral

infections >5 Years: increase in Mycoplasma pneumoniae

and β-hemolytic streptococcal infections Increased immunity with age

Age


Diameter of airways is smaller Distance between structures is shorter, allowing

organisms to move rapidly Eustachian tubes are short and open

Size


Immune system Malnutrition, anemia Allergies, asthma Preterm birth Cardiac anomalies Cystic fibrosis (CF) Day care

Resistance


Most common during winter and spring Mycoplasmal infections: more common in fall

and winter Infection-related asthma: more frequent in cold

weather RSV season: considered winter and spring

Seasonal Variations


Vary with age Generalized signs and symptoms and local

manifestations differ in young children Fever and meningismus Anorexia, vomiting, diarrhea, abdominal pain Cough, sore throat, nasal blockage or discharge Respiratory sounds

Clinical Manifestations


Ease respiratory effort Promote rest and comfort Prevent spread of infection Reduce temperature Promote hydration and nutrition Provide support and reassurance

Care Management


Nasopharyngitis: “common cold” Caused by numerous viruses

RSV, rhinovirus, adenovirus, influenza and parainfluenza viruses

Fever: varies with age of the child Managed at home No specific treatment

Upper Respiratory Tract Infections


Causes and risks Group A β-hemolytic streptococcal infection Risk for rheumatic fever

Clinical manifestations Diagnostic evaluation Therapeutic management Nursing care

Acute Streptococcal Pharyngitis


Acute Streptococcal Pharyngitis (Cont.)


Frequent co-occurrence with pharyngitis Causes and pathophysiology Clinical manifestations Therapeutic management

Tonsillectomy and adenoidectomy Nursing care

Postoperative care

Tonsillitis


Tonsillitis (Cont.)


Commonly known as the “flu” Caused by orthomyxoviruses

Types A, B, and C Clinical manifestations Therapeutic management Prevention Nursing care

Influenza

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Causes and pathophysiology Diagnostic evaluation Therapeutic management

Pharmacologic Surgical

Nursing care Prevention of recurrence

Otitis Media

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Causes and pathophysiology Herpes-like Epstein-Barr virus

Diagnostic tests Therapeutic management Prognosis Nursing care

Infectious Mononucleosis


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 Most often caused by H. influenzae type B

Croup Syndromes


A medical emergency Clinical manifestations

Sore throat, pain, tripod positioning Drooling, difficulty swallowing Inspiratory stridor, mild hypoxia, distress

Therapeutic management Prevention of progressive respiratory obstruction Intubation or tracheostomy

Acute Epiglottitis


Most common of the croup syndromes Generally affects children <5 years of age Organisms responsible

RSV, parainfluenza virus, M. pneumoniae, influenza A and B, pneumococci, staphylococci

Acute Laryngotracheobronchitis


Usually preceded by an upper respiratory tract infection

Inspiratory stridor Suprasternal retractions Barking or “seal-like” cough Increasing respiratory distress and hypoxia Can progress to respiratory acidosis, and

respiratory failure

Manifestations of LTB


Maintaining the airway Maintain hydration, orally or intravenously Nebulized mist with supplemental O2

Nebulizer treatments Epinephrine Steroids

Therapeutic Management


Also known as “spasmodic croup” Paroxysmal attacks of laryngeal obstruction Occurs chiefly at night Inflammation: mild or absent Most often affects children 1-3 years of age Therapeutic management

Similar to that for infectious croup

Acute Spasmodic Laryngitis


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

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

respiratory distress

Bacterial Tracheitis


Vigorous management Humidified oxygen Antipyretics Antibiotics Possible need for intubation Mechanical ventilation

Therapeutic Management


Lower airways: considered the “reactive” portion of the lower respiratory tract

Include bronchi and bronchioles Cartilaginous support not fully developed until

adolescence Constriction of airways

Infections of the Lower Airways


Also known as “tracheobronchitis” Mild, self-limiting disease

Causative agents Clinical manifestations Nursing care

Cough suppressants Fluids Rest

Bronchitis


Respiratory syncytial virus Common, acute, viral infection Winter and early spring Diagnostic evaluation Therapeutic management Prevention, prophylaxis Nursing care

Respiratory Syncytial Virus and Bronchiolitis


Primary disease or complication Causative agents

Inhaled organisms Bloodstream infection

Lobar pneumonia Pneumonitis Supportive and symptomatic care

Pneumonias


Bacterial Viral Mycoplasmal Pneumococcal Development of vaccine

Causes of Pneumonias


Causes of Pneumonias (Cont.)


Caused by Bordetella pertussis In United States, occurs most often in children

who have not been immunized Highest incidence in spring and summer Highly contagious Risk to young infants Vaccines

Pertussis (Whooping Cough)


Caused by Mycobacterium tuberculosis, human and bovine varieties

Transmission modes Urban, low income, nonwhite population

Clinical manifestations Diagnostic evaluation Prognosis and prevention

Tuberculosis (TB)


Recommended procedure is Mantoux test Purified protein derivative used Standard dose and administration technique

Positive reaction 5-mm induration 10-mm induration 15-mm induration

Recommendations for TB testing

Tuberculosis Testing


Isoniazid (INH) Rifampin Pyrazinamide Ethambutol 6-Month regimen Prophylaxis for patient at high risk: INH for 12-24

months

Therapeutic Management of Tuberculosis


Risk among small children (1-3 years of age) Beads, paper clips, other small objects in the nose Hotdogs, peanuts, popcorn, marbles, and coins

Diagnostic evaluation Therapeutic management Nursing care

Foreign Body Aspiration


Risk for child with feeding difficulties Prevention of aspiration Feeding techniques, positioning Avoidance of aspiration risks

Hydrocarbons, lipids Solvents Talcum powder

Aspiration Pneumonia


Movement of fluid into the lungs Pathophysiology

Cardiogenic Noncardiogenic

Therapeutic management Nursing care of the child with pulmonary edema

Pulmonary Edema


Acute lung injury Characterized as respiratory distress and

hypoxia within 72 hours after serious injury or surgery

Causes Sepsis Trauma Drug overdose Near drowning

Acute Respiratory Distress Syndrome


Pathophysiology Treatment Prognosis

Mortality rates remains high Nursing care

Intensive care

Acute Respiratory Distress Syndrome (Cont.)


Severity depends on nature of substance, environment, and duration of contact

Local injury Systemic injury Therapeutic management

Humidifying oxygen at 100%

Smoke Inhalation Injury


Passive (secondhand) smoke Scope of the problem Effects on the growing fetus Effects on children

Exposure to Environmental Tobacco Smoke


Chronic inflammatory disorder of airways Recurring symptoms Bronchial hyperresponsiveness Airway obstruction

Limited airflow or obstruction that reverses spontaneously or with treatment

Causes and pathophysiology

Asthma


Asthma (Cont.)


Step 1: mild, intermittent asthma Step 2: mild, persistent asthma Step 3 or 4: moderate, persistent asthma Step 5 or 6: severe, persistent asthma Clinical features of each classification

Classification of Asthma Severity in Children Aged 5 Years and Older


Diagnostic evaluation Pulmonary function tests Skin testing for allergens

Therapeutic management Goal: to maintain normal activities levels Prevention of exacerbations

Diagnosis and Management of Asthma


Long-term control medications Quick-relief medications Metered-dose inhaler Corticosteroids Cromolyn sodium

Drug Therapy for Asthma


Drug Therapy for Asthma (Cont.)


Albuterol, metaproterenol, terbutaline Long-term bronchodilators (salmeterol

[Serevent]) Theophylline: monitor serum levels Leukotriene modifiers Others

Drug Therapy for Asthma (Cont.)


Exercise Breathing exercises Hyposensitization Prognosis

Asthma Interventions


Asthma Interventions (Cont.)


Medical emergency Respiratory failure and death if untreated

Continuation of respiratory distress despite vigorous therapeutic measures

Concurrent infection in some cases Therapeutic intervention

Improving ventilation Pharmacologic agents

Status Asthmaticus


Prevent exacerbation Avoid allergens

Provide acute asthma care Relieve bronchospasm Monitor function with peak flowmeter Master self-management of inhalers, devices,

and activity regulation

Goals of Asthma Management


Goals of Asthma Management (Cont.)

54

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Multisystem involvement Increased viscosity of mucous gland secretions Elevation of sweat electrolytes Increase in enzymatic constituents of saliva Autonomic nervous system abnormalities

Autosomal recessive trait Defective gene inherited from both parents with an

overall incidence of 1:4

Cystic Fibrosis


Cystic Fibrosis (Cont.)


Secretion results in mechanical obstruction Thick inspissated mucoprotein accumulates,

dilates, precipitates, and coagulates to form concretions in glands and ducts

Respiratory tract and pancreas are predominantly affected

Cystic Fibrosis: Increased Viscosity of Mucous Gland Secretion


Sweat chloride test Newborn screening DNA identification of mutant genes Abnormal measurement of nasal potential

difference

Cystic Fibrosis: Diagnostic Evaluation


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

Cystic Fibrosis: Presentation


Meconium ileus Distal intestinal obstruction syndrome Excretion of undigested food in stool; increased

bulk, frothiness, and foul odor Wasting of tissues Prolapse of the rectum

Cystic Fibrosis: Presentation (Cont.)


Delayed puberty in girls Sterility in boys Parents’ report: child’s skin tastes “salty” Dehydration Hyponatremic/hypochloremic alkalosis Hypoalbuminemia

Cystic Fibrosis: Presentation (Cont.)


Complications are present in almost all patients with CF, but onset/extent is variable

Stagnation of mucus and bacterial colonization result in destruction of lung tissue

Tenacious secretions are difficult to expectorate: they obstruct bronchi/bronchioles

Cystic Fibrosis: Pulmonary Complications


Pseudomonas aeruginosa Burkholderia cepacia Staphylococcus aureus H. influenzae Escherichia coli Klebsiella pneumoniae

Cystic Fibrosis: Susceptibility to Infectious Pathogens


Gradual progression follows chronic infection Bronchial epithelium is destroyed Infection spreads to peribronchial tissues,

weakening bronchial walls Peribronchial fibrosis ensues O2/CO2 exchange decreases

Cystic Fibrosis: Respiratory Progression


Chronic hypoxemia: causes contraction/hypertrophy of muscle fibers in pulmonary arteries/arterioles

Pulmonary hypertension Cor pulmonale Pneumothorax Hemoptysis

Cystic Fibrosis: Further Respiratory Progression


Thick secretions: block ducts and cause cystic dilation, degeneration, diffuse fibrosis

Prevents pancreatic enzymes from reaching duodenum

Impaired digestion/absorption of fat, steatorrhea Impaired digestion/absorption of protein,

azotorrhea

Cystic Fibrosis: Gastrointestinal Tract


Endocrine function of pancreas initially stays unchanged

Eventually pancreatic fibrosis occurs; diabetes mellitus may result

Focal biliary obstruction results in multilobular biliary cirrhosis

Cystic Fibrosis: Gastrointestinal Tract (Cont.)


Pancreatic enzyme deficiency Sweat gland dysfunction Failure to thrive Increased weight loss despite increased

appetite

Cystic Fibrosis: Gastrointestinal Tract (Cont.)


Airway clearance therapies Bronchodilator medication Physical exercise Aggressive treatment of pulmonary infections Aerosolized antibiotics Home intravenous antibiotic therapy

Cystic Fibrosis: Respiratory Management


Replacement of pancreatic enzymes High-protein, high-calorie diet: as much as 150%

recommended dietary allowance Relief of intestinal obstruction (ileus) Reduction of rectal prolapse Treatment of chronic gastrointestinal reflux

Cystic Fibrosis: Gastrointestinal Management


Estimated life expectancy for child born with CF in 2009: 37.4 years

Progressive and incurable disease Transplantation

Increases life expectancy Availability of organs Surgical complications

Prognosis of Cystic Fibrosis


Coping with emotional needs of child and family

Need for treatments multiple times a day

Frequent hospitalization Home care Implications of genetic transmission

of disease

Cystic Fibrosis: Family Support


The most important consideration in managing tuberculosis in children is:

A. Skin testingB. ChemotherapyC. Adequate nutritionD. Adequate hydration

Question


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Chapter 40 Respiratory Dysfunction All Elsevier items and derived items 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc