RespirationRespirationRespirationRespiration

Elisa A. Mancuso RNC, MS, FNSElisa A. Mancuso RNC, MS, FNS

Professor of NursingProfessor of Nursing

Respiratory Alterations • ↑ Risk < 3 years

Smaller upper and lower airways Underdeveloped supporting cartilage

ineffective clearing of organisms Immature immune systems

Compensatory Mechanisms• Lungs- ↑ or ↓ RR• Kidneys- retain or filter H+ affects pH

Blood buffer system: H+, HgB, Na

Interact to maintain pH

Interpreting ABG’s

• Know your normal values!• PH 7.35-7.45

< 7.35 = Acidosis > 7.45 = Alkalosis

• PaCo2 35-45< 35 = Alkalosis > 45 = Acidosis

• HCO3 22-26< 22 = Acidosis > 26 = Alkalosis

PaO2 90-100% < 90 = Hypoxia

Respiratory or Metabolic?

ROME Respiratory opposite (pH & CO2)Metabolic even (pH & HCO3)

Respiratory reflects PaCO2 ↓ CO2 = alkalosis↑ CO2 = acidosis

Metabolic reflects HCO3 and BE ↓ HCO3 = acidosis↑ HCO3 = alkalosis

Respiratory Alterations

Respiratory Acidosis• ↓ PH and ↑ PaCO2• Causes

– ↓ RR– Neuromuscular problems: BPD,

RDS, CF• Respiratory depression and ↑ CO2

Respiratory Alkalosis• ↑ PH and ↓ PaCO2• Causes– ↑ RR ↑ Fever Stress

Metabolic Alterations

Metabolic Acidosis • ↓ PH and ↓ HCO3• Causes

– Renal failure, diarrhea, ketoacidosis

Metabolic Alkalosis • ↑ High PH and ↑ HCO3• Causes

– Vomiting, Meds for ulcers, NaHCO3, – NGT = HCL loss & ↑ HCO3 – Diuresis

Case Study Mariska, 4 years old presents with

following: RR = 54 C/O Chest tightnessBilateral expiratory & inspiratory wheezingFrightened appearance.ABG pH of 7.27, PaO2 88, PaCO2 48 and

HCO3 24.

What is her acid – base status?• Identify each component. • Find the cause• Answer????

Upper Respiratory Infections

URIAcute pharyngitis and

nasopharyngitis• Children get 7-10 colds/year!• Majority is viral = Rhinovirus

Signs and symptoms• low grade fever • sore throat • spontaneous recovery

– Self limiting 7-10 days

URIs Bacterial• Group A beta-hemolytic strep

(GABHS)Signs and symptoms• Abrupt onset• Fever >102, chills • Fatigue, HA• Nasal congestion• Abdominal pain & Anorexia • Vomiting, diarrhea• Halitosis • Fire red throat & petechiae • Exudative

Treatment of Strep Pharyngitis

• Throat culture IN and OUT. – Rapid antigen detection test 60-95%

sensitive.

• Antibiotics Prevents serious complication = Rheumatic

feverPEN-VK BID-TID drug of choice x 10 days• Amoxicillin 40-45mg/kg/day ÷ BID – ↑ tasting and ↓ dosing needed– ↑better compliance!

• Zithromax 10mg/kg/day 1 – 5mg/kg day 2-5

• Cefdinir (Omnicef) 14 mg/kg/day• Cefixine (Suprax) 8mg/kg/day

Treatment (cont)• Bed rest• Tylenol 10-15mg/kg every 4 hours

– √ Infant vs. Child concentration!

• Saline gtts and cool mist humidifier• Hydration • Decongestants > 6 months.• Contagious: Separate from others!

– Need meds x 24 hours – Then return to school– Feel better in 24-48 hours!– Must Complete all meds!

Tonsils• Lymphoid tissue in pharyngeal cavity• Filter and protect respiratory and GI

tract• ↑ Antibody formation

– until 3 years & immune system mature

• ↑ ↑ size in children until puberty• Inflamed with infections• If chronically enlarged 3+ → 4+

– Obstructive Sleep Apnea (OSA)– Difficulty breathing and eating

Tonsillitis

• Persistent cough • Dry mucous membranes• White patchy exudate• Secondary OM from blocked

Eustachian tubes• Viral-

Self- limiting

• Palliative measures• Pain & Hydration

Tonsillectomy• Most common indication today is OSA• 4 strep infections/season• Peri-tonsilar Abscess Post-op care• ↑ HOB with pt prone or on side• Encourage fluids PO -No straws!• Medicate for pain (no ASA) and N/V• Ice pack to anterior neck√ Hemorrhage (5-20%) Go to OR!• (1st 48 hours and then 5-7 days)• ↑ ↑ swallowing/vomiting bright red blood• ↑↑ RR ↑↑ HR ↑↑ Restlessness

Normal Eschar forms

Epiglottitis

• Medical Emergency – ↑ @ 3-6 years

• Haemophilus influenza type B (HIB) (50% pre-vaccination)– Dramatic ↓↓ since HIB vaccine

• Strep pneumoniae, staph aureous.• Rapid & severe inflammation

– of epiglottis and surrounding areas

– Complete airway obstruction

Signs and symptoms• Abrupt onset of sore throat• Fever 102-104 - toxic appearing• 4 D’s

– Dysphonia (muffled voice)– Dysphagia (↓ swallowing)– Drooling– Distress/Dyspnea

• Inspiratory stridor• Retractions ↑ RR ↑HR Pallor• Tripod position Thumb sign

on soft tissue x-ray

TreatmentMEDICAL EMERGENCY: ANESTHISIA STAT!!• DO NOT INSPECT THROAT!• LIMIT UPSETING PROCEDURES!• Establish Airway• Respiratory Isolation!• Humidified O2• Hydration

• Antibiotics (Meningitic doses)– Ampicillin 200-400 mg/kg/day ÷ q6H– Chloramphenicol 75-100mg/kg/day ÷ q6H

• Steroids– Methylprednisolone 2mg/kg/day ÷ q6H

CroupLaryngotracheobronchi

tis

• Acute spasmodic laryngitis – Upper airway

• ↑ 3 months to 5 years– peak @ 2 years

• Paroxysmal laryngeal edema– Attacks @ night

• Parainfluenza virus or allergic reaction• ↑ in fall and winter months• Precipitated with nasopharyngitis

Clinical signs• Awakes suddenly with barking cough • Inspiratory stridor• Hoarseness• Restlessness• Anxious• Retractions, ↓↓O2 • Stridor @ rest = severe croup• ↑ Temp 101-102• Duration few hours, Repeat x 2 nights• Symptoms improve with change in

temp

Treatment• Maintain airway• Position upright• Cool mist humidified O2• Steam shower or expose to cold night

air• Decadron 0.6mg/kg IM/PO x 1 dose• Racemic epinephrine 2.25% nebulizer

– for inspiratory stridor at rest

• Induce vomiting = stops laryngospasm• Hospitalize only when:

– ↑ Stridor ↓ O2 ↓LOC

Otitis Media (OM)• Acute inflammation & effusion of middle

ear

Common pathogens • Strep pneumonia (50%)

– ↓ incidence with Prevnar vaccine

• Haemophilus influenza (30%)-not type B!• Moraxella catarrhalis (20%)

– ↑↑ incidence with resistance

• Viruses • Food Allergies

PathophysiologyEustachian tube dysfunction • < 5 years = shorter, wider and straighter• Acute

– bacteria/purulent exudates

Signs and symptoms• ↑ ↑ Pain, ↑ ↑ irritability• Tugging on ears• Fever >102• Rhinorrhea, cough and congestion• Anorexia, vomiting and diarrhea• Tympanic membrane

Red & bulging

Tympanogram No movement of TM Hearing loss

To treat or not treat?

AAP guidelines to ↓ resistant organisms • < 6 months:

– with S/S of illness → Treat!

• 6 mos -2 years: – certain diagnosis → Treat!– Uncertain & no s/s of severe illness = Observe

• > 2 years: – certain diagnosis & no S/S of severe illness – Observation & Pain Relief

AMERICAN ACADEMY OF PEDIATRICS, Guidelines for Acute Otitis Media,

2004

Treatments

• Amoxicillin 40-45mg/kg/day ÷ BID– Now recommending high dose:

– 80mg/kg- 90mg/kg/day ÷ BID

• Augmentin 40-45mg/kg/day BID for resistance to amoxicillin

• Ceclor 40 mg/kg/day• Bactrim/Septra 8mg/kg/day • Rocephin for resistant OM’s Myringotomy Tubes

Frequent infections Prolonged fluid

Bronchiolitis (RSV)Disease of lower airways • Respiratory syncytial virus (RSV) = common

cause• Can be fatal in <2 months/premature• 90% of infants <1 year get RSV• ↑ incidence winter/spring• ↑ Contagious via direct contact & inhalation

– Use alcohol based hand rubs.

Pathophysiology• RSV affects epithelia cells of lungs• Bronchioles become edematous• Lumen filled with mucous - green thick

exudate • Bronchioles infiltrated with inflammatory cells

– Air trapping• Severe cases mucous plugging & apnea=

death

RSV Clinical signs• Nasal Aspirate Culture =

– (+) ELISA • enzyme-linked immunosuppressive assay

– (+) RSV Ag or rapid fluorescent antibody• Peak @ 72 hours after onset• Rhinorrhea with thick, tenacious, green

secretions• RR, retractions & cyanosis• Coughing, wheezing• CXR

– Hyperinflation (obstructive emphysema)– Atelectasis =↓ Breath sounds (PN)

• Hypoxia → apnea and even death

Therapy• Respiratory Isolation• Cool mist humidified O2

– √ O2 sats! >95% is nl• ↑ Hydration• Antibiotics for PN• Bronchodilators• Steroids• Severe Cases

– Racemic epinephrine – Mechanical ventilation

Prophylactic Approach• Respi Gam (RSV Immune Globulin) $600/vial• Synagis (Monoclonal AB) 15 mg/kg IM

– Binds with RSV to ↓ infection. – @ beginning of RSV season Oct - Nov– total of 5 monthly doses; Need ↑ titers to be

effective

Asthma

• Inflammation & Hyperactivity• Abrupt onset after URI or allergen• RAD= Reactive Airway Disease

– Reversible bronchospasm

• 8 million kids/year • 1st attack usually @ 3-8 years

Pathophysiology• Inflammation

– Histamine release to allergen/trigger (stimulus).– Edema→ Mucous Production → Bronchial Obstruction &

Spasm• Bronchoconstriction

– Hyper-responsiveness of stimuli:• Allergens:

– Cigarette smoke Dust mitesExercise

– Cold air Stress Drugs (ASA/NSAID) • • Urban factors:

– #1 Cockroach droppings– Diesel fumes

Early & Subtle Clinical signs

• Irritable• Itchy• Tired• Dry mouth• Dark circle under eyes• Chronic cough worse @ night

Clinical Signs Older child

• SOB and Dyspnea• Expiratory wheeze bilaterally• Chest pain or tightness → ↑ HR• Spasmodic or tight cough @

night• Abdominal pain and nausea• Mild Intermittent

– <2 days/week• Severe Persistent

– Constant/daily

Warning signs

• Retractions ↑ RR and Hypoxia<92% (Admit to hospital)

• As symptoms progress → – Expiratory & Inspiratory wheeze

• ↑ HR• Breathlessness • Anxious & Restless• Absent breath sounds

– No air movement – Respiratory arrest!

Status Asthmaticus• Limited or no response to therapy• Respiratory distress → arrest• ICU

– IV Hydration & Intubation

• Medications:– Steroids – Magnesium Sulfate IV – Bronchodilators Nebulizer RX– Antibiotics

Diagnostic Tests

• Allergy testing- – 4-8% have a food allergy

• Pulmonary Function Test (PFT)– Forced exhalation– √ before and after neb – Reliable when

•age > 5 years •good effort

Peak Expiratory Flow Rate (PEFR)

• Assess asymptomatic lung changes and function.

• Based on child’s height Ex: 47”=PEFR=200

• Peak flow zones – Visual = ↑ manage – Early interventions– Maintain control

Asthma Therapy

The National Asthma Education and Prevention Program (NAEPP) 2002

4 components of asthma management:

• Measures of assessment and monitoring

• Control factors that contribute to severity

• Education for a partnership in asthma• Pharmacologic therapy

Bronchodilators “Rescue meds”

Inhaled Beta 2 AgonistsAlbuterol (Proventil,Ventolin) 0.15-5 mg/kg/doseLevalbuterol (Zopenex) > 6 years 0.31mg/kg/dose SE = Tremors ↑ HR Hyperactivity

Bronchospasm = Overdose!

• AnticholinergicIpratropium (Atrovent) MDI 1-2 puffs q6-8HSE = Dizzyness HA Cough ↓ BP

• Methylzanthines Theophylline (PO) Aminophylline (IV) √ serum levels (10-20) SE = ↑ HR Arrhythmias

Systemic B2 agonists SC Epinephrine 1:1000=bronchodilation x 3doses Caution CARDIAC DOSE 1:10,000 SE = ↑ BP ↑ HR Tremors

Terbutaline (Brethine) SQ/IV SE = Restlessness cardiac arrthymias Stops pre-term

labor

Anti-Inflammatory medsSystemic Corticosteroids• onset - 3 H Peaks in 6-12 H• Loading dose 2mg/kg and taper slowly• No need to taper if short term use

Short-Acting (use 5-7 days ↓ SE)• Hydrocortisone (Solu-Cortef) 0.25-2 mg/kg/day• Methylprednisolone (Solu-Medrol) 1-2 mg/kg/dose• Prednisone PO 1-2 mg/kg/dose• Prednisolone (Orapred, Pediapred) PO 1-2 mg/kg• Dexamethasone (Decadron) 0.6-1.5 mg/kg/day

• SE = Hyperglycemia GI distress ↓ Growth

Cushing Syndrome = ↑ Wt. ↑ Infection Mood Lability

Controller MedsInhaled corticosteroids- Not rescue drug • Budesonide (Pulmicort) 2-4 puffs tid• Fluticasone (Flovent)• Triamcinolone (Azmacort, Kenalog)• Advair discus

– Synergistic effect with B2agonists– SE = Oral & pharyngeal irritation

Non-steroidals- • Cromolyn Na (Intal)

– Stabilizes mast cells & prevents attack.• Leukotriene Receptor Antagonists-(LRA)

– Leukotrienes cause inflammation (capillary permeability)

– Use at night when leukotrienes are highest.– Montelukast (Singulair) 5-10 mg PO/day– Zafirlukast (Accolate) 10-20 mg PO/day– Zileuton (Zyflo) 300-600 mg PO/day

SE = HA Vasculitis Flu like symptoms

Other Treatments• ↑ Fluids

– Dilute mucous & mobilize secretions

• May need allergy shots• Zyrtec or Clarinex =↓ allergy

symptoms. Singulair now indicated for allergy use as well as asthma maintenance

• Nasal Lavage • Treat cold symptoms>7-10 days

– 60-80% pt with allergic asthma have – sinusitis

Parent Teaching• Remove allergens

– Identify precipitating factors– ↓ Rugs, heavy drapes, pets, foods (eggs,

milk)– Mattress & pillow covers

• Dehumidifier - AC• Review

– Signs/symptoms of asthma– PEAK Flow daily– Meds SE & toxicity– Nebulizer use

• ↓ Antihistamines – May exacerbate wheezing

• Swimming = Best Exercise

Cystic FibrosisDysfunction of exocrine glands

– ↑↑ Na++ ↑ Cl- in sweat & saliva – (2- 5x normal levels)– ↑↑ Viscosity of secretions– GI & Pulmonary systems

Autosommial Recessive – 1/25 whites carry gene.

•Chromosome # 7•CC = Healthy•Cf = Carrier•ff = Disease

• 25% risk = healthy/disease• 50% risk = carrier

Mom→Dad ↓

C f

C CC Cf

f Cf ff

PathophysiologyPulmonary• ↑ Leukocyte DNA in sputum

– Long, thick strands

• ↑↑ Thick mucous (yellow/grey)• ↓↓ Diffusion of gases → ↓ O2 hypoxia ↑ CO2• ↑↑ Respiratory distress & Pseudomonas PN• Obstruction =

– Fibrotic and stiff lobes– ↓ compliancy & ↓ function

Pancreas• Thick secretions block ducts • Fibrosis = ↓↓ pancreatic enzymes

• Malabsorption Syndrome – Only 50% of food is absorbed– Inability to digest & absorb proteins &

fats – “Steatorrhea” foul smelling bulky

stools– ↓↓ fat soluble vitamins A,D,E and K.

• Bile ducts – Occluded: biliary cirrhosis & portal ↑

BP

Hallmark – CF Signs

• Meconium Ileus (newborn) – No mec passed in 1st 24 hours– Abdominal distention– 10-15% & 1st sign of CF

• Skin - “Infant tastes salty”– Sweat Test (Pilocarpine

Ionophoresis)– > 1 month old– Cl> 60 mEq = (+) CF

Respiratory Signs

• Frequent sinus & respiratory infections.

• Bronchitis & PN• Recurrent pneumothorax• SOB, wheezing, hemoptysis• Dyspnea, Hypoxemia• Barrel shaped chest

– AP>lateral

• Clubbed fingers

Gastrointestinal Signs• Steatorrhea

– Excretion of undigested fats and proteins– Bulky, frothy, foul smelling stool

• Abdominal Distension – 3rd spacing & edema RT ↓↓ protein & albumin

• Prolapsed rectum• Voracious appetite RT starving

– only 50% of food absorbed

• Failure to thrive – ↓↓ drop on growth chart 10-25% = short

stature

Diagnosis• Genetic testing

– DNA analysis: Chromosome # 7– Prenatal screen (↑↑mutations exist)– F508 mutation in 70% of pt with CF

• Sweat Test– Cl>60meq strongly suggests CF

• Stool specimen– 5 day collection √ fat content

• Duodenal Enzymes– ↓↓ trypsin and chymotrypsin – (absent in 80% of CF pt’s)– Immunoreactive Trypsin Test

• >140 = CF (+)

Therapy• Goals

– ↑ Life Expectancy > 30– ↑ Quality of life– ↓ Sequella of CF

• Nutrition – ↑ protein ↑ calories and moderate fat– Need 150% of daily requirements to replace

losses– ↑ Na intake in hot weather

• MedicationsPancrelipase (Pancrease, Pancrease MT4) PO– (10,000u lipase/36,000u protease & amylase)– Enteric coated & must give before all meals!– ↑ digestion of fats, proteins and carbs. – SE: diarrhea and abdominal cramping

Therapy • Supplements

– Fat Soluble Vitamins• A, D, E & K (2x dose)

– H2O Soluble Vitamins• C, B, B2, B6 (B-C complex)• Niacin, B12, Folic Acid

• Pulmonary-– 1st Assess breath sounds and O2!– Nebulizer treatments then PD & C. – CPT x 15-20 minutes in trendelenburg. – Vibrate all lung fields =mobilize

secretions

Inhalation Therapy• Dornase Alfa-Pulmozyme

– Recombinant DNAse 2.5 mg– Breaks down DNA in sputum – ↓↓ viscosity of sputum– SE- laryngitis– Administer via neb before PD&C

• Proventil • Thoracic expansion exercises

– Stretching & Breathing– Swimming (↑ mobility)

Family Support• Educate

– Disease process and S/S of illness– Meds and diet

• Pulmonary care ATC – Need ↑ support group to assist q 3-4 H– Breathing exercises– Antibiotics only for documented

infections!• Encourage verbalization of fears

– Numerous Hospitalizations– Invasive Procedures (CT) lung transplants– Anticipatory Grieving -Fatal Illness– Support group

• CF Foundation• www.cff.org www.cysticfibrosis.com

Foreign Body Aspiration↑ Risk @ 1-3 years of age

– Developmental stage ↑ curious and – hand–to-mouth or nose– 4th cause of accidental death < 5 years– Acute and dramatic onset

Common Objects• Small toys• Buttons• Paper clips• Batteries (Acid leaks = chemical PN)• Food• ↑ in size as absorbs H2O

– ↑ Edema = ↑ Obstruction– Hotdogs Grapes Nuts Seeds

Clinical SignsLaryngeal• Choking & Coughing • Aphonia = No cry or speaking• Rapid color change → blue• Inspiratory stridor• ↓ O2 → Change in LOC → Collapse/Unconscious

Bronchial# 1 site = R main stem bronchus• Wheezing Lung• Persistent respiratory infections

– Cough & congestion– Purulent secretions– Foul smelling breath

• Acute or chronic pulmonary lesions

Interventions• Immediate Intervention (Death in 4 mins!)

• CPR – Obstructed Airway– Infants-

• alternate 5 back blows with 5 chest thrusts – Kids >1 year

• Heimlich• CXR

– Identify object & location • Bronchoscopy

– Removal of object ASAP!• Post removal

– Humidity– Steroids

• ↓ Edema & ↓ inflammation – Antibiotics

Pneumonia• Classified according to agent or location:

– Viral (RSV) most common – Bacterial (strep pneumoniae, pseudomonas)– Fungal (candida)– Chemical/Aspiration (Oil, lotion, cleaners)

Pathophysiology• Inflammation of lung parenchyma• Consolidation - aveoli fill with exudate • Bronchial Obstruction

– RT ↑ restriction of lung – ↓ Impaired gas exchange ↓O2 & ↑ CO2

Primary Atypical Pneumonia

Mycoplasma pneumoniae• Most common pathogen in

older children 5-12 years of age

• ↑ incidence in Fall and Winter• ↑ Highly populated areas• Diagnosis:

– CBC & Differential– BC or Tracheal aspirate– CXR– ELISA test

Clinical signs• Sudden or gradual onset

– could be a 7-10 day duration of symptoms• Fever - low grade• Chest pain• Flushed cheeks with generalized pallor• Hacking cough• Pharyngitis• Coarse Crackles or rhonchi• ↓ Breath sounds with dullness

(consolidation)• Hypoxemia • Anorexia• Malaise

Therapy• O2 √ Pulse oximeter• ↑↑ Hydration PO/IV• Humidity• CPT

– Blow Bubbles• ↑↑ HOB & RestMedications• Azithromycin (Z-Pack)

(10 mg/kg day 1 then 5 mg/kg day 2-5)• Erythromycin

30-50 mg/kg/day PO/IV ÷ q 6-8 x 14 -21 days No IM causes tissue necrosis!

• Acetaminophen (Tylenol)– 10-15 mg/kg/dose √ (infant vs. children)– ↓ Pain & Fever

• Expectorants only No cough suppressant!

Bacterial Pneumonia• ↑ Risk @ birth-5 years• Strep pneumoniae (90%)

Clinical signs/symptoms• Abrupt onset after viral illness - URI

– ↓↓ immune system• High fever 104-105• Retractions, tachypnea, hypoxia• Rales/rhonchi• Chest Pain with deep inhalation

– Pleural effusion→ Shallow respirations & ↑ CO2

• Abdominal pain– Lower lobe infiltrate

Therapy• Similar to Mycoplasma• Maintain patent airway!• Isolate with same pt if hospitalized• Lying on affected side ↓ pleural rub/pain• CT for thoracentesis

Medications• Antibiotics- appropriate drug for the bug!

– High dose Amoxicillin or Augmentin (40mg/kg/day PO)

– Ceftriaxone (Rocephin) (50-75 mg/kg/day)• ↑ WBC or based on S/S

– Cefotaxime (Claforan) 100-200 mg/kg/day– Ceftiazidine (Fortaz) 150 mg/kg/day

• Tylenol• Expectorants