Respiratory Flashcards
What are characteristics specific to children?
- Infants 4-6 weeks are obligate nose breathers
- Tongue is larger in proportion to the mouth
- Smaller lung capacity
- Higher respiratory rates and demands for O2
- Airway is smaller at the cricoid
- Smaller, narrower airway (airway obstruction)
- Children rely on diaphragm for breathing
- Lack of firm body structure makes child more prone to retractions in resp distress
What shows respiratory distress?
- CREBS
- Loss of ability to speak
- Grunting
- Tripod position
What is CREBS?
cough, rate/regularity, effort, breathing sounds, saturation
Assessment focuses with respiratory distress
Position of comfort?
Vital signs
Lung auscultation (bilateral, diminished, absent?, adventitious sounds?)
Respiratory Effort (stridor, grunting, laboured, accessory muscles, tachypnea, paradoxical)
Colour
Cough (dry, wet, brassy, croupy)
Behavioural change
Family history
Respiratory failure
after respiratory distress, it is when they can no longer maintain effective gas exchange (function or structural failure) EARLY RECOGNITION
Signs of respiratory failure
- Cardinal signs (restlessness, tachypnea, tachycardia, diaphoresis)
- Early decompensation (mood changes, nasal flaring, headache, CNS symptoms, retractions, grunting, wheezing, increased WOB, head bobbing)
- Severe hypoxia (hypotension, decreased RR, dyspnea, bradycardia, cyanosis, seesaw respirations)
Alveolar hypoventilation
O2 need exceeds O2 intake, airway partially occluded, transfer of O2 and CO2 in alveoli is disrupted
Head bobbing
sign of resp distress, using neck muscles (scalene and sternocleidomastoid muscles) to help with ventilation and since the muscles in the neck are not very strong compared to the other muscles, the head starts bobbing.
Seesaw respirations
really strong contraction of the diaphragm where is dominates the weaker abdominal chest muscles. Retraction of the chest and expansion of the abdomen
What does O2 sats read?
how much hemoglobin (carrier of oxygen) is attached to the RBCs. Indirect measurement
How to read a hemoglobin curve
Look at the whole picture. Are they working at breathing and their O2 sat is high? Do they have alkalosis or acidosis?
What is PaO2?
the pressure of the oxygen as it diffuses across the alveolocapillary membrane and dissolves in the plasma. It helps bind the oxygen to the hemoglobin molecules and then transported to the cells
What is PCO2
carbon dioxide produced by cellular metabolism is dissolved in the plasma. It travels back to the lungs where it diffuses across the alveolocapillary membrane
Hemoglobin curve shift to L
increased pH
decreased temp
decreased PCO2
Hemoglobin shift to R
decreased pH
increased temp
increased PCO
2,3 DPG
What are the upper respiratory tract infections?
- Acute Streptococcal Pharyngitis
- Tonsilitis
- Croup Syndromes
What are the types of croup syndromes?
o Laryngotracheobronchitis
o Epiglottitis
o Bacterial tracheitis
What is acute streptococcal pharyngitis?
infection primarily affects the pharynx including the tonsils
most common in children 4-7
abrupt onset, lasts 3-5 days
tonsils and pharynx inflamed and covered with exudate
What is another name for acute streptococcal pharyngitis?
Strep throat
What are you at risk for with acute streptococcal pharyngitis?
Rheumatic fever (pain in joints, heart)
Acute glomerulonephritis (in kidneys)
Why do you get rheumatic fever with acute streptococcal pharyngitis
when you do not finish antibiotics
Tx of acute streptococcal pharyngitis
penicillin
Nursing care with acute streptococcal pharyngitis
cold or warm compresses, warm saline gargles, soft diet
Symptoms of Acute Streptococcal Pharyngitis
o Sore throat
o Minimal throat redness and pain
o Exudate
o Purulent drainage and white patches
o Difficulty swallowing, drooling, dehydration, resp distress
Tonsilitis
inflammation of palate tonsils
Infection of pharyngitis does not equal tonsilitis infection even though they both have inflammation of the tonsils
What can tonsilitis cause?
If adenoids enlarged: mouth breathing; Mouth odour, impaired taste & smell; Muffled & nasal voice; Persistent cough; otitis media or hearing difficulties
Hearing loss
Tonsilitis dx
Acute pain (inflammation of the pharynx)
Deficient fluid volume (inadequate intake)
Ineffective breathing patterns (obstruction by enlarged tonsils)
Impaired swallowing (inflammation and pain)
Knowledge deficit (parents)
Nursing care with tonsilitis
Soft to liquid diet
Cool-mist vaporizer
Warm saltwater gargles
Throat lozenges
Analgesic-antipyretic drugs
Post op
- position to facilitate drainage
- careful suctioning PRN
- discourage coughing, clearing throat, blowing nose
- regular analgesia for 24-48 hours
- NPO until able to swallow and no signs of hemorrhage
- observe for hemorrhage
Can you give codeine or aspirin to children?
NO
Codeine is converted to morphine and since metabolism is unpredictable in children, it can cause problems
Aspirin can cause Reye’s syndrome
How can we observe for hemorrhage
Direct observation, tachycardia, pallor, frequent clearing of throat or swallowing, vomiting or secretions with bright red blood
Croup syndromes
broad classification of upper airway illnesses that result from the inflammation and swelling of the epiglottis and larynx, usually extends to the trachea and bronchi
Bacterial croup
bacterial tracheitis & epiglottitis
Viral croup
spasmodic laryngitis & laryngotracheobronchitis (LTB)
Is bacterial or viral croup worse?
Bacterial
What are the airway changes in croup?
epiglottis swells occluding airway, trachea swells against cricoid cartilage resulting in restriction
What are the symptoms of croup?
o Hoarseness
o Seal-like “barking” or “brassy” cough
o Inspiratory stridor
o Varying degrees of respiratory distress
Mild croup
Occasional barking cough, no stridor at rest, no retractions
Moderate croup
Frequent barking cough, audible stridor at rest, no agitation or distress, no cyanosis
Severe croup
Frequent barking cough, prominent inspiratory stridor, tachypnea, marked retractions, agitation &/or distress, no cyanosis, may be lethargic
Impending resp failure with croup
Barking cough & stridor at rest less prominent, retractions may be less apparent, lethargy or decreased LOC, cyanosis
What to do when there is impeding resp failure?
Dexamethasone
Epinephrine
Acute Laryngotracheobronchitis (LTB)
Can be viral and bacterial
Clinical manifestations of Acute Laryngotracheobronchitis (LTB)
URI for several days; progresses to cough & hoarseness; low-grade fever; tachypnea, inspiratory stridor; barking cough, hoarseness
Children < 5 years
Boys > girls
Tx of Acute Laryngotracheobronchitis (LTB)
o Humidification, cool mist
o Medications
- Epinephrine
- Corticosteroids (dexamethasone)
o Encourage fluids; comfort measures
o Supplemental O2; oximetry
o Rest, parental reassurance
Acute Spasmodic Laryngitis
- Spasmodic croup, “midnight” croup
- Paroxysmal attacks of laryngeal obstruction that occur chiefly at night
- Signs of inflammation are absent or mild
Acute Spasmodic Laryngitis management
managed at home with cool mist
Acute Epiglottitis (Supraglottitis) **
- Potentially life-threatening – requires immediate attention
- Sudden onset of illness with high fever (>39)
What are the classic signs of Acute Epiglottitis (Supraglottitis)
Dysphonia, Dysphagia, Drooling, Distressed respiratory effort (tripod position)
Acute Epiglottitis (Supraglottitis) management
Lateral neck x ray
Intubate - Do not inspect mouth & throat unless prepared to intubate!!!
quiet environment; try to minimize crying!!; fluids, emotional support, droplet isolation for 24h after initiation of effective antibiotic therapy
antibiotics, O2, antipyretics for fever & sore throat
What is the difference between other strands of croup and Acute Epiglottitis (Supraglottitis)?
swelling continues after med tx
Bacterial Tracheitis
Serious cause of airway obstruction with features of LTB and epiglottitis
Croupy cough & stridor; High fever (>39) for several days; thick, purulent secretions
Bronchitis
inflammation of the large lower airways (trachea and bronchi)
Dry, hacking, non-productive cough; worse at night; becomes productive in 2-3 days
Bronchiolitis (RSV)
lower respiratory tract illness that occurs when an infecting agent causes inflammation and obstruction of the bronchioles
Patho of RSV
Virus invades mucosal cells lining bronchioles; infected cell membranes fuse to form giant cell with multiple nuclei - creates “syncytia” at cellular level; invaded cells die when virus bursts from inside cell to invade adjacent cells
Cell debris clogs & obstructs bronchioles & irritates airway; airway lining swells & produces excessive mucous; results in partial airway obstruction & bronchospasms - air can move in but not out - wheezes & crackles, air trapping
What is the initial signs of RSV
Initially ill with URI (nasal stuffiness, +/- cough); progresses to deeper & more frequent cough; more stressful, laboured breathing
S&S of RSV
Fever <390 C
Rapid RR, shallow, nasal flaring, retractions
Appear sick, less playful, not eating
Infants may spit up with thick, clear mucous
Air trapping: Bronchioles constrict, alveoli enlarge, makes it harder for CO2 to leave the body, PH goes up, PaCO2 goes down
What age is RSV most severe?
under 6 months
Highest risk groups with RSV
Premature birth (Absence of maternal antibodies, smaller airways)
Bronchopulmonary Dysplasia (BPD) - Bronchial hyper-responsivesness, Reduced lung capacity
Cardiac Disease (Pulmonary vascular hyper-responsiveness, Increased pulmonary blood flow)
Neuromuscular disease( Decreased respiratory muscle strength & endurance
Immune Deficiency (Decreased host defences, impaired capacity to eliminate virus)
Diagnosis of RSV
Chest X-ray – not recommended unless severity suggests alternative disorder
May be difficult to distinguish between RSV & asthma
Nasopharyngeal Wash (NPW) or Nasopharyngeal Swab (FLOQ Swab)
RSV antigen detection + other viral infections (e.g. COVID-19, rhinovirus, influenza, enterovirus)
Guidelines for admission for RSV (CPS)
Signs of severe respiratory distress - e.g. indrawing, grunting, RR > 60/min.
Supplemental O2 to keep sats > 90%
Dehydration or history of poor fluid intake
Cyanosis or history of apnea
Infant at high risk for severe disease - Infants born prematurely (<35 weeks gestation), <3 months old, hemodynamically significant cardiopulmonary disease, immunodeficiency
Family unable to cope
What therapies work with RSV
oxygen and hydration
What is not recommended with RSV
Ventolin (Salbutamol)
Corticosteroids
Antibiotics
Antivirals
3% hypertonic saline nebulization
Chest physiotherapy
Cool mist therapies or aerosol therapy with saline aerosol
What age group can be given synagis?
child has to be 2 or younger
Criteria for discharge for RSV
Tachypnea & work of breathing improved
Maintain O2 sats >90% without supplemental O2 OR stable for home oxygen therapy
Adequate oral feeding
Education provided and appropriate follow-up arranged
Pneumonia
inflammation or infection of the bronchioles and alveolar spaces of the lungs
Follows an upper respiratory tract infection with inhalation of organisms in the nasopharynx or organisms spread to the lung tissue
Asthma
a chronic disorder in children characterized by bronchial constriction/obstruction, hyperresponsive airways, airway inflammation and reoccurring symptoms
Asthma patho
Initial release of inflammatory mediators from bronchial mast cells, macrophages, & epithelial cells
Migration & activation of other inflammatory cells
Alterations in epithelial integrity & autonomic neural control of airway tone
Increase in airway smooth muscle responsiveness - wheezing, dyspnea, & eventual obstruction
Obstruction symptoms (asthma)
Inflammation & edema of mucous membranes
Accumulation of tenacious secretions from mucous glands
Spasm of smooth muscle of bronchi & bronchioles - decreases caliber of bronchioles
Immunologic factors (asthma)
Allergy is strongest epidemiologic risk factor for chronic asthma morbidity & mortality
- IgE is most active antibody in allergic reactions
- release of chemical mediators (histamine, leukotrienes, platelet-activating factor, prostaglandins, serotonin)
What does IgE do?
Mediates hypersensitive reaction in bronchial mucosa - specific tissue binding
Major effect of chemical mediators
o Increased permeability of blood vessels
o Contraction of smooth muscle
o Stimulation of mucous secretion
Vagal stimulation (asthma)
Balance of vagal (constrict) & sympathetic (opens) nerve influences maintenance of tone of bronchial smooth muscle
causing…
Irritant receptors react to triggers & stimulate reflex bronchospasm - normal response but in asthma this is abnormally severe
Ventilation (asthma)
Increased airway resistance - forced expiration - air trapping
Gas exchange (asthma)
Depends on ratio of poorly ventilated & hyperextended alveoli to well-ventilated alveoli
As severity of obstruction increases - reduced alveolar ventilation.
Signs of reduced alveolar ventilation (asthma)
- CO2 retention
- Hypoxemia
- Respiratory acidosis
- Respiratory failure
Asthma exacerbation
Episodes of progressively worsening SOB, cough, wheezing, chest tightness
Decreases in expiratory airflow
* Airways narrow because of bronchospasm, mucosal edema, & mucous plugging - air trapped behind narrowed airways
Hyperinflation - keeps airways open & permits gas exchange
Hypoxemia - ventilation/perfusion mismatch
Two types of asthma
Recurrent wheezing in early childhood; usually precipitated by viral infection (e.g. RSV)
Chronic asthma associated with allergy persisting into later childhood & often adulthood
Steps of asthma
- intermittent asthma - symptoms less or equal 2 days/week
- mild persistent asthma - symptoms > 2 times/week, but < than once/day
3/4. Moderate Persistent asthma - daily
5/6. severe persistent asthma - several times a day
Risk factors of asthma
Atopy (including hx of allergies or atopic dermatitis)
Heredity (e.g. parent/sibling)
Gender (boys > girls until adolescence then girls > boys)
Smoking or exposure to second-hand smoke
Maternal smoking during pregnancy
Ethnicity (African-American at greatest risk)
Low birthweight
Being overweight
Asthma triggers
Allergens
Occupational chemicals
Physical exercise
Cold air
Weather or temperature changes
Environmental change
Colds & infections - viral or bacterial
Animals
Medications
Strong emotion
Conditions
Foods
Endocrine factors
Manifestations of Asthma
Classic: Dyspnea, wheezing, & coughing
Prodromal itching (frontal neck or upper part of back)
Mood changes - feeling uncomfortable or irritable & increasingly restless
Headache, feeling tired, or chest feels “tight”
Breathing Changes - wheezing
Hacking, paroxysmal, irritative & non-productive cough which becomes productive as secretions accumulate
Coughing in absence of respiratory infection, esp. at night (interferes with sleep)
What does it look like when asthma is getting worse?
SOB, prolonged expiratory phase, audible wheezing, - RR & HR, shallow breathing
Pale - cyanosis
Restless & apprehensive - anxious facial expression; irritability
Listlessness
Sweating
Position
Voice changes – short, panting, broken phrases
Retractions
Asthma complications
o Increased susceptibility to infections
o Atelectasis
o Emphysema
o Pneumothorax (rare)
o Status asthmaticus (rare)
Detailed history with asthma
Current symptoms - medications, triggers
History of attacks - seasonal, with colds, (hospitalization, intubated?)
Family History - asthma or allergies
Paint the picture (Compare attacks, look at differences)
Therapeutic management of asthma
Allergen control (House dust mites, cockroach)
Drug therapy
Breathing exercises & physical training
Hypo-sensitization
Exercise
Supportive care with asthma
Maintain patent airway - humidified O2; positioning (raise head of bed; sit up)
Rest & stress reduction - Group care; quiet environment
Fluids - warm, may need IV
Medications
Avoidance of triggers
Reassurance - child and family
Discharge planning & teaching
Peek Expiratory Flow Meter (asthma)
Green = 80-100% - relatively free of symptoms
Yellow = 50-80% - Caution - worsening asthma
Red = Less than 50% - Danger - treatment not controlling symptoms
Medications for asthma
Corticosteroids – anti-inflammatories
- inhaled - “preventors”
- oral
- IV
Beta2 agonists - “rescuers or relievers”
- salbutamol
OTHER MEDS MUST HAVE
Magnesium sulphate - “rescuer”
Methylxannthines
Mast cell inhibitors - “preventors”
Leukotriene receptor antagonists “preventors”
