week 5 Flashcards
Anatomical differences - kids vs adults
- smaller nasal-pharynx, easily occluded with infection
- lymph tissue grows rapidly in early childhood, slowly atrophies in adolescents
- large tongue small mouth easily occluded
- long floppy epiglottis
- larynx and glottis are higher up on the neck increasing risk for aspiration
- cartilage in neck is flexible (when neck is bent airway can collapse)
- diaphragm is main muscle to breath in children, others less developed –/> hard to compensate for edema spasm and trauma
Anatomical differences - kids vs adults - nasal parynx
- occludes easily when infected
Anatomical differences - kids vs adults - lympth tissue
grows faster in early childhood, atrophies in adolescents
Anatomical differences - kids vs adults - tongue
larger tongue, smaller mouth = easily occluded
Anatomical differences - kids vs adults - epiglottis
long floppy epiglottis –> aspiration
Anatomical differences - kids vs adults - larynx and glottis
higher up = increased risk for aspiration
Anatomical differences - kids vs adults - cartilage in neck
flexible –> when neck is bent airway can collapse
Anatomical differences - kids vs adults - diaphragm
main muscle for breathing (others less developed)
= less able to compensate for edema spasm trauma
Airway infant - normal vs edema
- normal = 4mm
- edema from sickness = 1mm
- decreased X-sectional area = 75%
Respiratory assessment - what to ask (4)
- family history of lung disease
- vitals
- audible inspiratory and expiratory breath sounds
- retractions
Respiratory assessment - vitals (12)
- resp rate is not just a number
- assess rate depth and ease of respirations
- auscultation
- are breath sounds equally bilaterally
- do they go all the way to bases
- do you hear any adventitious sounds = wheezes, fine/course crackles, referred upper airway noise
- how hard is the patient working?
- tachypnea
- patients colour
- cough
- behavioural change
Respiratory assessment - audible inspiratory expiratory breath sounds?
- stridor - grunting on expiration
- high pitched musical stridor on inspiration –> foreign body aspiration
Stridor
grunting on expiration
High pitched musical stridor on inspiration
foreign body aspiration
Respiratory assessment - retractions (5)
- tracheal tug
- intercostal
- substernal
- subcostal
- scalene retractions
Tachypnea
- can child articulate without having to catch his breath
- paradoxical breathing/seesaw breathing
Patient’s colour - respiratory
- mucous membranes or skin colour
- pink pale, cyanotic, mottled
- crying make it better or worse
Cough
- productive/non-productive
- seal like-croup
- forceful/weak moving secretions or are they pooling
Behavioural change - respiratory
decrease in LOC
Respiratory distress vs failure - airway patency
RD = open and maintainable
RF = not maintainable
Respiratory distress vs failure - Breathing (3)
RD
- tachypenea
- increased effort-decreased effort
- good air movement
RF
- bradypnea
- decreased effort-apnea
- poor to absent air movement
Respiratory distress vs failure - circulatory (2)
RD = tachycardia, pallar
RF = bradycardia, cyanosis
Respiratory distress vs failure - LOC
- RD = anxiety, agitation
- RF = lethargy, unresponsiveness
Upper airway obstruction - breath sounds
- stridor (typically inspiratory)
- barking cough
- hoarseness
Lower airway obstruction - breath sounds
- wheezing (typically expiratory)
- prolonged expiratory phase
Lung tissue disease - breath sounds
- grunting
- crackles
- decreased breath sounds
Disordered control of breathing - breath sounds
normal
RSV - goals of nursing care
- suction q1hr for secretions (esp before feeding)
- maintain fluid volume
- CPAP or BIPAP - helps with pressures, open lungs, clear secretion
Cystic Fibrosis - goals of nursing care
- complicated genetic condition, growth curves
- life expectancy in Canada vs US is 15 years different
- impacts endocrine, GI, respiratory, reproductive, etc
Respiratory case study: 5yo male presents with chronic cough
- cough is productive increased at night
- worse with exercise and upper respiratory infections
- growth normal
- chest x rays normal except for mild hyperinflation
Asthma!!!
Asthma - what
- chronic inflammatory disease of airway
- increased 40% in last decade
- typically develops in childhood, 50% before age 3, majority before 8 y/o
asthma - challenge with ICU
CAN’T intubate!! lungs are too hyper-inflated
Asthma - pathogenesis (6)
- airway inflammation contributing to airflow limitation
- bronchioconstriciton
- edema
- chronic mucus plugging
- airway wall remodeling
- leads to bronchial obstruction
Normal airway vs asthmatic airway
- bronchoconstriction due to edema !
- sludgy mucus plugfs
- muscles are constricted
challenge with Treating asthma
- ventalin = bronchodilator
- but can only open airways so far… like balloon with elastics on it and trying to blow it up
Asthma - physical exam findings (4)
- wheezing
- crackles in lung
- forced expiratory phase
- muscle retractions (often can be normal)
Diagnostic studies for asthma
- chest X-ray (will diffuse hyper inflation)
Wheezing + asthma (6)
- localized or diffuse airway narrowing or obstruction from larynx to small bronchi
- high pitched whistling sound made while breathing
- associated with difficulty breathing
- presents on expiration or inspiration
- absence of wheezing in asthmatic = improvement of bronchoconstriction, or severe widespread airflow obstruction
- “silent chest” = sign of respiratory muscle fatigue and failure leading to status asthmaticus
PRAM scoring (pediatric respiratory assessment measure) - assesses what (5)
- suprasternal retractions
- scalene muscle contractions
- air entry
- wheezing
- oxygen saturation
PRAM scoring - suprasternal retractions
absent = 0
present = 2
PRAM scoring - scalene muscle contractions
absent = 0
present = 2
PRAM scoring - air entry
normal = 0
decreased at base = 1
widespread decrease = 2
PRAM scoring - wheezing
absent = 0
expiratory only = 1
expiratory and inspiratory = 2
audible without stethoscope/silent chest = 3
PRAM scoring - O2 sat on room air
> 95% = 0
92-94% = 1
<92% = 2
PRAM scoring - what is a concerning score
6 or higher
Asthma treatment - at home (4)
1) bronchodilators (short acting ventolin/salbutamol)
2) leukotriene modifiers (singulair/montelukast)
3) inhaled corticosteroids (fluticasone/Flovent)
4) combination therapy (inhaled steroid and long-acting bronchodilator)
Asthma treatment - in hospital (4)
1) Atrovent/Ipratropium bromide (anticholinergic bronchodilator)
2) dexamethasone (systemic steroids)
3) salbutamol nebulizers via IV
4) magnesium sulfate via IV
when asthmatics should come in to hospital
puffers ever 4 hours
Salbutamol side effect
makes Heart race (tachycardia)
Asthma and exercise (5)
- exercise can trigger asthma
- symptoms are worse with cold dry air
- exercise helps lung function better and prevent obesity
- as long as asthma is well controlled and short acting bronchodilator is used before, children with asthma should be able to do sports
- pulmonary function testing best first, then exercise testing
Respiratory case: 4 month old infant brought to ER because of lethargy. Physical exam finds
- 24 week preemie with chronic lung disease, patent ductus arteriosus (PDA), apnea of prematurity
- occasional apneic episodes with feeds, desats to 80s and bradycardia
- now 4 months of age (41 weeks gestational age)
- baseline O2 sats are normal
diagnosis - apnea of infancy
Apnea of infancy - what (4)
- unexplained episodes of cessation of breathing for 20 seconds or longer, OR a shorter respiratory pause associated with bradycardia, cyanosis, pallor, and/or marked hypotonia
- called apnea of prematurity when present in infant less than 37 weeks gestational age
- usually ceases by 37 weeks post-menstrual age but may persist for several weeks beyond term
- extreme episodes usually cease at 3 weeks post-conceptional age
Apparent Life-Threatening Event (ALTE) (5)
- Episode in an infant that is frightening to observer and is characterized by a combo of
- apnea
- colour change
- unresponsive
- change in muscle tone, choking, gagging
Prematurity (3)
- preterm infants -= greater risk of extreme apnea episodes
- risk decreases with time, ceasing at approx. 43 weeks post-menstrual age
- in infants with recurrent significant apnea monitoring may be considered
Obstructive sleep apnea (what)
- disorder of breathing during sleep characterized by a) prolonged partial upper airway obstruction, and/or b) intermittent complete obstruction that disrupts ventilation during sleep
- combo of structural and neuromuscular factors
- dynamic process
- site of airway collapse in children most often at level of adenoid
Prevalence of obstructive sleep apnea (3)
- children all ages
- most common in preschool-aged children (when tonsils and adenoids are largest in r/t underlying airway size
- estimated prevalence rates of approx. 2%
Obstructive sleep apnea - high risk populations (5)
- obesity
- downs syndrome
- Prader Willi syndrome
- neuromuscular disease
- craniofacial anomalies
Respiratory case -
- 6 y/o female presents to ER after one week nasal congestion adn mild cough, two days ago developed high fevers, chills, increased cough
- ill appearing, tachypneic, febrile
- crackles on exam over right posterior lung fields
- no prior pneumonia or wheezing
- FHx of asthma
- no recent travel out of country
- WBC 35,000
- white-out on X-Ray of right lung
Right upper Pneumonia
Pneumonia - what (3)
- inflammation of lung parenchyma
- portion of lung involved in gas transfer
- alveoli, alveolar ducts, respiratory bronchioles
Pneumonia - comon cause
- respiratory virus in first years of life
pneumonia - risk factors (2)
daycare
cigarette smoking
Pneumonia - clinical signs (10)
- shaking chills
- high fever
- cough
- chest pain
- mild URI
- decreased appetite
- abrupt onset high fever
- rusty-coloured sputum
- respiratory distress
- cyanosis
Pneumonia - physical exam (6)
- retractions
- dullness to percussion
- tubular breath sounds
- rales
- diminished tactile and vocal fremitus
- decreased breath sounds
Pneumonia - lab findings (5)
- leukocytosis with left shift
- WBC <5000/mm3 (poor prognosis)
- ABG: hypoxemia
- bacteremia on blood culture
- positive sputum culture
Mild pneumonia clinical features (temp, respirations, mental status, colour, feeding, HR, cap refil)
- temp <38.5
- mild or absent resp distress
- increased RR (but moderately)
- mild or absent retractions
- no grunting
- no nasal falring
- no apnea
- mild SOB
- normal colour
- normal mental status
- normozemia (O2 sat >92 RA)
- normal feeding (infants) no vomiting
- normal HR
- cap refil <2 seconds
severe pneumonia clinical features (temp, respirations, mental status, colour, feeding, HR, cap refil)
- temp >38.5
- moderate to severe respiratory distress (infant >70, children >50)
- moderate/severe suprasternal, intercostal, subcostal retractions
- severe difficulty breathing
- grunting
- nasal flaring
- apnea
- significant SOB
- cyanosis
- altered mental status
- hypoxemia <90 percent at RA
- not feeding (infants) S/S of dehydration (older children)
-tachycardia - cap refil >2 seconds
Complications of pneumonia (6)
- empyema (purulent drainage in pleural space)
- pleural effusion
- pericarditis
- meningitis
- osteomyelitis
- metastatic abscesses
Treatment of pneumonia - all children (7)
- decision to hospitalize based on severity of illness and home environment
- can often treat as outpatient
- patients with empyema or pleural effusion should be hospitalized
- oxygen
- thoracentesis
- chest tube drainage
- decortication
Treatment of pneumonia - neonates (3)
- parenteral antibiotics (ampicilin, gentamicin)
- treat as rule out sepsis
- once stabilized, they can be discharged
Respiratory case - 2 month old infant brought to ER with persistant cough and difficulty breathing
- audible stridor, harsh honking cough, suprasternal subcostal cest wall retractions
- Upper Resp Infection symptoms. low grade fever, nontoxic appearing
whooping cough?
Stridor - what (3)
- harsh, high-pitched predominantly inspiratory sound produced by partial obstruction of airway, resulting in turbulent airflow
- associated with degrees of difficulty in breating
- usually associated with suprasternal retractions, when severe with intercostal, subcostal, substernal
Causes of stridor in infants and children - nasopharynx
- choanal atresia
- thyroglossal cyst
- hypertrophic tonsils
- retropharyngeal or peritonsillar abscess
choanal atresia
narrowing of back of nasal cavity c
retropharyngeal or peritonsillar abscess
tonsil stones
Causes of stridor in infants and children - larynx
- laryngomalcia
- viral croup
- vocal cord paralysis
- laryngeal stenosis
- laryngospasm
- vocal cord dysfunction
Laryngomalcia
laryngeal web, cyst, or laryngocele = noisy breathing
falls in, blocks the airway
Viral croup
- spasmodic croup
- epiglottitis
Causes of stridor in infants and children - trachea
- subglottic stenosis
- hemangioma
- forein body
- tracheomalacia
- bacterial tracheitis
- external compression
Acute laryngotracheobronchitis - etiology
- parainfluenza virus 1, 2, 3
- respiratory syncytial virus
- rhinovirus
- influenza virus a
- adenovirus
Acute laryngotracheobronchitis - epidemiology
- fall and early winter
- more common in boys
- mostly at night
- duration from hours to days
Recurrent (spasmodic croup) (7)
- 6% of children
- not associated with obvious infection
- abrupt onset, usually during sleep
- barking cough, hoarsness, stridor
- usually resolves within hours
- may be a hypersensitivity reaction
- associated with airway hyper-reactivity
Epiglottitis - what (5)
- threatening infection
- incidence is 10-40 cases per 1 million
- widespread vaccination against haemophilus influenzae type B and has decreased incidence dramatically
- age 2-4 years
- various organisms can cause it streptococcus pneumoniae, haemophilus parainfluenzae, varicella, etc.
Epiglottitis symptoms (6)
- sore throat
- muffling or changes in voice
- difficulty speaking
- high fever
- dysphagia
- drooling
- respiratory distress
treating croup
treat with nebulized epi and puffers of epi to help vasoconstrict everything there to open up airway
- q1hr
dexamethozone (kicks in in 4 hours)
What is cystic fibrosis (what, prevelance, symptoms, complications)
- genetic disorder impacting CFTR gene
- most common debilitating disease of childhoodd-
- results in thickened secretion of sweat glands, GI tract, pancreas, respiratory tract, exocrine tissues
- complications = obstruction, chronic infection, tissue damage, resp failure
Cystic fibrosis - pathophysiology - respiratory (3)
- thickened mucous
- secretions plug tubes in lungs
- difficulty clearing secretions
Cystic fibrosis - pathophysiology - pancreas and digestive (3)
- bile ducts, intestinal glands, gal bladder obstructed by mucous
- pancreatic enzyme activity lost
- malabsorption
Cystic fibrosis - pathophysiology - integumentary (4)
- sweat glands produce too much chloride
- salty taste of skin
- electrolyte imbalance
- dehydration
Cystic fibrosis - pathophysiology - other complications
fertility issues
complications of CF (8)
- hemoptysis
- pneumothorax
- bacterial colonization
- intestinal obstruction
- GERD
- diabetes
- portal hypertension
- decreased fertility
Diagnosis of cystic fibrosis
- newborn screening panel
Presentation of patient with cystic fibrosis (9)
- respiratory infections
- poor weight gain
- pancreatic insufficiency
- “sweat test”
- persistent cough with thick sputum
- foul smelling greasy stools
- malnutrition
- dehydration/electrolyte imbalance
- nasal polyps
Non-phamacological orders for patient with CF
- contact isolation
- vitals q12hr
- physiotherapy to mobilize secretions
- CF diet (high fat high protein)
- Pancreatic elastase stool test
- Pulmonary function test
Drug therapy for cystic fibrosis (9)
- ANTIBIOTICS - oral, inhaled/nebulized, IV
- bronchodilators (salbutamol, levalbuterol)
- mucous thinners (hypertonic saline, dornase alfa)
- CFTR modulators (ivacaftor, lumacaftor, tezacafter, etc)
- anti inflammatorys (steroids, NSAIDs)
- oral pancreatic enzymes (pancrelipase)
- acid reducing meds (omeprazole)
- stool softener (polyethylene glycol)
- oxygen therapy
Goals for cystic fibrosis management (2)
- nutrition management
- airway clearance techniques
Cystic fibrosis potential surgeries/procedures (5)
- bowel surgery
- nasal and sinus surgery
- lung transplant
- liver transplant
- non-invasive ventilation
Life expectancy - CF
- median survival 50 years old
What is dornase alfa used for
enzyme that decreases viscosity of mucus present in the lungs
what is salbutamol used for
bronchodilation
what is tobramycin
antibiotic used to treat bacterial infections in respiratory tract
what is pancrelipase
enzyme med that aids food digestion
why do CF patients take vitamin d supplements?
- CF –> decreased metabolism of vit D = defficiency
- promote bone health, improve lung function
Omeprazole role
proton pump inhibitor to decrease production of gastric acid
- allow for pancreatic enzymes to function better
ursodiol use
- gallstone dissolusion agent
piperacillin tazobactam use
antibiotic (penicillin and beta-lactamase inhibitor) to treat bacterial infections
SMOFlipid
- a lipid emulsion providing fatty acids to meet metabolic demands
Bronchiolitis and Respiratory Syncytial virus - what
- lower respiratory tract infection caused by virus/bacteria = inflammation/obstruction of bronchioles
Pathophysiology of RSV (3)
- mucus hyper-secretion
- cell wall thickening
- smooth muscle contraction
Diagnosis of RSV
- children under 2, esp infants under 3 months
- chest X ray –> hyperinflation, patchy atelectasis, inflammation
- Labs = enzyme linked immunosorbent assay (ELISA) or immunoflurescent assay
Management of RSV (3)
- educate parents and caregivers to reduce exposure and transmission of disease
- hand hygiene
- limit exposure to crowds other children cigarette smoke
Treatment of RSV (4)
- humidified O2 (severe)
- hydration (IV/oral)
- nasal suctioning
- fowler’s position
Meds to treat RSV (4)
- nebulized hypertonic saline
- acetaminophen
- vitamin D
- nebulized salbutamol/ventolin
Goals of care - RV (7)
- care for equipment
- med admin
- head to toe (vitals, resp)
- o2 support
- client education
- fluid and nutrition support
- emotional suport
