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NSG 102H -Pediatric Lectures 4 and 5

NSG 102H -Pediatric Lectures 4 and 5

NSG 102H -Pediatric Lectures 4 and 5

Respiratory Disorders to be Discussed

Upper Respiratory

  • Nasophayngitis
  • Pharynigitis
  • Influenza
  • Otitis Media (ears)
  • Infectious Mononucleosis
  • Croup syndromes

Lower Respiratory

  • Bronchitis
  • RSV/Bronchiolitis
  • Pertussis
  • Pulmonary Dysfunction

 

If there is a code in a pediatric unit, the first thing that is brought is an intubation kit; their problems are generally respiratory in nature.

Cardiomyopathy – more prone to arrhythmias which are detrimental and can kill you. Give irregularities in the electrical system

Mono is respiratory because it presents in the throat first

Croup – sounds lower but is UR

 

Caused by Noninfectious Irritants

  • Foreign body aspiration – choking (toddlers on toys)
  • Aspiration pneumonia
  • Environmental tobacco smoke exposure – Asthma is sensitive to this

Long-term Respiratory Dysfunction

  • Asthma
  • Cystic Fibrosis

 

Anytime there is a unilateral presentation (unilateral expansion of lungs, etc) you should wonder if it is a foreign body aspirate.

 

GENERAL ASPECTS OF RESPIRATORY TRACT INFECTIONS

  • Respiratory infections are cause of majority of acute illnesses in children
  • Upper respiratory tract
    • Oronasopharynx, pharynx, larynx, and trachea
  • Lower respiratory tract
    • Bronchi, bronchioles, and alveoli

 

  • Infectious Agents
  • Viruses: Most infections are viral
    • Respiratory syncytial virus (RSV)
    • Adenovirsus, Parainfluenza, coxsackieviruses  A and B
    • Others: (primary or secondary infections)
    • Group A ?-hemolytic streptococci
    • Staphylococci
    • Chlamydia trachomatis, mycoplasma organisms, pneumococci
    • Haemophilus influenzae

Age

  • Infants <3 months: maternal antibodies
  • 3-6 months: infection rate increases – building up immune system. This is the time between the disspearance of maternal antibodies and the development of their own immune system. Normal to get 5-7 colds per season
  • Toddler and preschool ages: high rate of viral infections
  • >5 years: increase in mycoplasmal pneumonia and ?-streptococcal infections
  • Increased immunity with age – as you get older, you gain immunity

NSG 102H -Pediatric Lectures 4 and 5

Size

  • Diameter of airways: subject to considerable narrowing from edematous mucous membranes
  • Distance between structures is shorter, allowing organisms to rapidly move down
  • Short eustachian tubes: allows pathogens easy access to the middle ear
  • Important slide
  • If you are an adult with mucus and a cough, there are large airways to let things out
  • Children have shorter airways
  • The tongue takes up more room in the child’s airway
  • Smaller nares in children (if child has a stuffy nose, they will breathe through their mouth)

 

Short Eustachian tubes. KNOW THIS SLIDE

4 mm new born airway is very tiny. A small amount of swelling and mucus is very impactful

Can babies die of RSV? Yes. The tiny airway makes it dangerous

RSV vaccine for kids with chronic illness

If you are preterm/immunosuppressed – you need the vaccine because they can die from RSV due to airway collapse. Airways get swollen/tight

 

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

 

Clinical Manifestations of Respiratory Infections

  • Vary with age
  • Generalized signs and symptoms and local manifestations differ in young children:
    • Fever
    • Anorexia (no desire to eat bc so sick), vomiting, diarrhea, abdominal pain
    • Cough, sore throat, nasal blockage or discharge
    • Respiratory sounds
  • Abdominal pain is a key symptom in school aged kids
  • Respiratory sounds – wheezing, bronchi, adventitious

 

Nursing Interventions for Respiratory Infections

  • Ease respiratory effort
  • Fever management
  • Promote rest and comfort
  • Infection control
  • Promote hydration and nutrition
  • Family support and teaching

 

Febrile seizure hx means you should do fever management. The reason we manage fevers in a respiratory illness is because a fever causes physiological signs like increased HR and respiratory rate. So, you want to prevent respiratory expenditure

Increase HR is physiological sign to dehydration – tachypnea and tachycardia

 

Drug Alert: Over-the-Counter Cold Preparations

Over-the-counter cold preparation such as pseudoephedrine and some antihistamines are not appropriate for the treatment of the common cold in infants and toddlers; these may cause serious side effects in such children and have been associated with death in infants (Rimsza and Newberry, 2008; Ryan, Brewer, and Small, 2008). Advise parents to consult the primary care physician before using these drugs in infants and toddlers.

Most of the time its recommended to do nothing.

OTC with antihistamine or Sudafed can cause tachycardia and lead to the opposite response

Cold lasts 7-10 days

 

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
      • Symptoms are more severe in infants
      • Fever common in young children. Older children have low grade fevers
      • Symptoms may last up to 10 days
    • Babies cry, children tend to run around
    • Home management—varies with age (fluids, reduce fever)
    • Cry of this baby will be different if they have a fever

 

Pharyngitis

  • **Causes: 80%-90% are viral
  • Etiology: may be viral or bacterial
  • Clinical manifestations: caused by inflammation, edema, “kissing tonsils” may cause difficulty in swallowing and breathing
  • Therapeutic management: differentiate b/w strep and viral infection, fever reduction, tonsillectomy in extreme dx:  peritonsillar abscess (PTA)- medical emergency*
  • Nursing considerations: fever reduction/pain reliever, fluids, cool-mist vaporizer, throat lozenges

 

We worry about tonsils and bacteria is due to “kissing tonsils” they are literally touching. It can cause airway occlusion

NSG 102H -Pediatric Lectures 4 and 5

Acute Streptococcal Pharyngitis

  • Group A ?-hemolytic streptococci (GABHS)
  • Manifestations/treatment regimen: pharyngitis and strawberry tongue, enlarged lymph nodes, headache, abdominal pain and fever
  • Onset is quick
  • Risk for serious sequelae
    • Acute rheumatic fever
      • Heart valve damage that lasts lifelong – requires valve replacement
    • Acute glomerulonephritis – kidney damage
    • Scarlet fever (though rarely seen in United States)
  • We worry about the sequllae related to strep
  • If you have strep, you have about 10 days to treat it. If you don’t treat it, it doesn’t’t necessarily mean you get the sequalle, but we do worry about it. Can lead to arthritis.

 

Pharmacologic Interventions—Strep

  • Penicillin
    • Oral
      • Needs 10-day treatment to decrease risk of rheumatic fever and glomerulonephritis post strep
      • Issues with medication compliance
    • IM: Penicillin G – not preferred
      • Resolves compliance issue (one injection)
      • Painful injection
      • Penicillin G procaine is less painful injection
        • Can use ELMA to reduce pain of injection
      • CANNOT give penicillin G by IV route – toxic reaction and embolism
    • Erythromycin if penicillin allergy
    • Other antibiotics
  • Wont be asked about drug doses for strep
  • Partial treatment can allow the infection to come back
  • IM penicillin comes with the risk of allergies. You have to wait 20-30 min after to make sure there is no anaphylactic reaction

 

Tonsillitis and Pharyngitis

Location of Various Tonsillar Masses

  • Tonsillitis manifestations: kissing tonsils from edema, may obstruct passage of food or air. Enlargement of adenoids can block posterior nares and make it hard for child to breath – can cause mouth breathing.

Nursing Concerns—Post-Op Tonsillectomy (removal of palantine tonsils). Need 3+ infections a year and fail to respond to antibiotics

  • Airway
    • Positioning
  • Bleeding
    • Observation—frequent swallowing?
    • Prevention of recurrent bleeding
    • Maintain quiet environment
    • Minimize agitation/crying
  • Comfort

Tonsils are lymph tissue and help with infection to some extent. There is criteria to remove it but it is not longer the first line

Anatomically, tonsils are near the airway. There are stitches. There is swelling. Increased risk for bleeding.

Avoid direct pressure in the back near the tonsil stitches

Little kids will try to keep swallowing and it can cause nausea because they keep swallowing blood. This is an important post-op symptoms.

  • Be aware of signs of hemorrhage

 

Influenza: type A, B, and C

  • Clinical manifestations: subclinical, mild, moderate, severe
  • Therapeutic management: usually requires only symptom mgmt.
  • Prevention: vaccination
  • Nursing considerations: same as URI, relieve symptoms
  • Spread by contact – droplet infections

 

Pharmacologic Intervention for Influenza in Children

  • Antivirals for children
    • Oseltamivir (Tamiflu): age restrictions
    • Zanamivir (RELENZA) (7 years old+)
  • Must start within 48 hours of symptom onset
  • Avoid aspirin—possible link with Reye syndrome

 

Influenza Vaccines

  • Now recommended for children over age 6 months
  • New vaccine annually
  • Injected and inhaled vaccines
  • Contraindications to influenza vaccines
    • Egg allergies
  • Child is asthmatic with temp of 99.8, do you give flu vaccine? Don’t give vaccine if child is sick

 

Otitis Media

Often preceded by viral respiratory infections like RSV and flu

Strep pneu, H. influenza, and Morazella catarrhalis = most common bacteria causing AOM

  • Otitis Media (OM)
    • Primarily due to malfunctioning Eustachian tubes
  • Acute Otitis Media (AOM)
  • Otitis Media with Effusion (OME)

 

OM and Infant Feeding Methods

  • Breast-fed infants have less OM than bottle-fed infants
    • Immunoglobulin A
    • Position in breast-feeding may decrease reflex in eustachian tubes

Clinical Manifestations

AOM

  • Follows an URI
  • Earache (otalgia)
  • Fever (maybe)
  • Reddened, bulging, membrane with purpulent effusion
  • Purulent discharge
  • AOM – can follow a cold
  • Chronic – ears ringing, fullness, difficulty hearing, long term
  • TXM with antibiotics – oral amoxicillin

 

Chronic OM

  • Hearing loss
  • Difficulty communicating
  • Feeling of fullness, tinnitus, vertigo

 

Clinical Manifestations: Behavioral***

Infant/Young child

  • Crying
  • *Fussiness, restlessness, irritability
  • Rub, hold, pull ear
  • Rolling side to side
  • Difficulty comforting
  • Loss of appetite

Older Child

  • Crying, verbalizing feeling of discomfort
  • Irritability
  • Loss of appetite

 

Focus of Nursing Care

  • Prevention of infection
  • Prompt identification: fever, pain, etc go into the MD to get evaluation
  • Teach family so that child is successfully treated: use meds properly, complete abx for 10 days*,

Pharmacologic Interventions

  • First-line antibiotics
    • Amoxicillin PO 80 to 90 mg/kg/day, divided twice daily Ă—10 days
  • Second-line antibiotics
    • Amoxicillin-clavulanate (Augmentin), azithromycin
    • Cephalosporins IM
      • If highly resistant organism or noncompliant with oral doses
      • IM is painful
        • Reconstitute with 1% lidocaine (without epinephrine) to decrease pain of injection
  • Analgesic-antipyretic drugs
    • Acetaminophen
    • Ibuprofen (only if >6 months of age)
  • No steroids, antihistamines, decongestants, antibiotic ear drops
  • Don’t need to memorize. Amoxicillin
  • If you still have persistent fever/symptomatic at 72 hours after abx it isn’t working and should be switched

NSG 102H -Pediatric Lectures 4 and 5

Anatomic Position of ET in Child and Adult

Bacteria in eardrum. Its bulging, red

***

Adult don’t get as many ear infections because they are anatomically superior.

 

Otitis Externa

  • Infections of the external ear
  • “Swimmer’s ear”
  • Relief of pain
  • Nursing considerations

 

Infectious Mononucleosis

  • Characterized by increased mononuclear elements of the blood; general symptoms of infectious process
  • Common among adolescents
  • Principal cause is Epstein-Barr virus
    • High LFT, no contact sports – spleen injury
  • No specific treatment

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
  • viral in nature

 

Croup Syndromes

  • Broad classification of upper airway illnesses that result from swelling of epiglottis and larynx
  • Kids will often be drooling because it blocks their airway
  • Child may be tripoding
  • Retractions may be present
  • Croup usually comes from a virus. Barking, horrible cough w/ inspiratory stridor. More prevalent at night bc dry. Seal like. Fluids, motrin
  • Etiology: Viral ( acute spasmodic laryngitis/spasmodic croup, laryngotracheo bronchitis, laryngotracheitis) or Bacterial (bacterial tracheitis, epiglottitis).
  • Clinical Manifestations: inspiratory stridor (high-pitched musical sound, seal-like barking cough & hoarseness
  • Viral syndromes are mild & managed at home

 

Acute Epiglottitis: serious obstructive  inflammatory process in children 2-5 usually but can occur in infancy.

  • Clinical manifestations:
    • Onset is abrupt and can rapidly progress to respiratory distress
    • Sore throat, pain, tripod positioning, retractions
    • Sitting forward leading with mouth open and tongue protruding
    • Drooling
    • Inspiratory stridor, mild hypoxia, distress
    • Suprasternal and substernal retractions may be evident
    • Cherry red edematous epiglottis
    • Therapeutic management:
      • Potential for respiratory obstruction
    • Nursing considerations
      • Don’t need to do tons of invasive stuff because you don’t want to further the inflammation.
      • Need anesthesiologist for intubation/ENT can intubate under fluoroscopy
      • You have 1 try to intubate a patient with epiglottitis
      • Have a crash cart, intubation tray
      • May need to x-ray the patient, have the mom/dad hold them. You want them to be calm. You do not want the child to cry
      • Airway must be stable before you do anything else
      • Hypoxia, hypercapnia, and acidosis can happen quickly
      • Avoid anything invasive like IV insertion or intubation if you can help it – want to prevent further agitation
      • Never use tongue depressor
    • Prevention: Hib influenza vaccine

 

  • Medical emergency
  • Severe inspiratory stridor
  • Hypoxia
  • Incredible swelling
  • Tripod positioning – medical emergency
  • Swelling in epiglottis – child will drool, wont be talking
  • Wont be coughing
  • Emergency trach is the last step

 

Acute Epiglottitis: Nursing Alerts

  • 3 clinical observations that are predictive of epiglottitis are absence of spontaneous cough, presence of drooling,& agitation
  • Throat inspection should be attempted only when immediate endotracheal intubation can be performed if needed

 

**Nursing Considerations—Epiglottitis**

  • Position for comfort
  • Decrease anxiety
  • No tongue blade
  • Keep suction at bedside
  • Keep emergency respiratory equipment at bedside

NSG 102H -Pediatric Lectures 4 and 5

Acute Laryngitis

  • More common in older children and adolescents
  • Usually viral
  • Usually caused by virus
  • Chief complaint is hoarseness
  • Generally self-limiting and without long-term sequelae
  • Not detrimental because it does not obstruct the airway
  • Treatment: symptomatic

 

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
    • Winter-time type of sickness accompanied by a barking cough

 

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

*Do pulse ox on this kid

 

Therapeutic Management of LTB

  • Airway management
  • Maintain hydration (PO or IV)
    • If they are very tachypneic they will not be able to drink so insert IV
  • High humidity with cool mist
  • Nebulizer treatments:
    • Epinephrine (racemic Epi nebulizer to decrease swelling)
    • Steroids

 

Signs of Increasing Respiratory Distress in Children

  • RESTLESSNESS – across all age groups
  • Tachycardia
  • Tachypnea
  • Retractions
    • Substernal
    • Suprasternal
    • Intracostal

 

 Acute Spasmodic Laryngitis (another form of croup)

  • AKA spasmodic croup, midnight croup
    • Barking cough
    • This is the most common croup
      • We wont need to differentiate between the types of croup
    • Characterized by recurrent paroxysmal attacks of laryngeal obstruction
    • Occur chiefly at night
    • Inflammation: mild or absent
    • Most often affects children ages 1-3 years
    • Therapeutic management – same as management for infectious croup

 

Bacterial Tracheitis

  • Infection of the mucosa of the upper trachea
  • Usually children <3
  • 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
    • TXM with antibiotics
    • Might be a complication of croup
    • Seen in kids with cystic fibrosis
  • The child has a history of previous URI with croupy cough, stridor unaffected by position, toxicity, absence of drooling, and high fever. Thick, purulent tracheal secretions are common, and respiratory difficulties are secondary to these copious secretions. The child’s white cell count will be elevated. Children with this condition may develop a life-threatening upper airway obstruction, respiratory failure, acute respiratory distress syndrome (ARDS), and multiple organ dysfunction

 

Therapeutic Management of Bacterial Tracheitis

  • Humidified oxygen
  • Antipyretics: Tylenol and motrin
  • Antibiotics
  • May require intubation

NSG 102H -Pediatric Lectures 4 and 5

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
  • Constriction of airways

 

Bronchitis

  • Description: usually occurs in association with URI
    • Inflammation of large airways – trachea and bronchi
    • Viral agents are primary cause
  • Age group: first 4 years of life
  • Etiology: usually viral
  • Predominate characteristics: persistent dry, hacking cough (worse at night) becoming productive in 2-3 days
  • Treatment: symptomatic, antipyretics and humidity
  • Cant always be seen on a chest x-ray, pneumonia you can see consolidation on x-ray

 

Bronchiolitis

  • Description: most common infectious disease of lower airways
  • Age group: usually children 2-12 months of age; rare after age 2 years. Peak incidence ~6 months of age
    • Usually manifests as wheezing in young child 2-12 mo
    • Airway reacting to virus
    • If they are very uncomfortable they may need an IV
  • Etiology: viruses, predominantly RSV (respiratory syncytial viruses), adenoviruses, parainfluenza viruses, Mycoplasma pneumonia (this kind of pneumonia cannot be seen on chest xray)
  • Predominate characteristics: labored respirations, poor feeding, cough tachypnea, retractions & nasal flaring, incr. nasal mucous, wheeze, may have fever
  • Treatment: supplemental oxygen, suctioning nasopharynx, ensure adequate fluid intake, maintain adequate oxygenation
    • Steroids and antihistamines are generally not helpful
    • Synagis for prevention of RSV – for premies and children with chronic lung disease
    • These children are usually on contact precautions in the hospital
  • The bronchiolar mucosa swells, and lumina are subsequently filled with mucus and exudate. The walls of the bronchi and bronchioles are infiltrated with inflammatory cells, and peribronchiolar interstitial pneumonitis is usually present

 

Pertussis (Whooping Cough)

  • Caused by Bordetella pertussis
  • In the United States, it occurs most often in children who have not been immunized
  • Highest incidence in spring and summer
  • Can result in encephalopathy, seizures, and pneumonia
  • Highly contagious: whole family will be treated even if they have been immunized
  • Risk to young infants
  • Vaccines

 

Aspiration Pneumonia

  • Risk for child with feeding difficulties
  • Prevention of aspiration
  • Feeding techniques, positioning
  • Avoid aspiration risks
    • Dysphagia and stroke patients (patients who are immobile are at the highest risk)
    • Aspiration of stomach contents

Pneumonia:

  • Inflammation of pulmonary parenchyma
  • More frequently seen in early childhood
  • Can be bacterial, mycoplasmal, or aspiration
  • Neonates—Group B streptococci, gram-negative enteric bacteria,
  • cytomegalovirus, Ureaplasma urealyticum, Listeria monocytogenes,
  • trachomatis
  • Infants—RSV, parainfluenza virus, influenza virus, adenovirus, meta- pneumovirus, pneumoniae, H. influenzae, M. pneumoniae, Myco- bacterium tuberculosis
  • Preschool children——RSV, parainfluenza virus, influenza virus, adenovirus, metapneumovirus, pneumoniae, H. influenzae, M. pneumoniae, M. tuberculosis
  • School-age children— pneumoniae, Chlamydia pneumoniae,?M. tuberculosis, and respiratory viruses
  • Clinical manifestation: depends on etiology
    • Usually have high fever, unproductive or productive cough, tachypnea, breath sounds crackles, decreased breath sounds, rales), dullness with percussion, ches pain, retractions, nasal flaring, pallor to cyanosis, diffuse infiltration on chest xray, irritability, restlessness, malaise, lethargy, anorexia, vomiting, diarrheal, abdominal pain
  • Prevention = pneumonia vaccine

NSG 102H -Pediatric Lectures 4 and 5

Foreign Body Aspiration

  • Etiology: Foods, small toys, house hold items
  • Clinical Manifestations: spasmodic coughing, gagging, dyspnea, tachypnea, nasal flaring, retractions, anxious expression, sitting in forward position, incr. irritability, decr. responsiveness
  • Diagnostic test: Chest x-ray
  • Clinical therapy: removal of foreign body
  • Nsg Mgmt: assessment, monitoring, supporting child/family & preventing future airway obstruction
  • Concern about children putting things in their noses
  • **One sided presentation

 

Environmental Tobacco Smoke Exposure

  • respiratory illness
  • respiratory symptoms: cough, sputum, wheezing
  • AOM, OME (ear infections – due to small/short Eustachian tubes)
  • Linked to Asthma
  • Nursing Mgmt: education

 

Asthma

  • Chronic inflammatory disorder of airways
  • Bronchial hyper-responsiveness
  • Episodic
  • Limited airflow or obstruction that reverses spontaneously or with treatment

 

Risk Factors for Asthma

  • Age
  • Atopy: allergic/skin responses Ă  eczema incidence related to asthma
  • Heredity
  • Gender
  • Mother <age 20 years
  • Smoking (maternal and grandmaternal)
  • Ethnicity (African-Americans at greatest risk)
  • Previous life-threatening attacks
  • Lack of access to medical care
  • Psychologic and psychosocial problems
  • Linkages to allergic and inflammatory genes on chromosome 5

*Child may not be wheezing aka no breath sounds, but this is a bad sign because it means there is airway compromise

*Asthma is somewhat familial

 

Asthma Types and Categories

  • Types
    1. Recurrent wheezing usually precipitated by a viral respiratory tract infection (e.g., RSV)
    2. Chronic asthma associated with allergy persisting into later childhood and often adulthood
    3. Associated with girls who develop obesity and early-onset puberty by age 11
    4. Cough-variant asthma
  • Categories
    1. Intermittent, mild persistent, moderate persistent, and severe persistent
      • Differences in management of different types of asthma
      • Medication according to peak flow

NSG 102H -Pediatric Lectures 4 and 5

Asthma

  • Description: exaggerated response of bronchi to a trigger
    • Most common chronic disease of childhood.
    • Higher incidence in African Americans
  • Age group: infancy to adolescence
  • Etiology: most often viruses (ie: RSV in infants), maybe any variety of UIR pathogens, IgE levels
  • Predominant characteristics: wheezing & cough
  • Bronchospasm and obstruction
    • Mechanism responsible for obstructive symptoms:
    • Inflammatory response to stimuli
    • Airway edema and accumulation of secretions of mucus
    • Spasm of smooth muscle of bronchi and bronchioles
    • Airway remodeling – causes permanent cellular changes
  • This trapping of gas forces the individual to breathe at higher and higher lung volumes. Consequently, the person with asthma fights to inspire sufficient air. This expenditure of effort for breathing causes fatigue, decreased respiratory effectiveness, and increased oxygen consumption. The inspiration occurring at higher lung volumes hyperinflates the alveoli and reduces the effectiveness of the cough. As the severity of obstruction increases, there is a reduced alveolar ventilation with carbon dioxide retention; hypoxemia; respiratory acidosis; and, eventually, respiratory failure.
  • Allergen control for asthma: beware of dust mites, cockroaches, trash, cat and dog danger, tobacco smoke, mold spores

 

  • Treatment: inhaled corticosteriods, bronchodilators, leukotriene modifiers, allergen, “triggers” control. Want to be able to identify what exacerbates the child’s asthma. Some are aggravated by colds, etc

Ă  Cough is typically a dry cough

 

Asthma and Airway Obstruction

 

*Admin bronchodilator first and then steroid

 

Asthma Severity Classification in Children Ages 0 to 11

  • Step I: mild, intermittent asthma
  • Step II: mild, persistent asthma
  • Step III or IV: moderate, persistent asthma
  • Step V or VI: severe, persistent asthma

 

Drug Therapy for Asthma

  • Long-term control meds
    • Inhaled corticosteroids, cromolyn sodium and nedocromil, long-acting b2-agonists, methylxanthines, and leukotriene modifiers
    • Salmeterol = long acting beta 2 agonist (bronchodilator)
      • NOT for exacerbations
      • Usually on this daily even if you are not wheezing
    • Quick-relief (“rescue”) medications
      • Short-acting b2-agonists, anticholinergics, and systemic corticosteroids are used as quick-relief (or rescue) medications
      • Beta adrenergic agonists (albuterol)
        • Txm of acure exacerbations – allows smooth muscle to relax
        • Steroids are part of the protocol for acute exacerbation but they take 4-6 hours for effects to take place
        • IV PO prednisone

 

Asthma Drug Routes

  • Inhaled for most medications
    • MDI with spacer
      • Significance of the spacer: allows you to inhale the entirety of the medication. It gives you time to slowly inhale and get all of the medication
    • Nebulizer
  • Generally less effective in treating asthma
    • Oral
    • IV

Inhaler (aerochamber)

Signs of SEVERE Respiratory Distress in Children with Asthma

  • Remains sitting upright, refuses to lie down
  • Sudden agitation
  • Agitated child who suddenly becomes quiet
  • Diaphoresis

 

Status Asthmaticus – chronic constant wheezing

  • Respiratory distress continues despite vigorous therapeutic measures
  • Concurrent infection in some cases
  • Therapeutic intervention
  • Emergency treatment—epinephrine

0.01 ml/kg subQ (maximum dose 0.3 ml)

  • IV magnesium sulfate – potent muscle relaxant
  • IV ketamine: smooth muscle relaxation
  • IV corticosteroids
  • Heliox: decrease airway resistance
    • They are respiratory distressed and anxious because they cant breathe
    • Code situation

NSG 102H -Pediatric Lectures 4 and 5

 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

 

Cystic Fibrosis (CF)

  • Autosomal recessive genetic disease
  • Abnormal gene is located on the long arm of chromosome 7
  • 95% known cases occur in Caucasians
  • Most common lethal genetic illness among Caucasian children
  • Approximately 3% of U.S. Caucasian population are symptom-free carriers

 

CF Incidence in U.S. Live Births

  • 1 in 3300 whites (95% of cases)
  • 1 in 16,000 African-Americans
  • 1 in 32,000 Asians

 

Effects of Exocrine Gland Dysfunction in CF

Increased Viscosity of Mucous Gland Secretion

  • Results in mechanical obstruction
    • “rubber band mucus”ee
  • Thick, inspissated mucoprotein accumulates, dilates, precipitates, coagulates to form concretions in glands and ducts
  • Respiratory tract and pancreas are predominantly affected

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

 

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
  • Decreased O2/CO2 exchange
  • Results in hypoxia, hypercapnia, acidosis
  • Compression of the pulmonary blood vessels and progressive lung dysfunction lead to pulmonary hypertension, cor pulmonale, respiratory failure, and death

NSG 102H -Pediatric Lectures 4 and 5

Infectious Pathogens

  • Pseudomonas aeruginosa
    • Lingering infection. Hangs out in moist places
    • Harder to treat
  • Burkholderia cepacia
  • Staphylococcus aureus
  • Haemophilus influenzae
  • Escherichia coli
  • Klebsiella pneumoniae

 

Respiratory Progression

  • Gradual progression follows chronic infection
  • Bronchial epithelium is destroyed
  • Infection spreads to peribronchial tissues weakening bronchial walls
  • Peribronchial fibrosis
  • Decreased O2-CO2 exchange

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Further Respiratory Progression

  • Chronic hypoxemia causes contraction/hypertrophy of muscle fibers in pulmonary arteries/arterioles
  • Pulmonary hypertension
  • Cor pulmonale
  • Pneumothorax
  • Hemoptysis

 

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
    • We see failure to thrive in these individuals

 

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

 

Presentation of CF

  • Wheezing respiration; dry, nonproductive cough
  • Generalized obstructive emphysema
  • Cyanosis
  • Clubbing of fingers and toes
  • Repeated bronchitis and pneumonia
  • Meconium ileus
  • Distal intestinal obstruction syndrome
  • Excretion of undigested food in stool—increased bulk, frothy, and foul
  • Wasting of tissues
  • Prolapse of the rectum
  • Presentation of CF (cont’d)
  • Delayed puberty in females
  • Sterility in males
  • Parents report children taste “salty”
  • Dehydration

 

Diagnostic Evaluation

  • Before onset of symptoms
    • Newborn screening as part of metabolic screening panel in 48 of 50 U.S. states (diagnosed before onset of symptoms)
  • Quantitative sweat chloride test
  • After onset of symptoms
    • Chest x-ray
    • Pulmonary function tests
    • Stool fat and/or enzyme analysis
    • Barium enema

NSG 102H -Pediatric Lectures 4 and 5

Treatment Goals for CF

  • *Prevent or minimize pulmonary complications
  • Adequate nutrition for growth
  • Assist in adapting to chronic illness

 

Respiratory Management of CF

  • CPT (chest physical therapy)
  • Bronchodilator medication
  • Forced expiration
  • Aggressive treatment of pulmonary infections
  • Home IV antibiotic therapy
  • Aerosolized antibiotics

GI Management

  • Replacement of pancreatic enzymes
  • High-protein, high-calorie diet as much as 150% RDA
  • Prevention/early management of intestinal obstruction
  • Reduction of rectal prolapse
  • Salt supplementation

 

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

 

Nursing Diagnosis: CF

  • Ineffective airway clearance r/t thick mucous in lungs
  • Risk for infection r/t presence of mucous secretions conducive to bacterial growth
  • Imbalanced nutrition: less than body requirements r/t need for increased calories to meet metabolic needs
  • Parental role conflict r/t interruption in family life due to home care regimen and child’s frequent exacerbations