Saturday, November 20, 2010

Maternal and Child Health Nursing Chapter 40

Chapter 40
Nursing Care of a Child with a Respiratory Disorder
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Respiratory disorders are among the most common causes of illness and hospitalization in children. Overall, respiratory dysfunction in children tends to be more serious than in adults because the lumens in a child's respiratory tract are smaller and therefore more likely to become obstructed. Because respiratory disorders range from minor illnesses such as a simple upper respiratory tract infection to life-threatening lower respiratory tract diseases, such as pneumonia, and because the level of acuity can change quickly, respiratory disorders are often difficult for parents to evaluate. Both a child and parents need a great deal of nursing support when disease interferes with the function of breathing, because even very young children can panic when breathing becomes labored. Early diagnosis and treatment are essential in preventing a minor problem from turning into a more serious one.
Because respiratory disorders are such a common cause of childhood illness and hospitalization, National Health Goals have been established for children with respiratory illnesses (Box 40.1).
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Anatomy and Physiology of the Respiratory System
The respiratory system can be separated into two divisions for discussion: the upper respiratory tract, composed of the nose, paranasal sinuses, pharynx, larynx, and epiglottis; and the lower tract, composed of the bronchi, bronchioles, and alveoli. Through inspiration, the respiratory system delivers warmed and moistened air to the alveoli; transports oxygen across the alveolar membrane to hemoglobin-laden red blood cells; and allows carbon dioxide to diffuse from red blood cells back into the alveoli. Through expiration, carbon dioxide-filled air is discharged to the outside. Levels of oxygen and carbon dioxide in the lungs, blood, and body cells are shown in Figure 40.1.
The respiratory center is located in the medulla of the brain. Peripheral receptors located in the aortic arch and carotid arteries sense diminished PO2 levels and respond by increasing the respiratory rate. Central respiratory receptors in the medulla sense increased PCO2 levels along with body acidity, temperature, and blood pressure as another stimulus to respiration. Depth of respiration is influenced by proprioceptors located in the lung periphery that register lung fullness. An inhibitory center in the pons halts inspiratory impulses before the lungs become overextended. Often children with chronic lung disease such as cystic fibrosis have adapted so well to a chronically high PCO2 level that central receptor sites no longer register this as abnormal. In these instances, the main stimulus for respiration is a low oxygen level. In such children, administering high levels of oxygen can be dangerous because it alleviates oxygen want or their main respiratory stimulus.
Respiratory Tract Differences in Children
Embryologic development of the respiratory tract is discussed in Chapter 8. The ethmoidal and maxillary sinuses are present at birth; the frontal sinuses (the sinuses most
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frequently involved in sinus infection) and the sphenoidal sinuses do not develop until 6 to 8 years of age. Due to rapid growth of lymphoid tissue, tonsillar tissue is normally enlarged in early school-age children.
FIGURE 40.1 Partial pressure of gas (mm Hg) as measured in peripheral and systemic circulation. Because of the differences in partial pressure of the gases in the different areas, O2 moves from alveoli to pulmonary capillaries (i.e., the gas moves from the area of greater concentration to one of a lesser concentration). When it reaches the tissue capillaries, O2 partial pressure in cells is less, so O2 goes into the tissues and CO2 moves out.
Respiratory mucus functions as a cleaning agent by moving invading organisms or other particles out of the lungs. However, newborns produce little respiratory mucus, which makes them more susceptible to respiratory infection than older children. Excessive production of mucus in children up to 2 years of age can actually lead to obstruction because the bronchial lumens are so small in a child of this age.
After 2 years of age, the right bronchus is noticeably shorter, wider, and more vertical than the left. This is the reason inhaled foreign bodies most often lodge in the right bronchus. Infants' chest muscles are not fully developed, so they use their abdominal muscles to assist in inhalation. The change to thoracic breathing begins at 2 to 3 years of age and is complete at 7 years. Because accessory muscles are used more in children than adults, weakness of these muscles from disease may more easily result in respiratory failure in children than in adults.
In infants, the walls of the airways have less cartilage than in older children and adults and so are not as strong and more likely to collapse after expiration. An advantage of immature development is that a lessened amount of smooth muscle in the airway means an infant does not develop bronchospasm as readily as an older child or adult. Therefore, wheezing (the sound of air being pushed through constricted bronchioles) may not be a prominent finding in infants even when the lumen of the airway is severely compromised.
Assessing Respiratory Illness in Children
Assessment of respiratory illness in children includes an interview, physical examination, and laboratory testing. If the child is in acute distress, the interview and health history may cover only the most important details: when the child first became ill and what symptoms are present. It is important, however, to get as accurate a picture as possible, because the problem could be the result of a variety of circumstances (Box 40.2).
Symptoms of hypoxemia (deficient oxygenation of the blood), for example, are often insidious. Peripheral vasoconstriction (a mechanism to save the available oxygen for central life-sustaining body organs) leads to a pale appearance. Tachypnea and tachycardia (efforts to oxygenate cells better), anxiety, and confusion (caused by limited cerebral perfusion) may occur. A poor feeding pattern may be one of the first signs noted in the infant because an infant cannot suck and breathe rapidly at the same time. Cardiac arrhythmia may occur because of inadequate cardiac tissue perfusion. Always ask about home remedies that may have been used in an attempt to increase breathing space or effort (Box 40.3).
Physical Assessment
Physical assessment of a child with a respiratory disorder includes observation of presenting symptoms such as cough, cyanosis, or pallor, as well as evaluation of respirations and breath sounds. Breath sounds are best heard if an infant or child is not crying. Spending time comforting a child to prevent crying is time well spent.
Cough
A cough reflex is initiated by stimulation of the nerves of the respiratory tract mucosa by the presence of dust, chemicals, mucus, or inflammation. The sound of coughing is caused by rapid expiratory air movement past the glottis. Coughing is a useful procedure to clear excess mucus or foreign bodies from the respiratory tract. It becomes harmful and needs suppression only when there is no mucus or debris to be expelled and the amount of coughing becomes exhausting. This might occur with respiratory tract inflammation. Paroxysmal coughing
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refers to a series of expiratory coughs after a deep inspiration. Commonly, this occurs in children with pertussis (whooping cough) or those who have aspirated a foreign body or a liquid they attempted to drink.
Although helpful in removing mucus, coughing increases chest pressure and so may decrease venous return to the heart. This lowers cardiac output and can lead to fainting (syncope). Paroxysmal coughing may increase the pressure in the central venous circulation to such an extent that bleeding into the central nervous system (CNS) can result. Because young children often vomit after a series of coughs, they may be suspected initially of having a gastric disturbance even though they are coughing.
Rate and Depth of Respirations
Tachypnea (an increased respiratory rate) often is the first indicator of airway obstruction in young children. When assessing respiratory rate, particularly in infants, try to count respiratory rate before waking the infant, because crying distorts respiratory rate. Assess also the depth and quality of respiration, as these also reveal anoxia or lack of oxygen in body cells.
Retractions
When children must inspire more forcefully than normally to inflate their lungs because of an airway obstruction or stiff, noncompliant lungs (as in newborns with pulmonary dysplasia), intrapleural pressure is decreased to the point that the nonrigid parts of the chest (the intercostal spaces) draw inward, creating retractions (Fig. 40.2). Retractions occur more commonly in newborns and infants than in older children because the intercostal tissues are weaker and less developed in the younger child. Retraction of upper chest muscles (supraclavicular or suprasternal) suggests upper airway obstruction; retraction of intercostal or subcostal muscles suggests lower airway obstruction.
Restlessness
When children or infants have decreased oxygen in body cells (hypoxia), they become anxious and restless. In infants, restlessness coupled with tachypnea may be one of the first signs of airway obstruction. Be careful not to interpret the excessive movements of infants with respiratory distress as a sign that they are improving; anxious, restless stirring may be their only way of signaling that their respiratory obstruction is becoming acute.
Cyanosis
Cyanosis (a blue tinge to the skin) indicates hypoxia. It becomes apparent when the PO2 is under 40 mm Hg or the level of unoxygenated hemoglobin increases to over 3 g/100 mL (because incompletely oxygenated red blood cells in the circulation are what give blood a dark color). If children have a low red blood cell count, cyanosis may not be apparent because there are not enough red blood cells to give the arterial blood its color. This occurs at hemoglobin levels below 5 g/100 mL. The degree of cyanosis present, therefore, is not always an accurate indication of the degree of airway difficulty. When children have accompanying
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peripheral vasoconstriction caused by shock, cyanosis of the extremities also may or may not be apparent.
FIGURE 40.2 Sites of respiratory retraction.
As the PO2 drops and cyanosis results, children increase their respiratory effort in an attempt to supply more oxygen to the tissues. When they do this, the difference in pressure between the intralumen of a not yet fully developed trachea and the surrounding tissue becomes so great that the trachea may collapse, compounding the obstruction problem.
Clubbing of Fingers
Children with chronic respiratory illnesses often develop clubbing of the fingers, a change in the angle between the fingernail and nailbed because of increased capillary growth in the fingertips (Fig. 40.3). The increased capillary growth occurs as the body attempts to supply more oxygen routes (more capillaries) to distal body cells.
FIGURE 40.3 Clubbing of the fingers. (Left) The angle between the nail and digit is normally about 20 degrees in a child. (Center) Flattened angle represents early stage of clubbing. (Right) In advanced clubbing, the nail is rounded over the end of the finger. Note also that the distal phalanx is bulbous and of greater depth than the proximal portion of the finger (interphalangeal depth).
Adventitious Sounds
Normal breath sounds are reviewed in Chapter 33. Adventitious sounds (extra or abnormal breathing sounds) are caused by pathologic conditions and can be heard on lung assessment in children with respiratory disorders. Normally, on chest auscultation, the inspiratory sound is softer and longer than the expiratory sound. This is referred to as vesicular breathing. If you listen over the trachea, this pattern in terms of the length of inspiration (breathing in) and expiration (breathing out) is reversed. This is bronchial or tubular breathing. If you hear bronchial breath sounds in the periphery of the lungs, where normally you would expect to hear a vesicular pattern, it indicates that gas exchange in peripheral alveoli is so compromised (as in pneumonia) that you are listening to transmitted tracheal sounds.
Accessory sounds of respiration result from the vibrations produced as air is forced past obstructions such as mucus. If the obstruction is in the nose or pharynx, the noise produced is a snoring sound (rhonchi). If the obstruction is at the base of the tongue or in the larynx, you will hear a harsh, strident sound on inspiration. This is laryngeal stridor. It is often most marked when a child is in a supine position and less marked when a child sits upright. If an obstruction is in the lower trachea or bronchioles, it is most noticeable on expiration. An expiratory whistle sound (wheezing) occurs. If alveoli become fluid-filled, fine crackling sounds (rales) are heard. Diminished or absent breath sounds occur when the alveoli are so fluid-filled that little or no air can enter them.
Chest Diameters
With chronic obstructive lung disease, children may be unable to exhale completely, allowing air to be chronically trapped in lung alveoli (hyperinflation). This produces an elongated anteroposterior diameter of the chest, sometimes termed a pigeon breast. There is an accompanying
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tympanic or hyperresonant (loud and hollow) sound heard on percussion over lung spaces.
Laboratory Tests
A number of laboratory tests can be used to confirm or rule out the presence of a respiratory problem and to help identify the cause and severity of the problem. These include analysis of arterial blood gases, nasopharyngeal culture, and sputum analysis.
Blood Gas Analysis
Blood gas analysis is an invasive method for determining the effectiveness of ventilation and acid–base status. The normal values of arterial blood gases (ABGs)—the amount of oxygen and carbon dioxide in the blood—are shown in Table 40.1.
Blood gas analysis provides important information about oxygenation of the blood, as values may indicate not only whether the arterial partial pressure of oxygen (PO2) is adequate but also whether the oxygen saturation of hemoglobin is adequate. The oxygen saturation level will fall if adequate oxygen cannot reach the bloodstream because of respiratory distress or if the hemoglobin is defective and cannot carry a full complement of oxygen (as with sickle cell anemia or thalassemia major). If a child has a severe anemia, the saturation level may be adequate (95% to 100%), but body cells may still not be receiving enough oxygen because of the limited number of red blood cells present. With increased PCO2 or decreased PO2, a low pH, or decreased temperature, the ability of hemoglobin to accept oxygen diminishes so, again, cells may become hypoxic.
PCO2 measures the efficiency of ventilation. In children who are hypoventilating (breathing very shallowly), PCO2 will be increased because they cannot blow off CO2; in children who are hyperventilating (breathing deeply), PCO2 will be decreased because they are blowing off too much. When children cannot evacuate accumulated CO2 because of an obstruction or hypoventilation, the partial pressure of CO2 in the arterial blood rises and the concentration of carbonic acid (formed when carbon dioxide dissolves in plasma) also rises. This leads to acidosis (a decrease in serum pH or an increase in acidity).
TABLE 40.1 Arterial Blood Gas Values
Measure Definition Normal Value Clinical Significance
Po2 Partial pressure of oxygen in arterial blood 80–100 mm Hg Decreased if child cannot inspire adequately
Pco2 Partial pressure of carbon dioxide in arterial blood 35–45 mm Hg Increased if child cannot expire adequately
O2 saturation The percentage of hemoglobin carrying oxygen 95%–100% Decreased if O2 cannot reach red blood cells, if unoxygenated cells are being mixed with oxygenated ones, or if hemoglobin is defective
pH The hydrogen ion concentration of blood 7.35–7.45 Decreased if CO2 is being retained as carbonic acid in blood
HCO3 The bicarbonate concentration in blood 22–26 mEq/L Increased in respiratory alkalosis; decreased in respiratory acidosis
Base excess Bicarbonate available for buffering -2.5 or +2.5 mEq/L (+) = alkaline excess
(-) = alkaline deficit
If respiratory distress is incomplete, the body can compensate for developing acidity for a long time by increasing kidney tubular reabsorption of bicarbonate. When respiratory distress is relieved (by removal of an obstruction or by assisted ventilation), the amount of bicarbonate present in the bloodstream may exceed the amount of acid produced at that point, and the child's condition may change from acidosis to alkalosis. With alkalosis, the respiratory rate decreases as a means to conserve CO2. As a result, periods of apnea may occur. Children require close observation during this time, including frequent blood gas and electrolyte determinations to ensure prompt treatment to reverse these changes when they occur. Respiratory alkalosis and respiratory acidosis are compared in Table 40.2. Box 40.4 shows steps for evaluating ABGs.
To analyze blood gases, arterial blood rather than venous blood must be used (arterial blood will reflect how well the lungs are oxygenating the blood, whereas venous blood will reflect only the oxygenation of the particular extremity from which the blood was drawn). In the young infant, the temporal artery may be used as a site for blood gasses; in newborns, an umbilical artery catheter can be used. In older children, the radial artery is the site of choice because of the collateral circulation present at the wrist. (If clotting should occur in the radial artery, the hand would still be well nourished by collateral circulation; see the Allen test in Box 40.5.)
For an ABG assessment, a specimen is withdrawn into a heparinized syringe (to prevent clotting). After any arterial puncture, always firmly compress the site. Otherwise, blood from the punctured vessel can seep into subcutaneous tissue, possibly causing a large hematoma and obscuring the site for further assessment. If frequent
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specimen collections are required, an arterial catheter, inserted either peripherally or centrally, may be used. Doing so allows frequent specimen collections without the trauma of additional punctures. Be sure to apply dressings over the area where an arterial catheter exits the skin to help prevent a young child from fussing or playing with the site. Soft restraints, such as an elbow or hand restraint, may be needed to keep a child from dislodging the catheter.
TABLE 40.2 Comparison of Respiratory Alkalosis and Respiratory Acidosis
Acid–Base Condition Cause Findings
Respiratory alkalosis Hyperventilation Rapid, deep breathing
Confusion, unconsciousness
Elevated plasma pH (above 7.45)
Elevated urine pH (above 7)
Decreased Pco2 (below 40 mm Hg)
Plasma bicarbonate
–Initially normal
–Compensated: below 20 mEq/L
Base excess: 0 or a negative reading such as -4
Respiratory acidosis Hypoventilation trapping carbon dioxide in alveoli Shallow breathing; inability to expire freely
Confusion, disorientation
Decreased plasma pH (below 7.35)
Decreased urine pH (below 6)
Elevated Pco2 (over 40 mm Hg)
Plasma bicarbonate
–Initially normal or elevated
–Compensated: above 25 mEq/L
Base excess: 0 or a positive reading such as +4
In small infants, when it is impossible to obtain arterial blood directly, heel or finger sticks may be used. If the heel or finger is warmed for about 20 minutes in warm water before the procedure, local blood flow increases so much that the blood gas levels of the capillaries approach those of arteries.
Be certain to note the use of oxygen, if any, and its liter flow on laboratory slips for ABG assessments. Also note the site where the specimen was obtained. While being transported to the laboratory, ABG specimens should be kept on ice to ensure accurate results (CO2 levels decline in room air).
The oxygen saturation of hemoglobin can be obtained noninvasively using pulse oximetry and transcutaneous oxygen monitoring.
Pulse Oximetry
Pulse oximetry is a continuous, noninvasive technique for measuring oxygen saturation. For the measurement, a sensor and a photodetector are placed around a vascular bed, most often a finger in a child or a foot in an infant (Fig. 40.4). Infrared light is directed through the finger from the sensor to the photodetector. Because hemoglobin absorbs light waves differently when it is bound to oxygen than when it is not, the oximeter can detect the degree of oxygen saturation (SaO2) in the hemoglobin.
Oxygen saturation is closely aligned with PO2 (Fig. 40.5). When SaO2 is 95%, the PO2 is within the normal range of 80 to 100 mm Hg. When SaO2 has fallen to 90%, the PO2 is 60 mm Hg. An easy rule to remember concerning the relationship between SaO2 and PO2 is the 60 to 30, 90 to 60 rule: when SaO2 is 60, PO2 is 30; when SaO2 is 90, PO2 is 60. Any SaO2 reading under 90, therefore, is cause for concern.
One advantage of pulse oximetry is that it is noninvasive. A second advantage is that the continuous monitoring provided by a pulse oximeter allows you to modify your care appropriately. If an oxygen level should begin to fall while you are handling an infant, for example, you could immediately stop care until the infant's PO2 again returns to normal. A disadvantage is that the sensor is small and must be checked frequently to see that it remains in place. Excess light in a room may distort the reading. Therefore, the sensor may need to be covered with a blanket in a neonatal intensive care unit or brightly lit nursery for readings to be accurate. Young children also tend to remove the sensors just as they frequently remove adhesive bandages from their fingers.
Transcutaneous Oxygen Monitoring
Transcutaneous monitoring is another means of continuous, noninvasive measurement of oxygen saturation. For this determination, electrodes heated to 44°C are attached to an infant's chest. The heat causes vasodilation underneath the skin and brings the peripheral arterial blood to the surface to be read for oxygen content. This is converted to mm Hg for a monitor readout. The oxygen saturation level read by this method correlates with intra-arterial PO2, the same as with pulse oximetry. Transcutaneous monitoring has a disadvantage compared with pulse oximetry because the probe position needs to be changed every 3 to 4 hours to
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prevent a burn to the skin, and sensor recalibration is necessary with each position change.
FIGURE 40.4 A school-aged child wearing a pulse oximeter checks her oxygen saturation level.
FIGURE 40.5 Oxyhemoglobin dissociation curve.
Nasopharyngeal Culture
When done efficiently, nasopharyngeal cultures cause little discomfort and reveal a great deal of information about the microorganisms causing a disease. However, most children are terribly frightened by having something placed in their noses or throats and so may resist accordingly. Firm, calm support during the procedure while you touch a moistened swab to the mucus membrane of the nose or throat is essential. Nose and throat cultures can reveal only the organisms present in the upper respiratory tract. As a result, they may not show organisms causing a lower respiratory tract infection. A throat culture will miss pathogenic organisms if the culture tip is not touched to the infected aspect of the pharynx.
Respiratory Syncytial Virus Nasal Washings
Nasal washings are obtained to diagnose an infection by the respiratory syncytial virus (RSV). For this, a child is placed in the supine position, and 1 to 2 mL sterile normal saline is dropped with a sterile needleless syringe into one nostril. The nose is then aspirated using a small, sterile bulb syringe. The secretions removed are placed in a sterile container to be sent to the laboratory for analysis. Nasal washings are even more uncomfortable for children than nasal swabbing because of the saline that is instilled. Provide comfort to a child afterward and assure the child the specimen collection is over.
Sputum Analysis
Because they cannot raise sputum with a cough, sputum collection is rarely feasible in children younger than school age. Older children, however, are able to cough and raise sputum. Teach them exactly what you want (a specimen of what they are coughing up, not just clearing from the back of their throat). Then ask them to breathe in and out several times, cough deeply and spit mucus they have raised into a sterile specimen jar.
Diagnostic Procedures
In addition to cultures, a number of other diagnostic procedures are used to identify respiratory disorders in children. Many of these procedures are also used with adults, with modifications to account for the physical and developmental differences of children. Bronchoscopy (visualization of the bronchi through a bronchoscope) is discussed in Chapter 36. Radiologic examination (chest x-ray and bronchography) and pulmonary function testing are discussed in the following sections.
Chest X-Ray
Chest x-ray films will show areas of infiltration or consolidation in the lungs; if a foreign body is opaque, an x-ray study will show its location. Chest x-ray films are more difficult to obtain in infants than in older children, because infants cannot take a breath and hold it when instructed. It is therefore difficult to picture the lungs at their most expanded position. Computed tomography (CT) scans may be ordered for children with chronic lung disease because this technique can best mark disease progress.
Bronchography
On a chest x-ray, the air-filled larynx, trachea, and major bronchi are revealed as dark spaces. Any obstruction or distortion in the organs is apparent. For further definition of structures, a radiopaque solution may be introduced into the respiratory tract by an ultrasonic nebulizer or by a catheter inserted into the trachea before the x-ray study is performed. Children may require conscious sedation for this because nebulization can be frightening. Afterward, children may have an increase in mucus production from bronchial irritation by the procedure. Observe them carefully after such a procedure for possible respiratory obstruction from accumulating mucus.
Pulmonary Function Studies
The process of ventilation, or the work of breathing, involves three main forces: (1) an inertial force that must be overcome to change the speed and direction of air when the lungs change from exhalation to inhalation, or vice versa; (2) an elastic force to help the lungs expand with inhalation and “snap back” with exhalation; and (3) the flow resistance force or resistance to the movement of air through the bronchial tree that must be overcome. Flow resistance must be at a minimum for best ventilation. It becomes increased when the bronchioles are narrowed or plugged with mucus. Pulmonary function tests measure the forces of inertia, elasticity, and flow resistance.
The alveoli of the lungs are never completely empty at the end of expiration because the bronchioles collapse,
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trapping air in the alveoli. In contrast, alveoli are never completely filled on inspiration because their potential for expansion exceeds that necessary for good respiratory function. Children with obstructive lung diseases such as asthma or cystic fibrosis have some difficulty moving air into the lungs, but they have even more difficulty moving air out of the lungs. Even if they do expire the same amount of air as the average child, they expire it over a longer period. Children with restrictive ventilatory disorders, such as neuromuscular disorders, have equal difficulty with inspiration and expiration.
A number of lung capacity studies can be done to determine the degree of obstruction or restricted ventilation ability. For these studies, the child breathes into a spirometer, a device that records the force of air exchange.
Children younger than 4 years of age are usually unable to participate in pulmonary function tests because these tests require their cooperation. All children need good preparation and teaching for these tests because they must breathe forcefully through the mouth into a mouthpiece on cue. Some tests require the nose be closed by a clamp or clip or an assistant's hand while the child blows out. This can be a frightening feeling for children with respiratory disease. They may need some trial runs to assure themselves that they can breathe with the clamp in place. Without good orientation to the equipment, they may become so anxious about their performance that they develop tachypnea or fail to inhale or exhale at their full capacity, so the test results are skewed.
Common pulmonary function tests are outlined in Table 40.3. The results of pulmonary function studies help determine the nature and extent of a child's respiratory problem and the best methods for achieving more effective ventilation.
Health Promotion and Risk Management
A number of ways to promote respiratory health are available for parents and children. The common cold is the most common respiratory disorder seen in children. Children as young as toddlers can be taught to help avoid spreading colds through their family by washing their hands, properly disposing of tissues, and covering their mouth while coughing. These measures need to be stressed again with school-age children to help prevent them from contracting or spreading germs through their schoolroom. The incidence of Haemophilus influenzae type B, the cause of bronchiolitis, as well as influenza can be reduced by ensuring that children receive their routine immunizations against these (HIB and influenza vaccine). Children with chronic respiratory illnesses also should receive the pneumococcal vaccine. Parents of children with asthma can take major steps to reduce exacerbations by environmental control. Reducing respiratory irritation by reducing secondary smoke can help prevent asthma, upper respiratory infections, and otitis media.
TABLE 40.3 Pulmonary Function Tests
Test Measurement Clinical Implications
Vital capacity (VC) The maximum amount of air expelled after a maximum inspiration Decreased if bronchial lumens are narrowed or obstructed
Tidal volume (TV) The amount of air inhaled and exhaled in a normal respiratory movement Decreased if bronchial lumens are constricted
Residual volume The amount of air remaining in the lungs after a maximum expiration Increased if there is air trapping in alveoli, as in obstructive lung disease
Functional residual capacity (FRC) The volume of air remaining in the lungs after a normal expiration Increased if ability to breathe out is impaired
Forced expiratory volume (FEV) The amount of air expired in 1 sec Decreased in obstructive disease that prevents free expiration
Therapeutic Techniques Used in the Treatment of Respiratory Illness in Children
The primary goal of nursing interventions in the care of children with respiratory disorders is to maintain or re-establish the airway to help ensure that adequate oxygen reaches the blood. Often this includes interventions aimed at liquefying and removing mucus secretions so they do not clog the bronchial pathways. Such clogging prevents adequate oxygenation and contributes to the development of bronchial and alveolar infections.
Expectorant Therapy
Any irritation of the respiratory tract causes the production of large amounts of mucus. The amount produced can become so great that the natural mechanisms for clearing it (coughing and upward cilia action) are no longer adequate. If a child is breathing rapidly because of respiratory distress, the frequent passage of air over the mucus tends to dry it and make it more viscid, compounding the removal problem. A number of measures may be used to liquefy and raise mucus.
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Liquefying Agents
Pharmacologic agents (expectorants) such as guaifenesin (Robitussin), given orally, are designed to liquefy mucus in the trachea and bronchi. Instilling saline nose drops or using saline nasal sprays can be effective in moistening and loosening dried mucus in the nose (Karch, 2004).
Humidification
Humidification is the provision of moisture to the airway. Common methods of delivering moisture include vaporizers and nebulizers.
Vaporizers
Vaporizers emit a stream of air moistened by fine droplets of water into a room, providing either a cool or a warm mist to the entire room. Caution parents when using warm mist that a serious scald burn can result if children accidentally pull a vaporizer over on themselves. To avoid this type of accident, they should be certain the vaporizer is never placed within reach of the child. Although cool mist can create a clammy atmosphere in a room, this can be advantageous for a child who also has a fever, helping to cool and moisten the whole environment. Caution parents to clean vaporizers thoroughly after use to prevent the growth of Pseudomonas or other pathogenic organisms.
Nebulizers
Nebulizers are mechanical devices that provide a stream of moistened air directly into the respiratory tract. Most are hand-held masks that fit over the nose and mouth and are attached to an electrical pump as a power source (Fig. 40.6). Ultrasonic nebulization delivers such minuscule droplets into the respiratory tract that even the smallest bronchioles can be moistened. Nebulizers also serve as an important means for the delivery of respiratory tract medications (Fink, 2004). Drugs such as antibiotics or bronchodilators can be combined with the nebulized mist and sprayed into the lungs.
Many children find nebulizer treatments uncomfortable because the feeling of the mist in their upper respiratory tract can be frightening or irritating. Assure them that aerosol administration is the most effective route for moisture and medication to reach and cause an effect in the respiratory tract.
FIGURE 40.6 Child using a nebulizer.
During aerosol medication administration, watch carefully for signs of both local tracheal or bronchial effect (spasm or edema) that might result from airway irritation as well as systemic symptoms that might result from absorption of a medication by the membrane.
Coughing
As a rule, encourage coughing rather than suppressing it in children because it is an effective method of raising mucus. Changing a child's position and suggesting mild exercise and deep breathing are helpful techniques to initiate coughing. If a cough is caused by mucus dripping from the nose because of nasal congestion, a decongestant such as pseudoephedrine (Sudafed) will best halt the draining mucus and therefore the cough. Caution parents not to give adult cough syrups to children. A number of these contain codeine in doses that may be too high for the child's weight.
Chest Physiotherapy
Simply changing a child's position helps mucus to move, initiate a cough reflex, and be expelled. When a child is positioned so the chest is lower than the abdomen, gravity aids in the removal of mucus from the lower lobes and bronchi. When a child sits upright, gravity aids drainage from the upper lobes and bronchi. When lying supine, anterior bronchi drain; when prone, posterior bronchi drain. Frequent changes of position are important, therefore, to prevent mucus from pooling in certain lung areas. If a child has a localized mucus problem, lying predominantly in one position can encourage drainage of that lung segment. When the child is repositioned and the mucus drains into new bronchi, this will often cause a cough from irritation caused by this new drainage.
Three techniques are involved with chest physiotherapy (CPT) to further loosen mucus for expectoration: postural drainage, percussion, and vibration. Each technique can be used alone, but they are usually more effective at moving mucus toward the mainstem bronchus when performed together.
CPT is best scheduled before meals or at least an hour after a meal so the subsequent coughing does not cause vomiting. Techniques are described in Box 40.6 and summarized below. Limit CPT to approximately 30 minutes each time, because these techniques can be tiring. Modifications in the techniques or shortening of the time periods may be necessary, depending on a child's ability to tolerate the position changes and the techniques.
Common postural drainage positions for the infant are shown in Figure 40.7. An infant may be positioned on your lap, whereas a slant board or other surface is needed for postural drainage with an older child. Not all positions are tolerated well. Be ready to modify the positions used depending on the child's condition and tolerance.
To perform percussion (cupping), strike a cupped or curved palm (palm down) against the chest. This technique causes a loud, thumping noise that sounds as if it hurts, but you can assure parents it does not. In infants and some small children, a specialized device, a nipple, or
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a small oxygen mask may be used as the palm of the hand is too big (Fig. 40.8). These devices concentrate the motion and may increase the amount of mucus removed.
FIGURE 40.7 Positions for bronchial drainage for major segments of all lobes in infants. This procedure is most readily performed with the infant in your lap, with your hand on the chest over the area to be cupped or vibrated. (A) Apical segment of left upper lobe. (B) Posterior segment of left upper lobe. (C) Anterior segment of left upper lobe. (D) Superior segment of right lower lobe. (E) Posterior basal segment of right lower lobe. (F) Lateral basal segment of right lower lobe. (G) Anterior basal segment of right lower lobe. (H) Medial and lateral segments of right middle lobe. (I) Lingular segments (superior and inferior) of left upper lobe.
Vibration is done by pressing a vibrating hand against a child's chest during exhalation. Like percussion, it mechanically loosens and helps move tenacious secretions upward. Vibration also may be accomplished by a mechanical vibrator or a vibrating vest.
Position a child so the lobe of the lung to be drained is in a superior position. Because percussing or vibrating is exhausting, a child may not have all lobes drained at each session. For example, before breakfast, the upper right
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and the left upper and lower lobes might be done; before lunch, the right lower lobe and right middle lobe might be done; before supper or at bedtime, the upper and lower lobe on both sides might be done.
FIGURE 40.8 Alternative percussion device. To assist with percussing an infant or small child, a nipple or mask such as that from a manual resuscitation bag may be used.
After each position, ask the child to cough. Children cough best if you demonstrate the proper technique by taking a deep breath, blowing it out, taking a second deep breath, blowing that out, taking a third deep breath, and then coughing. The irritation of mucus in the major airway by the third breath makes a cough happen almost spontaneously.
Formerly, CPT was done in hospital settings by respiratory therapists. However, in today's health care climate of managed care, nurses are now often the health care provider who performs CPT and teaches it to parents. One or both parents may need to learn the technique before their child is discharged so that it can be continued conscientiously at home. Although not effective with all children, it is used most frequently with children with cystic fibrosis (van der Schans, Prasad, & Main, 2005).
FIGURE 40.9 (A) Flutter device. The metal ball (shown) is enclosed in the chamber and causes the vibration. (B) Adolescent using flutter device.
Mucus-Clearing Devices
A mucus-clearing device (a Flutter device) can be used to aid in the removal of mucus. This device looks like a small plastic pipe. A stainless-steel ball inside the device moves when the child breathes out, causing vibrations in the lungs (Fig. 40.9). This vibration helps loosen mucus so that it can be moved up the airway and expectorated. This device is used most frequently with children who have cystic fibrosis or pneumonia to help remove mucus from the lungs.
Therapy to Improve Oxygenation
Improving oxygenation almost automatically relieves breathing distress (Frey & Shann, 2004).
Oxygen Administration
Oxygen administration elevates the arterial oxygen saturation level by supplying more oxygen to red blood cells by the respiratory tract. Oxygen may be delivered to infants by flooding an incubator or by using a plastic hood, mask or canula. Plastic oxygen hoods are tight-fitting enclosures that can keep oxygen concentration at nearly 100% (Fig. 40.10). Always check that the hood fits snugly over the infant's head, making sure it does not rub against the infant's neck, chin, or shoulders. Be sure the gas does not blow directly into the infant's face.
Although a nasal catheter or nasal prongs can be used for infants, they are usually reserved for older children. These provide a concentration of approximately 50% with an oxygen flow of 4 L/min. Most children do not like nasal prongs because they are intrusive. Assess their nostrils carefully when using these as the pressure of prongs can cause areas of necrosis, particularly on the nasal septum.
FIGURE 40.10 Oxygen hood for an infant.
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A snug-fitting oxygen mask is yet another method for supplying nearly 100% oxygen and is the method frequently used in emergencies (Fig. 40.11). Masks are often not well tolerated by children because they tend to slip and obstruct their view. If necessary, let them hold a mask rather than strapping it in place to allow them more control.
Regardless of the delivery method used, oxygen must be administered warmed and moistened. Without proper humidification, oxygen dries mucous membranes and thickens secretions, thus compounding breathing difficulty. Oxygen, like any other drug, requires careful administration and follow-up assessment. If concentrations are too low, oxygen is not therapeutic; in concentrations greater than those desired, it can be toxic. If newborns are subjected to oxygen concentrations over 100 mm Hg for an extended time, retinopathy of prematurity can occur (see Chapter 26). In any child, administering oxygen concentrations of 70% to 80% for an extended period may lead to a thickening of the lung alveoli and a loss of lung pliancy (oxygen toxicity or bronchopulmonary dysplasia). For these reasons, oxygen should not be given in high concentrations for long periods unless adequate facilities for blood gas analysis are available (ATS, 2003).
When caring for a child with any form of oxygen equipment, follow good safety rules. Because oxygen supports combustion, keep open flames away from oxygen and minimize the risks of sparks. Since oxygen is humidified, oxygen equipment is a good source of microbial contaminants. Change equipment according to your agency's policy, but at least once a week to keep bacterial counts within safe limits. Monitor and record a child's oxygen saturation level via pulse oximetry or transcutaneous pulse oximetry as indicated. Obtain ABG measurements with any change in condition or oxygen flow or as otherwise ordered.
FIGURE 40.11 A nurse assesses a child's lungs while he receives oxygen therapy via a mask. (Steve Woit/Stock Boston.)
Pharmacologic Therapy
Children notice difficulty with exchange of air when their airways become obstructed because of unusual mucus production, bronchoconstriction, or inflammation. A number of drugs may be used in children to reverse these processes. Nasal sprays such as normal saline can be administered to moisten and loosen nasal secretions. Antihistamines given by this route can reduce mucus production and thereby enlarge the airway. Decongestants cause vasoconstriction, leading to shrinkage of the mucous membranes, which expands breathing space. Expectorants such as guaifenesin (Robitussin) help to raise mucus. Most of these agents also cause drowsiness, so their doses must be regulated, especially in adolescents who will be driving. Bronchodilators such as albuterol (Ventolin), terbutaline (Brethine), and levalbuterol (Xopenex) are examples of drugs used to open the lower airway. Antibiotics may be given intravenously, intramuscularly, orally, or inhaled through nebulization to reduce infection and limit purulent mucus and inflammation. Corticosteroids taken either orally or by inhalation enlarge the airway by reducing further inflammation (Karch, 2004).
Metered-Dose Inhalers
A metered-dose inhaler (MDI) is a hand-held device that provides a route for medication administration directly to the respiratory tract. The child inhales while pressing a trigger on the apparatus. Small children may need a spacer device attached to the apparatus, a plastic extension tube or chamber that helps better coordinate inhalation with the medication delivery. For successful use, children need to follow five general rules: shake the canister, exhale deeply, activate the inhaler as they begin to inhale, take a long slow inhalation, and then hold their breath for 5 to 10 seconds. They should take only one puff at a time, with a 1-minute wait between puffs (Karch, 2004).
Incentive Spirometry
Incentive spirometers are devices that encourage children to inhale deeply to aerate the lungs fully or move mucus. Although manufactured in different configurations, a common type consists of a hollow plastic tube containing a brightly colored ball or dome-shaped disk that will rise in the tube when a child inhales through the attached mouthpiece and tubing. The deeper the inhalation, the higher the ball rises in the tube.
Children need instruction on how to use this type of device, because their first impression is that they should blow out against the mouthpiece rather than inhale
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(Fig. 40.12A). Incentive spirometry is effective with children because the device and procedure resemble a game more than an actual treatment.
FIGURE 40.12 (A) Incentive spirometry is an appealing method to encourage children to aerate their lungs. (B) Encouraging children to take a deep breath and try to blow a cotton ball across the table is also an entertaining way to help them fully expand their lungs.
Breathing Techniques
Some children need exercises prescribed to help them better inflate alveoli or more fully empty alveoli. Blowing a piece of cotton or a plastic ball across a table, blowing through a straw, or blowing out with the lips pursed are effective techniques for better emptying alveoli (see Fig. 40.12B). Yet another method for increasing aeration is to ask a child to blow up a balloon, as this requires the child to take a deep inhalation. For best results, make these activities a game or contest rather than an exercise.
Tracheostomy
A tracheostomy is an opening into the trachea to create an artificial airway to relieve respiratory obstruction that has occurred above that point (Dougherty et al., 2003). The procedure to create the airway is called a tracheotomy; the resultant airway is the tracheostomy. Tracheostomies also may be used as a route for suctioning mucus when accumulating mucus causes lower airway obstruction. A danger of tracheostomies is that they eliminate the warming and filtering action of the nose and pharynx, making children more susceptible to infection. For these reasons, endotracheal intubation, not tracheostomy, has become the method of choice to relieve airway obstruction and for short-term oxygenation. The exception to this is obstruction in the pharynx, because it is often impossible to pass an endotracheal tube beyond obstruction at this point. Tracheostomies are also still used for long-term home care (Fiske, 2004).
Emergency Intubation
Few medical emergencies are as frightening to a child or parents as an acute obstruction of a child's upper airway requiring a tracheotomy or endotracheal intubation. The child suddenly becomes limp and breathless, with his or her color changing quickly to systemic cyanosis. Tracheotomies are done more easily on a treatment room table than on a bed or crib, so it is generally best to carry a child immediately to a treatment room for the procedure. If a child cannot be moved quickly, however, because of accessory equipment, don't lose time in transport. For tracheotomy, the cricoid cartilage of the trachea is swabbed with an antiseptic; if readily available, a local anesthetic may be injected into the cartilage ring. (This is not necessary in the unconscious child.) An incision is made just under the ring of cartilage and a tracheostomy tube with its obturator in place is inserted into the opening (Fig. 40.13A). When the obturator is removed, the child can breathe through the hollow tracheostomy tube. Have suction equipment available for immediate use to clear any blood caused by the incision (this is minimal) and any obstructing mucus from the trachea.
The color change in children after tracheostomy is usually dramatic. They inhale deeply a number of times through the tube, and color returns to normal. A few sutures may be necessary at the tube insertion site to halt bleeding or to reduce the size of the incision so the tube fits snugly.
As children begin to breathe normally and, if unconscious, regain consciousness, they often thrash and push at people around them, both from oxygen deficit and from fright. They call for a parent but can make no sound, adding to their fright. Assure a child that everything is all right, even though he or she cannot speak (see Fig. 40.13B). A school-age child can understand a simple explanation such as, “You can't speak right now because of the tube in your throat.” As soon as the child's respirations are even and he or she is no longer experiencing acute respiratory distress, show the child how, by placing a finger over the tracheostomy tube opening, air will again flow past the larynx and he or she can speak. If this causes the child to become short of breath, supply a paper and pencil or chalkboard for communication.
FIGURE 40.13 (A) Tracheostomy tubes: (left) a plastic tube, inner cannula, and obturator; (right) a plastic, cuffed tube. (B) A nurse assesses heart rate on a child receiving oxygen by a tracheostomy. (Frank Sitemen/Stock Boston.)
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Be certain parents understand why the tube is in place and how important it is that it remain patent. Assure them that it is a temporary measure to provide oxygen (provided this is true). If they were not present in the room for the procedure, encourage them to visit the child as soon as possible to assure themselves their child is again all right. Children have difficulty relaxing enough to accept this strange new way of breathing until their parents can relax and accept it also. Some children hyperventilate, not because of respiratory difficulty, but because of this fear.
Suctioning Technique
Most tracheostomy tubes used with children today are plastic. They do not include an inner cannula that would require removal and regular cleaning. Most children, however, do require frequent suctioning (perhaps as often as every 15 minutes) to keep their airway free of mucus. Use sterile technique to prevent introducing microorganisms, and suction gently yet thoroughly. Ineffective suctioning does not remove obstructive mucus and because of irritation can actually cause more mucus to form. Be certain you know how deeply to suction. Some children need to be suctioned only the length of the tracheostomy tube so that the catheter does not touch and irritate the tracheal mucosa. Others need to be deeply suctioned to reduce the possibility that mucus will become so copious or so thickened that it obstructs the trachea below the tube.
Tracheostomy suctioning technique is shown in Box 40.7. Because suctioning removes air as well as secretions from the trachea, children may become oxygen-deprived during the procedure. Although not evidence-based, preoxygenating them by “bagging” or administering oxygen for approximately 5 minutes before the procedure may help reduce this problem (Pritchard, Flenady, & Woodgate, 2005). Occasionally, a child may have such thick mucus that it is necessary to insert a drop or two of normal saline into the tracheostomy tube before suctioning. This shouldn't be routine, however, as fluid running into the trachea produces a frightening, suffocating feeling.
Young children may need to wear elbow restraints while being suctioned to keep their hands away from the sterile catheter. In addition, restraints may be necessary at all times when they are alone to prevent them from fussing with the tracheostomy tube and accidentally removing it.
Check frequently on children with tracheostomies to assess for possible respiratory difficulty. Spend time playing with them or just sitting and rocking them so they can think of you in ways other than as the person who comes to suction them. If parents cannot stay with the child, assure them that you check on their child more frequently than what is necessary for suctioning alone, so they can feel confident if the child should have another episode of acute obstruction, someone will be nearby. If the tracheostomy tube is to be left in place after discharge from the hospital, be certain parents have enough experience with changing tubes if that will be necessary or suctioning so they can safely care for the child at home (Fiske, 2004).
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Tracheostomy tubes are held in place by cloth ties that fasten at the back of the child's neck. Change ties when they become soiled or loose, and check them frequently to be certain they remain tied. Children may fuss with and untie such things, whereas adults will not. Assess that the ties fit snugly but allow for one finger to be inserted underneath them so they don't rub and cause pain. For preschoolers or younger children, it is a good idea to cover the tracheostomy opening with a gauze square tied to the child's neck like a bib while they eat. This prevents crumbs or spilled liquids from entering the tracheostomy opening. Do not give children small toys that could fit into the lumen of the tube and cause obstruction (Box 40.8).
Each child is considered individually as to when it is time to remove a tracheostomy tube. Tubes are generally sealed off partially by adhesive tape or a commercial occlusion device for a day or two before removal; then they are completely occluded (but not removed) for another day. This provides a weaning period where suctioning is still possible if it is needed. Occasionally, children cough so forcefully that they dislodge a tracheostomy tube. You might be with a child when this occurs, or you might walk into the room and find the tube lying beside the child on the bedclothes. As long as the child is not in distress, this is not an emergency. Because the incision site usually does not close completely to occlude the tracheal opening when a tube is dislodged, the child still has a patent airway. Always keep a new tube and inserter (obturator) at the bedside in case replacement is necessary. Slide the obturator into the tube and gently replace it in the tracheal opening. Remove the obturator and secure the new tube in place. If you do this quickly yet calmly, the average child is not alarmed and so will not protest. If, however, a child senses your excitement or if you indicate that something is terribly wrong, a child may begin to cry and turn away, making it difficult to replace the tube without assistance.
Endotracheal Intubation
Endotracheal intubation (nasal or oral intubation) is the preferred means of bypassing upper airway obstruction and allowing free entry of air to the trachea. There is little difference in efficiency between oral and nasal methods (Spence & Barr, 2005). However, since intubation tubes cause edema and local irritation, they cannot be left in place as a permanent solution. As with tracheostomies, children cannot speak while intubated. Supply those old enough to write with a pencil and paper for effective communication. Preschoolers can point to pictures to indicate what they need. Providing simple drawings or photos (a
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drink, a straw, a blanket, the television turned on, a urinal) to make needs known is helpful. Endotracheal tubes are held in place by being taped to the face. Make sure tubes are carefully secured, because children can easily dislodge them. As much as possible, limit the number of tape changes to protect the skin on the child's cheeks.
TABLE 40.4 Terms Commonly Used With Ventilator Therapy
Term Definition Clinical Application
IMV Intermittent mandatory ventilation Number of mandatory breaths the ventilator will deliver each hour. A child may breathe most of the time without assistance, but a set (mandatory) number of breaths per minute is delivered to ensure adequate lung expansion and oxygenation.
PEEP Positive end-expiratory pressure Pressure delivered to lungs at the end of each expiration to keep alveoli from collapsing on expiration and to ensure adequate oxygenation
Sigh A deep inhalation delivered by the ventilator Method used to fully inflate the lungs a number of times each minute
CPAP Continuous positive airway pressure A constant pressure exerted on the alveoli to keep them from collapsing on expiration
Fio2 Concentration of oxygen the child is receiving (inspiring) A child on oxygen therapy will have an Fio2 from 22% to 100%
A capnometer is a device that measures the amount of CO2 in inhaled or exhaled breaths. It uses infrared technology and is attached to the distal end of the endotracheal tube. By measuring the percentage of CO2 in expired air, the arterial CO2 (PCO2) can be estimated. Used in this way, a capnometer can reduce the number of arterial punctures needed for ABG analysis.
Assisted Ventilation
When it is not possible to improve oxygen saturation to sufficient levels by the methods described above, assisted ventilation may be necessary (Graham, 2004). Positive-pressure machines deliver moistened or nebulized air or oxygen to the lungs under enough pressure and with appropriate timing to produce artificial, periodic inflation of alveoli; they rely on the elastic recoil of the lungs to empty the alveoli.
Depending on the type of ventilator, the inspiration–expiration cycle is determined by a timed interval, a volume limit, or a pressure limit, depending on the child's condition. Ventilators can supply high tidal volumes at a low frequency rate or low tidal volumes at rates as high as 200 to 300 breaths/min. Hyperinflation of lungs can occur with high-frequency ventilation because there is not enough time for expiration to occur. For this reason, some high-frequency ventilators are set so air is sucked out of the lungs rather than depending on the normal elastic recoil of the lungs. Some commonly used terms associated with ventilator therapy are presented in Table 40.4.
Children who need respiratory assistance are frightened. A great many fight ventilators or refuse to lie quietly and let the ventilator breathe for them. Pancuronium (Pavulon) may be administered intravenously to a point of abolishing spontaneous respiratory action to overcome resistance and allow mechanical ventilation to be accomplished at lower pressures because without normal respiratory action, there is no normal muscle resistance to
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overcome (Box 40.9). Clearly, a child who receives pancuronium has no spontaneous respiratory function and needs critical observation and frequent ABG analysis because he or she depends totally on caregivers at that point.
Mechanical ventilation for a prolonged period requires that children either have a tracheotomy performed or have an endotracheal tube passed (Fig. 40.14). A cuffed tube is used with ventilators so the seal at the trachea is airtight. Infants need a nasogastric tube inserted to prevent stomach distention from air entering the esophagus. Providing adequate nutrition may be difficult for children on ventilators. Enteric (nasogastric) feedings or total parenteral nutrition solves this problem. Providing a balance of rest, stimulation, and assurance for the child is a challenge for nursing personnel and parents.
Once children become accustomed to assisted ventilation, it can be difficult to discontinue a device, even when there is no longer a clinical indication for it. This is most pronounced in adolescents, who are aware of the role of oxygen and proper ventilation for life function. You may need to provide a number of trial periods free of the ventilator with someone remaining close by them so they can be assured that if they do have difficulty breathing, someone is standing by to help. Many children are too afraid to fall asleep on the first night off a ventilator unless someone is with them and has assured them they will be there through the night.
FIGURE 40.14 An infant with an endotracheal tube receiving assisted ventilation.
Lung Transplantation
Lung transplantation is a possibility for children with a chronic respiratory illness such as cystic fibrosis (Teets & Borisuk, 2004). The transplant may involve a single lung, or it can be done in conjunction with heart transplantation if chronic respiratory disease has caused ventricular hypertrophy of the heart.
As with any organ transplantation, children need continued immunosuppression therapy with drugs such as cyclosporine or azathioprine (Imuran) following a lung transplant to decrease cell-mediated immunity. Although this level of immunosuppression is the key to successful transplantation, it also makes post-transplant children susceptible to fungal, bacterial, and viral lung infections. In addition, families experience a tremendous psychosocial toll as they wait to see whether the new transplant will be rejected. Children may need to have chest physiotherapy or use a portable spirometry device daily to help mobilize secretions resulting from loss of nerve innervation or a reaction to accumulating mucus in the transplanted lung.
Disorders of the Upper Respiratory Tract
The upper respiratory tract warms, humidifies, and filters the air that enters the body (Fig. 40.15). As such, the structures of the upper respiratory tract constantly come into contact with a barrage of foreign organisms, including pathogens, that can lead to airway irritation and illness. Congenital malformations of respiratory structures also cause some upper respiratory tract disorders.
FIGURE 40.15 Structures of the upper respiratory tract.
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Choanal Atresia
Choanal atresia is congenital obstruction of the posterior nares by an obstructing membrane or bony growth, preventing a newborn from drawing air through the nose and down into the nasopharynx (Bonafos et al., 2004). It may be either unilateral or bilateral.
Newborns up to approximately 3 months of age are naturally nose-breathers. Infants with choanal atresia, therefore, develop signs of respiratory distress at birth or immediately after they quiet for the first time and attempt to breathe through their nose. Passing a soft number 8 or 10 French catheter through the posterior nares to the stomach is a part of birthing room procedure in many health care facilities. If such a catheter will not pass bilaterally, the diagnosis of choanal atresia is confirmed immediately at birth.
Choanal atresia can also be assessed by holding the newborn's mouth closed, then gently compressing first one nostril, then the other. If atresia is present, infants will struggle as they experience air hunger when their mouth is closed. Their color improves when they open their mouth to cry. Atresia is also suggested if infants struggle and become cyanotic at feedings because they cannot suck and breathe through the mouth simultaneously.
The treatment for choanal atresia is either local piercing of the obstructing membrane or surgical removal of the bony growth. Because infants with choanal atresia have such difficulty with feeding, they may receive intravenous fluid to maintain their glucose and fluid level until surgery can be performed. Some infants may need an oral airway inserted so they can continue to breathe through their mouths. Following surgery, children have no further difficulty or symptoms.
Acute Nasopharyngitis (Common Cold)
The common cold is the most frequent infectious disease in children—in fact, toddlers have an average of 10 to 12 colds a year. School-age children and adolescents have as many as four or five yearly. The incubation period is typically 2 to 3 days. Most occur in the fall and winter.
Acute nasopharyngitis (the common cold) is caused by one of several viruses, most predominantly by rhinovirus, coxsackie virus, respiratory syncytial virus, adenovirus, and parainfluenza and influenza viruses. Children are exposed to colds at school or while playing with other children. If they are in ill health from some other cause, or if their immune system is compromised, they are more susceptible than others to the cold viruses. Although difficult to prove, stress factors also appear to play a role in the development of common colds in children.
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Assessment
Symptoms begin with nasal congestion, a watery rhinitis, and a low-grade fever. The mucous membrane of the nose becomes edematous and inflamed, constricting airway space and causing difficulty breathing. Posterior rhinitis, plus local irritation, leads to pharyngitis (Bagarazzi, 2003). Upper airway secretions that drain into the trachea lead to a cough. Cervical lymph nodes may be swollen and palpable. The process lasts about a week and then symptoms fade. In some children, a thick, purulent nasal discharge occurs because bacteria such as streptococci invade the irritated nasal mucous membrane and cause a secondary purulent infection.
Infants can be critically ill yet not develop a fever because their temperature-regulating system is still immature. With the common cold, they often develop a fever elevated out of proportion to the symptoms, possibly as high as 102° to 104°F (38.8° to 40°C). Infants also may develop secondary symptoms, such as vomiting and diarrhea, as a general response. Because they cannot suck and breathe through their mouth at the same time, they refuse feedings. This can lead to dehydration. Older children rarely develop as high a fever, rarely above 102°F (38.8°C). Because older children can breathe through their mouth, nasal congestion does not seem as acute.
Therapeutic Management
There is no specific treatment for a common cold. Although many parents ask to have antibiotics prescribed, because colds are caused by a virus, antibiotics are not effective unless a secondary bacterial invasion has occurred. If a child has a fever, it can be controlled by an antipyretic such as acetaminophen (Tylenol) or children's ibuprofen (Motrin). Help parents understand that these drugs are effective only in controlling fever symptoms; they do not reduce congestion or “cure” the cold. Therefore, they should not be given unless the child has a fever, generally defined as an oral temperature over 101°F (38.4°C). Remind parents that children younger than 18 years should not be given acetylsalicylic acid (aspirin) because this is associated with the development of Reye's syndrome, a potentially fatal neurologic disorder (see Chapter 49).
If infants have difficulty nursing because of nasal congestion, saline nose drops or nasal spray may be prescribed to liquefy nasal secretions and help them drain. Removing nasal mucus via a bulb syringe before feedings also allows infants to breathe more freely and be able to suck more efficiently. Caution parents that if they use a bulb syringe, they must compress the bulb first, then insert it into the child's nostril. If they insert the bulb syringe first, then depress the bulb, they will actually push secretions further back into the nose, causing increased obstruction.
There is little proof that oral decongestants relieve congestion to an appreciable degree with the common cold. Most parents believe these products give relief, however, and feel better if one is prescribed for their child. It is not good policy to suppress the cough of a common cold, because a cough raises secretions, preventing pooling of secretions and the danger of consequent infection. Guaifenesin is an example of a drug that loosens secretions but does not suppress a cough. Parents may use a cool mist vaporizer to help loosen nasal secretions if they wish. The efficiency of home vaporizers is questionable, however, and safe use of a vaporizer, including proper cleaning, must be stressed or it can serve as a reservoir for infection.
Pharyngitis
Pharyngitis is infection and inflammation of the throat (Bagarazzi, 2003). The peak incidence occurs between 4 and 7 years of age. It may be either bacterial or viral in origin. It may occur as a result of a chronic allergy in which there is constant postnasal discharge that results in secondary irritation. At least a slight pharyngitis usually accompanies a common cold.
Viral Pharyngitis
If the causative agent of the pharyngitis is a virus, the symptoms are generally mild: a sore throat, fever, and general malaise. On physical assessment, regional lymph nodes may be noticeably enlarged. Erythema will be present in
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the back of the pharynx and the palatine arch. Laboratory studies will indicate an increased white blood cell count.
If the inflammation is mild, children rarely need more than an oral analgesic such as acetaminophen or ibuprofen for comfort. Warm heat applied to the external neck area using a warm towel or heating pad also can be soothing. By school age, children are capable of gargling with a solution such as warm water to help reduce the pain. Before this age, children tend to swallow the solution unless the procedure is well explained and demonstrated to them.
Because children's throats feel so sore, they often prefer liquids to solid food. Infants, especially, must be observed closely until the inflammation and tenderness diminish to be certain that they take in sufficient fluid to prevent dehydration (Bagarazzi, 2003).
Streptococcal Pharyngitis
Group A beta-hemolytic streptococcus is the organism most frequently involved in bacterial pharyngitis in children. All streptococcal infections must be taken seriously because they can lead to cardiac and kidney damage from an autoimmune process (Posner, 2003).
Assessment
Streptococcal infections are generally more severe than viral infections. The fact that symptoms are mild, however, does not rule out streptococcal infection. With a streptococcal pharyngitis, the back of the throat and palatine tonsils are usually markedly erythematous (bright red); the tonsils are enlarged and there may be a white exudate in the tonsillar crypts. Petechiae may be present on the palate. A child typically appears ill with a high fever, an extremely sore throat, difficulty swallowing, and overall lethargy. Temperature is usually elevated to as high as 104°F (40°C). The child often has a headache. Swollen abdominal lymph nodes may cause abdominal pain. A throat culture, often completed as a quick office procedure, confirms the presence of the Streptococcus bacteria.
Therapeutic Management
Treatment consists of a full 10-day course of an oral antibiotic such as penicillin G or clindamycin. Cephalosporins or broad-spectrum macrolides such as erythromycin may be prescribed if resistant organisms are known to be in the community. Help parents understand the importance of completing the full 10 days of therapy. The prolonged treatment is necessary to ensure the streptococci are eradicated completely. If they are not, the child may develop a hypersensitivity or autoimmune reaction to group A streptococci that results in rheumatic fever (although the chance of rheumatic fever occurring is probably as low as 1%) or glomerulonephritis.
Symptoms of acute glomerulonephritis (blood and protein in urine) appear in 1 to 2 weeks after the pharyngitis. For this reason, 2 weeks after treatment, children may be asked to return to the health care facility with a urine specimen to be examined for protein so that developing acute glomerulonephritis can be detected (Meyers, 2003).
To ensure that a child receives the full antibiotic course, help parents make a reminder sheet to place on a cabinet or refrigerator door. In addition, instruct them about measures for rest, relief of throat pain, and maintaining hydration, the same actions as for a common cold. Because it is impossible for parents to discriminate between a pharyngitis caused by a virus (and needing no therapy other than comfort measures) and a streptococcal pharyngitis (needing definite therapy to prevent life-threatening illnesses), a child with pharyngitis always should be examined by health care personnel.
Retropharyngeal Abscess
In infants, the lymph nodes that drain the nasopharynx are located behind the posterior pharynx wall. These nodes may become infected in an infant following an acute nasopharyngitis or pharyngitis. Since these nodes disappear by preschool age, the problem is usually limited to young infants (Rutstein, 2003).
Assessment
Typically, infants have an upper respiratory tract infection or sore throat for a few days. Suddenly, they refuse to eat. They develop a high fever and may drool because they cannot swallow saliva past the obstruction in the back of their throat. They “snore” with respirations as the pharynx becomes further occluded. To allow themselves more breathing space, they may hyperextend the head, a very unusual position for infants.
Physical assessment reveals enlargement of the regional lymph nodes. The mass in the posterior pharynx may not be visible if it is below the point of vision. An ultrasound or x-ray study using a swallowed contrast medium will reveal the bulging tissue in the pharynx. Laboratory studies will reveal leukocytosis.
Therapeutic Management
Because the most common cause of retropharyngeal abscess is group A beta-hemolytic streptococcus, benzathine penicillin G or penicillin V is effective. As a result of their poor swallowing, infants' mouths may need to be suctioned to remove secretions. Be careful not to touch the suction catheter to the posterior pharynx because this might rupture the abscess, possibly leading to aspiration of the abscess contents (producing respiratory obstruction or a pneumonia caused by the aspirated purulent material). Blood vessels invade some retropharyngeal abscesses, so rupture of the structure also could lead to profuse bleeding (dangerous to the child both because of the loss of blood from major arteries such as the carotid artery and because the blood could be aspirated).
Place infants in a side-lying position to allow difficult-to-swallow mouth secretions to drain forward. Limit oral intake to fluids. A hard food such as a toast crust (a food often recommended for teething) could rupture the abscess with its hard edges.
Although some postpharyngeal abscesses resolve on their own, some need to be incised by a surgeon to promote drainage. This is done with the child in a Trendelenburg
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position so that drainage from the abscess can be suctioned away to prevent aspiration. After surgery, maintain the child in a Trendelenburg or a side position to encourage further drainage and prevent aspiration. Monitor vital signs closely. Observe any drainage from infants' mouths to detect fresh bleeding. Frequent swallowing is also a sign of postpharyngeal bleeding. Increased respiratory rate suggests airway obstruction.
Oral fluid is introduced as soon as the infant's swallowing and gag reflexes are intact after surgery. Although the throat is undoubtedly still sore, most infants suck eagerly and need supplemental intravenous fluid administration following surgery for only a short time.
On admission to the hospital, parents may be thoroughly frightened by the extent of the child's symptoms (gurgling or snoring sound, high temperature, dyspnea). Allow parents to handle the infant and care for him or her while overnight in the hospital to help them allay their fears and regain confidence in their ability to give care.
Tonsillitis
“Tonsillitis” is the term commonly used to refer to infection and inflammation of the palatine tonsils. “Adenitis” refers to infection and inflammation of the adenoid (pharyngeal) tonsils.
Tonsillar tissue is lymphoid tissue that filters pathogenic organisms from the head and neck area. The palatine tonsils are located on both sides of the pharynx; the adenoids are in the nasopharynx. Tubal tonsils are located at the entrance to the eustachian tubes. Lingual tonsils are located at the base of the tongue. All of the tonsils, referred to collectively as Waldeyer's ring, are easily infected because of the bacteria that pass through or are screened through them with lymph (Smith & Osborne, 2003).
Assessment
Infection of the palatine tonsils presents with all of the symptoms of a severe pharyngitis. Children drool because their throat is too sore for them to swallow saliva. They may describe swallowing as so painful it feels as if they are swallowing bits of metal or glass. In addition, they usually have a high fever and are lethargic. Tonsillar tissue appears bright red and may be so enlarged the two areas of palatine tonsillar tissue meet in the midline. Pus can be detected on or expelled from the crypts of the tonsils.
In addition to fever, lethargy, pharyngeal pain, and edema, the symptoms of adenoidal tissue infection also include a nasal quality of speech, mouth breathing, difficulty hearing, and perhaps halitosis or sleep apnea. The mouth breathing, change in speech, and apnea result from the postpharyngeal obstruction by the enlarged tissue. The difficulty with hearing occurs because of eustachian tube obstruction. Long-term obstruction this way can further cause serous and acute otitis media (middle ear infection).
Tonsillitis occurs most commonly in school-age children. The responsible organism is identified by a throat culture. In children younger than 3 years of age, the cause is often viral. In school-age children, the organism is generally a group A beta-hemolytic streptococcus (Curtin-Wirt et al., 2003).
Therapeutic Management
Therapy for bacterial tonsillitis includes an antipyretic for fever, an analgesic for pain, and a full 10-day course of an antibiotic such as penicillin or amoxicillin. If the cause is viral, no therapy other than comfort or fever reduction strategies is necessary. Although the pain of the infection will subside a day or two after the antibiotic administration is begun, remind parents that children need the full 10-day course of antibiotic to eradicate streptococci completely from the back of the throat. After a tonsillar infection, tonsillar tissue may remain hypertrophied, or it may atrophy and appear smaller than it did previously.
Tonsillectomy
Tonsillectomy is removal of the palatine tonsils. Adenoidectomy is removal of the pharyngeal tonsils. In the past, tonsillectomy was a common procedure after tonsillitis, but today it is not recommended unless all other measures to prevent frequent infections prove ineffective. Tonsillar tissue is removed by ligating the tonsil or by laser surgery. Because sutures are not placed, the chance for hemorrhage after this type of surgery is higher than after surgery involving a closed incision. The danger of aspiration of blood at the time of surgery and the danger of a general anesthetic compound the risk.
Chronic tonsillitis is about the only reason for removal of palatine tonsils. Adenoids may be removed if they are so hypertrophied they cause obstruction or sleep apnea. At one time, adenoids and palatine tonsils were always removed together; today, depending on the symptoms and the extent of hypertrophy and infection, children may have a tonsillectomy, an adenoidectomy, or both.
Tonsillectomy or adenoidectomy is never done while the organs are infected, because an operation at such a time might spread pathogenic organisms into the bloodstream, causing septicemia. Parents often ask why an operation to remove tonsils must be delayed until the child is well again. They think that as long as the tonsils are sore, they should be immediately removed. Help them understand why this is not possible and why it is safer to schedule surgery for a later date. Most parents report an improvement in their child's general health and performance after tonsillectomy surgery, as this ends the chronic infections.
FIGURE 40.16 Positioning a child after tonsillectomy. The pillow under the chest helps secretions flow out of the mouth.
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Epistaxis
Epistaxis (nosebleed) is extremely common in children and usually occurs from trauma, such as picking at the nose, from falling, or from being hit on the nose by another child. In homes that lack humidification, the hot dry environment makes children's mucous membranes dry, uncomfortable, and susceptible to cracking and bleeding. In all children, epistaxis tends to occur during respiratory illnesses. It also may occur after strenuous exercise, and it is associated with a number of systemic diseases, such as rheumatic fever, scarlet fever, measles, or varicella infection (chickenpox). It can occur with nasal polyps, sinusitis, or allergic rhinitis. Some families show a familial predisposition.
Nosebleeds are always frightening because of the visible bleeding and a choking sensation if blood should run down the back of the nasopharynx. The fear is generally out of proportion to the seriousness of the bleeding.
Keep children with nosebleeds in an upright position with their head tilted slightly forward to minimize the amount of blood pressure in nasal vessels and to keep blood moving forward, not back into the nasopharynx (Osterhoudt, 2003). Apply pressure to the sides of the nose with your fingers (Fig. 40.17). Make every effort to quiet the child and to help him or her stop crying, because crying increases pressure in the blood vessels of the head and prolongs bleeding. If these simple measures do not control the bleeding, epinephrine (1:1,000) may be applied to the bleeding site to constrict blood vessels. A nasal pack may be necessary to provide continued pressure.
Teach parents that every child has occasional nosebleeds. Chronic nasal bleeding, however, should be investigated to rule out a systemic disease or blood disorder.
FIGURE 40.17 Emergency therapy for a nosebleed is to sit the child up and apply pressure to the sides of the nose.
Sinusitis
Sinusitis is rare in children younger than 6 years of age because the frontal sinuses do not develop fully until age 6 (Chung, 2003). It occurs as a secondary infection in older children when streptococcal, staphylococcal, or H. influenzae organisms spread from the nasal cavity. Children develop a fever, a purulent nasal discharge, headache, and tenderness over the affected sinus. A nose and throat culture will identify the infectious organism.
Treatment for acute sinusitis consists of an antipyretic for fever, an analgesic for pain, and an antibiotic for the specific organism involved. Oxymetazoline hydrochloride (Afrin), supplied as nose drops or a nasal spray, shrinks the edematous mucous membranes and allows infected material to drain from the sinuses. To avoid a rebound effect, this type of nasal spray should be used for only 3 days at a time; otherwise, it actually causes more nasal congestion than was present originally. Warm compresses to the sinus area may encourage drainage and relieve pain. Some children need acetaminophen (Tylenol) for pain.
Sinusitis is considered by many adults to be a minor illness. It needs to be treated, however, because it can have serious complications if the infection spreads from the sinuses to invade the facial bone (osteomyelitis) or the middle ear (otitis media). Chronic sinusitis can also interfere with school and social interactions because of the constant pain.
Laryngitis
Laryngitis is inflammation of the larynx. It results in brassy, hoarse voice sounds or inability to make audible voice
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sounds. It may occur as a complication of pharyngitis or from excessive use of the voice, as in shouting or loud cheering. Laryngitis is as annoying for children as it is for adults. Sips of fluid (either warm or cold, whichever feels best) offer relief from the annoying tickling sensation often present. The most effective measure, however, is for the child to rest the voice for at least 24 hours, until inflammation subsides. For infants with laryngitis, attempt to meet their needs before they have to cry for things. Simply caution older children not to speak. Provide them with a paper and pencil or chalkboard for communication.
Congenital Laryngomalacia/Tracheomalacia
Congenital laryngomalacia means that an infant's laryngeal structure is weaker than normal and collapses more than usual on inspiration. This produces laryngeal stridor (a high-pitched crowing sound on inspiration) present from birth, possibly intensified when the infant is in a supine position or when sucking (Carden et al., 2005).
Assessment
The infant's sternum and intercostal spaces may retract on inspiration because of the increased effort needed to pull air into the trachea past the collapsed cartilage rings. Many infants with this condition must stop sucking frequently during a feeding to maintain adequate ventilation and to rest from their respiratory effort, which is exhausting.
Therapeutic Management
When parents wake at night and listen in a quiet house to the sound of stridor, it seems unbearably loud. This makes it difficult for them to believe it is safe for them to care for the infant at home.
Most children with congenital laryngomalacia need no routine therapy other than to have parents feed them slowly, providing rest periods as needed. The condition improves as infants mature and cartilage in the larynx becomes stronger at about 1 year of age. Many parents sleep at night with the child's crib next to their bed or with one hand resting on the infant's chest so they can be assured during the night the child is continuing to breathe. At health care visits, assess whether the parents are receiving enough sleep at night and are not becoming too exhausted to be able to continue their daily activities. Showing them a weight chart that demonstrates their child is growing and thriving despite this problem can be reassuring.
Be certain parents know the importance of bringing the child for early care if signs of an upper respiratory tract infection develop. If not, laryngeal collapse will be even more intense during these times, and complete obstruction of the trachea could occur. Any time stridor becomes more intense, advise parents to have the infant seen by their primary care provider, because generally this indicates beginning obstruction and probably the beginning of an upper respiratory tract infection. As parents become more accustomed to the sound their infant makes while breathing, they will become astute reporters of change in their infant's condition; listen to them carefully when they report a change to prevent overlooking this important information.
Croup (Laryngotracheobronchitis)
Croup (inflammation of the larynx, trachea, and major bronchi) is one of the most frightening diseases of early childhood for both parents and children. In children between 6 months and 3 years of age, the cause of croup is usually a viral infection such as parainfluenza virus. In previous years, the most common cause was H. influenzae. However, since immunization against this organism has been included in a routine immunization series, the incidence of croup from this cause has declined by 90% (Phillips, 2003).
Assessment
With croup, children typically have only a mild upper respiratory tract infection at bedtime. Temperature is normal or only mildly elevated. During the night, they develop a barking cough (croupy cough), inspiratory stridor, and marked retractions. They wake in extreme respiratory distress. The larynx, trachea, and major bronchi are all inflamed. These severe symptoms typically last a number of hours and then, except for a rattling cough, subside by morning. Symptoms may recur the following night. Cyanosis is rarely present, but the danger of glottal obstruction from the laryngeal inflammation is very real. Pulse oximetry and transcutaneous SaO2 monitors are helpful measures to document whether hypoxemia is occurring.
Therapeutic Management
One emergency method of relieving croup symptoms is for a parent to run the shower or hot water tap in a bathroom until the room fills with steam, then keep the child in this warm, moist environment. If this does not relieve symptoms, instruct parents to bring the child to an emergency department for further evaluation and care. When a child is seen at the emergency room, cool moist air with a corticosteroid such as dexamethasone, or racemic epinephrine, given by nebulizer, can reduce inflammation and produce effective bronchodilation to open the airway (Bjornson & Johnson, 2004). Intravenous therapy may be prescribed to keep the child well hydrated. Maintain accurate intake and output records and test urine specific gravity to ensure that hydration is adequate.
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Epiglottitis
Epiglottitis is inflammation of the epiglottis (the flap of tissue that covers the opening to the larynx to keep out food and fluid during swallowing). Although it is rare, inflammation of the epiglottis is an emergency because the swollen epiglottis cannot rise and allow the airway to open. It occurs most frequently in children from 2 to about 7 years of age (Cromer & Foley, 2004).
Epiglottitis can be either bacterial or viral in origin. H. influenzae type B has been replaced as the most common bacterial cause of the disorder by pneumococci, streptococci, or staphylococci. Echovirus and respiratory syncytial virus also can cause the disorder.
Assessment
Symptoms begin as those of a mild upper respiratory tract infection. After 1 or 2 days, as inflammation spreads to the epiglottis, the child suddenly develops severe inspiratory stridor, a high fever, hoarseness, and a very sore throat. The child may have such difficulty swallowing that he or she drools saliva. The child may protrude the tongue to increase free movement in the pharynx.
If a child's gag reflex is stimulated with a tongue blade, the swollen and inflamed epiglottis can be seen to rise in the back of the throat as a cherry-red structure. It can be so edematous, however, that the gagging procedure causes complete obstruction of the glottis and respiratory failure. Therefore, in children with symptoms of epiglottitis (dysphagia, inspiratory stridor, cough, fever, and hoarseness), never attempt to visualize the epiglottis directly with a tongue blade or obtain a throat culture unless a means of providing an artificial airway, such as tracheostomy or endotracheal intubation, is readily available. This is especially important for the nurse who functions in an expanded role and performs physical assessments and routinely elicits gag reflexes.
With epiglottitis, laboratory studies will show leukocytosis (20,000 to 30,000 mm3), with the proportion of neutrophils increased. A blood culture to evaluate for septicemia and ABGs to evaluate respiratory sufficiency may be ordered. However, because excessive crying can precipitate entrapment of the epiglottis and obstruction, such tests may be delayed in preference to a lateral neck x-ray film or sonogram, which will show the enlarged epiglottis. Do not allow a child with possible epiglottitis to go to these departments accompanied only by parents or a nursing aide, in case obstruction occurs in the x-ray or sonograph room.
Therapeutic Management
Children need moist air to reduce the epiglottal inflammation. If cyanosis is present, they need oxygen. An antibiotic, such as a second-generation cephalosporin (e.g., cefuroxime), may be prescribed until a throat culture indicates a specific antibiotic drug. Because they can't swallow, children need intravenous fluid therapy to maintain hydration. They may need a prophylactic tracheostomy or endotracheal intubation to prevent total obstruction, although it is often difficult to intubate children with epiglottitis because the tube cannot be passed beyond the edematous epiglottis. After antibiotic therapy begins, the epiglottal inflammation recedes rapidly. By 12 to 24 hours, it has reduced enough that the airway may be removed. Antibiotic administration will continue for a full 7 to 10 days. Siblings of the ill child may be prescribed prophylactic antibiotic therapy to prevent them from developing the same symptoms.
Initially, the symptoms of epiglottitis are not unlike those of croup. As a result, parents may not realize the extent of the occlusion in their child, especially if the child has had croup on other occasions. They may question why a prophylactic tracheostomy was necessary this time when it was not used when the child had croup. Explain to them the difference between the two diseases (Table 40.5).
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Some infants with epiglottitis die because obstruction occurs before a tracheotomy can be accomplished. If this should happen, parents can be assured they could not realize the seriousness of their child's symptoms. This may make them overcautious, bringing other children to health care settings repeatedly for symptoms that are obviously not serious. It will take time for them to regain confidence in themselves as parents and in their ability to judge a child's health.
TABLE 40.5 Comparison of Laryngotracheobronchitis (Croup) and Epiglottitis
Assessment Laryngotracheobronchitis Epiglottitis
Causative organism Usually viral Usually pneumococci or streptococci
Usual age of child 6 mo–3 yr 3–6 yr
Seasonal occurrence Late fall and winter None
Onset pattern Preceded by upper respiratory infection; cough becomes worse at night Preceded by upper respiratory infection; suddenly very ill
Presence of fever Low grade Elevated to about 103°F
Appearance Retractions and stridor; prolonged inspiratory phase of respirations; not very ill-appearing Drooling; very ill-appearing; neck hyperextended to breathe. (Do not attempt to view enlarged epiglottis, or immediate airway obstruction can occur.)
Cough Sharp, barking Muffled cough
Radiographic findings Lateral neck radiograph showing subglottal narrowing Lateral neck radiograph showing enlarged epiglottis
Possible complications Asphyxia due to subglottic obstruction Asphyxia due to supraglottic obstruction
Aspiration
Aspiration (inhalation of a foreign object into the airway) occurs most frequently in infants and toddlers. When a child aspirates a foreign object, the immediate reaction is choking and hard, forceful coughing. Usually, this dislodges the object. However, if the airway becomes so obstructed that coughing is impossible (no sound with cough), or if there are signs of increased respiratory difficulty accompanied by stridor, some intervention is essential. A series of Heimlich subdiaphragmatic abdominal thrusts are recommended for children, the same as for adults. This recommendation does not extend to infants, however, because of the great risk of rupturing the liver (American Heart Association, 2005).
For the Heimlich maneuver, stand behind the child and place a fist just under the child's diaphragm (a point immediately below the anterior rib cage). Embrace the child, grip your fist with your other hand, and pull back and up with a rapid thrust. The pressure created by this action of pushing up on the diaphragm forces the aspirated material out of the trachea (Fig. 40.18).
FIGURE 40.18 Heimlich maneuver on a school-age child.
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If a child is lying on his or her back at the time of the aspiration, stand at the head of the bed or table, place your hands in the same position as described above, and exert the same inward and upward thrust. A Heimlich maneuver may cause the child to vomit as well as expel an aspirated object. Turn the child's head to the side to prevent aspiration of vomitus.
For infants, use back thrusts to dislodge an aspirated object. Turn the infant prone over your arm and administer up to five quick back blows forcefully between the infant's shoulder blades, using the heel of the hand (Fig. 40.19A). If the object is not expelled, turn the infant while carefully supporting the head and neck and hold the infant in a supine position draped over your thigh. Be sure to keep the infant's head lower than his or her chest. Provide up to five quick downward thrusts in the lower third of the sternum (see Fig. 40.19B; American Heart Association, 2005). This is generally enough to dislodge the foreign object. However, if this does not occur, rescue breathing may then be attempted.
Bronchial Obstruction
The right main bronchus is straighter and has a larger lumen than the left bronchus in children older than 2 years of age. For this reason, an aspirated foreign object that is not large enough to obstruct the trachea may lodge in the right bronchus, obstructing a portion or all of the right lung. The alveoli distal to the obstruction will collapse as the air remaining in them becomes absorbed (atelectasis), or hyperinflation and pneumothorax may occur if the foreign body serves as a ball valve, allowing air to enter but not leave the alveoli.
FIGURE 40.19 Back blows (A) and chest thrusts (B) to relieve complete foreign body airway obstruction in an infant. (From
American Heart Association. [2000]. Resuscitation in the newborn. Dallas, TX: AHA.
)
Assessment
After aspirating a small foreign body, the child generally coughs violently and may become dyspneic. Hemoptysis, fever, purulent sputum, and leukocytosis will result if the object scratches the airway or infection develops. Localized wheezing (a high whistling sound on expiration made by air passing through the narrowed lumen) may occur. Because this is localized, it is different from the generalized wheezing of a child with asthma.
A chest x-ray will reveal the presence of a radiopaque object. Objects most frequently aspirated include bones,
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popcorn, nuts, and coins. As a rule, nuts or popcorn should not be given to children younger than school age. These objects are coated with oil, and as they swell with moisture in the respiratory tract, they cause not only obstruction but also lipid pneumonia, a persistent and difficult-to-treat type of pneumonia. Foreign bodies that are inhaled this deeply are rarely coughed up spontaneously, despite the severe coughing that ensues. Because objects such as plastic and nuts cannot be visualized well on x-ray film, an x-ray study may be inconclusive.
Therapeutic Management
Children who are seen in emergency departments after aspirating a foreign body are in distress from pain and are choking and coughing. Their parents are frightened by the degree of distress. Parents may feel bad about having offered the child (or allowed the child to reach) a food such as a peanut. Children need quick orientation to the treatment environment, as they move from the emergency department to x-ray and then possibly to surgery or a treatment room. If possible, allow the parents to go with them as appropriate. Throughout, be vigilant in observing the child for coughing up the foreign body or developing increasing respiratory distress.
A bronchoscopy may be necessary to remove the foreign body (Brown & Padman, 2004). Children are often given conscious sedation for a bronchoscopy (for details of a bronchoscopy procedure and conscious sedation, see Chapter 36). After bronchoscopy, assess the child closely for signs of bronchial edema and airway obstruction that occurs from mucus accumulation due to the bronchus manipulation. Obtain frequent vital signs (increasing pulse and respiratory rates suggest increased edema and obstruction).
Keep a child NPO for at least an hour after a bronchoscopy. Check for return of the gag reflex. Once the gag reflex is present, offer the first fluid cautiously to prevent additional aspiration. Cool fluid may feel more soothing and also helps to reduce the soreness in the throat. Breathing cool, moist air or having an ice collar applied may further reduce edema.
Obviously, parents need to be cautioned about the dangers of aspiration to keep it from happening again. Do not lecture them, however. A parent whose child has just been through this experience already recognizes the danger of aspiration and realizes he or she needs to be more careful in the future.
Disorders of the Lower Respiratory Tract
The structures of the lower respiratory tract are subject to infection by the same pathogens that attack the upper respiratory tract. Inflammation and infection of the lungs or bronchi is particularly troublesome: it occurs in various forms and is caused by several organisms. Other illnesses that occur in the lower respiratory tract, such as asthma and cystic fibrosis, can lead to secondary pneumonia infections and chronic illness.
Influenza
Influenza involves inflammation and infection of the major airways. It is caused by the orthomyxoviruses influenza types A, B, or C. It is marked by a cough, fever, fatigue, aching pains, a sore throat, and often accompanying gastrointestinal symptoms such as vomiting or diarrhea. The disease spreads readily through a home or a classroom because children are contagious on the day before symptoms appear and for about the next 5 days.
Children usually need an antipyretic such as acetaminophen (Tylenol) to control fever. Oseltamivir (TamiFlu), a new antiviral drug that halts viral proliferation, can be taken by children over 1 year of age (Karch, 2004). Because TamiFlu only halts virus replication, it needs to be taken at the first sign of illness. Although most children recover without incident, influenza can lead to bronchitis or pneumonia. The condition can be largely prevented by yearly influenza vaccine. Because the influenza virus mutates yearly, the influenza vaccine is specific for only that year and must be readministered yearly (Goldrick, 2004).
Bronchitis
Bronchitis, or inflammation of the major bronchi and trachea, is one of the more common illnesses affecting preschool and school-age children. It is characterized by fever and cough, usually in conjunction with nasal congestion. Causative agents include the influenza viruses, adenovirus, and Mycoplasma pneumoniae, among others.
Assessment
A child usually has a mild upper respiratory tract infection for 1 or 2 days; he or she then develops a fever and a dry, hacking cough, which is hoarse and mildly productive in older children. The cough is serious enough to wake a child from sleep. These symptoms may last for a week, with full recovery sometimes taking as long as 2 weeks.
On auscultation, rhonchi and coarse crackles (the sound of rales) can be heard. A chest x-ray will reveal diffuse alveolar hyperinflation and some markings at the hilus of the lung.
Therapeutic Management
Therapy is aimed at relieving respiratory symptoms, reducing fever, and maintaining adequate hydration. An antibiotic is prescribed for bacterial infections. If mucus is viscid, an expectorant may be needed to help the child raise it. It is important that children with bronchitis cough to raise accumulating sputum. Cough syrups to suppress coughing, therefore, are rarely indicated.
Bronchiolitis
Bronchiolitis is inflammation of the fine bronchioles and small bronchi. It is the most common lower respiratory illness in children younger than 2 years, peaking in incidence
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at 6 months of age. It occurs most often in the winter and spring. Many children who develop asthma later in life have numerous instances of bronchiolitis during their first year of life. Viruses, such as adenovirus, parainfluenza virus, and respiratory syncytial virus (RSV), in particular, appear to be the pathogens most responsible for this illness (Zsolway, 2003).
Assessment
Typically, infants have 1 or 2 days of an upper respiratory tract infection, then suddenly begin to demonstrate nasal flaring, intercostal and subcostal retractions on inspiration, and an increased respiratory rate. They may have a mild fever, leukocytosis, and an increased erythrocyte sedimentation rate, indicating the amount of bronchial inflammation present. Both accumulating mucus and inflammation block the small bronchioles, so air can no longer enter or leave alveoli freely. Most infants develop alveolar hyperinflation because air enters more easily than it leaves inflamed, narrowed bronchioles. The expiratory phase of respiration is prolonged, and wheezing may be present. After initial hyperinflation, areas of atelectasis may occur as the air that cannot be expired is absorbed. Tachycardia and cyanosis develop from hypoxia. Infants soon become exhausted from rapid respirations. A chest x-ray may show pulmonary infiltrates caused by a secondary infection or collapse of alveoli (atelectasis). Pulse oximetry shows low oxygen saturation. A throat culture will identify the offending organism.
Therapeutic Management
For children with less severe symptoms, antipyretics, adequate hydration, and maintaining a watchful eye for progression to more serious illness is all that is necessary. Hospitalization is warranted for children in severe distress (e.g., if the infant is tachypneic, has marked retractions, seems listless, or has a history of poor fluid intake).
Antibiotics are not commonly used in the treatment of bronchiolitis, because bacteria are rarely a causative factor. Children with chronic pulmonary disease may receive anti-RSV immunoglobulin if RSV was identified as the causative agent (Zsolway, 2003).
If symptoms are severe, children need humidified oxygen to counteract hypoxemia and adequate hydration to keep respiratory membranes moist. Nebulized bronchodilators, epinephrine, and steroids may be used, although there is little evidence they make a major difference in reducing symptoms (King et al., 2004). Some children need ventilatory assistance to achieve adequate ventilation. All infants with bronchiolitis need to be carefully observed because if RSV is the cause, apnea may occur. In some infants, extracorporeal membrane oxygenation (the same as that used for heart surgery) is necessary to maintain adequate oxygenation.
Feeding is often a problem because infants tire easily and therefore cannot finish a feeding. Intravenous fluids may be given for the first 1 or 2 days of illness to eliminate the need for oral feeding.
Respiratory Syncytial Virus (RSV) Bronchiolitis
RSV is a pathogenic RNA virus that is the most common cause of bronchiolitis in young children. Symptoms begin as a mild upper respiratory infection that quickly extends to include the bronchioles. The infant becomes lethargic and possibly cyanotic. Dehydration occurs as the child becomes too fatigued to suck. Respiratory distress with nasal flaring, retractions, grunting, rales, rhonchi, and expiratory wheezing noted on auscultation occur. All infants with an RSV infection must be monitored closely because the virus tends to cause apnea or periodic halting of respirations. The diagnosis is confirmed by throat or nasal culture.
Therapy is supportive (supplemental oxygen and hydration therapy), although life-threatening apnea may require ventilatory support with mechanical ventilation. Ribavirin, an antiviral agent, is effective against RSV, but ribavirin aerosol treatment is controversial as the drug is teratogenic and could be harmful to pregnant caregivers. Because RSV infection spreads readily from one child to the next, infants should be isolated for care. Nursing care should be organized so nurses do not care for infants infected with RSV and those who are not.
The disease peaks in severity between 48 to 72 hours. Recurrent apneic episodes are rare, so home monitoring for apneic episodes is usually not necessary. Two products are available for the prevention of RSV infection: Respiratory
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Syncytial Virus Immune Globulin Intravenous (RSV-IGIV), made from RSV antibody positive donor serum, and Palivizumab, a humanized monoclonal antibody produced by recombinant DNA technology. These may be given prophylactically to premature infants during the winter months (Zsolway, 2003).
Asthma
Asthma, an immediate hypersensitivity (type I) response (see Chapter 42), is the most common chronic illness in children, accounting for a large number of days of absenteeism from school and many hospital admissions each year. It tends to occur initially before 5 years of age, although in these early years it may be diagnosed as frequent occurrences of bronchiolitis rather than asthma (Table 40.6). The condition may be intermittent, with symptom-free periods, or chronic, with continuous symptoms. If a parent has asthma, the chance a child will also develop asthma is increased (Clayton, 2003).
Asthma tends to occur in children with atopy or those who tend to be hypersensitive to allergens. Mast cells release histamine and leukotrienes that result in diffuse obstructive and restrictive airway disease because of a triad of inflammation, bronchoconstriction, and increased mucus production. Most children with asthma can be shown to have sensitization to inhalant antigens such as pollens, molds, or house dust. Food also may be involved. Severe bronchoconstriction can occur because of exposure to cold air or irritating odors, such as turpentine or smog, as well as inhalation of a known allergen. Air pollutants such as cigarette smoke may lower the threshold for hypersensitivity reactions and worsen the condition. Although there may be a seasonal factor responsible for a particular child's symptoms, most children have multiple sensitivities and are affected all year long. Aspirin can be a trigger, so caution adolescents with asthma that if they begin to take aspirin as an adult, it may initiate an attack.
TABLE 40.6 Comparison of Bronchiolitis, Pneumonia, and Asthma
Assessment Bronchiolitis Pneumonia Asthma
Cause Usually respiratory syncytial virus Possibly bacterial (pneumococcal, or H. influenzae), viral, or mycoplasmal; possibly secondary to aspiration Hypersensitivity type I immune response
Age of child Under 2 yr All through childhood Onset 1–5 yr
Onset pattern Follows an upper respiratory infection Follows an upper respiratory infection Follows initiation by an allergen
Appearance Fatigued, anxious, shallow respirations, increasing anteroposterior diameter of chest Fatigued, anxious, shallow respirations Wheezing, exhausted, frightened
Cough Paroxysmal, dry Productive, harsh cough Paroxysmal, with thick mucus production
Fever Low grade Elevated None
Auscultatory sounds Barely audible breath sounds, crackles, expiratory wheezing Decreased breath sounds, rales Wheezing
Mechanism of Disease
Asthma primarily affects the small airways and involves three separate processes: bronchospasm, inflammation of bronchial mucosa, and increased bronchial secretions (mucus). All three processes act to reduce the size of the airway lumen, leading to acute respiratory distress. Bronchial constriction occurs because of stimulation of the parasympathetic nervous system (cholinergic mediated system), which initiates smooth muscle constriction. Inflammation and mucus production occur because of mast cell activation to release leukotrienes, histamine, and prostaglandins. Once viewed as a long-term, poorly controlled disorder, newer therapy makes this a reversible or manageable disorder (Kallstrom, 2004).
Assessment
The word “asthma” is derived from the Greek word for panting, a description of the child's distress. Typically, after exposure to an allergen or trigger, an episode begins with a dry cough, often at night as bronchoconstriction begins. Because bronchioles are normally larger in lumen on inspiration than expiration even with bronchoconstriction, children may inhale normally or have little difficulty. They develop increasing difficulty exhaling, however, as it becomes more and more difficult to force air through the narrowed lumen of the inflamed bronchioles filled with mucus. This causes the typical dyspnea and wheezing (the sound caused by air being pushed forcibly through obstructed bronchioles) typically associated with this disorder. Remember that wheezing is heard primarily on expiration. However, when severe, wheezing may be heard
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on inspiration as well. Hearing it on inspiration means the child is having extreme breathing difficulty. If the child coughs up mucus, it is generally copious and may contain white casts bearing the shape of the bronchi from which it was dislodged.
History
Assessment should include a thorough history of the development of the child's symptoms—for example, what the child was doing at the time of the attack, and what actions were taken by the parents or child to decrease or arrest the symptoms. When an acute attack has passed, ask the parent or child to describe the home environment, including any pets, the child's bedroom, outdoor play space, classroom environment, and type of heating in the house, to see whether more environmental control could reduce future occurrences.
Physical Assessment
A physical assessment includes examining for the specific symptoms of asthma. In many children, the initial wheezing is so loud it can be heard without a stethoscope. In others, it is evident only by auscultation. Asthma affects all lobes of the lungs, so although the wheezing may be more prominent in one lobe than in another, it is generally audible in all lung fields. Audible wheezing in only one lobe suggests that only one bronchus is plugged, which suggests that a foreign body such as a peanut is more likely responsible than asthma. Cyanosis may be present. The eosinophil count is elevated.
Bronchospasm leads to CO2 trapping and retention; therefore, arterial oxygen saturation monitored by a pulse oximeter will begin to decrease because of the child's inability to fully aerate the lungs. The child becomes frightened because of an acute feeling of suffocation. A peak flow meter shows decreased ability to exhale.
Air-filled lungs are hyperresonant to percussion (i.e., they make a louder, hollower noise on percussion than usual). In normal respiration, the inspiration phase of breathing is longer than the expiration phase. During an asthma attack, however, the child must work so hard to exhale that the expiration phase becomes longer than the inspiration phase. Time the two phases to demonstrate this. Also observe for retractions, because children use intercostal accessory muscles to achieve full breaths.
As constriction becomes acute, the sound of wheezing may decrease because so little air can leave the alveoli. Hypoxemia and possibly cyanosis will become severe. When blood gases show an increased PCO2 level and the sound of wheezing suddenly stops, respiratory failure is imminent.
During attacks, children with asthma are generally more comfortable in a sitting or standing position rather than lying down. If seated in a chair, they lean forward and raise their shoulders to give themselves more breathing space. Do not urge children to “lie down and relax,” as this can cause severe anxiety and increased difficulty in breathing. Children who do agree to lie down are either at the end of an attack and so beginning to feel less threatened by the dyspnea or are so exhausted by the paroxysms of coughing they no longer have the strength to sit upright.
Over time, as a child has many bouts of asthma, he or she develops a shield-like or barrel-shaped chest from constant overinflation of air in alveoli. Clubbing of the fingers (from the growth of excess capillaries initiated when oxygen deprivation is sensed in distal parts) may be noticeable. If a child has been treated for a long period with steroids, he or she may develop growth restriction.
Pulmonary Function Studies
Good pulmonary function depends on good ventilation (both drawing adequate air into the lungs and expelling it again), adequate transfer of gases across the alveolar capillary membranes, and adequate volume and distribution of pulmonary capillary blood flow to transport oxygen to body cells. In children with asthma, the vital capacity (air that they are able to exhale) may be low or the capacity may be normal, but, because of narrowed bronchioles as a result of bronchospasm, the expiratory rate will be abnormally long (more than 10 seconds, rather than the normal 2 or 3 seconds). If a child has bronchial plugging, the vital capacity will be low because of air absorption behind blocked bronchi. A gross measure of vital capacity is to ask a child to blow out a match. A child with an average vital capacity should be able to do this when the match is held at 6 inches. When a vital capacity test is abnormal, it may be repeated after an inhalation treatment to show the effect of the treatment.
Peak Expiratory Flow Rate Monitoring
Children with asthma often use a home peak flow meter daily to measure gross changes in peak expiratory flow over time and help in planning an appropriate therapeutic regimen (Fig. 40.20). Children with asthma should be able to tell you their usual reading and personal best score.
To use a peak flow meter, a child places the indicator on the apparatus at the bottom of the numbered scale, and takes a deep breath. He or she places the meter in the mouth and blows out as hard and fast as possible. He or she then repeats this two more times and records the highest number achieved as the peak flow meter result. During a 2-week period when the child feels well, this should be done daily. The highest number achieved during this time is recorded as the child's personal best.
Children are assigned “zones” to rate their expiratory compliance:
  • Green zone (80% to 100% of their personal best) means no asthma symptoms are present, and they should take their routine medications.
  • Yellow zone (50% to 80% of personal best) signals caution. An episode of asthma may be beginning.
  • Red zone (below 50% of personal best) indicates an asthma episode is beginning. A child should immediately take his or her prescribed medication such as an inhaled beta-2-agonist, then repeat the peak flow assessment. If the second reading is not in the green zone, the parent should alert the primary care provider of the impending asthma attack.
Therapeutic Management
Therapy for children with asthma involves planning for the three goals of all allergic disorders: avoidance of the allergen by environmental control; skin testing and hyposensitization to identified allergens; and relief of symptoms by pharmacologic agents.
FIGURE 40.20 Children with any chronic illness require periodic evaluation and sometimes home monitoring. Here a child with asthma practices using a home peak flow meter to track her peak expiratory flow readings on a daily basis.
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Cough suppressants are contraindicated with asthma because, as a rule, as long as children can continue to cough up mucus, they are not in serious danger. When they stop coughing up mucus, thick plugs form that then may lead to pneumonia, atelectasis, and further acidosis.
A child with mild but persistent asthma usually is prescribed an inhaled anti-inflammatory corticosteroid such as fluticasone (Flovent) daily. Children who have moderate persistent symptoms usually are prescribed a long-acting bronchodilator at bedtime in addition to the inhaled anti-inflammatory daily corticosteroid. Children who have severe persistent asthma symptoms take a high dose of both an oral corticosteroid and an inhaled corticosteroid daily as well as a long-acting bronchodilator at bedtime. In addition, children may be prescribed a short-acting beta-2-agonist bronchodilator, such as albuterol or terbutaline, to use if an attack should begin (Box 40.11). Cromolyn sodium is a mast cell stabilizer given by a nebulizer or metered-dose inhaler that can prevent bronchoconstriction and thereby prevent the symptoms of asthma (Box 40.12). Cromolyn sodium is not effective once symptoms have begun.
Another group of drugs used in the treatment of asthma are leukotriene receptor antagonists such as montelukast (Singulair). This drug is also used for prophylaxis and chronic treatment of asthma in children over 6 years of age. It is not effective in an acute attack.
Metered-dose inhalers require that the child trigger the inhaler at the same time he or she breathes in (Fig. 40.21A). Because it is difficult for children younger than approximately 12 years to do this, placing a spacer tube between the inhaler and the mouthpiece better coordinates inhaling and trigger release (see Fig. 40.21B). If children are to receive medication by nebulizer or inhaler, be certain they know how to use these properly. It is easy for children to take this type of medication lightly (the belief it is “not really medicine” because it is not swallowed). As a result, overdose from constant use of nebulizers or metered-dose inhalers can occur.
Dehydration occurs rapidly in children during an asthma attack because they have decreased oral intake (children stop drinking because they are coughing, or coughing makes them vomit and parents stop offering fluid) as well as increased insensible loss that occurs from tachypnea. Dehydration may contribute to increased mucus plugging
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and further airway obstruction. Encourage children to continue to drink fluids (ask about favorite beverages and offer small sips of them). Avoid milk or milk products because they cause thick mucus and difficulty swallowing. In an emergency setting, an intravenous line is established to supply continuous fluid therapy and also provide a route for emergency drug administration.
FIGURE 40.21 (A) Many children with asthma use a metered dose inhaler to administer a bronchodilator to themselves. Be certain children respect such medicine as medicine so they use sensible precautions. (B) Younger children need a “spacer” with inhalers so they do not need to correlate administration with inhalation.
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Status Asthmaticus
Under ordinary circumstances, an asthma attack responds readily to the aerosol administration of a bronchodilator such as albuterol, terbutaline, or levalbuterol (Xopenex). When children fail to respond and an attack continues, they are in status asthmaticus. This is an extreme emergency because if the attack cannot be relieved, the child may die of heart failure caused by the combination of exhaustion, atelectasis, and respiratory acidosis from bronchial plugging.
Assessment
A child with status asthmaticus is in acute respiratory distress. Both heart rate and respiratory rate are elevated. SaO2 and PO2 are low; PCO2 is elevated because the bronchi are so constricted the child cannot exhale, resulting in CO2 accumulation. The rising PCO2 rapidly leads to acidosis. In contrast to the loud wheezing initially heard in an asthma attack, children with status asthmaticus may have so little air able to pass in or out of their lungs that breath sounds are limited. Pulse oximetry will reveal the poor oxygenation.
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Status asthmaticus is often initiated by pulmonary infection, which acts as the triggering mechanism for the prolonged attack. If this occurs, obtain cultures from coughed sputum, and be prepared to administer a broad-spectrum antibiotic until the culture results are available. Be certain the sputum obtained for culture was coughed from deep in the respiratory tract and not just from the back of the child's throat.
Therapeutic Management
By definition, a child in status asthmaticus has failed to respond to first-line therapy. Continuous nebulization with an inhaled beta-2-agonist and intravenous corticosteroids may be necessary to reduce symptoms. The PO2 usually is maintained at more than 90 mm Hg with oxygen administration. This is best given by face mask or nasal prongs. These methods supply good oxygen concentrations and yet leave the child's face unobscured for easy observation. To prevent drying of pulmonary secretions, always give oxygen with humidification. Oxygen is best administered at a concentration of 30% to 40%, not 100%. If concentrations greater than 40% are needed, a Venturi mask that allows for rebreathing may be used. Some children in severe status asthmaticus have such a carbon dioxide buildup (because they cannot exhale properly) that they develop carbon dioxide narcosis with no stimulation for inhalation. The child's respiratory stimulus, therefore, is hypoxia, or lack of oxygen. If 100% oxygen were administered, the oxygen lack would disappear, and respirations would cease. The idea “if a little is good, a lot is better” does not apply here. After it has been ascertained that the child is not in acidosis (from blood gas and pH studies), oxygen levels may be increased, but for initial therapy, unless prescribed otherwise, keep the level at 40%.
During the acute stage of status asthmaticus, children need increased fluid to combat dehydration and keep airway secretions moist. Drinking tends to aggravate coughing, so an intravenous infusion such as 5% glucose in 0.45 saline is usually prescribed to supply fluid. If a child can drink, do not offer cold fluids because these tend to aggravate bronchospasm.
Monitor intake and output; measure the specific gravity of urine. Under stress, antidiuretic hormone is released, so fluid retention and overhydration may occur.
An increasing PCO2 is a danger sign because it indicates the degree of hypoventilation. In severe attacks, endotracheal intubation and mechanical ventilation may be necessary to maintain effective respirations (Clayton, 2003).
Bronchiectasis
Bronchiectasis is chronic dilatation and plugging of the bronchi. It may follow pneumonia, aspiration of a foreign body, pertussis, or asthma. It is often associated with cystic fibrosis (Wagener & Headley, 2003).
Children develop a chronic cough with mucopurulent sputum. Young infants may have accompanying wheezing or stridor. If a large area of lung is involved, children may have cyanosis. As the disease becomes chronic, children develop symptoms of chronic lung disease, such as clubbing of the fingers and easy fatigability. Their physical growth may become restricted. Their chest may become enlarged from overinflation of alveoli caused by the air trapped behind inflamed bronchi.
Chest physiotherapy may be necessary to raise the tenacious sputum. An antibiotic will be necessary if infection is present. The cause of the bronchiectasis must be identified and relieved before the chronic process can be relieved. Surgery to remove the affected lung portion may be necessary.
Pneumonia
Pneumonia (infection and inflammation of alveoli) occurs at a rate of 2 to 4 children in 100. It may be of bacterial origin (pneumococcal, streptococcal, staphylococcal, or chlamydial) or viral in origin, such as respiratory syncytial virus (RSV). Aspiration of lipid or hydrocarbon substances also causes pneumonia. Pneumonia is commonly divided into two types: hospital acquired (pneumococcal or streptococcal pneumonia) and community acquired (chlamydia, viral pneumonias) (Thibodeau & Viera, 2004). It is the most common pulmonary cause of death in infants younger than 48 hours of age. It occurs most often in late winter and early spring. Newborns who are born more than 24 hours after rupture of the amniotic membranes and those who aspirated amniotic fluid or meconium during birth are particularly prone to developing pneumonia in their first few days of life (Greenberg, 2004). When it is known that the fetal membranes have been ruptured for more than 24 hours before birth, prophylactic broad-spectrum antibiotics may be given to prevent pneumonia. The differences between bronchiolitis, pneumonia, and asthma are summarized in Table 40.6. Pneumocystis carinii pneumonia, the type seen almost exclusively with HIV/AIDS infection, is discussed in Chapter 42.
Pneumococcal Pneumonia
The onset of pneumococcal pneumonia is generally abrupt and follows an upper respiratory tract infection. In infants, pneumonia tends to remain bronchopneumonia with poor consolidation (infiltration of exudate into the alveoli). In older children, pneumonia may localize in a single lobe, and consolidation may occur. With this, children may have blood-tinged sputum as exudative serum and red blood cells invade the alveoli. After 24 to 48 hours, the alveoli are no longer filled with red blood cells and serum but fibrin, leukocytes, and pneumococci. At this point, the child's cough no longer raises blood-tinged sputum but thick purulent material.
Assessment
Children develop a high fever, nasal flaring, retractions, chest pain, chills, and dyspnea. Some children report the pain as being abdominal. The fever with pneumococcal pneumonia may rise so high and fast a child has a febrile seizure (see Chapter 49).
Children with pneumococcal pneumonia appear acutely ill. Tachypnea and tachycardia develop. Because the lung space is filled with exudate, respiratory function will be diminished. Breath sounds become bronchial (sound transmitted from the trachea) because air no longer or only poorly enters fluid-filled alveoli. Crackles (rales)
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may be present as a result of the fluid. Dullness on percussion over a lobe indicates that total consolidation has occurred. Chest x-rays will usually show this type of lung consolidation in older children but only patchy diffusion in young children. Laboratory studies will indicate leukocytosis.
Therapeutic Management
Before antibiotic therapy was available for pneumonia, it was almost always a fatal disease, especially in infants, so parents may be more worried about a child's condition than is warranted (Box 40.14).
Therapy for pneumococcal pneumonia is antibiotics. Either ampicillin or a third-generation cephalosporin is effective against pneumococci. Amoxicillin-clavulanate (Augmentin) also may be prescribed for penicillin-resistant organisms. Children need rest to prevent exhaustion. Plan nursing care carefully to conserve the child's strength. At the same time, turn and reposition a child frequently to avoid pooling of secretions. Intravenous therapy may be necessary to supply fluid, especially in infants, because infants tire so readily with sucking they may not be able to achieve a good oral intake. They may need an antipyretic such as acetaminophen to reduce fever.
Humidified oxygen may be necessary to alleviate labored breathing and prevent hypoxemia. Assess oxygen saturation levels frequently via pulse oximetry. Chest physiotherapy encourages the movement of mucus and prevents obstruction. Older children may need to be encouraged to cough so that secretions do not pool and become further infected.
Following pneumonia, children usually have a period of at least a week when they tire easily and need frequent, small feedings. Parents need to be cautioned that this degree of fatigue is an expected outcome and not a complication in itself. Children with chronic illness, those who have had a splenectomy, or those who are immunocompromised should receive a pneumococcal vaccine to prevent pneumococcal pneumonia.
Chlamydial Pneumonia
Chlamydia trachomatis pneumonia is most often seen in newborns up to 12 weeks of age because the chlamydial organism is contracted from the mother's vagina during birth. Symptoms usually begin gradually with nasal congestion and a sharp cough; infants fail to gain back their birthweight. Symptoms progress to tachypnea, with wheezing and rales audible on auscultation. Laboratory assessment will show an elevated level of immunoglobulin IgG and IgM antibodies, peripheral eosinophilia, and a specific antibody to C. trachomatis. Such an infection is treated with a macrolide antibiotic such as erythromycin with good results (Bhargava, 2003).
Viral Pneumonia
Viral pneumonia is generally caused by the viruses of upper respiratory tract infection: the RSVs, myxoviruses, or adenoviruses. Symptoms begin as an upper respiratory tract infection. After a day or two, additional symptoms such as a low-grade fever, nonproductive cough, and tachypnea begin. There may be diminished breath sounds and fine rales on chest auscultation. RSV may cause apnea. Chest x-rays will show diffuse infiltrated areas.
Because this is a viral infection, antibiotic therapy usually is not effective. The child needs rest and, possibly, an antipyretic for the fever; intravenous fluid may be necessary if a child becomes exhausted or is dehydrated and refusing fluids. After recovery from the acute phase of illness, a child will have a week or two of lethargy or lack of energy, the same as occurs with bacterial pneumonia. Parents may be confused because their child is not receiving an antibiotic, despite the diagnosis of pneumonia. Explain the difference between viral and bacterial infections so they can better understand their child's therapy and plan of care.
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Mycoplasmal Pneumonia
The mycoplasma organisms are similar to yet larger than viruses. Mycoplasmal pneumonia occurs more frequently in older children (over 5 years) and more often during the winter.
The symptoms of mycoplasmal pneumonia make it difficult to differentiate from other pneumonias. The child has a fever and a cough and feels ill. Cervical lymph nodes are enlarged. The child may have a persistent rhinitis.
Mycoplasmal organisms generally are sensitive to erythromycin or tetracycline. Erythromycin is the preferred drug for children younger than 8 years of age, because tetracycline tends to stain teeth brown and possibly stunt long bone growth (Karch, 2004).
Lipid Pneumonia
Lipid pneumonia is caused by the aspiration of an oily or lipid substance. It is much less common than it once was because children are not given oil-based tonics, such as castor oil or cod liver oil anymore, as they were in the past. Today it is most often caused by aspirated oily foreign bodies such as peanuts or popcorn. A proliferative inflammatory response occurs when lung lipases act on the aspirated oil. This is then followed by diffuse fibrosis of the bronchi or alveoli. The area then becomes secondarily infected.
A child may have an initial coughing spell at the time of aspiration. A period follows during which the child is symptomless; then a chronic cough, dyspnea, and general respiratory distress occur. A chest x-ray shows densities at the affected site.
Antibiotic therapy is ineffective unless a secondary bacterial infection has occurred. Surgical resection of a lung portion may be necessary to remove a lung segment if the pneumonitis does not heal by itself.
Hydrocarbon Pneumonia
A number of common household products such as furniture polish, cleaning fluids, turpentine, kerosene, gasoline, lighter fluid, and insect sprays have hydrocarbon bases. These products are a common cause of childhood poisonings and result in hydrocarbon pneumonia.
Assessment
Children who swallow a hydrocarbon-based product usually exhibit gastrointestinal symptoms such as nausea and vomiting. Next, they become drowsy and develop a cough from inhalation as vapors from the stomach rise and are inhaled. As bronchial edema occurs from irritation and inflammation, respirations become increased and dyspneic.
Physical assessment shows an increased percussion sound caused by the presence of air trapped in the alveoli beyond the point of inflammation. Rales may be heard as air passes through collecting mucus. Because air cannot reach and inflate the alveoli fully, breath sounds may be diminished.
Therapeutic Management
Irritation from fumes of hydrocarbon ingestion may occur when children initially swallow the fluid. If they are given an emetic to induce vomiting, it can cause them to aspirate vomitus or cause additional irritation. Parents should telephone a poison control center to ask for advice if their child has swallowed any poison, rather than inducing vomiting. In the emergency room, gastric lavage may be done by health care personnel with great care to remove the substance from the stomach and help prevent inhalation.
The child is usually admitted to a hospital observation unit for a short time. Obtain vital signs and observe the child's general appearance carefully for evidence of increased respiratory tract obstruction or increasing drowsiness or other symptoms of CNS involvement from CNS intoxication. Cool, moist air administered by a nebulizer with supplemental oxygen may be prescribed to decrease lung inflammation. If febrile, a child needs an antipyretic. Frequent changes of position will prevent pooling of secretions, which could lead to a secondary infection. Chest physiotherapy will help to move secretions and reduce areas of stasis.
The initial inflammation reaction from hydrocarbon aspiration may lead to such occlusion that emphysema (pocketing of air in alveoli) occurs, causing rupture of the alveoli into the pleural space, with consequent pneumothorax and atelectasis.
Often, children who swallow a household cleaner or other substance are aware they should not have been handling substances kept under the sink. As a result, they cannot help but interpret the hospitalization, blood drawing, and other uncomfortable procedures as punishments for their action. They may benefit from therapeutic play with puppets or dolls that will help alleviate their guilt and anger at being “punished” so severely.
Hydrocarbon pneumonia is slow to resolve, so the child will be ill for some time. After the illness, reinforce with parents the need to keep poisons in a safe place. Offer a listening ear so they can explain they were unaware of the extreme danger of these everyday household products.
Atelectasis
Atelectasis is the collapse of lung alveoli. It may occur in children as a primary or secondary condition.
Primary Atelectasis
Primary atelectasis occurs in newborns who do not breathe with enough respiratory strength at birth to inflate lung tissue or whose alveoli are so immature or so lacking in surfactant that they cannot expand. This is seen most commonly in immature infants or in infants with CNS damage. It may occur if infants have mucus or meconium plugs in the trachea.
When atelectasis occurs, the newborn's respirations become irregular, with nasal flaring and apnea. After a few minutes, a respiratory grunt and cyanosis may occur. The sound of a respiratory grunt is caused by the newborn's glottis closing on expiration. At first, this is a helpful action because it increases pressure in the respiratory tract, keeps alveoli from collapsing, and allows for better alveoli exchange surfaces. This action is also tiring, however, and as the infant tires, hypoxemia will increase, and
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the infant will become hypotonic and flaccid. The Apgar score will invariably be low.
As infants cry or are administered oxygen, more alveoli become aerated and cyanosis may decrease. The cause of the atelectasis must be established so that therapy directed to the specific cause can be initiated.
Secondary Atelectasis
Secondary atelectasis occurs in children when they have a respiratory tract obstruction that prevents air from entering a portion of the alveoli. As the residual air in the alveoli is absorbed, the alveoli collapse. The causes of obstruction in children include mucus plugs that may occur with chronic respiratory disease or aspiration of foreign objects. In some children, atelectasis occurs because of pressure on lung tissue from outside forces, such as compression from a diaphragmatic hernia, scoliosis, or enlarged thoracic lymph nodes (Fig. 40.22).
The signs of secondary atelectasis depend on the degree of collapse. Asymmetry of the chest may be noticed. Breath sounds on the affected side are decreased. If the process is extensive, tachypnea and cyanosis will be present. A chest x-ray will show the collapsed alveoli (a “whiteout”).
Children with atelectasis are prone to secondary infection because mucus, which provides a good medium for bacteria, becomes stagnant without air exchange.
Therapeutic Management
Atelectasis caused by inspiration of a foreign object will not be relieved until the object is removed by bronchoscopy. Atelectasis caused by a mucus plug will resolve when the plug resolves or is moved or expectorated. Children may need assisted ventilation to maintain adequate respiratory function until this time.
Make certain the chest of a child with atelectasis is kept free from pressure so that lung expansion is as full as possible (to allow as much breathing space as possible). If restraints are being used to keep an infant positioned, make certain that body restraints are not crossing the chest area and interfering with chest expansion. Check clothing to be certain it is loose and nonbinding. Make certain the child's arms are not positioned across the chest, where their weight could interfere with deep inspiration.
FIGURE 40.22 (A) Atelectasis caused by compression of lung tissue. (B) Atelectasis caused by obstruction.
A semi-Fowler's position generally allows for the best lung expansion because it lowers abdominal contents and increases chest space. Increase the humidity of the child's environment to prevent further bronchial plugging; suction and chest physiotherapy may be necessary to keep the respiratory tract clear and free of mucus. Observe closely for increased respirations or cyanosis, as these indicate failing oxygenation. Atelectasis is a serious disorder that must be considered as a possibility in all children with respiratory distress.
Pneumothorax
Pneumothorax is the presence of atmospheric air in the pleural space; its presence causes the alveoli to collapse (Fig. 40.23). Pneumothorax in children usually occurs when air seeps from ruptured alveoli and collects in the pleural cavity. It also can occur when external puncture wounds allow air to enter the chest (Kravitz, 2003).
Pneumothorax occurs in approximately 1% of newborns, probably due to rupture of the alveoli from the extreme intrathoracic pressure needed to initiate a first inspiration. The infant develops tachypnea, grunting respirations, flaring of the nares, and cyanosis. Auscultation reveals absent or decreased breath sounds on the affected side. Percussion may not be revealing, despite the hollow air space; as so much air is present, this may be hyperresonant. A more revealing sign may be the shift of the apical pulse (mediastinal shift) away from the site of the pneumothorax and the resulting atelectasis. A chest film will show the darkened area of the air-filled pleural space.
The child needs oxygen therapy to relieve respiratory distress. A thoracotomy catheter or needle may be placed in the pleural space and atmospheric air aspirated or low-pressure suction with water-seal drainage applied to remove accumulated air. In most children with pneumothorax, symptoms are relieved within 24 hours after suction is begun. The use of water-seal drainage with children is discussed in Chapter 41.
FIGURE 40.23 (A) Pneumothorax. A tear in the tracheobronchial tree has caused air to move into the pleural space; the lung collapses and the mediastinum shifts to the unaffected side. (B) Aspiration of air from the pleural space allows lung to reexpand after a pneumothorax.
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If the air in the pleural space is from a puncture wound such as a stab wound, cover the chest wound immediately with an impervious material, such as petrolatum gauze, to prevent further air from entering. In an emergency, an impervious object can be your gloved hand.
Pneumothorax is always a potentially serious respiratory problem. The extent of the symptoms and the outcome will depend on the cause of entry of air into the pleural space and whether it can be removed.
Bronchopulmonary Dysplasia
Bronchopulmonary dysplasia (BPD) is chronic pulmonary involvement that occurs in 10% to 40% of infants who are treated for acute respiratory distress in the first days of life. The condition is thought to occur from a combination of surfactant deficiency (decreased from lung trauma), barotrauma (lung damage from ventilator pressure), oxygen toxicity (from high levels needed to counteract the original respiratory distress), and continuing inflammation. The condition most often occurs in infants who received mechanical ventilation for respiratory distress syndrome at birth (Good, 2003).
Infants with BPD develop tachypnea, retractions, nasal flaring, tachycardia, oxygen dependence, and abnormal x-ray findings that show areas of overinflation and atelectasis. On auscultation, decreased air movement can be detected. Although some infants have such decreased lung function that they are left ventilator-dependent, administration of a corticosteroid and a bronchodilator greatly reduces inflammation and improves respirations.
Tuberculosis
Tuberculosis is a highly contagious pulmonary disease. The causative agent is Mycobacterium tuberculosis (tubercle bacillus). The mode of transmission is inhalation of infected droplets. The incubation period is 2 to 10 weeks (Watson, 2003).
Children generally contract this disease from someone in the immediate family. When any member of a family contracts tuberculosis, all family members must be tested (a Mantoux skin test) to screen for the disease. In some children, the contact is not known, and the disease is first detected when symptoms appear. Children who are homeless or severely impoverished or who have chronic illness or malnutrition tend to be more susceptible than other children because of their overall susceptibility to infection.
When M. tuberculosis invades a child's lung, there is primary inflammation. The child develops a slight cough. As the disease progresses, anorexia, weight loss, night sweats, and a low-grade fever occur.
Leukocytes and lymphocytes invade the lung area, effectively walling off the primary infection. The wall surrounding the bacteria then calcifies and confines the organism permanently. This development of a primary focus is the most usual form of tuberculosis in children. If a child is in poor health or does not have adequate calcium intake for the body to confine the infection, tuberculosis may spread to other lung areas or to other parts of the body (miliary tuberculosis). Other body sites that may be affected are bones and joints, lymph nodes, kidneys, and the subarachnoid space (tuberculous meningitis).
Assessment
Most children with tuberculosis have a history of a recent contact. All children should have a tuberculin test as part of basic preventive health care at 9 to 12 months of age, and yearly thereafter if they live in an area in which there is a high risk of tuberculosis. The test should not be done immediately after measles immunization or the test will read falsely negative (a child with tuberculosis will be considered free of the disease). Also, the measles vaccine can cause a primary tuberculosis focus to become miliary; it is important, therefore, to have a negative tuberculin result before administering this vaccine.
For a Mantoux test, also called a purified protein derivative (PPD) test, 5 units of protein derivative vaccine is injected intradermally, usually on the left lower arm. A health care professional inspects the area in 72 hours and notes the reaction. A positive reaction (the formation of
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5 to 15 mm of reddened induration) indicates the child has been exposed to tuberculosis or has developed antibodies to the foreign products of the tuberculosis organism (Fischbach, 2005). Children with positive reactions need follow-up with a chest x-ray to ascertain the importance of the reaction; that is, whether a current infection exists. Skin testing should not be done on children who are known to have had tuberculosis. Such a child will have such an intense reaction that the skin at the site of the test may slough and necrose.
To confirm a diagnosis of active disease, sputum may be analyzed. Make certain the child understands that you want him or her to expectorate mucus raised from the lungs, not just from the back of the throat. Have the child demonstrate a deep cough to you so you can be sure you are both talking about the same thing. Infants and children younger than 5 years do not raise sputum but swallow it. In young children, therefore, gastric lavage may be necessary to obtain the sputum specimen (because tuberculosis bacteria are acid-fast, they are not destroyed by gastric secretions). Schedule this test early in the morning before the child eats. This prevents vomiting and also allows for the collection of large numbers of organisms because the child has been coughing sputum and swallowing it all night. To collect the specimen, a nasogastric tube is passed either nasally or orally. The stomach contents are then aspirated and placed in a sterile container for laboratory processing. Analysis is generally done for 3 consecutive days because individual specimens may not contain organisms.
Having a large tube passed into the stomach is uncomfortable, and the concept itself is frightening. Offer support during the procedure. Encourage children to express their feelings about the procedure afterward. They may enjoy playing with a plastic catheter and a doll into which a tube can be inserted after the procedure (therapeutic play). It is revealing to see the force and the anger they use to insert the tube into the doll. This helps you to understand how they envision the procedure being done to them.
In the early course of tuberculosis, because the initial focus of the tuberculosis is so small, it may not be evident on a chest x-ray. As local inflammation occurs, however, cloudiness in the inflamed area will be noticeable on the film, as will calcification as it occurs.
Children who have primary tuberculosis are not infectious because they have a minimal pulmonary lesion and little or no cough. They need not be isolated. As soon as drug therapy has been started, they can return to regular activities, including school.
Before drug therapy was available, a diagnosis of tuberculosis meant a hospital stay of approximately a year. Parents who believe that tuberculosis is still treated this way will need assurance that it is all right for their child to return home and attend regular school as soon as he or she starts taking medication.
Therapeutic Management
A number of medications are effective against tuberculosis. Isoniazid (INH) is the drug of choice. INH may produce peripheral neurologic symptoms if pyridoxine (vitamin B) is not administered concurrently. Rifampin is often used in combination with INH. Para-aminosalicylic acid (PAS) is bacteriostatic to M. tuberculosis and for a long time served as the mainstay of therapy. However, PAS administration may lead to such gastrointestinal disturbances in children that it is not used as much as in the past. If it is prescribed, it should be administered after meals, never on an empty stomach.
Ethambutol is used with older children. It must be used with caution with infants because one side effect is optic neuritis; the inability to do adequate eye examinations in children under school age to discover this side effect can make ethambutol unsafe for long-term use.
In addition to drug therapy, children should receive a diet high in protein, calcium, and pyridoxine, especially if INH is being used, to wall off organisms in lung tissue.
Because tuberculosis therapy can last up to 18 months, a major concern during treatment is that the tuberculosis organism will become resistant to commonly used drugs. Children should have periodic chest x-rays for the rest of their life to make certain their disease does not become active again later in life. A woman who had tuberculosis as a child should tell her primary care provider about this when she becomes pregnant; lung changes that occur in pregnancy as a result of the pressure of the growing uterus against the lungs can break down calcifications and reactivate tuberculosis. Children who develop another chronic disease that interferes with appetite, and therefore with calcium intake, also have a high risk of reactivation of calcium-contained tuberculosis.
Because children will be taking medicine for a long time, they need periodic health care visits to evaluate the extent of drug adherence. Assess that they receive regular childhood immunizations so they do not contract a second disease until they have fully recovered from tuberculosis. It is most important to prevent pertussis (whooping cough) because the paroxysmal cough caused by this illness could easily reactivate tuberculosis lesions.
The bacille Calmette-Guerin (BCG) vaccine is available against tuberculosis, but it is not used routinely in the United States. A skin test will be strongly positive after effective BCG vaccination. For this reason, most people advocate placing children on prophylactic INH when there is known tuberculosis in the home rather than vaccinating them against tuberculosis. With this method, as long as a repeat PPD test remains negative, you know that they are disease-free. After BCG vaccine is administered, the value of skin testing would be lost.
Cystic Fibrosis
Children with cystic fibrosis (CF) have a generalized dysfunction of the exocrine glands. Mucus secretions of the body, particularly in the pancreas and the lungs, are so tenacious that they have difficulty flowing through gland ducts. There is also a marked electrolyte change in the secretions of the sweat glands (chloride concentration of sweat is two to five times above normal). The cause of the disorder is an abnormality of the long arm of chromosome 7. This results in the inability to transport small molecules across cell membranes; this leads to dehydration of epithelial cells in the airway and pancreas and dried secretions.
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The disorder is inherited as an autosomal recessive trait. It occurs in approximately 1 in 2,500 live births. It occurs most commonly in whites, rarely in blacks and Asians. Although the disease can be fatal in early life, as many as 50% of children now live to be more than 30 years of age. With the availability of lung transplants, full life expectancy is possible. Because the gene that causes the disorder can be isolated, chorionic villi sampling or amniocentesis can be done early in pregnancy to detect fetuses who have the disease. All newborns can be screened at birth by a simple heel puncture blood sample for the disorder (Merelle et al., 2005). In the future, it is expected that gene therapy will be available to reverse the effect of the involved gene.
Boys with CF may not be able to reproduce because they have persistent plugging and blocking of the vas deferens from tenacious seminal fluid. Girls may have such thick cervical secretions that sperm penetration is limited. Artificial insemination or in vitro fertilization can be accomplished if they desire to become pregnant.
Pancreas Involvement
The acinar cells of the pancreas normally produce lipase, trypsin, and amylase, enzymes that flow into the duodenum to digest fat, protein, and carbohydrate. With CF, these enzyme secretions become so thickened that they plug the ducts; eventually, there is such back-pressure on the acinar cells that they become atrophied and then are no longer capable of producing the enzymes. The islets of Langerhans and insulin production are little influenced by this process until late in the disease because they have endocrine (ductless) activity.
Without pancreatic enzymes in the duodenum, children cannot digest fat, protein, and some sugars. The child's stools become large, bulky, and greasy (steatorrhea). The intestinal flora increases because of the undigested food; this, when combined with the fat in the stool, gives the stool an extremely foul odor, often compared to that of a cat's stool. The bulk of feces in the intestine leads to a protuberant abdomen. Because children are benefiting from only about 50% of the food they ingest, they show signs of malnutrition—emaciated extremities and loose, flabby folds of skin on their buttocks. The fat-soluble vitamins, particularly A, D, and E, cannot be absorbed because fat is not absorbed, so children develop symptoms of low levels of these vitamins. These four symptoms—malnutrition, protuberant abdomen, steatorrhea, and fat-soluble vitamin deficiencies—are the same four symptoms that are part of celiac disease (malabsorption syndrome), so they are referred to as the celiac syndrome (see Chapter 45).
Meconium in a newborn is normally thick and tenacious. In approximately 10% of children with CF, it may be so thick, because pancreatic enzymes are lacking, that it obstructs the intestine (meconium ileus). The newborn develops abdominal distention with no passage of stool. Meconium ileus should be suspected in any infant who does not pass a stool by 24 hours of life (McCollough & Sharieff, 2003). Rectal prolapse from straining to evacuate hard stool is another common finding in infants with CF.
Lung Involvement
Pockets of infection begin in pooled thick secretions of the bronchioles. The organisms most frequently cultured from lung secretions in children with CF are Staphylococcus aureus, Pseudomonas aeruginosa, and H. influenzae. Secondary emphysema (overinflated alveoli) occurs because the air cannot be pushed past the thick mucus on expiration, when all bronchi are narrower than they are on inspiration. Bronchiectasis and pneumonia occur. Atelectasis occurs as a result of complete absorption of air from alveoli behind blocked bronchioles. The child's fingers become clubbed because of the inadequate peripheral tissue perfusion. The anterior-posterior diameter of the chest becomes enlarged. Respiratory acidosis may develop because obstruction interferes with the ability to exhale carbon dioxide.
Sweat Gland Involvement
Although the sweat glands themselves do not appear to be changed in structure, the electrolyte composition of perspiration is changed. In children with CF, the level of chloride to sodium is increased two to five times above normal. Some parents report they knew their newborn had the disease before they had laboratory tests done because when they kissed their child, they could taste such strong salt in the perspiration.
Assessment
If CF is not diagnosed by a screening blood sample at birth, it is diagnosed by documenting the chromosomal abnormality, and the history and the combination of the abnormal concentration of chloride in sweat, the absence of pancreatic enzymes in the duodenum, the presence of immunoreactive trypsinogen in the blood, and pulmonary involvement.
CF may be suspected in a newborn when he or she loses the normal amount of weight at birth (5% to 10% of birthweight), but then, because the infant cannot make use of the fat in milk, does not gain it back at the usual time of 7 to 10 days and perhaps not until 4 to 6 weeks of age. Nurses are the individuals who often weigh babies and may be the first to detect this lack of weight gain. Nurses may also be the first health care provider to suspect CF because meconium is so tenacious the infant is unable to pass stool. All babies with meconium ileus are tested for CF. This can be done by a chromosome analysis or analysis of serum immunoreactive trypsin (IRT) in the stool, which is elevated because obstruction in the pancreas occurs as early as during fetal life.
Children who are not diagnosed at birth may be seen in a health care setting at about 1 month of age because of a feeding problem. Using only about 50% of their intake because of their poor digestive function, they are always hungry. This causes them to eat so ravenously they tend to swallow air. This is manifested as colic or abdominal distention and vomiting. The appearance of typical CF stools (large and greasy) is an important finding because children with simple colic do not show these changes in stool consistency.
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Respiratory infections begin to occur at 4 to 6 months of age. Even at this early stage of the disease, wheezing and rhonchi may be heard on chest auscultation.
By the time a child with CF is a preschooler, a cough is a prominent finding. On percussion, the chest is hyperresonant, reflecting the emphysema present. Rales and rhonchi are heard. Clubbing of the fingers may already be apparent. It is rare for a child to go undiagnosed beyond this time because the symptoms of the illness have become so persistent and evident.
Sweat Testing
Sweat testing is a time-honored method for detecting the abnormal concentrations in sweat in children with CF. Sweat is collected and analyzed for sodium chloride content. With chromosomal determination available, sweat tests are no longer necessary, but parents may ask about the procedure if they hear about it from friends. A normal concentration of chloride in sweat is 20 mEq/L. A level of more than 60 mEq/L chloride in children is diagnostic of CF.
Duodenal Analysis
Analysis of duodenal secretions for detection of pancreatic enzymes may be done to show the extent of the pancreatic involvement by passing a nasogastric tube into the duodenum and then aspirating secretions for analysis. This test may take a considerable amount of time because the tube is allowed to pass through the pylorus and into the duodenum by natural peristaltic action. You can tell that a tube has passed from the stomach into the duodenum by aspirating secretions from the tube and testing them for pH. Stomach secretions are acid (pH less than 7.0); duodenal secretions are alkaline (pH more than 7.0). The initial insertion of the tube typically is frightening to children because they may choke and gag as it passes the pharynx. Children, however, are generally surprised that once the initial insertion is done, the tube is not uncomfortable. They need a great deal of support during the procedure, however, because it is so unusual for them and initially so uncomfortable. Duodenal analysis may also be done by endoscopy; for this, children usually receive conscious sedation (Burton & Germann, 2004).
The secretions removed from the duodenum are sent to the laboratory for analysis of trypsin content, the easiest pancreatic enzyme to assay. Keep the secretions cold during transport. They should be analyzed immediately for accurate results.
Stool Analysis
Stool may be collected and analyzed for fat content, although description of the large greasy appearance may be all that is necessary.
Pulmonary Testing
A chest x-ray generally confirms the extent of the pulmonary involvement (pockets of emphysema and perhaps beginning pneumonia infiltration are present). Pulmonary function tests may be done to determine if atelectasis and emphysema are present.
Therapeutic Management
Therapy for children with CF consists of measures to reduce the involvement of the pancreas, lungs, and sweat glands.
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Key Points
  • Respiratory tract disorders tend to occur more frequently in children than adults, because the lumens of bronchi are narrow and obstruction and infection can occur more easily.
  • Infants with respiratory illness need extremely close observation because they cannot describe oxygen deprivation. Young children do not comprehend the fact that oxygen supports combustion. Observe them more frequently than adults to be certain that no flames, such as birthday candles, are brought within 10 feet of an oxygen source.
  • Acute nasopharyngitis (common cold) is the most common infectious disease in children. There is no specific therapy for a common cold other than comfort measures.
  • Tonsillitis is infection and inflammation of the palatine tonsils. Adenitis is infection and inflammation of the adenoid tonsils. Children with recurring infections may have their tonsils surgically removed.
  • Laryngotracheobronchitis (croup) is inflammation of the larynx, trachea, and major bronchi. Epiglottitis is inflammation of the epiglottis. Both of these conditions can cause severe impairment of the airway. Children with epiglottitis should never be assessed for a gag reflex with a tongue blade because the elevated epiglottis can completely occlude the airway.
  • Bronchitis is inflammation of the major bronchi and trachea. Bronchiolitis is inflammation of the fine bronchioles. Both conditions are caused by bacterial or viral invasion.
  • Respiratory syncytial virus infection is an infection that accounts for the majority of lower respiratory infections in young children. Infants with RSV infections must be observed closely because they are prone to apnea.
  • Asthma, a type I hypersensitivity reaction, is a diffuse and obstructive airway disease with wheezing as the most common symptom. Newer drugs such as leukotriene receptor antagonists and careful environmental control have aided in the management of this disorder.
  • Pneumonia may occur from a variety of organisms (viral, pneumococcal, chlamydial, mycoplasmal, lipid, and hydrocarbon). Except for viral pneumonia, children need specific antibiotics, depending on the organism present.
  • Tuberculosis is a lung infection that is growing in incidence, with some strains becoming very resistant to the usual therapy. The entire family needs drug therapy if one member develops a primary lesion.
  • Cystic fibrosis is a disease in which there is generalized dysfunction of the exocrine glands. This results in malabsorption and tenacious pulmonary secretions, leading to infection and pneumonia. Lung transplantation can be used to replace the diseased lung tissue and increase the child's lifespan.
Critical Thinking Exercises
  • Michael is the 4-year-old you met at the beginning of the chapter. His grandmother brought him to the emergency room because his respirations were rapid and he had a sharp, barking cough. He is diagnosed as having laryngotracheobronchitis (croup). Both he and his grandmother shouted information at you. What about Michael's actions would lead you to believe his airway is not yet extremely constricted? Would you encourage him to lie down and rest? What emergency care does Michael need?
  • One of Michael's ambulatory roommates has a permanent tracheostomy tube in place from pulmonary dysplasia as an infant. Her parents are going to enroll her in kindergarten starting next month. What precautions would you want to review with her parents to keep this experience safe?
  • When the 4-year-old in the ambulatory bed next to Michael returns from tonsillectomy surgery, what observations would be most important to make? Why is the 7th day after tonsillectomy surgery a particularly important day for close observation?
  • Examine the National Health Goals related to respiratory disorders in children. Most government-sponsored money for nursing research is allotted based on these goals. What would be a possible research topic to explore pertinent to these goals that would be applicable to Michael's family and also advance evidence-based practice?
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American Heart Association. (2005). Pediatric advanced life support. Dallas, TX: Author.
American Thoracic Society. (2003). Statement on the care of the child with chronic lung disease of infancy and childhood. American Journal of Respiratory and Critical Care Medicine, 168 (3), 356–396.
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Bagarazzi, M.L. (2003). Pharyngitis. In M.W. Schwartz (Ed.), 5-minute pediatric consult (3rd ed.). Philadelphia: Lippincott Williams & Wilkins.
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Suggested Readings
Bezyack, M.E. (2004). Respiratory distress: Making the diagnosis in kids. Nursing Spectrum, 17 (2), 30–31.
Buysse, C.M., de Jongste, J.C., & de Hoog, M. (2005). Life-threatening asthma in children: Treatment with sodium bicarbonate reduces PCO2. Chest, 127 (3), 866–870.
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Clayton, S. (2005). Paediatric asthma: Overcoming barriers to an improved quality of life. British Journal of Nursing, 14 (2), 80–85.
Farber, H.J., & Oliveria, L. (2004). Trial of an asthma education program in an inner-city pediatric emergency department. Pediatric Asthma, Allergy & Immunology, 17 (2), 107–115.
Hay, A.D., Schroeder, K., & Fahey, T. (2004). 10-minute consultation: Acute cough in children. British Medical Journal, 328 (7447), 1062.
Horner, S.D. (2004). Effect of education on school-age children's and parents' asthma management. Journal for Specialists in Pediatric Nursing, 9 (3), 95–102.
Lessard, M.J. (2004). Pediatric asthma: An epidemic to be controlled. Nursing Spectrum, 8 (1), 20–21.
Low, D.E., Pichichero, M.E., & Schaad, U.B. (2004). Optimizing antibacterial therapy for community-acquired respiratory tract infections in children in an era of bacterial resistance. Clinical Pediatrics, 43 (2), 135–151.
Naim, M.Y., Smith, R., & Schears, G. (2004). Severe respiratory distress. Clinical Pediatrics, 43 (4), 403–405.
Salyer, J.W. (2004). Respiratory care of bronchiolitis patients: A proving ground for process improvement. Respiratory Care, 49 (6), 581–583.

1 comment:

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