Respiratory

Alterations in Health (Diagnosis)

• Oxygen supports cellular oxygenation in acute and chronic respiratory problems such as hypoxemia, cystic fibrosis, and asthma, and is delivered through several systems. Pulse oximetry monitors the effect of inhalation therapy. Common pediatric respiratory treatments are nebulized aerosol, metered-dose inhaler, dry powder inhaler, chest physiotherapy, oxygen therapy, suctioning, and artificial airways. Oxygen is a drug and requires a provider order.

Health Promotion & Disease Prevention

Assessment — Risk Factors

Assessment — Expected Findings

• Expected SaO2 is 95% to 100%, and may run lower in chronic respiratory illness or cyanotic heart disease
• Early hypoxemia: tachypnea, tachycardia, restlessness, pallor of skin and mucous membranes, accessory muscle use, nasal flaring, dyspnea
• Late hypoxemia: confusion and stupor, cyanosis, bradypnea, bradycardia, hypotension
• Hypoxemia follows hypovolemia, hypoventilation, or interrupted arterial flow
• WHO recommends supplemental oxygen for a child in respiratory distress with SpO2 under 90%
• Suctioning is indicated by early hypoxemia signs, adventitious sounds, visible secretions, cyanosis, or no spontaneous cough

Laboratory Tests

Diagnostic Procedures

Nursing Care

• Pulse oximetry probe goes on fingertip, toe, earlobe, or around the foot; site must be dry with good circulation; remove nail polish or earrings
• Position the child comfortably and support the arm when using a finger
• Compare the oximeter pulse with the radial pulse — a discrepancy needs further assessment
• For continuous monitoring set high and low alarms, confirm they work and are audible, and move the probe per policy to prevent pressure necrosis in infants
• For a low SaO2: confirm probe placement with the LED over the top of the nail, verify the delivery system is working at the prescribed flow, and increase flow as ordered
• Nebulizer: treatment runs 10-15 min using mouthpiece, mask, or blow-by; take vitals and saturation before and after; pour medication into the cup and connect to air or oxygen; coach slow deep mouth breathing; watch for tracheal or bronchial spasm or edema; help the family obtain a home unit
• Schedule inhaled treatments before meals or at least 1 hr after, and at bedtime, to reduce vomiting and aspiration risk
• Position semi-Fowler's or Fowler's to ease breathing and expand the chest; use a calm approach and explain everything to child and family
• Give oxygen at the lowest flow that corrects hypoxemia and humidify it to loosen secretions and protect the mucosa

Medications

Therapeutic Procedures

• Chest physiotherapy: manual or mechanical percussion, vibration, postural drainage, cough, huffing, and breathing exercises for thick secretions the child cannot clear; contraindicated with unstable hemodynamics, ARDS, or increased ICP
• Tracheotomy is the sterile surgical incision into the trachea to create an airway; the resulting stoma is the tracheostomy, permanent or temporary
• May be emergent for epiglottitis, croup, or foreign-body aspiration, or planned
• Artificial airways placed orotracheally, nasotracheally, or through a tracheostomy; pediatric tubes are plastic and may be cuffed to prevent dislodgement

Client Education

• MDI: shake well, remove cap, prime one to two doses if new, attach a spacer, hold with mouthpiece down and thumb near it with index and middle fingers on top
• MDI closed-mouth method: seal lips around the inhaler, take a breath in and out, tilt head back slightly, press the canister while starting a slow deep breath over 3-5 seconds
• DPI: do not shake, remove the cap, prepare the dose per manufacturer instructions, exhale completely, seal lips and inhale fast and deep, hold 5-10 seconds, remove and exhale slowly through pursed lips
• Wait 1 minute (or the directed interval) between puffs; wipe the DPI mouthpiece weekly with a dry cloth and never wash it with water
• Rinse the mouth and spit after inhaled corticosteroids, and clean the MDI and spacer after each use
• Home tracheostomy care: keep a spare tube available in case of dislodgement, and suction to prevent occlusion

Interprofessional Care

Complications

• Wrong dose delivered from poor technique — inhaling too fast, failing to coordinate breath with actuation, not holding the breath long enough; reinforce technique
• Oral fungal infection from inhaled corticosteroids — inspect the mouth and have the child rinse after each dose
• Combustion: post 'No Smoking' or 'Oxygen in Use' signs, know the nearest fire extinguisher, dress the child in cotton rather than synthetics or wool that generate static, avoid spark-producing toys, keep alcohol and acetone away, and teach the fire risk of smoking near oxygen
• Oxygen toxicity, driven by high concentration, long duration of therapy, and the severity of lung disease — headache, confusion, nausea, substernal pain, dry nonproductive cough, altered vision, greater work of breathing, and CNS effects; hypoventilation with a climbing PaCO2 can bring rapid loss of consciousness
• Prevent toxicity with the lowest effective oxygen level, monitor ABGs, report a rising PaCO2, and wean flow gradually
• Accidental decannulation is an emergency before the tract matures because reinsertion is difficult — keep a spare tube and obturator at the bedside and have a second staff member present whenever the tube is moved
• Occlusion by secretions blocks air exchange — maintain patency with suctioning

Alterations in Health (Diagnosis)

• Covers pneumonia, bronchiolitis, bronchitis, croup syndromes, bacterial tracheitis, tonsillitis, pharyngitis, nasopharyngitis, and allergic rhinitis. Tonsils are vascular lymph tissue in the pharynx that filter organisms entering by mouth; the palatine tonsils are removed in tonsillectomy and the adenoids on the nasopharyngeal roof in adenoidectomy. Enlarged tonsils can obstruct breathing, drainage, sleep, swallowing, and speech, and can block the eustachian tube causing otitis media or hearing loss.

Health Promotion & Disease Prevention

Assessment — Risk Factors

• Exposure to a viral or bacterial agent; tonsillitis mostly ages 5-15 and rare under 2 years
• Infants 3-6 months are vulnerable as maternal antibodies wane before their own develop
• Viral infections peak in toddlers and preschoolers and drop off after age 6
• Daycare attendance, immature immune system, poor hand hygiene and covering coughs, hands in mouth
• Low birth weight and prematurity
• Anatomy: short narrow airway obstructs easily with mucus or edema; short respiratory tract lets infection reach the lower airway quickly; short open eustachian tubes give organisms access to the middle ear

Assessment — Expected Findings

• Tonsillitis: sore throat with painful swallowing, mouth odor, headache, malaise, fever, red edematous tonsils, tender anterior cervical nodes, no cough
• Nasopharyngitis: fever, rhinorrhea (clear, green, or yellow), sneezing, cough, nasal congestion, fatigue; infants also show poor sleeping and feeding and fussiness, plus conjunctivitis, headache, earache
• Streptococcal pharyngitis: severe sore throat and fever without nasal discharge, headache, abdominal pain, dysphagia, strawberry tongue, sandpaper trunk rash
• Bronchitis/tracheobronchitis: preceded by URI with congestion and coryza, tachypnea, wheezes and crackles, possible progression to distress
• Bronchiolitis: starts as URI with congestion and cough then moves lower with wheezing and crackles
• Mild bronchiolitis: little or no distress, normal mental status and activity
• Moderate bronchiolitis: tachypnea with mild to moderate retractions, no grunting or head bobbing, no apnea, alert, may have SpO2 under 90%
• Severe bronchiolitis: persistent tachypnea, marked distress with retractions, grunting, nasal flaring, head bobbing, hypoxemia, agitation, apnea, or poor responsiveness

Laboratory Tests

• Throat culture or rapid antigen detection test for group A beta-hemolytic streptococcus
• Rapid testing for influenza A and B, RSV, and COVID-19
• Croup and bronchiolitis are usually diagnosed from history and exam; x-ray only if pneumonia is suspected
• Allergic rhinitis: skin testing and serum IgE immunoassay
• Pneumonia: chest radiograph for infiltrates, sputum Gram stain and culture in older children, PCR for viral causes

Diagnostic Procedures

• Lateral neck soft-tissue radiograph in epiglottitis shows the thumb sign from a swollen epiglottis

Nursing Care

• Viral tonsillitis is supportive — rest, warm fluids, warm salt-water gargles; give antibiotics for bacterial tonsillitis
• Post-tonsillectomy: position to promote drainage, elevate the head of bed once fully awake
• Watch for bleeding — frequent swallowing, throat clearing, restlessness, bright red emesis, tachycardia, pallor; assess airway and vital signs and monitor for breathing difficulty from secretions, edema, or bleeding
• Comfort with an ice collar, acetaminophen or ibuprofen, and antiemetics as needed
• Croup: provide cool mist humidity, give oxygen if needed, nebulized racemic epinephrine, and corticosteroids by mouth, IV, or IM (dexamethasone)
• Encourage oral intake if tolerated; give IV fluids, antibiotics if bacterial, and antivirals if influenza is confirmed
• Epiglottitis is a medical emergency, usually caused by Haemophilus influenzae — do not inspect the throat, keep the child calm and upright
• Allergic rhinitis: avoid allergens, use saline spray or irrigation, nasal corticosteroids first line, then antihistamines, beta-adrenergic decongestants, mast cell stabilizers, leukotriene modifiers, ipratropium
• Bacterial pneumonia usually arises from nasopharyngeal flora inhaled into the lungs, most often Streptococcus pneumoniae; viral pneumonia predominates under 5 years and follows a viral URI

Medications

• Acetaminophen or NSAIDs to lower fever and control pain — check allergies and teach correct dosing
• Antibiotics for group A strep infection; teach caregivers to finish the full course
• Zanamivir for influenza A and B in children 7 years and older, started within 48 hr of symptom onset, inhaled twice daily for 5 days
• Amantadine is no longer recommended because of high resistance

Therapeutic Procedures

• Tonsillectomy and/or adenoidectomy

Client Education

• Report bright red bleeding to the provider immediately
• Post-tonsillectomy: rest, plenty of fluids advancing to a soft diet, limit activity to reduce bleeding risk, give pain medication, full recovery takes about 14 days
• Call the provider for difficulty breathing, poor oral intake, increasing pain, or signs of infection, hemorrhage, or dehydration
• Use a cool-air vaporizer for humidity at home; for spasmodic croup run a hot shower and sit with the child in the steam
• Give medications at accurate doses and correct intervals; oral rehydration solutions are appropriate for fluid replacement
• Warning signs to report: difficulty breathing, chest pain or pressure, cyanosis of face and lips, decreased urine output, confusion, inability to tolerate oral fluids

Interprofessional Care

Complications

• Post-tonsillectomy hemorrhage — inspect the throat with good light and a tongue depressor, watch for tachycardia, repeated swallowing and throat clearing, and hemoptysis; hypotension is a late sign of shock; notify the provider at once
• Dehydration — push oral fluids and watch for dry mucous membranes, concentrated urine, and lethargy
• Chronic infection: tonsils chronically infected with group A strep can seed rheumatic fever and kidney infection
• Pleural effusion — fluid in the pleural space with fever, malaise, poor appetite, cough, chest pain, hypoxia; prepare for emergent needle aspiration and chest tube to closed drainage, manage the chest tube, assess respiratory status, give oxygen

Alterations in Health (Diagnosis)

• Asthma is a chronic inflammatory airway disorder producing intermittent, reversible obstruction of bronchi and bronchioles, and is a leading cause of school absence. Family history, environmental exposure, and premature birth are the main contributors. Severity is classified as intermittent, mild persistent, moderate persistent, or severe persistent, and treatment follows a stepwise approach.

Health Promotion & Disease Prevention

Assessment — Risk Factors

• Family history of asthma or allergies
• Male sex until about age 20, after which rates equalize
• Tobacco smoke or vaping exposure
• Low birth weight
• Black race
• Being overweight
• Indoor allergens: mold, cockroach antigen, dust and dust mites, animal dander
• Outdoor allergens: grasses, pollen, trees, shrubs, molds, spores, weeds, air pollution

Assessment — Expected Findings

• Chest tightness, cough, audible wheezing, mucus production
• Coarse lung sounds with wheezing throughout and possible crackles
• Short, broken speech; restlessness, irritability, anxiety, sweating
• Accessory muscle use, retractions while sitting, tripod positioning, falling SaO2
• Silent chest with inaudible breath sounds signals severe obstruction
• History to collect: onset and duration, precipitating factors, prior exacerbations, medication changes, what relieves symptoms, other medications, self-care measures, home and school environment, home heating and cooling source

Laboratory Tests

• No laboratory test diagnoses asthma; allergy testing can identify triggers
• CBC with differential (raised WBC, eosinophils, neutrophils) to exclude other problems

Diagnostic Procedures

• Pulmonary function tests are the most accurate way to diagnose asthma and grade severity — baseline at diagnosis and repeated to judge the treatment plan
• Spirometry measures FEV1 for airflow and FVC for lung volume, before and after a bronchodilator to demonstrate reversibility
• Peak expiratory flow rate meter measures air forcefully exhaled in 1 second (L/min) and is used for management, not diagnosis
• Bronchoprovocation testing with methacholine, cold air, or histamine, and exercise challenge

Nursing Care

• Avoid identified allergens and confirm correct inhaler technique
• Build an asthma action plan and teach peak flow meter use
• Assess airway patency, respiratory rate, symmetry, effort, and accessory muscle use; auscultate all fields
• Absent wheezing can mean severe constriction rather than improvement
• Assess skin color, vital signs, and oxygen saturation; review CBC, chest x-ray, and possibly ABGs
• Position to maximize ventilation — tripod position works best
• Give oxygen as prescribed and keep intubation equipment nearby
• Establish and maintain IV access; stay calm and reassuring

Medications

• Short-acting beta2 agonists (albuterol, levalbuterol) for acute exacerbations and before exercise to prevent exercise-induced asthma
• Long-acting beta2 agonists (salmeterol, formoterol) must be paired with anti-inflammatory therapy and never used for an acute attack
• Ipratropium, a cholinergic antagonist, relaxes bronchial smooth muscle — off-label for exacerbations; watch for CNS and cardiac stimulation, dizziness, altered vision, dry nasal passages, and sore throat
• Leukotriene modifiers (montelukast, zafirlukast) block inflammation and lower airway resistance; zafirlukast is approved from 5 years
• Cromolyn, a mast cell stabilizer, for long-term control in children over 2 years
• Omalizumab (anti-IgE) from 6 years for moderate to severe asthma with at least one allergen sensitivity not controlled on standard therapy
• Dupilumab (anti-IL-4 receptor) from 6 years for moderate to severe asthma
• Mepolizumab and benralizumab (anti-IL-5) from 6 years for severe eosinophilic asthma

Therapeutic Procedures

Client Education

• Rinse the mouth after using a corticosteroid inhaler
• Report redness, sores, or white patches in the mouth
• Take oral medications with food
• Teach correct metered-dose inhaler and nebulizer technique to child and family

Interprofessional Care

• Respiratory services for inhalers and breathing treatments
• Nutrition services for weight change related to medication or diagnosis
• Rehabilitation when prolonged weakness limits activity

Complications

• Status asthmaticus — a prolonged severe attack with life-threatening obstruction that does not respond to usual treatment
• Signs: wheezing, labored breathing, nasal flaring, no air movement, accessory muscle use, inability to speak full sentences, distended neck veins, tachycardia, tachypnea, hypoxia, diaphoresis
• Continuous pulse oximetry and cardiorespiratory monitoring
• Position sitting upright, standing, or leaning slightly forward
• Humidified oxygen with continuous short-acting bronchodilator therapy; ipratropium bromide can be added to the nebulizer for more bronchodilation
• Obtain IV access and monitor ABGs and electrolytes

Alterations in Health (Diagnosis)

• Cystic fibrosis is inherited through a mutated gene and causes mucus glands to secrete abnormally thick, tenacious mucus that mechanically obstructs organs, chiefly the lungs, pancreas, and GI tract.

Health Promotion & Disease Prevention

Assessment — Risk Factors

• Both biological parents carry the recessive trait
• Non-Hispanic white American ethnicity

Assessment — Expected Findings

• Family history of cystic fibrosis; history of repeated respiratory infections and growth failure
• Meconium ileus at birth — abdominal distention, vomiting, failure to pass stool — is the earliest newborn sign
• Early respiratory findings: wheezing, rhonchi, cough
• Increasing involvement: dyspnea, with obstructive emphysema and atelectasis on chest x-ray
• Advanced disease: cyanosis, barrel chest, clubbing of fingers and toes, repeated bronchitis or bronchopneumonia
• Mucus stasis raises infection risk
• GI findings: steatorrhea with large, frothy, bulky, greasy, foul-smelling stools; failure to gain weight or weight loss

Laboratory Tests

• Nutritional panel for deficiency of fat-soluble vitamins A, D, E, and K
• CBC to screen for anemia
• Immunoreactive trypsinogen low from pancreatic insufficiency
• Sputum culture for Pseudomonas aeruginosa, Haemophilus influenzae, Burkholderia cepacia, Staphylococcus aureus, Escherichia coli, or Klebsiella pneumoniae

Diagnostic Procedures

• Sweat chloride test — an electrical current stimulates sweating and samples are taken from two sites
• Sweat chloride 29 mmol/L or less is normal, 30-59 mmol/L is equivocal and needs further evaluation, 60 mmol/L or higher confirms cystic fibrosis
• DNA testing to identify the mutation
• Pulmonary function tests to evaluate the small airways
• Chest x-ray showing diffuse atelectasis and obstructive emphysema; abdominal x-ray for meconium ileus

Nursing Care

• Assess lung sounds, respiratory status, vital signs, and oxygen saturation
• Obtain sputum for culture and sensitivity and give antibiotics as prescribed
• Airway clearance therapy usually twice daily, morning and evening, and never right before or after meals
• Chest physiotherapy with postural drainage using manual or mechanical percussion
• Positive expiratory pressure devices such as a flutter valve encourage forceful exhalation
• Active cycle of breathing with huffing or forced expiration
• Give oxygen as prescribed while watching for carbon dioxide retention
• Diet: well-balanced, high protein and high calorie, three meals plus snacks, with encouraged oral fluids
• Give pancreatic enzymes within 30 min of every meal and snack

Medications

• Albuterol, a short-acting beta2 agonist — monitor for tremor and tachycardia
• Dornase alfa aerosol thins mucus and improves lung function, given once or twice daily; can cause laryngitis; monitor sputum thickness, ability to expectorate, and PFT improvement
• Antibiotics IV or aerosolized, commonly tobramycin and azithromycin; high doses are often needed with blood levels drawn before and after some IV doses to keep them therapeutic
• Pancreatic enzymes treat pancreatic insufficiency by aiding digestion and absorption — give with all meals and snacks, adjust by stool character and weight, and either swallow the capsule or sprinkle the contents on food, formula, or breast milk
• CFTR modulators improve production, processing, or function of the CFTR protein and are prescribed to improve lung function
• Daily multivitamin plus vitamins A, D, E, and K

Therapeutic Procedures

Client Education

• Teach proper use of MDI, PEP device, and nebulizer, plus CPT and breathing exercises at home
• Understand all equipment and medications before discharge and know how to obtain supplies
• Keep regular provider visits and dental hygiene
• Stay current on immunizations including annual influenza and pneumococcal vaccines
• Understand the role of diet and ways to raise calorie intake

Interprofessional Care

• Respiratory therapy, physical therapy, social services, pulmonologist, pharmacist, pediatrician, infectious disease specialist, and dietitian
• Lung transplant may be considered in advanced disease

Complications

• Respiratory: recurrent infection and bacterial colonization, emphysema, spontaneous pneumothorax, nasal polyps, hemoptysis
• Gastrointestinal: meconium ileus, rectal prolapse, intestinal obstruction, GERD
• Endocrine: diabetes mellitus

Alterations in Health (Diagnosis)

• Emergencies requiring rapid assessment and intervention, and a chance to teach families and communities. In respiratory insufficiency the child works harder to breathe while gas exchange stays largely adequate, or becomes hypoxic and acidotic; in respiratory failure the blood can no longer be adequately oxygenated. Apnea means breathing stops longer than 20 seconds, central or obstructive in origin, sometimes with hypoxemia or bradycardia. Respiratory arrest is total cessation of breathing, and a foreign body can obstruct the airway. Sudden unexpected infant death is an infant death in the first year that is sudden and unexpected, whether or not a cause is later found.

Health Promotion & Disease Prevention

Assessment — Risk Factors

• Respiratory emergencies: infants and toddlers, obstructive lung disease from infection, anaphylaxis, bronchiectasis, or asthma, and restrictive disease from cystic fibrosis, pneumonia, or interstitial lung disease
• Drowning: ages 1-4 years, swimming pool access, inadequate supervision near water, no life jacket, no swimming lessons, absent protective barriers
• Brief resolved unexplained event: gastresophageal reflux, respiratory or other infection, seizure, feeding regimen, metabolic disorders, neurologic disorders, sleep position
• Sudden unexpected infant death: maternal smoking in pregnancy, secondhand smoke, co-sleeping, non-crib sleep surface, prone or side-lying sleep, low birth weight, prematurity, twin or multiple birth, limited prenatal care, respiratory illness, family history, poverty, and age 1-6 months
• Poisoning: age under 6 years and toddlers especially; medications, household chemicals, and hazardous substances stored improperly; cosmetics, plants, and heavy metals as toxic sources; lead from lead-based paint or contaminated soil

Assessment — Expected Findings

• Early respiratory distress: restlessness, tachycardia, tachypnea, nasal flaring, grunting, retractions, diaphoresis, dyspnea, and wheezing
• Advanced hypoxia: bradycardia, extreme restlessness, central or peripheral cyanosis, stupor, and coma
• Choking: universal choking sign of clutching the neck, inability to speak, weak ineffective cough, high-pitched sound or no sound, cyanosis
• Submersion: record where and when the child was submerged, whether CPR or rescue breathing was needed, respiratory status, core temperature for hypothermia, and any head or neck injury
• Brief resolved unexplained event: apnea during the event, color change to pallor or cyanosis, hypotonia, and being sleepier than usual
• Poisoning history: name and location of the agent, amount ingested, and time of ingestion
• Acetaminophen 0-24 hr: nausea, vomiting, sweating, pallor; 24-72 hr: apparent improvement with right upper quadrant pain; 72-96 hr hepatic stage: confusion, stupor, jaundice, coagulation disturbance with the greatest risk of death; then gradual recovery
• Aspirin acute toxicity: vomiting, nausea, tinnitus, disorientation, dizziness, tachypnea, abdominal pain, and seizures; chronic toxicity is subtler but adds tachycardia, bleeding tendencies, and more severe seizures

Laboratory Tests

• Directed by history and assessment: CBC with differential, ABGs, urinalysis, blood cultures, liver function tests, and blood levels of lead, iron, and acetaminophen

Diagnostic Procedures

• Chest x-ray, viral studies, lumbar puncture, and CT for altered mental status

Nursing Care

• Follow American Heart Association CPR guidelines for respiratory and cardiac arrest and facility protocol for activating the rapid response team
• Use current basic life support and pediatric advanced life support guidelines for neonates and children
• Position to maintain a patent airway, monitor respiratory status and vital signs, give oxygen, suction as needed, and prepare for intubation
• Give prescribed medications, IV fluids, and emergency drugs; update the family on the child's status; and keep a calm, comforting manner
• Choking: back blows combined with chest thrusts for infants, abdominal thrusts for children and adolescents
• Remove visible obstructions or large debris from the mouth but never perform a blind finger sweep
• Place a recovered child who resumes breathing in the recovery position — side-lying with knees bent for stability
• Submersion injury care depends on the degree of cerebral insult: give oxygen and possibly mechanical ventilation, monitor vital signs, manage shivering, and watch for cerebral edema and respiratory distress
• Brief resolved unexplained event: monitor for recurrent events and keep the family informed about testing

Medications

Therapeutic Procedures

Client Education

• Learn CPR and recognize the signs of choking
• Teach prevention strategies including recognizing choking hazards for toddlers
• Drowning can happen anywhere water is present — bathtub, toilet, bucket, pool, pond, or lake — and even a small amount of water is enough; submersion injury is more common than drowning and usually leads to hospitalization and sometimes rehabilitation
• Latch toilet seats closed, never leave a child alone in the bathtub, and never leave a child unattended in a pool even if they can swim
• Poison prevention: keep toxic agents out of reach, lock cabinets, use the dosing device supplied with liquid medicine, discard unused medications, never call medicine candy, use non-mercury thermometers, remove lead-based paint, wash hands before eating, and consider parental workplace lead exposure
• Teach safe sleep and the risks of co-sleeping
• Routine lead screening at 1, 2, and 3 years, with case management for elevated levels and referral to community nursing, teachers, and early intervention

Interprofessional Care

Complications

• Outcome varies with the degree of anoxic insult or the blood lead level; cognitive impairment can follow lead exposure