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Altered Respiratory Function II

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RDS is more associated with _______ _______.
Premature infants
- usually has to do with the absorption of fluid
- babies born by c section have more fluid

What is Respiratory Distress Syndrome (RDS) [Hyaline Membrane Disease]?
- deficiency in surfactant
- alveoli collapse on EXPIRATION
- damage to pulmonary capillary epithelium leading to the formation of hyaline membrane
- pulmonary edema which contributes to impaired gas exchange


What is Hyaline Membrane Disease?
Collection of damaged cells
What is surfactant?
- helps with alveoli expanison
- lipid protein compound that decreases surface tension (so alveoli don\'t have to work as hard to expand)
What are predisposing factors of respiratory distress syndrome (RDS)?
1. LESS than 35 weeks gestation
2. Infants of DIABETIC mothers
3. Cesarean Section
4. SECOND born of twins


What are the S&S of Respiratory Distress Syndrome (RDS)?
1. Cyanosis
2. Generalized Edema
3. Hyptonia (\"floppy\")
4. Decreased bowel sounds
5. More pronounced hypoxia
6. Hypercapnia (excessive CO2 in bloodstream)
7. Acidosis





What does a radiograph show of a person who has respiratory distress syndrome (RDS)?
- alveolar ateletctasis (over both lung fields)
- dark streaks
How to manage respiratory distress syndrome (RDS)?
1. Resuscitate
2. Prevent cold stress
3. Maintain ventilation and oxygenation (ventilate with bagging first)
4. Keep NPO
5. Monitor
6. Administer surfactant (Nebulized form via EET)
7. Suctioning (but wait an hour before suctioning)





What should be monitored when someone has respiratory distress syndrome (RDS)?
1. V/S
2. O2 Sats
3. Glucose levels
4. I&O
5. Respiratory assessment
6. ABGs (with changes in ventilatory setting) - blood gases are checked before and after




What is a pneumothorax?
gas or air in the cavity between the chest wall and the lungs (causing lung collapse)
What is apnea?
- cessation of respirations for MORE than 20 seconds
OR
- cessation for any amount of time when symptoms are present (ex. cyanosis, low HR, hypotonia or metabolic acidosis)

What can result from apnea?
- hypoxia
- CP (cerebral palsy)
- SIDS (sudden infant death syndrome)

Types of apnea of prematurity?
1. Central Apnea - centrally located in the brain (breathing centre is affected) - related to small hemorrhages (bleeds) on the brain
2. Obstructive Apnea - obstruction in airway (could be congenital or inflammation)
3. Mixed
**many times it is mixed apnea (central and obstructive)


What is the difference between apnea and periodic breathing? (they are not the same thing)
- periodic breathing is periods where babies will slow down and stop breathing (but it is not true apnea)
- apnea is the cessation of breathing for more than 20 seconds or when for any amount of time when symptoms of respiratory distress are present
What are the causes of apnea?
1. Prematurity
2. Infection (can lead to inflammation)
3. CNS (can affect breathing centre)
4. Drugs
5. Metabolic disorders
6. Airway
7. Temperature
8. Oxygenation






How is apnea managed?
1. INVESTIGATIONS (is there a bleed on the brain, circulation problems? etc.)
2. SLEEP STUDY (measure HR, breathing, things that happen leading up to apnea; usually tested for 24 hours)
3. Assist VENTILATION
4. Give O2 (O2 CPAP or BIPAP)
5. Medications - caffiene and theophylline helps to stimulate breathing; has to be within therapteutic range so CLOSE monitoring of blood levels
6. Fluid restrictions (ensure they are not getting more fluid than they need) - ensure accurate I&O
7. Nutrition (TPN lipids)
8. Monitor V/S and apnea
9. Gentile tacile stimulation ***(if baby is on monitor and HR begins to drop, give them a little rub on the back or feet - can stimulate breathing)
10. Avoid triggering reflexes (don\'t stimulate vagal reflex while suctioning - can cause them to have apnea)








What is apnea of infancy (AOI)?
- Apnea occuring in infants GREATER than 37 weeks gestation
- usually LESS than 43 weeks after conception
- may or may not be able to find pathological reason
- it will usually go away over time
- family needs to be taught monitoring and CPR



Types of respiratory infections
1. Upper respiratory tract infections (Nose, pharynx [connects the mouth and nasal passages with the esophagus])
2. Lower respiratory tract infections (Bronchi and bronchioles)
3. Croup syndromes (infections of epiglottis and larynx [upper part of trachea where vocal cords are located]) - more serious

What are various respiratory infectious agents?
1. Viruses:
- RSV - respiratory syncytial virus
- Rhinovirus
- Parainfluenza
- Adenovirus
2. Bacterial agents:
- Group A beta-hemolytic streptococci
- Staphylococci
- Chlamydia trachomatis
- Mycoplasma
- Pneumococci
- Haemophilus influenzae










Who is susceptible/resistant to respiratory infections?
1. Infants UNDER 3 MONTHS have maternal antibodies
2. 3-6 MONTHS: infection rate INCREASES
3. Toddler/Preschooler: high rate of VIRAL infections
4. OLDER then 5 YEARS: increase in MYCOPLASMA PNEUMONIA and BETA-STREP infections


Which seasons are respiratory infections most common?
- most common during WINTER and SPRING
When are mycoplasma infections most common?
Mycoplasma infections are most common in:
FALL & WINTER
When is asthamtic bronchitis most frequent?
In cold weather
What season is respiratory syncytial virus (RSV) most common?
RSV most common in:
WINTER and SPRING
What are the S&S of respiratory infections?
- vary with age; different in young children
- Fever
- Anorexia
- Vomiting/Diarrhea
- Abdominal pain
- cough/sore throat
- nasal blockage or discharge
- respiratory sounds






What is Acute Nasopharyngitis?
- \"common cold\"
- caused by viruses such as RSV, rhinovirus, adenovirus, influenza and parainfluenza viruses
What are the S&S of acute nasopharyngitis (\"common cold\")?
- fever (varies with age of the child)
- may develop mucus (secretions may turn from yellow to green - should seek medical attention)
- may have trouble breathing (not able to eat or drink)

What is Acute Viral Pharyngitis?
- occurs mostly in YOUNG SCHOOL AGE children during SPRING and WINTER
- has GRADUAL onset and is SELF-LIMITING
What are the S&S of Acute Viral Pharyngitis?
- low grade fever
- malaise (fatigue)
- anorexia
- headache
- rhinorrhea (excessive discharge of mucus from the nose)
- cough
- sore throat
-*possible tonsilar erythema (swelling and redness of tonsils)






What is Acute Streptococcal Pharyngitis?
- caused by Group A beta-streptococci
- Strep is RARE in chidlren LESS than 2 YEARS of age
- risk for serious sequalae (may go on to develop Acute Rheumatic Fever or Acute Glomerulonephritis)

What are the S&S of Acute Streptococcal Pharyngitis?
- SUDDEN onset
- fever (high fever over 40)
- headache
- rhinorrhea (excessive discharge of mucus from the nose)
- cough
- SEVERE SORE THROAT

- erythema (redness)
- petechaiae of soft palate
- white exudate on posterior pharynx
- abdominal pain/vomiting
- urticaria (transient condition of the skin; pale or reddened irregular, elevated patches and severe itching)
- lymphadenopathy (swollen lymph nodes)
- leukocytosis (increased WBCs)
- acutely ill up to 2 WEEKS













How to manage upper respiratory tract infections?
- Diagnose: throat culture
- Treat:

Bacterial: Antibiotics (ex. Penicillin, Erythromycin, Cephalosporin) for MINIMUM of 10 DAYS
- reculture 14 DAYS AFTER treatment

Viral and Strep: Antipyretics and relieve sore throat

****for strep throat - perform throat culture, then go on antibiotics for a minimum of 10 days







What is tonsiltitis and adenoiditis?
- inflammation of TONSILS and ADENOIDS
- tonsil have a role in IMMUNITY
- same cause, S&S, diagnosis and management as PHARYNGITIS
- surgical management is controversial (tonsilectomy - really vascular area and can be hard to manage; should not be done as quickly and routinely is controversial)


What is included in a preoperative assessment for a tonsilectomy?
1. Recent URTI (upper respiratory tract infection)
2. High temperature (child should not go to OR if they have a fever)
3. Allergies
4. History of bleeding tendencies (**do not have ASA (aspirin) 2 weeks before or after surgery - risk for bleeding)
5. Uncontrolled illnesses
6. Family history of reaction to anesthetic
7. Loose teeth (if they are being intubated, they could aspirate on loose teeth)





What is included in postoperative care for a tonsilectomy?
- *side-lying or prone position
- monitor v/s
- monitor for bleeding (indication of too much bleeding: frequent swallowing - blood could be going down back of throat)
- small amounts of fluid when fully awake - avoid red/brown fluid and no straws
- relieve throat pain - avoid citrus (could be irritating to throat)
- home management instructions




What are the S&S of Influenza?
- dry throat/nasal mucosa
- cough

Sudden onset:
- fever/chills
- flushed face
- photophobia (abnormal sensitivity to light)
- myalgia (muscle aches)

- croup (common in small children)








What is Otitis Media?
Inflammation of the middle ear WITH or WITHOUT effusion (fluid)
- caused by STREP PNEUMONIAE or HAEMOPHILUS INFLUENZAE
- most common from 6 MONTHS - 2 YEARS and 5-6 YEARS
- can be acute, chronic or acute with fluid (effusion)
- prevent recurrence of ear infections with effusion by using tympanostomy tubes (t tubes)



Why is otitis media more common in infants and young children?
Eustachian tube is SHORTER, WIDER, STRAIGHTER and more HORIZONTAL in a child compared to an adult
Risk factors for Otitis Media
1. Second hand smoke
2. Daycare
3. Supine (lying on back) positioning when eating/drinking

What are possible sequelae of otitis media?
- temporary hearing loss
- mastoiditis (inflammation of the mastoid process)
- meningitis (inflammation of the meninges)

How is otitis media managed?
1. Antibiotics
2. Analgesics (pain)
3. Antipyretics (fever)
4. Facilitate drainage (tympanostomy tubes)


What is croup syndrome?
- primarily caused by VIRUS (but may be bacterial or virus)
- charcterized by hoarseness, \'barking\' cough, INPIRATORY stridor
- varying degrees of respiratory stress
- affect LARYNX, TRACHEA, and BRONCHI
- causes epiglottitis, laryngitis, laryngotracheaobronchitis



What are the S&S of Acute Epiglottitis?
- drooling (key sign)
- sore throat
- dysphagia (difficulty swallowing)
- tripod positioning
- retractions (drawing in between ribs)
- INSPIRATORY stridor
- mild hypoxia
- distress
**Potential for respiratory obstruction (**do not perform oral exam unless you have medical assistance ready to intubate!)







How is Acute Epiglottitis diagnosed?
- Throat swab
- xray
How is Acute Epiglottitis prevented?
Haemophilus influenzae type B vaccine (Hib vaccine)
How is Acute Epiglottitis managed?
1. Antibiotics (ex. Ceftriaxone, Ampicillin)
2. Allow position of comfort
3. Mist
4. IV hydration
5. O2 and airway on hand (never leave child alone who has epiglottitis)
6. Use caution with throat inspection (need medical assistance!)




What is Acute Laryngotracheobronchitis (LTB)?
- MOST COMMON of CROUP syndromes
- usually affects children YOUNGER than 5 YEARS
- more common in BOYS
- this type can be managed at HOME
- organisms responsible (RSV, parainfluenza virus, mycoplasma pneumoniae, influenza A and B)



What are the S&S of laryngotracheobronchitis (LTB)?
- INSPIRATORY stridor
- suprasternal retractions (drawing in above the clavicle and sternum)
- \"barking\" or \"seal-like\" cough
- increasing respiratory distress and hypoxia
- can progress to respiratory acidosis, respiratory failure and death



How to manage laryngotracheobronchitis (LTB)?
1. Airway management
2. Maintain hydration (PO & IV)
3. High humidity with cool mist
4. Nebulizer treatments (Epinephrine and Steroids)


What are 2 types of lower airway infections?
1. Bronchiolitis
2. Pneumonias
What is Bronchiolitis?
- caused by respiratory synctial virus (RSV)
- most common in WINTER and SPRING (vaccine available)
- very contagious by DIRECT contact
- bronchiolar mucosa swell, lumina fill with exudate, interstitial pneumonitis, hyperinflation and air trapping
*smaller baby can deteriorate quickly and die from it



How is Bronchiolitis diagnosed?
- NP (Nasopharyngeal) swab: to determine if RSV is present
What are the S&S of bronchiolitis?
INITIAL:
- rhinorrhea (excessive mucus secretion from the nose)
- pharyngitis (swelling of pharynx)
- coughing
- intermittent fever

PROGRESSION:
- increased coughing
- wheezing/crackles
- tachypnea (fast RR)
- retractions (drawing in)

SEVERE:
- listlessness (lethargic)
- increased tachypnea (increased RR)
- apneic spells (periods of cessation of breathing)
- deteriorating breath sounds















How to manage bronchiolitis?
1. Isolation (very contagious through direct contact)
2. O2 and pulse oximetry
3. High humidity
4. Hydration
5. Bronchodilators/Corticosteroids
6. ANTIVIRALS / immune globulin




What is Pneumonia?
- infection of PULMONARY PARENCHYMA (lung tissue)
- alveoli are infected and swollen
- most common in EARLY INFANCY/CHILDHOOD, then in YOUNG ADULTHOOD
- primary or secondary disease
- symptoms vary based on causitive agent and patient status
- upon auscultation, decreased sounds on the side with pneumonia




What are the causes of pneumonia?
- Bacterial OR Viral (bacterial is a lot worse)
- Aspiration
- Histomycosis, coccidiomycosis, other fungi
- \"Atypical pneumonias\"
- Chlamydial pneumonia



What are the general S&S of pneumonia?
- Fever
- Respiratory signs (crackles)
- Behavior
- GI signs (vomiting)

**see pg. 246 in textbook for more symptoms of pneumonia




What is Viral Pneumonia?
- not as bad as bacterial
- occurs more frequently than bacterial
- often associated with VIRAL URTI\'s
- onset may be ACUTE or INSIDIOUS (silent)
S&S vary:
- MILD to HIGH fever
- MILD cough to SEVERE cough
- malaise

- treatment is symptomatic








What is Atypical (Mycolplasmal) Pneumonia?
- most common cause of pneumonia in children 5-12 YEARS
- onset SUDDEN or INSIDIOUS (silent)
- usually systemic symptoms followed by: RHINITIS (inflammation of mucous membrane in the nose), SORE THROAT and DRY HACKING COUGH
- symptomatic treatment and appropriate ANTIBIOTICS
- usually recover in 7-10 DAYS



What is Bacterial Pneumonia?
- S&S may be SERIOUS and progress RAPIDLY
- different causative factors at different ages
- ACUTE onset
- SEVERE symptoms
- YOUNG CHILDREN are more SEVERELY affected



How is bacterial pneumonia diagnosed?
Xray (EARLY detection is important)
How is bacterial pneumonia managed?
1. Antibiotics
2. Oxygen (PRN)
3. Close monitoring
4. Bed rest (essential - even if they are starting to feel better)
5. Hydration
6. Antipyretics (reduce fever)
**may take weeks to resolve (viral recovery is quicker)





What are potential complications of bacterial pneumonia?
1. Empyema - collection of pus in pleural space (between lungs and chest wall)
2. Pneumothorax - collection of air in pleural space (between lungs and chest wall) leading to lung collapse
3. Otitis Media
4. Pleural Effusion (fluid in the pleural space)


What is aspiration pneumonia?
- inflammation of lungs and airways from breathing foreign material into the airway and lungs
- a child with feeding difficulties is at risk for aspiration pneumonia
- need to prevent aspiration pneumonia by feeding techniques and positioning
- AVOID:
1. Oily nose drops
2. Solvents
3. Talcum powder





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