Chp 39: Respiratory Disorders

Acute Asthma Attack

1. Assess airway patency and respiratory status. 2. Administer humidified oxygen by nasal cannula or face mask. 3. Administer quick-relief (rescue) medications. 4. Initiate an intravenous (IV) line. 5. Prepare the child for a chest radiograph if prescribed. 6. Prepare to obtain a blood sample for determining arterial blood gas levels if prescribed. In the event of an acute asthma attack, several interventions are necessary. First, the nurse assesses airway status to ensure airway patency. If the airway is not patent, emergency interventions such as endotracheal intubation may be necessary. The nurse also quickly assesses the child's respiratory status. If the airway is patent, the nurse administers oxygen by nasal cannula or mask as prescribed. Quick-relief (rescue) medications are administered as prescribed to treat the symptoms. An IV line is initiated so that IV medications can be administered if prescribed. The nurse prepares the child for a chest x-ray to assess airway status and to assist in ruling out a respiratory infection. Blood samples are obtained, and an arterial blood gas may be obtained. When the laboratory results are obtained, the nurse administers medications as prescribed to correct dehydration, acidosis, or electrolyte imbalances. During the episode and during treatment, the nurse continuously monitors respiratory status, pulse oximetry, and color. The nurse also needs to be alert to decreased wheezing or a silent chest, which may signal the inability to move air.

Precipitants Triggering an Asthma Attack

Allergens Outdoor: Trees, shrubs, weeds, grasses, molds, pollen, air pollution, spores Indoor: Dust, dust mites, mold, cockroach antigen Irritants: Tobacco smoke, wood smoke, odors, sprays Exposure to Occupational Irritants Exercise Cold Air Changes in Weather or Temperature Environmental Change: Moving to a new home, starting a new school Colds and Infections Animals: Cats, dogs, rodents, horses Medications: Aspirin, nonsteroidal antiinflammatory drugs, antibiotics, beta blockers Strong Emotions: Fear, anger, laughing, crying Conditions: Gastroesophageal reflux disease, tracheoesophageal fistula Food Additives: Sulfite preservatives Foods: Nuts, milk, other dairy products Endocrine Factors: Menses, pregnancy, thyroid disease

Cystic Fibrosis

Description 1. A chronic multisystem disorder (autosomal recessive trait disorder) characterized by exocrine gland dysfunction 2. The mucus produced by the exocrine glands is abnormally thick, tenacious, and copious, causing obstruction of the small passageways of the affected organs, particularly in the respiratory, gastrointestinal, and reproductive systems. 3. Common symptoms are associated with pancreatic enzyme deficiency and pancreatic fibrosis caused by duct blockage, progressive chronic lung disease as a result of infection, and sweat gland dysfunction resulting in increased sodium and chloride sweat concentrations. 4. An increase in sodium and chloride in sweat and saliva forms the basis for one diagnostic test, the sweat chloride test 5. Cystic fibrosis is a progressive and incurable disorder, and respiratory failure is a common cause of death; organ transplantations may be an option to increase survival rates. Respiratory system 1. Symptoms are produced by the stagnation of mucus in the airway, leading to bacterial colonization and destruction of lung tissue. 2. Emphysema and atelectasis occur as the airways become increasingly obstructed. 3. Chronic hypoxemia causes contraction and hypertrophy of the muscle fibers in pulmonary arteries and arterioles, leading to pulmonary hypertension and eventual cor pulmonale. 4. Pneumothorax from ruptured bullae and hemoptysis from erosion of the bronchial wall occur as the disease progresses. 5. Other respiratory symptoms a. Wheezing and cough b. Dyspnea c. Cyanosis d. Clubbing of the fingers and toes e. Barrel chest f. Repeated episodes of bronchitis and pneumonia Gastrointestinal system 1. Meconium ileus in the newborn is the earliest manifestation. 2. Intestinal obstruction (distal intestinal obstructive syndrome) caused by thick intestinal secretions can occur; signs include pain, abdominal distention, nausea, and vomiting. 3. Stools are frothy and foul-smelling. 4. Deficiency of the fat-soluble vitamins A, D, E, and K, which can result in easy bruising, bleeding, and anemia, occurs. 5. Malnutrition and failure to thrive is a concern. 6. Demonstration of hypoalbuminemia can occur from diminished absorption of protein, resulting in generalized edema. 7. Rectal prolapse can result from the large, bulky stools and increased intraabdominal pressure. 8. Pancreatic fibrosis can occur and places the child at risk for diabetes mellitus. Integumentary system 1. Abnormally high concentrations of sodium and chloride in sweat are noted. 2. Parents report that the infant tastes "salty" when kissed. 3. Dehydration and electrolyte imbalances can occur, especially during hyperthermic conditions. Reproductive system 1. Cystic fibrosis can delay puberty in girls. 2. Fertility can be inhibited by the highly viscous cervical secretions, which act as a plug and block sperm entry. 3. Males are usually sterile (but not impotent), caused by the blockage of the vas deferens by abnormal secretions or by failure of normal development of duct structures. Diagnostic tests 1. Quantitative sweat chloride test is positive 2. Newborn screening may be done in some states and may consist of immunoreactive trypsinogen analysis and direct DNA analysis for mutant genes. 3. Chest x-ray reveals atelectasis and obstructive emphysema. 4. Pulmonary function tests provide evidence of abnormal small airway function. 5. Stool, fat, enzyme analysis: A 72-hour stool sample is collected to check the fat or enzyme (trypsin) content, or both (food intake is recorded during the collection).

Asthma

Description 1. Asthma is a chronic inflammatory disease of the airways 2. Asthma is classified on the basis of disease severity; management includes medications, environmental control of allergens, and child and family education. 3. The allergic reaction in the airways caused by the precipitant can result in an immediate reaction with obstruction occurring, and it can result in a late bronchial obstructive reaction several hours after the initial exposure to the precipitant. 4. Mast cell release of histamine leads to a bronchoconstrictive process, bronchospasm, and obstruction. 5. Diagnosis is made on the basis of the child's symptoms, history and physical examination, chest radiograph, and laboratory tests 7. Status asthmaticus is an acute asthma attack, and the child displays respiratory distress despite vigorous treatment measures; this is a medical emergency that can result in respiratory failure and death if not treated. Assessment 1. Child has episodes of dyspnea, wheezing, breathlessness, chest tightness, and cough, particularly at night or in the early morning or both. Acute asthma attacks a. Episodes include progressively worsening shortness of breath, cough, wheezing, chest tightness, decreases in expiratory airflow secondary to bronchospasm, mucosal edema, and mucus plugging; air is trapped behind occluded or narrow airways, and hypoxemia can occur. b. The attack begins with irritability, restlessness, headache, feeling tired, or chest tightness; just before the attack, the child may present with itching localized at the front of the neck or over the upper part of the back. c. Respiratory symptoms include a hacking, irritable, nonproductive cough caused by bronchial edema. d. Accumulated secretions stimulate the cough; the cough becomes rattling, and there is production of frothy, clear, gelatinous sputum. e. The child experiences retractions. f. Hyperresonance on percussion of the chest is noted. g. Breath sounds are coarse and loud, with crackles, coarse rhonchi, and inspiratory and expiratory wheezing; expiration is prolonged. h. Child may be pale or flushed, and the lips may have a deep, dark red color that may progress to cyanosis (also observed in the nail beds and skin, especially around the mouth). i. Restlessness, apprehension, and diaphoresis occur. j. Child speaks in short, broken phrases. k. Younger children assume the tripod sitting position; older children sit upright, with the shoulders in a hunched-over position, the hands on the bed or a chair, and the arms braced to facilitate the use of the accessory muscles of breathing (child avoids a lying-down position). Exercise-induced attack: Cough, shortness of breath, chest pain or tightness, wheezing, and endurance problems occur during exercise. m. Severe spasm or obstruction: Breath sounds and wheezing cannot be heard (silent chest), and cough is ineffective (represents a lack of air movement). n. Ventilatory failure and asphyxia: Shortness of breath, with air movement in the chest restricted to the point of absent breath sounds, is noted; this is accompanied by a sudden increase in the respiratory rate. Medications 3. Nebulizer, metered-dose inhaler (MDI): May be used to administer medications; if the child has difficulty using the MDI, medication can be administered by nebulization (medication is mixed with saline and then nebulized with compressed air by a machine). 4. If an MDI is used to administer a corticosteroid, a spacer should be used to prevent yeast infections in the child's mouth. 5. The child's growth patterns need to be monitored when corticosteroids are prescribed.

Epiglottitis

Description 1. Bacterial form of croup 2. Inflammation of the epiglottis occurs, which may be caused by Haemophilus influenzae type b or Streptococcus pneumoniae; children immunized with H. influenzae type b (Hib vaccine) are at less risk for epiglottitis. 3. Occurs most frequently in children 2 to 8 years old, but can occur from infancy to adulthood 4. Onset is abrupt, and the condition occurs most often in winter. 5. Considered an emergency situation because it can progress rapidly to severe respiratory distress Assessment 1. High fever 2. Sore, red, and inflamed throat (large, cherry red, edematous epiglottis) and pain on swallowing 3. Absence of spontaneous cough 4. Dysphonia (muffled voice), dysphagia, dyspnea, and drooling 5. Agitation 6. Retractions as the child struggles to breathe 7. Inspiratory stridor aggravated by the supine position 8. Tachycardia 9. Tachypnea progressing to more severe respiratory distress (hypoxia, hypercapnia, respiratory acidosis, decreased level of consciousness) 10. Tripod positioning: While supporting the body with the hands, the child leans forward, thrusts the chin forward and opens the mouth in an attempt to widen the airway. Interventions 1. Maintain a patent airway. 2. Assess respiratory status and breath sounds, noting nasal flaring, the use of accessory muscles, retractions, and the presence of stridor 3. Do not measure the temperature by the oral route. 4. Monitor pulse oximetry. 5. Prepare the child for lateral neck films to confirm the diagnosis (accompany the child to the radiology department). 6. Maintain NPO (nothing by mouth) status. 7. Do not leave the child unattended. 8. Avoid placing the child in a supine position because this position would affect the respiratory status further. 9. Do not restrain the child or take any other measure that may agitate the child. 10. Administer intravenous (IV) fluids as prescribed; insertion of an IV line may need to be delayed until an adequate airway is established because this procedure may agitate the child. 11. Administer IV antibiotics as prescribed; these are usually followed by oral antibiotics. 12. Administer analgesics and antipyretics (acetaminophen or ibuprofen) to reduce fever and throat pain as prescribed. 13. Administer corticosteroids to decrease inflammation and reduce throat edema as prescribed. 14. Nebulized epinephrine (racemic epinephrine) may be prescribed for severe cases (causes mucosal vasoconstriction and reduces edema); heliox (mixture of helium and oxygen) may also be prescribed to reduce mucosal edema. 15. Provide cool mist oxygen therapy as prescribed; high humidification cools the airway and decreases swelling. 16. Have resuscitation equipment available, and prepare for endotracheal intubation or tracheotomy for severe respiratory distress. 17. Ensure that the child is up to date with immunizations, including Hib conjugate vaccine If epiglottitis is suspected, no attempts should be made to visualize the posterior pharynx, obtain a throat culture, or take an oral temperature. Otherwise, spasm of the epiglottis can occur, leading to complete airway occlusion.

Bronchiolitis and Respiratory Syncytial Virus (RSV)

Description 1. Bronchiolitis is an inflammation of the bronchioles that causes production of thick mucus that occludes bronchiole tubes and small bronchi. 2. RSV causes an acute viral infection and is a common cause of bronchiolitis (other organisms that cause bronchiolitis include adenoviruses, parainfluenza viruses, and human metapneumovirus). 3. RSV, although not airborne, is highly communicable and is usually transferred by direct contact with respiratory secretions. 4. RSV occurs primarily in the winter and spring. 5. RSV is rarer in children older than 2 years, with a peak incidence at approximately 6 months of age. 6. At-risk children include children older than 1 year of age who have a chronic or disabling condition. 7. Identification of the virus is done via testing of nasal or nasopharyngeal secretions. 8. Prevention measures include encouraging breast-feeding; avoiding tobacco smoke exposure; using good hand-washing techniques; and administering palivizumab, a monoclonal antibody, to high-risk infants. Palivizumab is administered via intramuscular injection monthly for a 5-month period (usually from November to March). Interventions 1. For a child with bronchiolitis, interventions are aimed at treating symptoms and include airway maintenance, cool humidified air and oxygen, adequate fluid intake, and medications. 2. For a hospitalized child with RSV, isolate the child in a single room or place in a room with another child with RSV. 3. Ensure that nurses caring for a child with RSV do not care for other high-risk children. 4. Use contact and standard precautions during care; using good hand-washing techniques and wearing gloves and gowns are necessary. 5. Monitor airway status and maintain a patent airway. 6. For most effective airway maintenance, position the child at a 30- to 40-degree angle with the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. 7. Provide cool, humidified oxygen as prescribed. 8. Monitor pulse oximetry levels. 9. Encourage fluids; fluids administered intravenously may be necessary until the acute stage has passed. 10. Periodic suctioning may be necessary if nasal secretions are copious; use of a bulb syringe for suctioning may be effective. Suctioning should be done before feeding to promote comfort and adequate intake. 11. Administer ribavirin, an antiviral medication, as prescribed, Cough suppressants are administered with caution because they can interfere with the clearance of respiratory secretions.

Laryngotracheobronchitis

Description 1. Inflammation of the larynx, trachea, and bronchi 2. Most common type of croup; may be viral or bacterial and most frequently occurs in children younger than 5 years 3. Common causative organisms include parainfluenza virus types 2 and 3, respiratory syncytial virus (RSV), Mycoplasma pneumoniae, and influenza A and B. 4. Characterized by gradual onset that may be preceded by an upper respiratory infection Interventions 1. Maintain a patent airway. 2. Assess respiratory status and monitor pulse oximetry; monitor for nasal flaring, sternal retraction, and inspiratory stridor (see Fig. 39-2). 3. Monitor for adequate respiratory exchange; monitor for pallor or cyanosis. 4. Elevate the head of the bed and provide rest. 5. Provide humidified oxygen via a cool air or mist tent as prescribed for a hospitalized child 6. Instruct the parents to use a cool air vaporizer at home; other measures include having the child breathe in the cool night air or the air from an open freezer or taking the child to a cool basement or garage. 7. Provide and encourage fluid intake; IV fluids may be prescribed to maintain hydration status if the child is unable to take fluids orally. 8. Administer analgesics as prescribed to reduce fever. 9. Teach the parents to avoid administering cough syrups or cold medicines, which may dry and thicken secretions. 10. Administer corticosteroids if prescribed to reduce inflammation and edema. 11. Administer nebulized epinephrine (racemic epinephrine) as prescribed; this may be prescribed for children with severe disease experiencing stridor at rest, retractions, or difficulty breathing. 12. Administer antibiotics as prescribed, noting that they are not indicated unless a bacterial infection is present. 13. Heliox (mixture of helium and oxygen) may be prescribed; this medication reduces the work of breathing, reduces airway turbulence, and helps to relieve airway obstruction. 14. Have resuscitation equipment available. 15. Provide appropriate reassurance and education to the parents or caregivers. Isolation precautions should be implemented for a hospitalized child with an upper respiratory infection until the cause of the infection is known.

Pneumonia

Description 1. Inflammation of the pulmonary parenchyma or alveoli or both, caused by a virus, mycoplasmal agents, bacteria, or aspiration of foreign substances. 2. The causative agent usually is introduced into the lungs through inhalation or from the bloodstream. 3. Viral pneumonia occurs more frequently than bacterial pneumonia, is seen in children of all ages, and often is associated with a viral upper respiratory infection. 4. Primary atypical pneumonia, usually caused by Mycoplasma pneumoniae or Chlamydia pneumoniae, occurs most often in the fall and winter months and is more common in crowded living conditions; it is most often seen in children 5 to 12 years old. 5. Bacterial pneumonia is often a serious infection requiring hospitalization when pleural effusion or empyema accompanies the disease; hospitalization is also necessary for children with staphylococcal pneumonia (Streptococcus pneumoniae is a common cause). 6. Aspiration pneumonia occurs when food, secretions, liquids, or other materials enter the lung and cause inflammation and a chemical pneumonitis. Classic symptoms include an increasing cough or fever with foul-smelling sputum, deteriorating results on chest x-rays, and other signs of airway involvement. 7. Prevention of viral and bacterial pneumonia includes immunization of infants and children with heptavalent pneumococcal conjugate vaccine Viral Pneumonia Assessment a. Acute or insidious onset b. Symptoms range from mild fever, slight cough, and malaise to high fever, severe cough, and diaphoresis. c. Nonproductive or productive cough of small amounts of whitish sputum d. Wheezes or fine crackles 2. Interventions a. Treatment is symptomatic. b. Administer oxygen with cool humidified air as prescribed. c. Increase fluid intake. d. Administer antipyretics for fever as prescribed. e. Administer chest physiotherapy and postural drainage as prescribed. Primary Atypical Pneumonia Assessment a. Acute or insidious onset b. Fever (lasting several days to 2 weeks), chills, anorexia, headache, malaise, and myalgia (muscle pain) c. Rhinitis; sore throat; and dry, hacking cough d. Nonproductive cough initially, progressing to production of seromucoid sputum that becomes mucopurulent or blood-streaked 2. Interventions a. Treatment is symptomatic. b. Recovery generally occurs in 7 to 10 days. Bacterial Pneumonia Assessment a. Acute onset b. Infant: Irritability, lethargy, poor feeding; abrupt fever (may be accompanied by seizures); respiratory distress (air hunger, tachypnea, and circumoral cyanosis) c. Older child: Headache, chills, abdominal pain, chest pain, meningeal symptoms (meningism) d. Hacking, nonproductive cough e. Diminished breath sounds or scattered crackles f. With consolidation, decreased breath sounds are more pronounced. g. As the infection resolves, the cough becomes productive and the child expectorates purulent sputum; coarse crackles and wheezing are noted. 2. Interventions a. Antibiotic therapy is initiated as soon as the diagnosis is suspected; in a hospitalized infant or child, IV antibiotics are usually prescribed. b. Administer oxygen for respiratory distress as prescribed, and monitor oxygen saturation via pulse oximetry. c. Place the child in a cool mist tent as prescribed; cool humidification moistens the airways and assists in temperature reduction. d. Suction mucus from the infant, using a bulb syringe, to maintain a patent airway if the infant is unable to handle secretions. e. Administer chest physiotherapy and postural drainage every 4 hours as prescribed. f. Promote bed rest to conserve energy. g. Encourage the child to lie on the affected side (if pneumonia is unilateral) to splint the chest and reduce the discomfort caused by pleural rubbing. h. Encourage fluid intake (administer cautiously to prevent aspiration); intravenously administered fluids may be necessary. i. Administer antipyretics for fever and bronchodilators as prescribed. j. Monitor temperature frequently because of the risk for febrile seizures. k. Institute isolation precautions with pneumococcal or staphylococcal pneumonia (according to agency policy). l. Administer cough suppressant as prescribed before rest times and meals if the cough is disturbing. m. Continuous closed chest drainage may be instituted if purulent fluid is present (usually noted in Staphylococcus infections). n. Fluid accumulation in the pleural cavity may be removed by thoracentesis; thoracentesis also provides a means for obtaining fluid for culture and for instilling antibiotics directly into the pleural cavity. Children with a respiratory disorder should be monitored for weight loss and for signs of dehydration. Signs of dehydration include a sunken fontanel (infants), nonelastic skin turgor, decreased and concentrated urinary output, dry mucous membranes, and decreased tear production.

Bronchitis

Description 1. Inflammation of the trachea and bronchi; may be referred to as tracheobronchitis 2. Usually occurs in association with an upper respiratory infection 3. Is usually a mild disorder; causative agent is most often viral Assessment 1. Fever 2. Dry, hacking, and nonproductive cough that is worse at night and becomes productive in 2 to 3 days Interventions 1. Treat symptoms as necessary. 2. Monitor for respiratory distress. 3. Provide cool, humidified air to the child. 4. Encourage increased fluid intake; child may drink beverages that he or she likes as long as the respiratory status is stable. 5. Administer antipyretics for fever as prescribed. 6. A cough suppressant may be prescribed to promote rest.

Sudden Infant Death Syndrome (SIDS)

Description 1. SIDS refers to unexpected death of an apparently healthy infant younger than 1 year for whom an investigation of the death and a thorough autopsy fail to show an adequate cause of death. 2. Several theories are proposed regarding the cause of SIDS, but the exact cause is unknown. 3. SIDS most frequently occurs during winter months. 4. Death usually occurs during sleep periods, but not necessarily at night. 5. SIDS most frequently affects infants 2 to 3 months of age. 6. Incidence is higher in boys. 7. Incidence is higher in Native Americans, African Americans, and Hispanics and in lower socioeconomic groups. 8. Incidence has been found to be lower in breast-fed infants and infants sleeping with a pacifier. 9. High-risk conditions for SIDS: a. Prone position b. Use of soft bedding, sleeping in a noninfant bed such as a sofa c. Overheating (thermal stress) d. Cosleeping e. Mother who smoked cigarettes or abused substances during pregnancy f. Exposure to tobacco smoke after birth Assessment 1. Infant is apneic, blue, and lifeless. 2. Frothy blood-tinged fluid is in the nose and mouth. 3. Infant may be found in any position, but typically is found in a disheveled bed, with blankets over the head, and huddled in a corner. 4. Infants may appear to have been clutching bedding. 5. Diaper may be wet and full of stool. Prevention and interventions 1. Infants should be placed in the supine position for sleep. 2. Mother needs to be taught about the risk factors: cigarette smoking and substance abuse during pregnancy; use of soft bedding, sleeping in a noninfant bed such as a sofa; overheating (thermal stress); cosleeping; exposure to tobacco smoke after birth. Stuffed animals or other toys should be removed from the crib while the infant is sleeping. 3. Teach the parents to monitor for positional plagiocephaly caused by the supine sleeping position; signs include flattened posterior occiput and development of a bald spot in the posterior occiput area. 4. To assist in preventing positional plagiocephaly, teach the parents to alter head position during sleep, avoid excessive time in infant seats and bouncers, and place the infant in a prone position while awake (monitor the infant when in the prone position). 5. If SIDS occurs, the parents need a great deal of support as they grieve and mourn, especially because the event was sudden, unexpected, and unexplained.

Foreign Body Aspiration

Description 1. Swallowing and aspiration of a foreign body into the air passages 2. Most inhaled foreign bodies lodge in the main stem or lobar bronchus. 3. Most common offending foods are round in shape and include items such as hot dogs, candy, peanuts, popcorn, or grapes. Assessment 1. Initially, choking, gagging, coughing, and retractions are general findings. 2. If the condition worsens, cyanosis may occur. 3. Laryngotracheal obstruction leads to dyspnea, stridor, cough, and hoarseness. 4. Bronchial obstruction produces paroxysmal cough, wheezing, asymmetrical breath sounds, and dyspnea. 5. If any obstruction progresses, unconsciousness and asphyxiation may occur. 6. Partial obstructions may occur without symptoms. 7. Distressed child cannot speak, becomes cyanotic, and collapses. Interventions 1. Emergency care a. Interventions for the removal of a foreign body (or relief of choking) in a child (1 year of age or older) are the same as for the adult client. 2. After instituting emergency care measures, removal by endoscopy may be necessary. a. After endoscopy, the child receives high-humidity air. b. Observe for signs and symptoms of airway edema. 3. Prevention a. Keep small objects, including rubber balloons, out of reach of small children. b. Avoid giving small children small, round food items. 4. Parent, day care provider, and babysitter education a. Teach about the hazards of aspiration. b. Discuss potential situations in which small items may be aspirated. c. Teach about the symptoms of aspiration. d. Teach how to perform emergency care measures.

Tuberculosis

Description 1. Tuberculosis is a contagious disease caused by Mycobacterium tuberculosis, an acid-fast bacillus (see Chapter 54). 2. Multidrug-resistant strains of M. tuberculosis occur because of child or family noncompliance with therapeutic regimens. 3. The route of transmission of M. tuberculosis is through inhalation of droplets from an individual with active tuberculosis. 4. There is an increased incidence in urban low-income areas, nonwhite racial or ethnic groups, and first-generation immigrants from endemic countries. 5. Most children are infected by a family member or by another individual with whom they have frequent contact, such as a babysitter. Assessment 1. Child may be asymptomatic or develop symptoms such as malaise, fever, cough, weight loss, anorexia, and lymphadenopathy. 2. Specific symptoms related to the site of infection, such as the lungs, brain, or bone, may be present. 3. With increased time, asymmetrical expansion of the lungs, decreased breath sounds, crackles, and dullness to percussion develop. Interventions 1. Medications a. A 9-month course of isoniazid may be prescribed to prevent a latent infection from progressing to clinically active tuberculosis and to prevent initial infection in children in high-risk situations; a 12-month course may be prescribed for a child infected with human immunodeficiency virus (HIV). b. Recommendation for a child with clinically active tuberculosis may include combination administration of isoniazid, rifampin, and pyrazinamide daily for 2 months, and then isoniazid and rifampin twice weekly for 4 months. c. Inform the parents and child that bodily fluids, including urine, may turn an orange-red color with some tuberculosis medications. d. Directly observed therapy may be necessary for some children. 2. Place children with active disease who are contagious on respiratory isolation until medications have been initiated, sputum cultures show a diminished number of organisms, and cough is improving; this includes use of a personally fitted air-purifying N95 or N100 respirator (mask) by the nurse caring for the child. 3. Stress the importance of adequate rest and adequate diet. 4. Instruct the child and family about measures to prevent the transmission of tuberculosis. 5. Case finding and follow-up with known contacts is crucial to decrease the number of cases of individuals with active tuberculosis.

Tuberculin skin test (TST) or Mantoux test

Induration measuring 15 mm or more is considered to be a positive reaction in children 4 years or older who do not have any risk factors. Induration measuring 10 mm or more is considered to be a positive reaction in children younger than 4 years and in children with chronic illness or at high risk for exposure to tuberculosis. Induration measuring 5 mm or more is considered to be positive for the highest risk groups, such as children with immunosuppressive conditions or human immunodeficiency virus (HIV) infection. 1. The test produces a positive reaction 2 to 10 weeks after the initial infection. 2. The test determines whether a child has been infected and has developed a sensitivity to the protein of the tubercle bacillus; a positive reaction does not confirm the presence of active disease (exposure versus presence). 3. After a child reacts positively, the child will always react positively; a positive reaction in a previously negative child indicates that the child has been infected since the last test. 4. Tuberculosis testing should not be done at the same time as measles immunization (viral interference from the measles vaccine may cause a false-negative result). Sputum culture 1. A definitive diagnosis is made by showing the presence of mycobacteria in a culture. 2. Chest x-rays are supplemental to sputum cultures and are not definitive alone. 3. Because an infant or young child often swallows sputum rather than expectorates it, gastric washings (aspiration of lavaged contents from the fasting stomach) may be done to obtain a specimen; the specimen is obtained in the early morning before breakfast.

Assessment: Respiratory Syncytial Virus

Initial Manifestations ▪ Rhinorrhea ▪ Eye or ear drainage ▪ Pharyngitis ▪ Coughing ▪ Sneezing ▪ Wheezing ▪ Intermittent fever Manifestations as Disease Progresses ▪ Increased coughing and wheezing ▪ Signs of air hunger ▪ Tachypnea and retractions ▪ Periods of cyanosis Manifestations in Severe Illness ▪ Tachypnea more than 70 breaths/minute ▪ Decreased breath sounds and poor air exchange ▪ Listlessness ▪ Apneic episodes

Interventions for Cystic Fibrosis

Interventions: Respiratory system 1. Goals of treatment include preventing and treating pulmonary infection by improving aeration, removing secretions, and administering antibiotic medications. 2. Monitor respiratory status, including lung sounds and the presence and characteristics of a cough. 3. Chest physiotherapy (percussion and postural drainage) on awakening and in the evening (more frequently during pulmonary infection) needs to be done every day to maintain pulmonary hygiene; chest physiotherapy should not be performed before or immediately after a meal. 4. A Flutter mucus clearance device (a small, hand-held plastic pipe with a stainless steel ball on the inside) facilitates the removal of mucus and may be prescribed; store away from small children because if the device separates, the steel ball poses a choking hazard. 5. Hand-held percussors or a special vest device that provides high-frequency chest wall oscillation may be prescribed to help loosen secretions. 6. A positive expiratory pressure mask may be prescribed; use of this mask forces secretion to the upper airway for expectoration. 7. The child should be taught the forced expiratory technique (huffing) to mobilize secretions for expectoration. 8. Bronchodilator medication by aerosol may be prescribed; the medication opens the bronchi for easier expectoration (administered before chest physiotherapy when the child has reactive airway disease or is wheezing). Medications that decrease the viscosity of mucus may also be prescribed. 9. A physical exercise program with the aim of stimulating mucus expectoration and establishing an effective breathing pattern should be instituted. 10. Aerosolized or IV antibiotics may be prescribed and administered at home through a central venous access device. 11. Oxygen may be prescribed during acute episodes; monitor closely for oxygen narcosis (signs include nausea and vomiting, malaise, fatigue, numbness and tingling of extremities, substernal distress) because a child with cystic fibrosis may have chronic carbon dioxide retention. 12. Lung transplantation is occasionally performed. Interventions: Gastrointestinal system 1. A child with cystic fibrosis requires a high-calorie, high-protein, and well-balanced diet to meet energy and growth needs; multivitamins and vitamins A, D, E, and K are also administered; for those with severe lung disease, energy requirements may be as high as 20% to 50% or more of the recommended daily allowance. 2. Monitor weight and for failure to thrive. 3. Monitor stool patterns and for signs of intestinal obstruction. 4. The goal of treatment for pancreatic insufficiency is to replace pancreatic enzymes; pancreatic enzymes are administered within 30 minutes of eating and administered with all meals and all snacks (enzymes should not be given if the child is NPO). 5. The amount of pancreatic enzymes administered depends on the HCP's preference and usually is adjusted to achieve normal growth and a decrease in the number of stools to 2 or 3 daily (additional enzymes are needed if the child is consuming high-fat foods). 6. Enteric-coated pancreatic enzymes should not be crushed or chewed; capsules can be taken apart and the contents can be sprinkled on a small amount of food for administration. 7. Monitor for constipation, intestinal obstruction, and rectal prolapse. 8. Monitor for signs of gastroesophageal reflux; place the infant in an upright position after eating, and teach the child to sit upright after eating. Additional interventions 1. Monitor blood glucose levels and for signs of diabetes mellitus. 2. Ensure adequate salt intake and fluids that provide an adequate supply of electrolytes during extremely hot weather and when the child has a fever. 3. Monitor bone growth in the child. 4. Monitor for signs of retinopathy or nephropathy. 5. Provide emotional support to the parents, particularly when the child is diagnosed; parents will be fearful and uncertain about the disorder and the care involved. 6. Provide support to the child as he or she transitions through the stages of growth. 7. Teach the child and parents about the care involved and encourage independence in the child for self-care as age appropriate. 8. Instruct the parents to ensure that the child receives the recommended immunizations on schedule; in addition, annual influenza vaccinations are recommended for children 6 months of age and older.

Oxygen Delivery Systems: Advantages and Disadvantages

Oxygen mask Advantages Various sizes available; delivers higher O2 concentration than cannula Able to provide a predictable concentration of oxygen if Venturi mask is used, whether child breathes through nose or mouth Disadvantages Skin irritation Fear of suffocation Accumulation of moisture on face Possibility of aspiration of vomitus Difficulty in controlling O2 concentrations (except with Venturi mask) Nasal cannula Advantages Provides low-moderate O2 concentration (22%-40%) Child is able to eat and talk while getting O2 Possibility of more complete observation of child because nose and mouth remain unobstructed Disadvantages Must have patent nasal passages May cause abdominal distention and discomfort or vomiting Difficulty controlling O2 concentrations if child breathes through mouth Inability to provide mist if desired Oxygen tent Advantages Provides lower O2 concentrations (FiO2 up to 0.3-0.5) Child is able to receive desired inspired O2 concentrations, even while eating Disadvantages Necessity for tight fit around bed to prevent leakage of oxygen Cool and wet tent environment Poor access to child; inspired O2 levels fall when tent is entered Oxygen hood, face tent Advantages Provides high O2 concentrations (FiO2 up to 1.00) Free access to child's chest for assessment Disadvantages High-humidity environment Need to remove child for feeding and care

Quantitative Sweat Chloride Test

Production of sweat is stimulated (pilocarpine iontophoresis), sweat is collected, and sweat electrolytes are measured (more than 75 mg of sweat is needed). Normally, the sweat chloride concentration is less than 40 mEq/L (40 mmol/L). Chloride concentration greater than 60 mEq/L (60 mmol/L) is a positive test result (higher than 40 mEq/L (40 mmol/L) is diagnostic in infants younger than 3 months of age). Chloride concentrations of 40 to 60 mEq/L (40 to 60 mmol/L) are highly suggestive of cystic fibrosis and require a repeat test.

Laboratory Tests to Assist in Diagnosing Asthma

Pulmonary Function Tests: Spirometry testing assesses the presence and degree of disease and can determine the response to treatment. Peak Expiratory Flow Rate Measurement: Measures maximum flow of air that can be forcefully exhaled in 1 second; child uses a peak expiratory flowmeter to determine a "personal best" value that can be used for comparison at other times, such as during and after an asthma attack. Bronchoprovocation Testing: Testing that is done to identify inhaled allergens; mucous membranes are directly exposed to suspected allergen in increasing amounts. Skin Testing: Done to identify specific allergens. Exercise Challenges: Exercise is used to identify the occurrence of exercise-induced bronchospasm. Radioallergosorbent Test: Blood test used to identify a specific allergen. Chest Radiograph: May show hyperexpansion of the airways. Note: Some tests place the child at risk for an asthma attack; testing should be done under close supervision.

Progression of Symptoms in Laryngotracheobronchitis

Stage I ▪ Low-grade fever ▪ Hoarseness ▪ Seal bark and brassy cough (croup cough) ▪ Inspiratory stridor ▪ Fear ▪ Irritability and restlessness Stage II ▪ Continuous respiratory stridor ▪ Retractions ▪ Use of accessory muscles ▪ Crackles and wheezing ▪ Labored respirations Stage III ▪ Continued restlessness ▪ Anxiety ▪ Pallor ▪ Diaphoresis ▪ Tachypnea ▪ Signs of anoxia and hypercapnia Stage IV ▪ Intermittent cyanosis progressing to permanent cyanosis ▪ Apneic episodes progressing to cessation of breathing

what are priority concepts for respiratory disorders?

gas exchange & health promotion

Long-Term Control (Medications to Prevent Attacks)

▪ Corticosteroids (for antiinflammatory action) ▪ Antiallergy medications (to prevent an adverse response on exposure to an allergen) ▪ Nonsteroidal antiinflammatory drugs (for antiinflammatory action) ▪ Long-acting β2 agonists (for long-acting bronchodilation) ▪ Leukotriene modifiers (to prevent bronchospasm and inflammatory cell infiltration) ▪ Monoclonal antibody (blocks binding of immunoglobulin E [IgE] to mast cells to inhibit inflammation)

Quick-Relief Medications (Rescue Medications)

▪ Short-acting β2 agonists (for bronchodilation) ▪ Anticholinergics (for relief of acute bronchospasm) ▪ Systemic corticosteroids (for antiinflammatory action to treat reversible airflow obstruction)