Chapter 10 Elizabeth Mills, Rosemary Court and Susan Fidment To understand the pathophysiology of the respiratory system during an acute illness phase, and the care and management required by the child and family. Respiratory illness is very common in infants and children, and is the most frequent reason for children to attend the GP or be admitted to hospital. Different types of respiratory illness and conditions range from mild and self‐limiting, to severe and life threatening, and if the child has other medical issues, such as a long‐term, complex condition, then an acute respiratory illness can have a very serious effect on the child’s health (ALSG, 2016). Infants and young children have an increased susceptibility to respiratory illnesses and subsequent respiratory distress and progressive failure, potentially leading to respiratory arrest. This is due to a number of important factors (ALSG, 2016; Akers, 2015): Respiratory assessment is a fundamental skill of the nurse caring for the sick child. Assessing differing elements of respiratory function will give you an overall indication of the child’s respiratory status. A full respiratory assessment will include the following observations: Infants are particularly prone to apnoeas as they become exhausted from respiratory distress and the increased work of breathing. Seek senior help immediately if you think an infant or child is having apnoeas, as this is a sign that respiratory arrest may be imminent. Listen for audible noises made during the respiratory cycle (inspiration and expiration). Types of noises you may hear are: Using an oxygen saturation monitor with an infrared probe enables a measurement of the amount of oxygen dissolved in the blood to be made. Normal oxygen saturation levels should be 95% and above. In some groups of children, however, a lower measurement is acceptable, for example, children with certain cardiac conditions – please refer to local guidelines and policies. Pale skin colour can be an indication of inadequate oxygen delivery to the cells and/or inadequate circulatory perfusion to the skin. However, it is always best to seek clarification from parents or carers on the child’s normal skin colour, as some children are usually pale. This can also be difficult to detect in the child with a darker skin tone, and you will need to carefully observe the mucous membranes (inside the mouth and eye lids etc.). Children in respiratory distress will have a raised heart rate too, due to the circulatory system compensating for a lack of oxygen. However, check that the heart rate is increased in a comparable amount as a hugely increased heart rate may be indicating other issues such as a cardiac condition, which could be causing the respiratory distress, or another diagnosis. The effect of hypoxia on the brain is to alter the mental status; this could mean that a child becomes floppy or irritable and then more drowsy as the hypoxia progresses. Using a neurological assessment tool is useful, for example, AVPU or the Glasgow Coma Scale to objectively measure mental status. Due to the low levels of oxygen in Rosie’s blood, delivering oxygen is the first priority. In this emergency situation, use a non‐rebreathe oxygen mask, with the oxygen flow meter turned to 15 L. The non‐rebreathe mask has a reservoir bag which will fill with oxygen and deliver a high concentration of oxygen. However, once Rosie becomes more stable it may be more appropriate to use an oxygen mask, which will deliver a lower concentration of oxygen, or nasal prongs. If Rosie continues to require a high level of oxygen to maintain her oxygen blood levels then she would need to be nursed in an area that can deliver high‐flow nasal cannula oxygen therapy or non‐invasive CPAP or that can potentially intubate and ventilate (e.g., high‐dependency area, children’s critical care or intensive care). While observing the effect of the oxygen, Rosie appears to have white bubbly secretions coming from her nostrils and in her mouth. Because of the small size of an infant’s nostrils and airways, these can easily become blocked with secretions produced during a respiratory illness such as bronchiolitis. This can be a problem for infants particularly as they like to nose breathe, which is difficult once the nostrils become blocked. Often these secretions can be wiped away with a tissue. Some babies benefit from saline nose drops to keep the mucous loose and easily cleared from the nostrils. In a clinical ward, it may be appropriate to use gentle suctioning to clear secretions in the nostrils and mouth. This is a clinical skill which should only be performed when the need for it has been assessed, such as in respiratory distress or feeding difficulties, and it should not be performed routinely on infants with bronchiolitis (NICE, 2015). Refer to local guidelines and policies when performing suction, and only undertake this skill when you have been assessed as competent, or under direct supervision with a qualified healthcare professional. Bronchiolitis is highly infectious and infection control measures must be undertaken with regard to local policies and guidelines. In particular, good hand hygiene and grouping (cohorting) of infectious patients in restricted areas. Parents managing infants at home with bronchiolitis, should be advised on hand hygiene and washing of toys and equipment. Bronchiolitis is a common lower respiratory tract illness affecting children under the age of 2 years. It is most commonly seen in those under 1 year and peak incidence is age 3–6 months. It is estimated that a third of all children in the UK will have had bronchiolitis in their first year of life, and approximately 3% of children with bronchiolitis will need hospitalisation for supportive care. The disease is caused by a viral infection; approximately 80% of cases are caused by respiratory syncytial virus (RSV) but bronchiolitis can also be caused by other viruses, such as adenovirus and rhinovirus. The infection causes inflammatory obstruction of the lower airways and alveoli, due to necrosis of the cell lining. Ciliary damage impedes secretion clearance of the lower lung fields combined with increased mucous production. Air becomes trapped below the obstruction of secretions, and it becomes more difficult for the infant to exhale, hence a wheezy noise develops and respiratory distress follows. In severe cases, a consolidation or collapse occurs in the affected area of lung, and gaseous exchange may be impaired (Glasper & Richardson, 2010). Bronchiolitis normally presents as a cough with increased effort in breathing; it often affects the infant’s ability to feed. It can be confused with the ‘common cold’ as there are common features. However, the presence of lower respiratory tract infection, such as a wheeze or crackles, can be heard on auscultation. The symptoms are usually mild, but in some cases will be severe, particularly if the infant has associated risk factors, such as chronic lung disease, congenital heart disease, premature birth, neuromuscular disorder or an immunodeficiency disorder (NICE, 2015). Very young infants, for example, those under 6 weeks of age, may have apnoea (periods of no respiratory effort, which may or may not be self‐resolving). Symptoms usually peak at 3–5 days of the disease trajectory and the cough normally resolves within 3 weeks. Some children can be left with a residual wheeze. Treatment for bronchiolitis is mainly supportive. It may include giving oxygen therapy for low oxygen saturation (usually 92% and below), which may be via nasal cannulae or in a head box. Ideally, oxygen should be given humidified and warmed if it is given for any prolonged length of time. The amount of oxygen given should be titrated to the level of oxygen saturations of the infant to avoid over‐delivery of oxygen, which has been shown to have harmful effects if given in excess over a prolonged period of time. Support with hydration and feeding may be required for infants with severe infection. This may include intravenous fluids to correct dehydration and/or nasogastric feeding. Due to respiratory distress infants can have difficulty feeding adequately; this needs to be assessed on an individual basis. Secretion clearance from the nostrils, either with suction or saline nose drops, can often facilitate more effective feeding. No medication is recommended to treat bronchiolitis, although the use of paracetamol and ibuprofen may be used if the child is old enough, to treat discomfort. The use of antibiotics is not recommended for bronchiolitis; however, it may be required if the child develops a post‐viral, bacterial infection. Risk factors for severe illness include infants under the age of 2 months, prematurity, congenital heart disease and chronic lung disease. Parental/carer support is required, as this can be a frightening experience for parents and may be the first illness for their infant. Parents/carers at home with a child with bronchiolitis should be given advice about what to expect and when they need to call for advice or help (NICE, 2015). Babies and young children are vulnerable to upper airway problems because of the small size of their anatomy, as discussed previously. Croup is a common condition, also known as acute viral laryngotracheobronchitis, often caused by the parainfluenza virus. The peak incidence for croup is 2 years of age; however, it can occur from 6 months up to 5 years of age. Children with croup have the distinctive ‘croup’ sound on inspiration, called a stridor; this is due to swelling and oedema of the upper airway causing a partial obstruction. They may also have a barking cough, a mild fever and hoarse voice. Inhalation of warm moist air is often recommended; however, there is little evidence of benefit. Oral or nebulised steroids may be given to reduce the severity and length of the illness. Epiglottitis is swelling of the epiglottis and surrounding tissues due to infection. It is treated as a potentially life‐threatening emergency as total obstruction of the larynx can occur. Urgent hospital admission is required for a child with suspected epiglottitis. This condition has become much rarer in children since the introduction of the HIB vaccination as it is primarily caused by the Haemophilus influenzae bacteria. The most common age occurrence is 2–6 years. Children presenting with epiglottitis typically may be drooling, have a muffled voice and look very unwell, due to the overwhelming infection and pyrexia. It is very important not to upset the child who you may suspect has epiglottitis, do not insist that they lie flat, as they often find their own most effective position for breathing, which will often be leaning forward and they may prefer to sit on a parent’s lap. Causing the child unnecessary distress, for example, attempting cannulation, may invoke a complete obstruction of the upper airway and require emergency airway management. Antibiotic therapy will be required once the airway has been secured, and this will usually be with intubation. After antibiotic therapy has been established, recovery is normally rapid. This is an uncommon occurrence in children; however, because infants and children are inquisitive and put objects in their mouth or are learning to eat different types of food, then aspiration of a foreign body is a possibility. Children often have sudden onset of respiratory distress and a history of choking. Children with suspected aspiration of a foreign body will need a laryngo‐bronchoscopy to remove the object from the airway. Children who present with an acute choking episode need to be treated with the choking algorithm (ALSG, 2016) (Fig. 10.1). Figure 10.1 Choking algorithm. Pneumonia is globally recognised as the leading cause of death from infection in the under‐fives, accounting for approximately one‐fifth of childhood deaths worldwide (World Health Organization, 2014). Pneumonia is an infection affecting the lower respiratory tract and can be caused by viral or bacterial pathogens. Infants, children and young people are affected by different organisms. Infection can occur via the bloodstream or through inhalation via the airway epithelium. It is characterised by inflammation of the lung parenchyma leading to consolidation of alveoli. There are different classifications of pneumonia, which can relate to the anatomical distribution of the disease, the infective pathogen responsible for the disease, or whether the disease is community‐acquired or hospital‐acquired (nosocomial). According to Glasper and Richardson (2010), pneumonia can be classified by the site of its anatomical distribution: Lobar pneumonia involves a large portion of an entire lobe of a lung and is predominantly caused by Streptococcus pneumoniae. Bronchopneumonia begins in the terminal bronchioles, which become congested with exudate and form patches of consolidation involving several lobes of the lungs; it usually follows another respiratory illness, such as whooping cough or bronchiolitis. Interstitial pneumonia involves the walls surrounding the alveoli and bronchioles and is usually caused by viral or mycoplasma infections. The inflammatory process is confined within the alveolar walls and the peribronchiolar and interlobular tissues. Infectious organisms are spread to the lower respiratory tract either via the bloodstream or the upper respiratory tract. The body responds to the pathogen by triggering an immune response in the lungs. The lung capillaries begin to leak plasma proteins, red blood cells, and inflammatory and immune response mediators into the alveoli resulting in a reduced functional area for gaseous exchange. As a result the rate of breathing increases to meet the rising demand for oxygen and to combat the rising carbon dioxide levels. Mucus production increases and fluid continues to fill the alveoli. As the disease progresses the alveoli further fill with fluid and debris caused by the large number of white blood cells being produced to fight the infection. Ultimately some alveoli become solid as the normally hollow air space is filled with fluid and debris. This results in an area of consolidation within the lung where gaseous exchange is severely impaired. Viral pneumonia infects the walls of the alveoli and the parenchyma of the lung. The ciliated epithelial cells become damaged as the virus replicates in the alveolar epithelial cells, leading to rupturing of the walls of the alveoli and the bronchioles. Distinguishing between viral and bacterial infection can be difficult and it can also be hard to obtain a definitive diagnosis of bacterial infection in babies and young children. Recommendations suggest that in children where there is persistent or repetitive fever greater than 38.5 °C together with chest wall recession and a raised respiratory rate, a diagnosis of bacterial pneumonia should be considered (Harris et al., 2011). Chest X‐ray is only indicated when a child fails to respond to treatment or if complications are suspected. Signs and symptoms are often non‐specific and vary according to the age of the child and the causative pathogens. Respiratory assessment is the most important diagnostic tool. Chest X‐ray is only necessary if there is failure to respond to treatment or if complications are suspected. Full blood count, C‐reactive protein and blood cultures should be performed, and a blood gas to assess respiratory function may be indicated if there is acute respiratory distress. Nasopharyngeal aspirate for viral immunofluorescence and/or sputum specimen for microscopy, culture and sensitivity may also be considered. The priority for managing a child with pneumonia is prompt identification and treatment of respiratory distress. Full respiratory assessment should be undertaken, including pulse oximetry and supplementary oxygen administered if the oxygen saturation reading is below 92%. Children demonstrating signs of severe respiratory distress and decreasing levels of consciousness may require tracheal intubation and artificial ventilation in order to maintain adequate oxygenation. Assessment of the nutritional status of the child is important in preventing dehydration (see red flag box, next section). Symptoms of respiratory distress, such as tachypnoea and recession, can impede the ability to swallow and children should be assessed for dehydration. Dependent upon the severity of the respiratory distress it may be necessary to commence intravenous fluids or enteral feeding via a nasogastric tube. Presence of a nasogastric tube, however, can exacerbate respiratory distress if it occludes too much of the airway. Antimicrobial therapy is usually started with a diagnosis of bacterial pneumonia and the type of drug and route of administration will depend upon the age of the child, the severity of the illness and the causative pathogen (if known). Children who are not requiring oxygen and are drinking adequately can be managed at home with a course of oral antibiotics. If the pneumonia fails to respond to treatment there is a risk of developing empyema. Empyema is a serious respiratory condition which is caused by the pleural fluid within the pleural space becoming infected. Left untreated the pus thickens and causes sections of the pleura to stick together forming pockets of pus. The thickening deposits can extend to the outer layer of the lung, which prevents adequate lung expansion. Empyema is treated with insertion of a small chest drain connected to an underwater seal to allow the infected fluid to drain.
Disorders of the respiratory system
Aim
Introduction
Respiratory assessment
Respiratory noises
Measuring oxygen saturations
Skin colour
Heart rate
Mental status
Oxygen therapy
Clearance of nasal and oral secretions
Infection control precautions
Bronchiolitis
What is bronchiolitis?
Treatment
Upper airway disorders
Croup
Epiglottitis
Aspiration of a foreign body
Pneumonia
Altered physiology
Bacterial pneumonia
Diagnosis
Signs and symptoms
Investigations
Assessment and treatment
Complications
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