The respiratory system consists of the nose, pharynx, and larynx (upper respiratory tract) and the trachea, bronchi, and lungs (lower respiratory tract). The respiratory tract continually changes during the first 12 years of a child’s life. There are several anatomic differences that predispose children to respiratory difficulties (Box 11-1). This makes respiratory problems common during childhood. Most problems are mild and can be managed at home. Other conditions can be chronic and have an impact on the growth and development of the child. Respiratory distress and failure are the common factors for cardiac arrest in children. Respiratory diseases account for 25% of hospitalizations for children younger than 15 years of age. Pneumonia accounts for 31%, bronchiolitis and bronchitis for 25%, and asthma for 25% of the respiratory diseases (CDC, 2007).

Box 11-1 Pediatric Respiratory Differences

• Smaller nares and nasopharynx, which can be occluded with edema

• Obligatory nose breathers until 4 weeks of age and are unable to use mouth to breathe

• Small and floppy epiglottis, which can be occluded with edema

• Large tongue, which increases risk for occlusion of airway

• Larynx and glottis are located higher in neck, which increases risk for aspiration

• Trachea is shorter and narrow with flexible cartilage, which can be occluded with edema and neck and head flexion

• Enlarged tonsillar tissue, which increases risk for obstruction

• Underdeveloped respiratory muscles result in poor chest expansion and decreased expiratory lung volume

• Diaphragm and abdominal muscles used for breathing in children under 6 years of age can be impaired by abdominal distention

• Alveoli are underdeveloped and continue to develop until 12 years of age

• Higher metabolic rate, which increases oxygen demands

• Eustachian tubes are horizontal until age 7, which increases the risk of ear infections

• Higher respiratory rate with irregular breathing patterns in infants

Children with respiratory difficulties have common signs and symptoms that can progress to respiratory failure if not recognized. Assessment findings of the child’s respiratory system will vary depending on the age of the child. The nurse must recognize any change in the child’s breathing status. Signs and symptoms may include fever, anorexia, vomiting, diarrhea, abdominal pain, nasal blockage, nasal drainage, cough, sore throat, retractions, and abnormal respiratory sounds. Respiratory assessment should be comprehensive and frequent as the status can change rapidly. The assessment should include the guidelines shown in Box 11-2. Retractions can indicate respiratory distress. The severity of respiratory distress can be assessed using the depth and location of the retractions (Figure 11-1).

Box 11-2 Respiratory Assessment Guidelines

• Behavior changes such as irritability, restlessness, and level of responsiveness

• Child’s position of comfort

• Vital signs including respiratory rate, depth, rhythm, and ease

• Lung sounds including lobe areas, wheezing, crackles, rhonchi, or coarseness

• Respiratory effort including stridor, grunting, retractions (see Figure 11-1), nasal flaring, labored breathing, head bobbing, and tachypnea

• Color of skin and mucous membranes

• Cough including productivity, effort, and noise (barking, musical, croupy)

A variety of diagnostic tests can assist in monitoring respiratory function. Chest x-rays assist in identifying foreign objects or abnormalities in lung tissue. Pulse oximetry is a noninvasive method for measuring oxygen saturation. Pulmonary function test (PFT) and spirometry measure the vital and expiratory capacity.

Sudden Infant Death Syndrome

Sudden infant death syndrome (SIDS) is defined clinically as the sudden, unexpected death of an apparently healthy infant younger than 1 year of age for which a routine autopsy fails to identify the cause. It is also referred to as crib death or cot death. Although precise data are not available, it is estimated that in the United States, SIDS kills about 3000 infants per year. In industrialized countries, SIDS is one of the leading causes of death in early infancy; the peak incidence is between 2 and 4 months of age. It is more common in low–birth weight babies, in boys, in families with crowded living conditions, and during the winter months. Autopsy may reveal slight respiratory infection or otitis media, petechiae over the pleura, and pulmonary edema. Two clinical features of the disease remain constant: (1) death occurs during sleep, and (2) the infant does not cry or make other sounds of distress. In some cases, the baby is found in one corner of the crib with blood-tinged froth coming from the nose.

Theories concerning the cause of SIDS are numerous. Although there appears to be an increased incidence among siblings, no genetic pattern has been determined. The risk for SIDS is increased in twins.

Many theories concerning cause (e.g., suffocation, aspiration allergy, and hormone deficiency) have been disproved. The exact cause is not known. Some researchers propose that crib death results from an interruption of some basic function in the central or autonomic nervous system that causes apnea. Carotid bodies located in the neck and involved in the control of breathing have been found to be abnormal in victims of SIDS. Current opinion holds that SIDS has more than one cause.

The death rate has continued to decrease, and the focus is on decreasing risk factors that contribute to SIDS. The Back to Sleep program has produced positive results. Co-sleeping has been identified as an increased risk of SIDS even if mothers do not smoke or if they breastfeed. Health care providers should encourage a separate crib or bassinet for sleeping.

Health Promotion

Guidelines for Prevention of SIDS

• Always place infant on his or her back to sleep, and do NOT use side-lying position (see Box 11-3).

Box 11-3 Evidence-Based Practice

Infant Sleeping Position

Problem

Infants discharged from NICU are more likely to be placed in a prone position.

Evidence

Survey of 2300 mothers found 26% did not place 3-month-old in supine position; 42% reported bed sharing at 2 weeks and 27% at 12 months; higher incidence of prone sleeping position with African-American mothers.

Survey of nurses reported that most nurses felt for premature infants a nonsupine sleep position was best during hospitalization. 52% of NICU nurses discussed supine sleeping on discharge. 45% of nurses reported reflux and/or aspiration as reason for nonsupine position (Carrier, 2009).

Implications

Back to Sleep program (BTS) has shown to decrease the incidence of SIDS. Nurses have the opportunity to model and educate families about appropriate sleeping position.

Critical Thinking

Identify practices that would increase the use of supine sleep position for newborns and infants.

• Use a firm sleep surface with a safety-approved crib mattress.

• Keep soft objects and loose bedding out of infant’s sleep area.

• Avoid overheating, keeping head uncovered.

• Do not smoke during pregnancy or near babies.

• Avoid co-sleeping, but keep infant’s sleep area close. Keep infant’s bedroom door open.

• Avoid home respiratory or cardiac monitors used to reduce SIDS risk.

• Avoid devices that claim to maintain sleep position to reduce SIDS.

• Consider offering a clean, dry pacifier (controversial).

• Provide tummy time during awake periods.

• Stress that all care providers for infant follow the guidelines (AAP, 2005).

Cultural Considerations

African-American infants are twice as likely to be put to sleep on their stomachs, and parents may need more instruction (Carrier, 2009).

Babies with infantile apnea (also called near-miss infants) and subsequent siblings of babies with SIDS are often monitored at home until they are past the age of danger. Monitors can be leased. Parents are provided with ongoing education and support during this period. Parents are taught cardiopulmonary resuscitation before being discharged.

In dealing with grieving parents after the death of their infant, the nurse must convey some important facts: that the baby died of a disease entity called SIDS, that this disease currently cannot be predicted or prevented, and that they are not responsible for the child’s death. Grieving parents need time to say good-bye to their child. They should be encouraged to hold and rock their infant, shed tears, and assist in burial preparations. This process, not common in the past, is conducive to the resolution of grief (see also Chapter 22). One mother who was denied this experience stated that 5 years later, while visiting a florist’s shop, she noticed a heart-shaped wreath intended for an infant. She unexpectedly burst into tears and wept.

Parents of a child who dies of SIDS experience a great deal of guilt and are catapulted into a totally unexpected bereavement, requiring numerous explanations to relatives and friends. Often needless blame has been placed on one parent by the other or by relatives. The family babysitter and physician may also be targets of attack. Emergency department personnel need to be especially sensitive and supportive during this crisis. There have been occurrences of SIDS for which parents have been charged with child abuse and have even been jailed because of lack of public knowledge about the disease.

Sudden infant death syndrome can occur in the hospital, and many nurses and physicians have personal experience of the suffering that losing a child to SIDS can cause. Group therapy with other parents of SIDS victims is recommended. Two nationally supported organizations are the Compassionate Friends, Inc., and the National Sudden Infant Death Syndrome Foundation. These groups have local chapters in most states.

Bronchopulmonary Dysplasia

Bronchopulmonary dysplasia (BPD) is a chronic lung disease that occurs in newborns that are premature or have pulmonary disorders that require mechanical ventilator support with high positive pressure and oxygen. The lung tissue is immature and unable to withstand tissue damage resulting from the required oxygen supplement. The resulting fibrosis and alteration in lung compliance may last from several months to years. Improvements in treatment of low–birth weight preterm infants have increased the incidence of this disorder, and continue to be the primary issue for infants younger than 27 weeks of age (Belcastro, 2004). Newer mechanical ventilators are being used for low birth weight neonates in hopes of decreasing BPD.

Signs and Symptoms

The symptoms of BPD are directly related to the pathophysiology of the disease. Tachypnea, dyspnea, and wheezing can be a result of airway obstruction and increased airway resistance. Increased work of breathing can cause retractions and use of accessory muscles. The infants may display activity intolerance during feedings. They may be irritable and difficult to comfort. Cyanosis may develop during crying spells. Infants who needed intubation for a long period of time may have subglottic stenosis and inspiratory stridor develop. All of the symptoms can be associated with the chronic hypoxia state. The diagnosis is made on the basis of abnormal radiographic findings, signs of respiratory distress, oxygen dependency after 28 days of age, and a history of required mechanical ventilation during the first week of life.

Nursing Brief

Children in severe respiratory distress should receive nothing by mouth because of the increased workload of breathing and the increased risk for aspiration.

Treatment and Nursing Care

The treatment for infants with BPD is to provide adequate oxygenation and prevent progression of the disease process. Treatment includes oxygen, drug therapy, and nutritional support. Surfactant continues to be included in the course of medical treatment (Askins and Diehl-Jones, 2009). Infants may continue to need oxygen after hospital discharge. These infants do not tolerate excessive or even normal amounts of fluids. They may have problems develop with accumulation of fluids in the lungs that require the use of diuretics. The use of these drugs requires the monitoring of electrolytes and edema. Oral electrolyte supplements may be given. Bronchodilators (albuterol) and steroids may promote improved lung function. These infants are at risk for respiratory infections and should be given RSV-immune globulin (RespiGam) or palivizumab (Synagis) during the RSV season.

Infants with BPD are at high risk for growth failure, and nutrition is an important issue (VanRiper, 2010). They have higher metabolic needs, and providing adequate nutrition without causing respiratory distress can be difficult. Nursing care should be organized to provide periods of rest. Small, frequent feedings and nutritional supplements may be used. The environment should include measures to decrease stimulation.

Home Care Considerations

The Child with Bronchopulmonary Dysplasia

Advise parents that:

• All caregivers need CPR training.

• House and care should be smoke-free.

• Avoid contact with individuals with colds or fever.

• Avoid crowds.

• Place infant on back to sleep.

• Keep infant’s room door open.

Parents may be extremely anxious caring for a child with BPD. All equipment and procedures should be explained in simple terms. Children with tracheostomies can be cared for in the home setting, and home care teaching of the equipment is needed (Figure 11-2). Review care of the child with tracheostomy in Chapter 3. Extended hospitalization can interfere with the development of the normal parent-child relationship and with the normal development of the infant. Parental participation in the infant’s care should be encouraged. The family’s ability to cope and care for a child with a chronic illness needs to be evaluated as home discharge plans are developed. An adequate period of education may be necessary for the parents to become comfortable with the care required for their child. Families should be referred to social services to assist in providing additional support and to assist in helping the parent gain access to available community services. Parental support groups can be beneficial in providing additional assistance with coping skills necessary for caring for a child with complex care.

FIGURE 11-2 Humidified oxygen is provided to the child with a tracheostomy.

New treatment guidelines were released in 2004 by the American Academy of Pediatrics (AAP) (Box 11-4). Treatment included an observation option, pain management, and antimicrobial treatment. Development of resistant strains of bacteria and misuse of antimicrobials assisted in the development of new guidelines. When antimicrobials are used, amoxicillin remains the drug of choice, but recurrent infections may require other antimicrobials. Parents are taught to give the entire dose of the antimicrobial even though the child may appear well. Parents will need to understand the new course of treatment using the guidelines and their role in the management of AOM.

Box 11-4 Acute Otitis Media Guidelines

• Diagnosis of AOM by history, signs, and symptoms

• Assessment of pain and pain management for first 24 to 36 hours

• Optional treatment course of observation for 48 to 72 hours without antibacterial treatment; if child fails to respond within 48 to 72 hours, antibacterial therapy should be started

• Treatment using antibacterial agent; high-dose amoxicillin is recommended

• Encouragement of prevention by reducing risk factors

Insufficient evidence to recommend use of complementary and alternative medicine (CAM) (AAP, 2004)

Pain control may be needed for the child with AOM. Pain control is achieved using acetaminophen or ibuprofen as prescribed. Antihistamines and decongestants are not effective and may have side effects. Eardrops (Auralgan) may be prescribed to control pain. Warm or cold compresses may be applied to the ear. The child can be placed on the affected side with the ear on top of a hot water bottle (temperature of the water 115° F, or 46° C) or on a heating pad on the low setting. Children should be placed upright to decrease pain. If the ear is draining, the outer canal can be cleaned with sterile water or hydrogen peroxide. Parents should be instructed not to use cotton swabs in the ears.

Nurses need to be aware that environmental factors have been identified that can contribute to the risk for ear infections. Daycare outside the home, parental smoking, and pacifier use has been shown to increase the risk for recurrent otitis media. Breastfeeding for at least 6 months has reduced the risk for AOM. These factors should be discussed with parents.

Health Promotion

Risks for Otitis Media That Need to Be Discussed with Parents

• Parental smoking

• Excessive pacifier use

• Daycare outside the home

Community Considerations

Parents may wish to use alternative therapies in the care of their child. Many of the herbal remedies available have not been evaluated for use in the pediatric population. These remedies are not regulated by the U.S. Food and Drug Administration (FDA) and thus may not be as labeled. Homeopathy remedies are regulated. The AAP has not made any recommendation because of insufficient evidence of effectiveness.

Nursing Brief

Children should be fed in an upright position and should not be put to bed with a bottle.

For children with recurrent AOM or chronic OME, tympanostomy tubes may be effective. The physician performs the procedure by completing a myringotomy (myringo, eardrum; otomy, incision) and inserts a tiny tube into the eardrum. These tubes require surgical placement and special care by the parents. Eventually, the tubes fall out spontaneously.

Bronchiolitis

Bronchiolitis is an inflammation of the small airways. It occurs most often during late autumn through late spring and in children younger than 2 years of age. Bronchiolitis is usually caused by a viral infection. The most common causative organism is the respiratory syncytial virus (RSV). Children are usually exposed through other family members who have symptoms of an upper respiratory tract infection. Children who are at risk for respiratory distress have chronic lung diseases such as bronchopulmonary dysplasia (BPD) or cystic fibrosis (CF).

Inflammation of the bronchioles is associated with obstruction that is caused by edema and accumulation of mucus. There may be partial or complete obstruction. The alveoli are usually not affected. Normal gas exchange in the lung is affected. This leads to hypoxemia.

Signs and Symptoms

The infant first shows signs of a mild upper respiratory infection with rhinorrhea, sneezing, cough, and a low-grade fever. The infant’s appetite may be affected. Respiratory distress increases, and rapid breathing and wheezing develop. Bottle feeding may be difficult because of the rapid respiratory rate interfering with sucking and swallowing. As the disease progresses, nasal flaring, retractions, tachypnea (60 to 70 per minute), and cyanosis may occur. Breath sounds may be diminished if the bronchioles are severely obstructed.

Treatment

Mild cases of bronchiolitis can be managed at home. Treatment at home includes increasing the intake of fluids and increasing the humidity in the air. Also useful are antipyretics to control fever. The parents or caregiver should be instructed to bring the child back for reevaluation if any signs of increased respiratory distress occur or if the child’s condition worsens.

Indications for hospitalization include an infant younger than 6 months of age, sleeping respiratory rates of 50 to 60 per minute or higher, hypoxemia, apnea, or the inability to tolerate oral feeding.

When the child is hospitalized, intravenous fluids are started to hydrate the child and thin the secretions. The child is placed in an atmosphere of humidified oxygen (mist tent, croupette, or nasal cannula/mask). The goal is to keep oxygen levels at 92% or better with a pulse oximeter. With severe bronchiolitis, the physician may use a bronchodilator and a corticosteroid, but these remain controversial (Zorc, 2010). Antimicrobials may also be used for small or severely ill infants because these infants may be susceptible to a secondary bacterial infection. Fever is controlled with antipyretics. A laboratory study of a nasopharyngeal washing should be done to determine whether the causative organism is RSV. As a precautionary measure for the safety and concern of other children, the infant is placed in contact isolation until RSV has been ruled out.

When the causative organism is RSV, no medications can effectively treat the disease. Ribavirin, antimicrobials, antihistamines, and oral decongestants have been identified as being ineffective for treatment (Zorc, 2010). Medical attention has recently focused on active and passive immunizations. RSV-immune globulin (RespiGam) and palivizumab (Synagis) have been approved for use with children at high risk. Palivizumab may be preferred because of ease of administration (intramuscular); lack of interference with mumps, measles, and rubella (MMR) vaccine and varicella vaccine; and lack of complications associated with intravenous immune globulin (RespiGam). Monthly administration during RSV season (October to May) is recommended (AAP, 2009).