Respiratory problems
Just the factsIn this chapter, you’ll learn:
respiratory anatomy and physiology
tests used to diagnose respiratory disorders in children
treatments and procedures used for children with respiratory problems
respiratory disorders that affect children and nursing interventions for each.
Anatomy and physiology
The structures of the respiratory system are responsible for oxygen distribution and gas exchange. A child’s respiratory tract is constantly growing and changing for the first 12 years of life. It differs anatomically from an adult’s respiratory system in ways that predispose the child to respiratory difficulties, making respiratory problems common during childhood. (See Structures of the respiratory system, page 324.)
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Chest and lungs
The lungs are the main component of the respiratory system. They inspire air, extract oxygen, and exhale the waste product carbon dioxide.
Totally lobular
The right lung has three lobes; the left has two. The mediastinum is the space between the two lungs. The lungs are surrounded by a framework of ribs, vertebrae (posteriorly), and the sternum (anteriorly), creating the chest.
Structures of the respiratory system
This illustration shows the structures of the respiratory system.
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Roll out the barrel
At birth, the chest is relatively round-shaped. It will gradually develop into a flattened shape across the front and back as the child grows. However, certain respiratory diseases can alter the shape of the chest. For example, obstructive diseases like asthma and cystic fibrosis can produce a barrel-shaped chest when they become severe.
Upper respiratory tract
The upper respiratory tract consists of the:
nose and nasal passages
mouth and oropharynx
pharynx
larynx.
Nose and nasal passages
The nose and nasal passages serve as a conduit for air to and from the lungs. They’re lined with ciliated mucous membranes that filter, warm, and moisten the air.
Nasal for 4 weeks
Infants and young children have smaller nares and narrow nasal passages, making them prone to airway occlusion. Because neonates prefer to breathe through their noses, nasal patency is essential for such lifesustaining activities as breathing and feeding. The neurologic pathways that will coordinate mouth breathing won’t develop until age 4 weeks.
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Mouth and oropharynx
After about age 4 weeks, air may also enter the respiratory system via the mouth and oropharynx. The child’s small oral cavity and large tongue leave the child prone to airway occlusion.
Pharynx
The pharynx, or throat, serves as a conduit for the respiratory and digestive tracts. It’s composed of smooth muscle and mucous membranes. The tonsils and adenoids, located in the pharynx, grow rapidly in early childhood and can leave the child prone to occlusion if they become inflamed. The tonsils and adenoids may decrease in size after age 12. (See Locating the tonsils and adenoids, page 326.)
Larynx
The larynx, or the upper end of the trachea, consists of a rigid framework of cartilage. It contains the epiglottis, a flaplike structure that overhangs the entrance to the trachea, and the glottis, the opening to the trachea.
Locating the tonsils and adenoids
These illustrations show the locations of the tonsils and adenoids. Because of their locations, inflammation of these structures can cause airway occlusion.
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No solids or fluids beyond this point
The epiglottis and glottis prevent solids and fluids from entering the air passages during swallowing. The glottis contains the vocal cords, which produce vocal sounds when they vibrate. The child’s long, floppy epiglottis is vulnerable to swelling that may lead to obstruction.
Lower respiratory tract
The lower respiratory tract is composed of the:
trachea
bronchi
alveoli.
Trachea
The trachea acts as a passageway for air into the lungs. It’s made up of C-shaped rings of cartilage and is supported by smooth
muscle. In infants, the cartilage is soft, making the airway more easily collapsible when the neck is flexed. A child’s trachea is higher than an adult’s and gives rise to two major bronchi: the right and the left. The right bronchus is shorter, wider, and situated more vertically than the left. Because of this, aspirated foreign bodies are more likely to become lodged in the right bronchus. (See Estimating tracheal diameter.)
muscle. In infants, the cartilage is soft, making the airway more easily collapsible when the neck is flexed. A child’s trachea is higher than an adult’s and gives rise to two major bronchi: the right and the left. The right bronchus is shorter, wider, and situated more vertically than the left. Because of this, aspirated foreign bodies are more likely to become lodged in the right bronchus. (See Estimating tracheal diameter.)
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Bronchi
The bronchi, the larger air passages of the lungs, are composed of the same cartilaginous rings and smooth muscle as the trachea. The bronchi divide into progressively smaller passages called bronchioles.
As a child grows taller in stature, there’s increased branching of the bronchioles, leading to greater lung surface area. The cartilaginous rings disappear as the bronchioles get smaller, leaving the smallest divisions with a lining of a single layer of cells. The bronchioles terminate in alveoli.
Alveoli
Alveoli are the small, saclike structures in which the exchange of oxygen for carbon dioxide takes place. Each alveolus is surrounded by many capillaries.
Throughout the first 12 years of life, the alveoli change in size and shape and increase in number, resulting in an increased area available for gas exchange as the child grows. A neonate’s lung tissue contains about 25 million alveoli; this number increases to about 300 million by age 8.
No confusion—it’s diffusion
The alveoli promote gas exchange by diffusion (the passage of gas molecules through the respiratory membranes). By diffusion, oxygen from the alveoli passes to the blood, and carbon dioxide, a by-product of cellular metabolism, passes out of the blood into the alveoli, where it’s channeled away during exhalation.
Advice from the expertsEstimating tracheal diameter
One way to estimate the size of a child’s trachea is to remember the “rule of the finger.” The diameter of a child’s trachea is roughly equal to the diameter of his little (or pinky) finger. This rule may come in handy when selecting the appropriate size of endotracheal tube if intubation becomes necessary.
Airway resistance
Airway resistance (the effort or force required to move air into the lungs) is greater in children than in adults because children’s airways are narrower than those of adults. In infants, airway resistance is about 15 times that of an adult. When there’s edema or swelling in the airway due to an irritant or infectious
process, the airway is further narrowed, increasing the airway resistance even more.
process, the airway is further narrowed, increasing the airway resistance even more.
Child labor
Increased airway resistance makes the child work harder to breathe. This is indicated by:
increased respiratory rate
retractions
nasal flaring
use of accessory muscles.
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Pulmonary circulation
In pulmonary circulation, blood passes through the lungs to obtain oxygen to distribute to the cells and tissues of the body in a four-step process:
Oxygen-depleted blood enters the lungs from the pulmonary artery that arises from the heart’s right ventricle.
Blood then flows through the main pulmonary arteries into the smaller vessels of the main bronchi, through the arterioles and, eventually, into the capillary networks that surround the alveoli.
There, oxygen diffuses into the capillaries from the alveoli, and the oxygenated blood flows through progressively larger vessels, enters the main pulmonary vein, and flows into the left atrium.
From there, the oxygenated blood passes into the left ventricle and exits the heart through the aorta for distribution throughout the body.Inspiration and expiration
An infant’s ribs are primarily cartilage and are very flexible, making them inefficient in ventilating. Infants primarily engage in diaphragm breathing, also known as abdominal breathing. As the diaphragm moves downward during inspiration, a negative pressure is created, allowing the lungs to expand to draw air in.
Normal pediatric respiratory rates
This chart shows the normal respiratory rates from birth to age 18.
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Muscles to stabilize, muscles to breathe
The intercostal muscles of the chest are used for stabilization. However, after age 6, a child will begin to use the intercostal muscles for breathing. Then, contraction and relaxation of
these respiratory muscles moves air into and out of the lungs. Normally, expiration is passive. (See Normal pediatric respiratory rates.)
these respiratory muscles moves air into and out of the lungs. Normally, expiration is passive. (See Normal pediatric respiratory rates.)
Retractions reveal distress
When an infant or child is having difficulty breathing, retractions of the respiratory muscles will occur. The depth and location of the retractions will indicate the severity of the respiratory distress:
In mild distress, there are isolated intercostal retractions.
In moderate distress, there are subcostal, suprasternal, and supraclavicular retractions.
In severe distress, there are all of the retractions mentioned above along with accessory muscle use. (See Looking for retractions.)
Adventitious breath sounds
Adventitious breath sounds are sounds not normally heard on auscultation of the lungs. Due to the thinness of the chest wall, breath sounds seem louder and harsher in infants and young children, and adventitious breath sounds may transmit over larger areas.
Looking for retractions
This illustration shows you where to look for retractions. The types of retractions you see in a child can indicate the severity of his respiratory distress.
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Types of adventitious breath sounds
This chart describes the types of adventitious breath sounds you might hear in a pediatric patient.
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Ventriloquist lungs
Sounds may seem to originate in the lungs when they’re actually referred from the upper airway, such as when there’s mucus in the nose or throat. Auscultating in the axillae of infants and small children is a good way to hear adventitious breath sounds if they’re present. (See Types of adventitious breath sounds.)
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Blown away
When assessing breath sounds:
Encourage small children to breathe deeply by asking them to pretend they’re blowing out candles or have them blow away a tissue.
Listen with the bell of the stethoscope for low-pitched sounds.
Listen with the diaphragm for higher pitched sounds.
Diagnostic tests and monitoring techniques
Children with suspected or diagnosed respiratory problems may need to undergo invasive or noninvasive diagnostic tests as well as monitoring procedures.
Arterial blood gas
An arterial blood gas (ABG) analysis assesses gas exchange. It also assesses the ventilatory control system, determines the blood’s acid-base balance, and monitors respiratory therapy. The respiratory and metabolic systems work together to keep the body’s acid-base balance within normal limits. (See Understanding acid-base disorders.)
ABG analysis is done on a blood sample taken from a peripheral arterial puncture or an arterial catheter, such as an umbilical arterial catheter, arterial line, or central catheter. The normal pediatric values are similar to those for adults.
Understanding acid-base disorders
Acid-base disorders may have several causes and signs and symptoms, as outlined in the chart below along with arterial blood gas (ABG) analysis findings for each disorder.
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Nursing considerations
If the sample will be drawn from an arterial catheter, reassure the child that he won’t feel any pain. If the sample will be taken via arterial puncture, keep in mind that this is typically more painful than a venous puncture. Help minimize the trauma from a peripheral arterial puncture:
Be honest about the painful part of the procedure. (For example, say, “This is going to hurt for a few seconds. It’s OK to be scared, but you’re going to do a great job and it’s going to be over very quickly.”)
Blood borrowing
Explain that only a small amount of blood will be taken, and that the child’s body will quickly make new blood to replace it. (Young children think they have a finite amount of blood and may have many misconceptions about what happens to them when some of that blood is removed.)
Allow the parent to comfort the child during the blood drawing. A parent’s presence reassures the child that nothing terrible will happen to him.
Count and squeeze
Give the child coping mechanisms. (For example, say, “Count to 5 and the hurting part will be over,” or, “Squeeze your mother’s hand if it hurts.”)
Praise the child for doing a good job regardless of how he reacts.
Comfort the child and apply a bandage as soon as the sample has been drawn; covering the site reassures the child that the hurting part is truly over.
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Obtaining the sample
If a peripheral arterial puncture is performed, check arterial circulation to the area (for example, with the Allen test) before the puncture is made. After the puncture, apply firm pressure to the arterial site to stop the bleeding; then frequently assess the site for bleeding or hematoma formation.
To obtain the sample, follow these steps:
Draw the blood sample into a heparinized syringe because unclotted blood is required.
Remove air bubbles from the sample to avoid altering the gas concentration.
Keep the blood sample on ice and transport it immediately to the laboratory.
Chest X-ray
A chest X-ray is used to visualize internal structures on film. On a chest X-ray, soft tissues, such as organs and muscles, appear as gray forms.
Dem bones, dem bones
Dense tissue such as bone appears white and clearly defined. The chest X-ray is used to rule out foreign body aspiration, determine infectious process, and gain information on cardiac size and contour, vessel and cardiac chamber size, and status of pulmonary blood flow.
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Inspiration, expiration, front and back
Inspiratory and forced expiratory films are best to rule out foreign body aspiration. Anterior-posterior and lateral films are best to view internal structures for diagnosis of disease processes in the chest.
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Nursing considerations
Explain the procedure to the child, assuring him that there are no “hurting parts” to the test. If possible, show the child an actual X-ray film to illustrate what the X-ray can and can’t show. (Young children may think an X-ray machine will be able to tell what he’s thinking and feeling.)
Protect the child from radiation exposure by covering his gonads and thyroid gland with lead shields during the test.
Make sure the child holds still during the test and tell him that doing so is his special job. (You may need to assist the child to do so.)
Pulmonary function tests
Pulmonary function tests (PFTs) are a series of measurements used to evaluate ventilatory function. They aid in the assessment of lung function in children with acute or chronic respiratory disorders. (See Understanding PFT results, page 334.)
Serial testing
Normal values can change dramatically with growth. For this reason, serial determination of pulmonary function is more informative than a single PFT, especially when evaluating a disorder for severity or progression, or when evaluating the effects of treatment.
Understanding PFT results
You may need to interpret pulmonary function test (PFT) results in your assessment of a patient’s respiratory status. Use this chart as a guide to common PFTs.
Restrictive and obstructive
The chart mentions restrictive and obstructive defects.
A restrictive defect is one in which a person can’t inhale a normal amount of air; it may occur with chest wall deformities, neuromuscular diseases, or acute respiratory tract infections.
An obstructive defect is one in which something obstructs the flow of air into or out of the lungs; it may occur with such disorders as asthma, chronic bronchitis, emphysema, and cystic fibrosis.
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Breathing on cue
PFTs require the child to cooperate and understand instructions. Most children aren’t able to perform the testing until about age 5, because it requires manipulating equipment, holding their breath, and exhaling on cue with directions.
Nursing considerations
Explain the test to the child and his parents, stressing that there’s no pain involved. Tell the child that his job will be to follow instructions related to handling equipment, holding his breath, and inhaling on cue. Have him practice doing these things before the actual test. In addition:
Note that results may not be accurate because the young child may have difficulty following the necessary directions.
Instruct the child and his parents that he should have only a light meal before the test.
Withhold bronchodilators and intermittent positive-pressure breathing therapy before the test.
Pulse oximetry
Pulse oximetry is a noninvasive monitoring technique used to estimate arterial oxygen saturation through a probe that measures saturation by the absorption of red and infrared light as it passes through tissue. It measures the amount of oxygen carried by hemoglobin by reading the amount of light that passes through a vascular bed and converting the amount of light absorbed by the oxygen-carrying hemoglobin, which gives a saturation value.
Sensing saturation
The sensor can be located on an extremity, a digit, a palm, or an earlobe or wrapped around the foot (in an infant) and works best when there’s adequate peripheral perfusion. A reading of 95% or greater is ideal for most children.
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Nursing considerations
Explain this type of monitoring to the child and his parents, and put the probe on a parent or nurse so the child can see that it’s painless. Reassure him that even though it’s used to measure oxygen in the blood, no needles are needed. In addition:
Place the probe on a site with good perfusion, such as the finger, foot, or toe.
Periodically rotate sites for probe placement to prevent skin breakdown under the probe.
To ensure that the value is accurate, make sure the pulse reading on the pulse oximeter matches the child’s heart rate.
Treatments and procedures
Respiratory treatments and procedures commonly used for the pediatric patient include aerosol therapy, assisted ventilation, chest physiotherapy (CPT), endotracheal (ET) intubation, oxygen administration, and tracheotomy.
Aerosol therapy
Metered-dose inhalers (MDIs) are used to administer medications such as bronchodilators and inhaled corticosteroids to children.
Spaced out
Children need to use a spacer with a valve if they can’t coordinate inspiration with medication release or if they’re younger than age 5. The spacer is a tube that captures the aerosol released, allowing the child to breathe it in over a couple of minutes.
Under-age aerosol
Nebulizer therapy is sometimes used for infants. A nebulizer aerosolizes the medication, releasing it into a small mask that’s placed over the child’s face. The child can then breathe in the medication through his mouth by taking deep, slow breaths.
Liquid to vapor
Vaporizers are used to create vapor from a liquid. They’re most commonly used to vaporize cool water to increase the humidity in a room for the benefit of children with swollen, reactive airways. They can relieve many symptoms of upper airway irritation and congestion in young children.
Nursing considerations
Before beginning treatment, show the child the MDI with spacer or nebulizer mask. Let the child place the MDI/spacer to his mouth or the mask to his face before the medication has been added.
To determine the effectiveness of aerosol therapy, assess the patient’s breath sounds before and after treatment.
Monitor the patient’s tolerance of the procedure. An infant or young child may fight the MDI with spacer mask or the mask over his face during nebulizer therapy. (Calming techniques such as swaddling may be necessary.)
After teaching the child and his parents how to use the device correctly (which is necessary for optimal effectiveness), observe
while they demonstrate their technique; provide support and correct technique as needed. (See Using an MDI.)
Assisted ventilation
Assisted ventilation can be administered to children via mechanical ventilation or nasal continuous positive airway pressure (CPAP).
Mechanical ventilation
Mechanical ventilation involves inflation of the lungs with compressed gas. It may be needed for children who are unable to maintain adequate gas exchange due to airway obstruction, neuromuscular disease, or other pulmonary pathology.
Compress and pressurize
The compressed gas is pushed into the lungs with pressure, and the exhalation is then passive. Oxygen may also be administered. Mechanical ventilation requires the child to be intubated or to have a tracheostomy, whereas positive-pressure ventilations may also be given by a bag and mask apparatus.
Inflate and expand
Inflation pressures are limited to what’s necessary to provide sufficient lung expansion for adequate ventilation and prevention of atelectasis, while keeping a careful watch for damage to airways and lung parenchyma.
Pressure-cycle ventilators, most commonly used in infants, deliver an indefinite volume of gas at a fixed inflation pressure.
Volume-cycled ventilators, most commonly used in children and adolescents, deliver a fixed volume of gas at whatever inflation pressure is necessary, up to a preset maximum.
With any ventilator, the nurse must assess the child carefully and frequently for breath sounds, chest wall excursion, and ABG measurements and pulse oximetry.
Continuous positive airway pressure
CPAP is used to infuse oxygen or air under a preset pressure through nasal prongs or a small mask. The pressure increases the alveolar volume by preventing the alveoli from collapsing on expiration, which leads to an increased functional residual capacity and improves the diffusion time of oxygen.
It’s all relativeUsing an MDI
To optimize treatment, make sure your patient (and his parents) know how to use a metered-dose inhaler (MDI) properly by providing them with the following instructions:
Shake the canister while taking a deep breath in and out.
Use a spacer with each use of the MDI.
Depress the button on the canister at the beginning of the next inhalation.
Breathe the mist in deeply and hold your breath for the count of 10, then exhale.
Repeat as needed to complete the dosage. (Dosages are usually set in numbers of puffs or inhalations.)Nasal fashion statement
Some CPAP systems come with small, triangular-shaped masks that fit only over the nose. These masks help prevent skin breakdown and irritation around and inside the nares that can occur with long-term use of nasal prongs and for preterm neonates whose nares are very small to begin with.
Nursing considerations
Before beginning assisted ventilation, explain the procedure to the parents and the child. If ventilation must be initiated in an emergent situation, tell the child (and his parents) what’s happening as it’s being done.
Place the patient on a cardiorespiratory monitor and pulse oximeter during any form of assisted ventilation.
Obtain blood gases to monitor gas exchange and oxygenation status as ordered. (Prepare the child if an arterial puncture must be performed.)
Suction secretions
For infants who have an ET tube or tracheostomy, suction the airway as needed to prevent occlusion with secretions.
Frequently assess breath sounds and watch for signs of ET tube or tracheostomy dislodgment. Make sure the ET or tracheostomy tube is appropriately secured to prevent dislodgment.
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Assess for distress
In patients who are mechanically ventilated, observe for signs of pneumothorax, such as respiratory distress, absent or decreased breath sounds on one side (the affected side), hypotension, and oxygen desaturation on pulse oximetry.
For patients receiving CPAP via nasal prongs, cut and place a cushioning dressing (such as Duoderm) over the edges of the nares and the tip of the nose to protect the skin.
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