Respiratory system/ Khulood Shattnawi Alteration in Respiratory Function in Children The respiratory system is made up of the organs involved in the interchanges of gases, and consists of the nose, pharynx, larynx, trachea, bronchi, and lungs. The upper respiratory tract includes the following: nose, nasal cavity, ethmoidal air cells, maxillary sinus, larynx, and trachea. While the lower respiratory tract includes the following: lungs, bronchi and alveoli. Functions of respiratory system: • Removal of CO2 and replacement of O2 needed for metabolism. • Maintenance of acid-base balance (pH level). • Maintenance of body H2O level and heat balance. • Production of speech. • Facilitate the sense of smell. Respiratory differences in children: • Tonsiller tissue is normally enlarged in early school-age. • Respiratory mucus ( cleaning agent) : • In newborn: is little makes them more susceptible to respiratory infections. • Increase production of mucus up to 2 years of age lead to obstructions. • After 2 years of age the right bronchus become shorter, wider, and more vertical than the left bronchus, thus inhaled foreign bodies more often lodge in the right bronchus. • Infants use their abdominal muscle for breathing, the change to thoracic begin around the age of 2-3 years and completed at age of 7 years. • Because accessory muscles are used more in children than in adult, weakness of these muscles from diseases may lead to respiratory failure. • In infants, the walls of the airways are small in size and have less cartilage than older children and adults that’s why they are more likely to collapse after expiration. • Infants are obligatory nasal breathers. Assessment of Respiratory function Information of the child’s respiratory status is obtained from observations of physical signs and behavior. Respiration, the configuration of the chest, the pattern of respiratory movement, including rate, regularity, symmetry of movement, depth, effort expended in respiration, and use of accessory muscles of respiration, should be assessed. Respiration is best determined when the child is sleeping or quietly awake. Palpation and percussion provide information regarding areas of pain and tissue density. Auscultation of the lung fields is helpful in identifying specific pathologies and in assessing the child’s responses to treatment. Auscultation is essential when determining airway patency. Noisy breathing Noisy breathing has been described as abnormal breath sounds that are audible without the use of a stethoscope. These sounds result from blockage of the airway anywhere along the pathway from the nose to the bronchioles. Blockage at these points could be the result of foreign object inhalation, inflammation, airway constriction or external compression of the airways. In general, respiratory obstruction tends to occur more often in younger patients because the larynx is smaller in younger infants. Noisy breathing in a child/infant can cause great distress for the caregiver. It is a complaint that should be investigated immediately and thoroughly. Noisy breathing can be classified into three main types: snoring, stridor and wheezing.
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Respiratory system/ Khulood Shattnawi �
Alteration in Respiratory Function in Children
The respiratory system is made up of the organs involved in the interchanges of gases, and
consists of the nose, pharynx, larynx, trachea, bronchi, and lungs.
The upper respiratory tract includes the following: nose, nasal cavity, ethmoidal air cells, maxillary
sinus, larynx, and trachea. While the lower respiratory tract includes the following: lungs, bronchi
and alveoli.
Functions of respiratory system:
• Removal of CO2 and replacement of O2 needed for metabolism.
• Maintenance of acid-base balance (pH level).
• Maintenance of body H2O level and heat balance.
• Production of speech.
• Facilitate the sense of smell.
Respiratory differences in children:
• Tonsiller tissue is normally enlarged in early school-age.
• Respiratory mucus ( cleaning agent) :
• In newborn: is little makes them more susceptible to respiratory infections.
• Increase production of mucus up to 2 years of age lead to obstructions.
• After 2 years of age the right bronchus become shorter, wider, and more vertical than the
left bronchus, thus inhaled foreign bodies more often lodge in the right bronchus.
• Infants use their abdominal muscle for breathing, the change to thoracic begin around the
age of 2-3 years and completed at age of 7 years.
• Because accessory muscles are used more in children than in adult, weakness of these
muscles from diseases may lead to respiratory failure.
• In infants, the walls of the airways are small in size and have less cartilage than older
children and adults that’s why they are more likely to collapse after expiration.
• Infants are obligatory nasal breathers.
Assessment of Respiratory function
Information of the child’s respiratory status is obtained from observations of physical
signs and behavior. Respiration, the configuration of the chest, the pattern of respiratory movement,
including rate, regularity, symmetry of movement, depth, effort expended in respiration, and use of
accessory muscles of respiration, should be assessed. Respiration is best determined when the child is
sleeping or quietly awake.
Palpation and percussion provide information regarding areas of pain and tissue density.
Auscultation of the lung fields is helpful in identifying specific pathologies and in assessing the
child’s responses to treatment. Auscultation is essential when determining airway patency.
Noisy breathing
Noisy breathing has been described as abnormal breath sounds that are audible without the use of a
stethoscope. These sounds result from blockage of the airway anywhere along the pathway from the
nose to the bronchioles. Blockage at these points could be the result of foreign object inhalation,
inflammation, airway constriction or external compression of the airways. In general, respiratory
obstruction tends to occur more often in younger patients because the larynx is smaller in younger
infants.
Noisy breathing in a child/infant can cause great distress for the caregiver. It is a complaint that
should be investigated immediately and thoroughly.
Noisy breathing can be classified into three main types: snoring, stridor and wheezing.
Respiratory system/ Khulood Shattnawi �1. Snoring
Snoring is an abnormal breath sound that occurs while the child sleeps. Snoring is usually the
result of a partial obstruction of the upper respiratory tract that in turn causes vibration of air
as it passes through the nasopharynx and oropharynx. This obstruction may cause a child to
momentarily stop breathing during his/her sleep (sleep apnea). This sleep disturbance may
occur several times during the night and although the child may not be able to recall their
waking, sleep apnea can lead to fatigue and irritability throughout the day.
2. Stridor Stridor is a harsh, continuous, crowing sound that is caused by variable airway obstruction
that is an obstruction which blocks flow in one direction but not the other. Most commonly,
stridor occurs on inspiration and is caused by an extrathoracic variable airway obstruction.
Expiratory stridor can also be heard however this sound results from an intrathoracic variable
airway obstruction. It should be noted that an expiratory stridor may often resemble a wheeze.
A Biphasic stridor implies midtracheal involvement. If stridor occurs with hoarseness then an
obstruction of the larynx is indicated.
An acute onset of nocturnal stridor combined with a barky cough and hoarse voice should
point you towards croup. On the other hand, a chronic stridor from early infancy indicates an
underlying congenital abnormality.
3. Wheeze A wheeze is a continuous sound that is mainly heard on expiration. It indicates an
intrathoracic airway obstruction, resulting from dynamic compression of the bronchi.
Wheezing can be accompanied by feelings of tightness in the chest and labored breathing. It
is important to distinguish wheezing (a sound heard on expiration) from stridor (a sound
heard primarily on inspiration). Although anything that causes compression of the airways
can potentially cause wheezing, however in most cases wheezing is caused by asthma.
Specific questions should therefore be asked about environmental factors (grass, pollen,
trees), factors within the home (inhalants, moldy basements, dusty areas, sprays, perfumes,
parents occupation), school-related factors (dust, chalk) and pets. You should also ask about
family history, and whether the child or family members smoke.
**Remember, a child can start smoking at an early age, and will not feel comfortable telling
you this while parents are present.**
Children who are having difficult time breathing often show signs that they are not getting
enough oxygen, indicating respiratory distress. It is important to learn the signs of respiratory
distress to know how to respond appropriately.
Signs of respiratory distress:
•••• Breathing rate: An increase in the number of breaths per minute, usually > 60 breath/minute
in infants.
•••• Retractions: The chest appears to sink with each breath - one way of trying to bring more air
into the lungs. In severe airway obstruction, retraction becomes extreme. Subcostal retraction,
observed anteriorly at the lower costal margins, indicates a flattened diaphragm, since it not
only lowers the floor of the thorax, but also pulls on the rib cage in response to a greater than
normal decrease in intrathoracic pressure. In severe obstruction, retractions extend to the
supraclavicular areas and the suprasternal notch.
• Color changes: cyanosis seen around the mouth, on the inside of the lips, or on the
fingernails may occur when a person is not getting as much oxygen as needed. Cyanosis
become apparent when PaO2 is lower than 40 mmHg, or with increased of unoxygenated
level of hemoglobin (Hgb). The color of the skin may also appear pale or gray.
• Grunting: A grunting sound can be heard each time that the child exhales. This grunting is
the body's way of trying to keep air in the lungs so they will stay open. Grunting is frequently
Respiratory system/ Khulood Shattnawi �a sign of chest pain, suggesting acute pneumonia or pleural
involvement. It is also observed in pulmonary edema and is
a characteristic of respiratory distress syndrome.
• Nasal flaring: It is a sign of respiratory distress and a very
significant finding in an infant.
The openings of the nose spreading open while breathing
may indicate that a child is having to work harder to
breathe. The enlargement of the nostrils helps reduce nasal
resistance and maintain airway patency.
• Wheezing: A tight, whistling or musical sound heard with
each breath may indicate that the air passages may be
smaller, making it more difficult to breathe. Other abnormal
lung sounds that could be heard are rales (or crackles: short,
popping; sudden inflation of alveoli), ronchi (or gurgles:
continuous rattle; fluid in large airways) and pleural friction
rub (grating, leathery; inflamed pleura).
Associated observations:
• Cough, sound of coughing is caused by rapid expiration
past the glottis. Cough serves as a protective mechanism,
initiated by stimulation of the nerves of the respiratory tract
mucosa by the presence of dust, chemicals, mucus, or
inflammation. It is a useful procedure to
clear excess mucus or foreign bodies, but
becomes harmful and needs suppression
when there is no mucus or debris to be
expelled. Paroxysmal coughing is a series of
expiratory coughs after a deep inspiration (as
in case of pertussis), continuous coughing
increases the chest pressure, which cause the
venous return to heart to be decreased
(decreased cardiac output), that may lead to
fainting.
A cough is most often a symptom of lower respiratory disease, but can arise from a variety of
central nervous, pulmonary, and nonpulmonary origins (e.g., congenital heart disease). Asthma and
respiratory infections, usually viral, are the cause in most cases, but cystic fibrosis and psychological
problems are significant causes in older children. Ask the patient or parent for as much information
about the cough as possible, emphasizing the following points:
1. Quality of cough. It is extremely important to characterize the sound of the cough, since
certain diseases produce very distinctive coughs. Although it can be very helpful to obtain and
examine a sample of any sputum that is produced, infants and younger children usually
swallow sputum since they have generally not yet learned to spit. Determination of whether
the cough is productive or not can therefore be based on whether the cough sounds ‘dry’
(nonproductive) or ‘loose’ (productive).
2. Timing and duration of cough. A variety of timing patterns can provide clues as to the
origin of the cough. Ask about the cough’s occurrence with feeding, at night, in early
morning, and seasonal variations. Also determine whether the cough is of an acute or chronic
nature, the latter usually having lasted more than 3 to 4 weeks. Among those coughs that are
chronic, distinguishing between recurrent and persistent coughs may help to narrow the
differential diagnosis by pointing to relevant triggers or the possibility of recurrent infections.
Respiratory system/ Khulood Shattnawi �3. Aggravating factors. Certain stimuli can often be pin-pointed as cough-inducing factors.
Possibilities range from known infection, exercise, cigarette smoke, and weather changes (e.g.
cold air), to laughing, crying, or the presence of allergens. Environmental irritants associated
with molds on walls, air pollution, exhaust fumes, and wood-fire smoke should also be noted.
4. Associated clinical findings. Cough can present in association with several related signs and
symptoms. Be sure to obtain information regarding fever, hemoptysis, stridor, wheezing and
chest pain.
5. History. Evidence of a patient or family history of conditions such as asthma, eczema,
urticaria, or allergic rhinitis suggests a potential allergic
etiology.
• Clubbing: proliferation of tissue about the terminal phalanges,
accompanies a variety of conditions, frequently those associated with
chronic hypoxia, primarily cardiac defects and chronic pulmonary
disease. The change of the angle of the nail to the fingertip is occur
because of the increase of capillary growth in the fingertips, which
occur as the body attempts to supply more oxygen to the distal body
cells.
• Restlessness and apprehension: when children or infants have difficulty securing adequate
oxygen (hypoxia), they become anxious and restless. Restlessness and tachypnea in infants
are the first signs of airway obstruction.
• Increasing use of accessory muscles of respiration.
Diagnostic Procedures
Several procedures are available for assessing respiratory function and diagnosing respiratory
disease. All of these procedures require preparation and support of the child and the family to ensure
cooperation and accurate results. These procedures not only are useful in diagnosis, but also provide
information that guide nursing interventions, such as positioning, use of supplemental oxygen, and
assistance with coughing or deep breathing.
• Pulmonary function tests: noninvasive pulmonary mechanics are often measured at the
bedside of infants and children with the use of spirometry, a device that records the air exchange.
These tests are useful to evaluate the severity and course of a disease and to study the effects of
treatment. Pulmonary function tests used in children are:
• Forced vital capacity (FVC): maximum amount of air that can be expired
after maximum inspiration.
• Forced expiratory volume in 1 (FEV1) or 3 (FEV3) seconds: amount of air
that can be forced from lungs after maximum inspiration in 1 and 3 seconds.
• Tidal volume (TV): amount of air inhaled and exhaled during any respiratory
volume of air remaining in lungs after passive expiration.
• Radiologic examination:
• Radiography: x-rays produces images of internal structures of chest, including
air-filled lungs, airways, vascular marking, hearts, and great vessels.
• Bronchography: contrast medium is instilled directly into bronchial tree
through opaque catheter inserted via orotracheal tube. Detects distal bronchial
obstructions and malformations. Carried out with child under general anesthesia or
sedation
• Computed tomography (CT): sequence of x-rays, each representing a cross
section through lung tissue at different depth. Useful in identifying presence of
calcium or a cavity within a lesion, adenopathy, masses, or abnormalities.
Respiratory system/ Khulood Shattnawi �
• Magnetic resonance imaging (MRI): use of large magnet and radio waves to produce two or
three-dimensional image. It clearly identifies soft tissues, and requires cooperation or
sedation of child.
• Angiography: injection of dye to produce image of pulmonary vasculature. It
investigates pulmonary vascular anomalies and pulmonary hypertension. Performed
with child under general anesthesia.
• Other diagnostic procedures:
• Tracheal aspiration: sputum obtained by direct aspiration from trachea for examination
and culture.
• Bronchoscopy: direct observation of tracheobronchial tree via bronchoscope.
• Lung puncture: needle aspiration of lung fluid via syringe and needle through intercostal
space for histologic study or culture.
• Lung biopsy: removal of lung tissue via open thoracotomy or closed-needle procedures.
Used for diagnosis of protracted pulmonary disease unexplained by other means.
• Blood gas determination: blood gas measurements are sensitive indicators of change in
respiratory status in acutely ill patients. They provide valuable information regarding lung
function, lung adequacy, and tissue perfusion and are essential for monitoring conditions
involving hypoxemia, CO2 retention, and PH.
• Pulse oximetry: provides a continuous or intermittent noninvasive method of
determining O2 saturation (SaO2).
• Arterial blood gas (ABG) sampling: may be performed on blood from an artery
or a capillary. The blood samples are obtained by taking a deep heel stick after
dilation of the vascular bed by warming, or through an indwelling catheter
(arterial line) or by arteriopuncture. Although ABG values are similar for children
and adults, neonates can have slightly lower values and still be considered
normal. The significance of ABG determination is related primarily to the
relationships among three parameters: pH, Po2, and Pco2. Any change in a blood
gas value must be compared with the other values and with previous readings, as
well as with the child’s clinical appearance and behavior, medical history, and
associated physiologic factors. Clinical indicators for blood gas analysis include
changes in color, depth or rate of respiration, behavior, and vital signs.
Common Therapeutic Techniques used in the Treatment of Respiratory Illness in Children
• Oxygen therapy: the indication of administration of O2 is hypoxemia. O2 is delivered by
mask, nasal cannula, tent, hood, face tent, or ventilator. The mode of delivery is selected on the
basis of the concentration needed and the child’s ability to cooperate in its use. The concentration
of O2 delivered should be regulated according to the individual child’s needs. There are hazards
related to its use; therefore O2 should be continued only as long as needed (oxygen is a drug and
should not be administered or adjusted without a doctor's order, and is only administered as prescribed by dose, typically in liters per minute). Humidification of the gas before
administration to the patient is essential.
• Aerosol therapy: using the airway as the route of administration can be useful in avoiding
the systemic side effects of certain drugs and in reducing the amount of drug necessary to achieve
the desired effect. Medications can be aerosolized or nebulized with air or with O2-enriched gas.
Hand-held nebulizers are frequently used. The medicated mist is discharged into a small plastic
mask, which the child holds over the nose and mouth. To avoid particle deposition in the nose
and pharynx, the child is instructed to take slow, deep breaths through an open mouth during
treatment. The metered dose inhaler (MDI) is a self-contained, hand-held device that allows for
intermittent delivery of a specified amount of medication. Many bronchodilators are available in
this form. A major nursing responsibility during aerosol therapy is to assess the effectiveness of
the treatment and the patient’s tolerance of the procedure. Assessment of breath sounds and work
of breathing should be performed before and after treatment.
Respiratory system/ Khulood Shattnawi �
• Postural (Bronchial) drainage: is indicated whenever normal ciliary activity and cough are
not removing excessive fluid or mucus in the bronchi. Positioning the child to take maximum
advantage of gravity facilitate removal of secretions. Postural drainage is most effective in
children with chronic lung disease characterized by thick mucus secretions, such as cystic
fibrosis. Postural drainage is carried out three to four times daily and is more effective when it
follows other respiratory therapy, such as bronchodilator and/or nebulization medication.
Bronchial drainage is generally performed before meals (or 1-1½ hours after meals) to minimize
the chance of vomiting and repeated at bedtime. The length and duration of treatment depend on
the child’s condition and tolerance level-usually 20-30 minutes. There are positions to facilitate
drainage from all major lung segments, but all positions are not used at each session. Children
will usually cooperate for four to six positions, but more than six tend to exceed their limits of
tolerance.
• Chest Physiotherapy (CPT): CPT usually refers to the use of postural drainage in
combination with adjunctive techniques that are thought to enhance the clearance of mucus from
the airway.
• Percussion: The most common technique used in association with postural
drainage is manual percussion of the chest wall. The patient is dressed in a light
shirt and placed in a postural drainage position. The nurse then gently but firmly
strikes the chest wall with a cupped hand. A “popping” hollow sound (not a
slapping sound) should be the result. Percussion should be done over the rib cage
only and should be painless. Percussion can be performed with a soft, circular
mask.
• Vibration: can be used to help move secretions during exhalations. Hand-held
vibrators should be approved for use in an O2-enriched environment (tent, head
hood). CPT is contraindicated when patients have pulmonary hemorrhage,
pulmonary embolism, end-stage renal disease, or increased intracranial pressure.
• Deep breathing: is often encouraged when the child is relaxed and in the
desired position for drainage. The child is directed to take several deep breaths
using diaphragmatic breathing. The use of deep breathing enlarges the
tracheobronchial tree, enabling air to circulate around and through secretions that
are not affected by usual tidal volume. Expirations after these deep breaths often
carry secretions and may stimulate a cough. Other methods that can be employed
to stimulate deep breathing are the use of blow method that extends the expiratory
time and increases expiratory pressure. For example, play may include blowing
pinwheel toys, moving small items by blowing through a straw, blowing up
balloons, singing loudly, or blowing soap bubbles.
• Coughing exercise: with or without stimulation, children are also encouraged
to cough one or two hard coughs after a deep breath are efficient.
• Tracheostomy: consist of surgical opening in the trachea between the second and fourth
tracheal rings. It may be required in an emergency situation for epiglottitis, croup, or foreign
body aspiration. These tracheostomies remain in place for a short time. An infant or child
requiring long-term ventilatory support may also have a tracheostomy. Children who have
undergone a tracheostomy must be closely monitored for complications such as hemorrhage,
edema, aspiration, accidental decannulation, tube obstruction, and the entrance of free air into the
pleural cavity. The focus of nursing care is maintaining a patent airway, facilitating the removal
of pulmonary secretions, providing humidified air or O2, cleansing the stoma, monitoring the
child’s ability to swallow, and teaching while simultaneously preventing complications.