Alterations in Respiratory Function
● Acute respiratory tract infection - most common cause of illness in infancy/childhood
● incidence/severity influenced by:
○ Infectious agents involved
○ The child’s age, any underlying medical conditions, and the child’s natural
defenses.
● Asthma is the leading cause of chronic illness in children.
○ Leading cause of absences, missed work in parents
● The sequence of CPR in infants, children and adults is C-A-B (compressions, airway and
breathing).
○ Bacterial agents = more severe than viral
○ The younger the child the more severe the infection
● Anatomy and physiology
○ Respiratory tract composed of:
■ Upper
● Nose Sinuses Pharynx, Larynx, Epiglottis
■ Larynx- divides upper and lower airways
■ Lower
● Trachea, bronchi, bronchioles, alveoli, and lungs
● Airway differences in children
○ Shorter & narrower trachea-
■ airway diameter 4mm vs 20 mm (width of a straw) – the child’s little
finger is a good estimate for the child’s tracheal diameter; often used to
determine airway size.
○ When edema, mucus, or bronchospasm is present, air passage is greatly
diminished.
○ Newborns are obligatory nose breathers – only breathe through the mouth when
they are crying.
■ When get congested, issues with respiratory distress
○ Adults have better ability to deal with swelling
■ Newborn = pinky is size of airway (trachea)
● In children, the trachea is shorter and the angle of the right bronchus at bifurcation is
more acute than in the adult (much higher up) -T3 instead of T6
○ Mainstem - steeper slope
○ Easier for kids to aspirate and have things wind up in right lung
● Lower airway differences
○ Position of right main-stem bronchus – higher risk for aspiration
○ Growth of alveoli:
■ Gas exchange not possible before 24 weeks gestation
, ■ 36 weeks – lung sacs differentiate into alveoli
■ Alveoli increase in size/complexity/number as children grow (5-8 years)
■ Less alveolar surface area – reduced area for gas exchange
○ Smooth muscle in bronchi / bronchioles are underdeveloped, impacts ability to
expel mucus or irritants
○ Children under 6 years of age are abdominal breathers
■ Intercostal muscles are weak and immature
■ Flexible chest reduces air intake
■ Child relies on the use of diaphragm for inspiration
○ Respiratory depressed - increast chest pressure
■ Going to see retractions
○
○ Children increased RR to compensate
■ When they no longer can do this they decrease; more dangerous
○ Nasal flaring and grunting
○ Change in conciousness: most sensitive indicator
● Retraction sites in respiratory distress
○
, ○ Mild distress: intercostal retractions seen
○ Moderate distress: substernal and subcostal retractions seen
○ Severe distress: supraclavicular and suprasternal retractions seen
● Respiratory distress
○ Can lead to respiratory failure and cardiac arrest - early intervention vital
○ mild/initial respiratory failure
■ Restlessness, tachypnea, tachycardia, diaphoresis (if old enough to be
sweating)
○ moderate/early decompensation:
■ Nasal flaring, retractions, grunting, wheezing
■ Anxiety and irritability, confusion
○ Severe/Imminent respiratory arrest
■ Bradycardia, Cyanosis = late signs, dyspnea, stupor, coma
■ Issue: kids will arrest from respiratory problem but have cardiac flatline
that goes with it - very hard to bring kid back from cardiac arrest if havn’t
figured out respiratory component to arrest
● Pediatric Early Warning Scale (PEWS)
○ Assess patients objectively using vital signs
○ Takes behavior and CV/respiratory symptoms into account
○ May indicate need for Rapid Response or code
○
○ 0-2: child is stable (green)
○ 3 – reassess; report findings, document and reassess frequently (yellow)
○ 4 – notify hospitalist and charge nurse (orange)
○ 5 – same as 4 but call respiratory as well Consider a rapid response (red)
○ 6 – consider higher level of care; call for rapid response, 7 – transfer to higher
level of care (red) - PICU
● Factors affecting infections in children
, ○ Age of child (<7, not all of immunoglobulins, immunizations)
○ Viral infections (infant, toddler) - most common
○ Bacterial (school age) - most common
○ Size of the child - smaller = worse
○ Seasons - fall and winter (coincides with kids going back to school)
○ Living conditions
○ Pre-existing medical conditions
● S/S of infection
○ Irritable, restless
○ Anorexia
○ Malaise, muscular aches, chills
○ Discharge
○ HA
○ Mouth breathing
○ Cervical lymphadenitis
○ Temp - febrile seizures
● Apnea in infants
○ Apnea - cessation of respirations for > than 20 seconds
■ May be the 1st sign of respiratory dysfunction
■ Premature infants have immature respiratory control
● Normal to have apnea greater than 20 seconds
○ Stimulate them (rub/tap on feet)
○ Treatment: Stimulation, caffeine po until 37 weeks
● Brief Resolved Unexplained Event (BRUE) “Apparent life-threatening events (ALTE)”
○ Is an episode of apnea – most common in children < than 6 months
○ Color changes (cyanotic and pale) may occur, and the child may be limp
○ Causes: GI reflux, seizures, & lower respiratory infections, cardiac arrhythmias,
trauma
■ 50% of cases – medical issue, must treat the underlying condition
○ Go home with apnea monitor - will go off after 20 seconds
■ If true BRUE - pale, cyanosis, blue, limp
● Stimulate them
○ Subjective data:
■ Doing before? Observations during? How long? What helped? 1st or prior
episode? Family hx? Meds? Feeding patterns?
● Obstructive Sleep Apnea Syndrome (OSAS)
○ Recurrent episodes of partial and complete obstruction of the upper airway
○ Disrupts sleep and interferes with adequate respirations
● Acute respiratory tract infection - most common cause of illness in infancy/childhood
● incidence/severity influenced by:
○ Infectious agents involved
○ The child’s age, any underlying medical conditions, and the child’s natural
defenses.
● Asthma is the leading cause of chronic illness in children.
○ Leading cause of absences, missed work in parents
● The sequence of CPR in infants, children and adults is C-A-B (compressions, airway and
breathing).
○ Bacterial agents = more severe than viral
○ The younger the child the more severe the infection
● Anatomy and physiology
○ Respiratory tract composed of:
■ Upper
● Nose Sinuses Pharynx, Larynx, Epiglottis
■ Larynx- divides upper and lower airways
■ Lower
● Trachea, bronchi, bronchioles, alveoli, and lungs
● Airway differences in children
○ Shorter & narrower trachea-
■ airway diameter 4mm vs 20 mm (width of a straw) – the child’s little
finger is a good estimate for the child’s tracheal diameter; often used to
determine airway size.
○ When edema, mucus, or bronchospasm is present, air passage is greatly
diminished.
○ Newborns are obligatory nose breathers – only breathe through the mouth when
they are crying.
■ When get congested, issues with respiratory distress
○ Adults have better ability to deal with swelling
■ Newborn = pinky is size of airway (trachea)
● In children, the trachea is shorter and the angle of the right bronchus at bifurcation is
more acute than in the adult (much higher up) -T3 instead of T6
○ Mainstem - steeper slope
○ Easier for kids to aspirate and have things wind up in right lung
● Lower airway differences
○ Position of right main-stem bronchus – higher risk for aspiration
○ Growth of alveoli:
■ Gas exchange not possible before 24 weeks gestation
, ■ 36 weeks – lung sacs differentiate into alveoli
■ Alveoli increase in size/complexity/number as children grow (5-8 years)
■ Less alveolar surface area – reduced area for gas exchange
○ Smooth muscle in bronchi / bronchioles are underdeveloped, impacts ability to
expel mucus or irritants
○ Children under 6 years of age are abdominal breathers
■ Intercostal muscles are weak and immature
■ Flexible chest reduces air intake
■ Child relies on the use of diaphragm for inspiration
○ Respiratory depressed - increast chest pressure
■ Going to see retractions
○
○ Children increased RR to compensate
■ When they no longer can do this they decrease; more dangerous
○ Nasal flaring and grunting
○ Change in conciousness: most sensitive indicator
● Retraction sites in respiratory distress
○
, ○ Mild distress: intercostal retractions seen
○ Moderate distress: substernal and subcostal retractions seen
○ Severe distress: supraclavicular and suprasternal retractions seen
● Respiratory distress
○ Can lead to respiratory failure and cardiac arrest - early intervention vital
○ mild/initial respiratory failure
■ Restlessness, tachypnea, tachycardia, diaphoresis (if old enough to be
sweating)
○ moderate/early decompensation:
■ Nasal flaring, retractions, grunting, wheezing
■ Anxiety and irritability, confusion
○ Severe/Imminent respiratory arrest
■ Bradycardia, Cyanosis = late signs, dyspnea, stupor, coma
■ Issue: kids will arrest from respiratory problem but have cardiac flatline
that goes with it - very hard to bring kid back from cardiac arrest if havn’t
figured out respiratory component to arrest
● Pediatric Early Warning Scale (PEWS)
○ Assess patients objectively using vital signs
○ Takes behavior and CV/respiratory symptoms into account
○ May indicate need for Rapid Response or code
○
○ 0-2: child is stable (green)
○ 3 – reassess; report findings, document and reassess frequently (yellow)
○ 4 – notify hospitalist and charge nurse (orange)
○ 5 – same as 4 but call respiratory as well Consider a rapid response (red)
○ 6 – consider higher level of care; call for rapid response, 7 – transfer to higher
level of care (red) - PICU
● Factors affecting infections in children
, ○ Age of child (<7, not all of immunoglobulins, immunizations)
○ Viral infections (infant, toddler) - most common
○ Bacterial (school age) - most common
○ Size of the child - smaller = worse
○ Seasons - fall and winter (coincides with kids going back to school)
○ Living conditions
○ Pre-existing medical conditions
● S/S of infection
○ Irritable, restless
○ Anorexia
○ Malaise, muscular aches, chills
○ Discharge
○ HA
○ Mouth breathing
○ Cervical lymphadenitis
○ Temp - febrile seizures
● Apnea in infants
○ Apnea - cessation of respirations for > than 20 seconds
■ May be the 1st sign of respiratory dysfunction
■ Premature infants have immature respiratory control
● Normal to have apnea greater than 20 seconds
○ Stimulate them (rub/tap on feet)
○ Treatment: Stimulation, caffeine po until 37 weeks
● Brief Resolved Unexplained Event (BRUE) “Apparent life-threatening events (ALTE)”
○ Is an episode of apnea – most common in children < than 6 months
○ Color changes (cyanotic and pale) may occur, and the child may be limp
○ Causes: GI reflux, seizures, & lower respiratory infections, cardiac arrhythmias,
trauma
■ 50% of cases – medical issue, must treat the underlying condition
○ Go home with apnea monitor - will go off after 20 seconds
■ If true BRUE - pale, cyanosis, blue, limp
● Stimulate them
○ Subjective data:
■ Doing before? Observations during? How long? What helped? 1st or prior
episode? Family hx? Meds? Feeding patterns?
● Obstructive Sleep Apnea Syndrome (OSAS)
○ Recurrent episodes of partial and complete obstruction of the upper airway
○ Disrupts sleep and interferes with adequate respirations
