Capistrano Batch 2025 - Child with Respiratory Disorder

• Respiratory tract structures


  Distribute air and exchange gases
• Respiratory tract structures


  • All respiratory system structure functions in air distribution, except for alveoli
  • Alveoli is responsible for gas exchange
• Infant airway diameter


  Approximately 4 mm, in contrast to an adult's airway diameter of 20 mm
• Inflammatory process in the airway

  Causes swelling that narrows the airway, and airway resistance increases

  
• Upper airways


  • Oronasopharynx
  • Pharynx
  • Larynx
  • Eustachian tube and sinuses
  • Upper part of the trachea
• Lower airways


  • Trachea
  • Bronchi
  • Bronchioles
  • Alveoli
• Nose


  • Newborn are obligatory nose breathers until at least 4 weeks of age
  • The upper respiratory mucus serves as cleansing agent yet newborn produce very little mucus → susceptible to infection
  • Newborn and infant have very small nasal passages when excess mucus is present → airway obstruction

  
• Sinuses


  • Infants are born with maxillary and ethmoid sinuses
  • Children 6-8 years old develop frontal and sphenoid sinuses
  • Frontal sinuses are associated with infection
  • Younger children are less apt to acquire sinus infection
• Throat


  • The tongue of the infant relative to the oropharynx is larger than adults → posterior displacement of the tongue can quickly lead to severe airway obstruction
  • Early school age = children tend to have enlarged tonsillar and adenoidal tissue even in the absence of illness → can contribute to an increased incidence of airway obstruction
• Trachea


  • The infant's trachea is 4 mm wide compared to adult = 20mm → Presence of edema, increased mucus, bronchospasm → air passages diminished → Leading to resistance in airflow → increased work of breathing
  • Infants and children less than 10 years old under developed cricoid cartilage resulting to narrowing of the larynx → Presence of mucus and edema will result to airflow resistance → increase work of breathing
  • In infants and children, the larynx and glottis are placed higher in the neck → Increasing the chance of aspiration of foreign material into the lower airways
  • The muscle supporting the airway of children are less functional than those in adult
  • Children have large amount of soft tissue surrounding the trachea and the mucous membranes lining the airway are less securely attached compared with adults → This increases the risk for airway edema and obstruction
  • Upper airway obstruction can result in tracheal collapse during inspiration
  • Bifurcation of trachea occurs at the level of 3rd thoracic vertebra in children (adult level of 6th thoracic vertebra) → contributes to risk of aspiration

  
• Bronchi and bronchioles


  • Bronchi and bronchioles of infants and children are narrower in diameter than adults → Placing them at increased risk for lower airway obstruction (bronchitis/asthma)

  
• Alveoli


  • Develop at approximately 24 weeks gestation
  • Term infant: born with 50 million alveoli
  • After birth: alveolar growth slows until 3 months of age
  • Progresses until 7-8 years old same number of alveoli with adult = 300 million
• Chest wall


  • Infants' chest wall is highly compliant [pliable] and fail to support the lungs adequately → Functional residual capacity of the lungs will be greatly reduced if respiratory effort is diminished
  • Because of lack of support the tidal volume of infants and toddlers are dependent to diaphragm → If diaphragm movement is impaired, the intercostal muscles cannot lift the chest wall and respiration is further compromised
• Metabolic rate and oxygen need


  • Children have higher metabolic rate than adults
  • Resting respiratory rate are faster
  • Demand for O2 is higher → During respiratory distress, infants and children will develop hypoxemia more rapidly than adults
• Fetal lung development


  1. Week 4: the laryngotracheal groove forms on the floor foregut

  2. Week 5: the left and right lung buds push into the pericardioperitoneal canals (primordial of pleural cavity)

  3. Week 6: the descent of heart and lungs into the thorax. Pleuroperitoneal foramen closes.

  4. Week 7: the lung buds divide into secondary and tertiary bronchi

  5. Week 24: the bronchi divide 14 more times and the respiratory bronchioles develop

  6. By birth, there will be an additional 7 divisions of bronchi

  
• Fetal lung histology


  1. STAGE 1: PSEUDOGLANDULAR PERIOD (5-17 weeks) all the major elements of the lungs have formed except for those involved with gas exchange

  2. STAGE 2: CANALICULAR PERIOD (16-25 weeks) bronchi and terminal bronchioles increase in lumen size and the lungs become vascularized

  3. STAGE 3: TERMINAL SAC PERIOD (24 weeks to birth) more terminal sacs develop and interface with capillaries lined with Type I alveolar cells or pneumocytes

  4. STAGE 4: ALVEIOLAR PERIOD (Late fetal period to 8 years) 95% of mature alveoli develop after birth. A newborn has only 1/6 to 1/8 of the adult number of alveoli and lungs appear denser on x-ray

  
• Defenses of the respiratory system


  • Filtering the particles
  • Warming and humidifying inspired air
  • Absorbing noxious gases in the vascular upper airway

  
• Defenses of respiratory tract


  • Lymphoid tissues
  • Mucous blanket
  • Ciliary action – carry foreign agents away from the lungs
  • Epiglottis
  • Cough
  • Tracheobronchial dynamics
  • Position changes
  • Lymphatics
  • Humoral defenses

  
• Assessment of respiratory dysfunction in pediatric


  • Health history
  • Physical examination
  • Laboratory and diagnostic test
• Health history


  • Past medical history (recurrent colds, prematurity)
  • Family history (asthma)
  • History of present illness (onset, progression, and s/sx)
  • Treatments used at home
• Physical examination


  • Inspection and observation
  • Auscultation
  • Percussion
  • Palpation
• Laboratory and diagnostic test


  • Blood gas analysis (Arterial blood gas)
  • Pulse oximetry
  • Transcutaneous oxygen monitoring

  
• Blood gas analysis


  Measures O2 and CO2 gases

  
• Pulse oximetry


  • Estimating arterial O2 saturation
  • Normal O2 sat: 95-100%

  
• Transcutaneous oxygen monitoring


  Monitor oxygenation and ventilation
• Associated observations


  • Retractions
  • Stridor
  • Grunting
  • Wheezing
  • Clubbing
  • Cough
• Retractions


  • Sinking in of soft tissues relative to the cartilaginous & bony thorax
  • Nasal flaring
• Stridor


  High pitched, noisy respiration
• Grunting


  • Occurs on expiration, might occur with alveolar collapse
  • Sign of pain in older children; suggest pneumonia
• Wheezing


  Continuous musical sound originating from vibrations in narrowed airways
• Clubbing


  Proliferation of tissue about terminal phalanges

  
• Cough


  Protective mechanism; indicator of irritation
• Auscultation


  • Assessing lung sounds
  • Note adventitious sound heard on auscultation
• Wheezing sound


  • Clears with coughing → result of secretions in the lower trachea
  • Wheezing that does not clear with coughing is a result of obstruction of bronchioles

  
• Rales


  Crackling sound – result when alveoli filled with fluid
• Percussion


  • Note for sounds that are not resonant
  • Flat or dull sound – percussed over partially consolidated lung tissue like pneumonia
  • Tympany might be percussed with pneumothorax
• Palpation


  • Palpate sinuses for tenderness in children
  • Assess for enlargement or tenderness of lymph nodes of the head and neck
  • Document alteration in tactile fremitus
  • Compare central (carotid/femoral) and peripheral pulses = weak = poor perfusion
• Assessing respiratory illness


  • Clubbing of fingers
  • Adventitious sounds
  • Chest diameter

  
• Nursing diagnoses


  • Ineffective airway clearance
  • Ineffective breathing pattern
  • Impaired gas exchange
  • Risk for infection
  • Pain
  • Risk for fluid volume deficit
  • Altered nutrition less than body requirement
  • Activity intolerance
  • Fear

  
• Nasopharyngeal culture


  Provide valuable information about the microorganisms causing the disease in the upper respiratory tract