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Course: Pediatric Nursing

Topic: Nursing Care of Child with Respiratory Disorder (Part V)

The Nurses International Community

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Module Goals

Learners will be able to:
Identify common respiratory conditions in children (acute non-infectious conditions, ARDS, pneumothorax)
Identify risk factors associated with the respiratory illnesses in children
List common diagnostic procedures for the respiratory conditions and nursing implications
Describe nursing management of children experiencing the respiratory disorders

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Acute Non Infectious Conditions: Foreign Body Aspiration

An object is inhaled and becomes lodged in a child’s airway or lungs
The obstruction may lead to difficulties with ventilation and oxygenation thus resulting in significant morbidity or mortality
Significant cause of death in children for anatomic as well as developmental reasons
Items that are most commonly implicated in children include food, coins, toys, and balloons

Cramer et al., 2022

The Children’s Hospital of Philadelphia, n.d.a

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Anatomic Causes of Aspiration in Children

Laryngeal cleft
Laryngomalacia
Vocal cord paralysis
Esophageal atresia
Tracheoesophageal fistulas
Neurologic conditions that impair the oropharynx and esophagus may cause aspiration

Vijayasekaran, 2020

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Foreign Body Aspiration: Signs and Symptoms

Sudden onset of cough, choking, and/or dyspnea
Wheeze on auscultation
Asymmetric breath sounds
Child may be completely asymptomatic
Evidence of an aspiration event may be found during history taking

Cramer et al., 2022

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Foreign Body Aspiration: Diagnosis

Chest X-ray
Inspiratory and expiratory phase X-ray
Frontal and lateral chest films with additional neck films
Bronchoscopy
CT of the chest

The Children’s Hospital of Philadelphia, n.d.a

Contact info: info@nursesinternational.org

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Foreign Body Aspiration: Treatment

Bronchoscopy
Tracheotomy incision (rare) to extract a foreign body that is difficult to remove due to its size or shape
May require antibiotics, steroids or inhaled bronchodilators after removal of object due to potential infection and tissue irritation

Cramer et al., 2022

The Children’s Hospital of Philadelphia, n.d.a

Contact info: info@nursesinternational.org

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Foreign Body Aspiration: Nurses’ Role

Assess vital signs
Obtain history from the parents
Assess for respiratory distress
Listen to lung sounds for wheezing
Provide oxygen to maintain optimal oxygenation saturations
Start two large-bore intravenous access lines
Keep patient NPO in case endoscopy is required
Provide comfort care
Suction to ease drooling

Conners et al., 2022

Contact info: info@nursesinternational.org

Perform emergency BLS maneuvers for choking if necessary.

Children with respiratory distress require immediate intervention and basic life support measures to ensure airway, breathing, and circulation are intact. Blind sweeping of the mouth is not recommended. Infants require back blows and chest compressions, and children older than one year require abdominal thrusts. In severe cases of complete airway obstruction, direct laryngoscopy and foreign body removal with Magill forceps should be attempted emergently. If the foreign body is not visualized, endotracheal intubation should be performed, which will potentially dislodge the foreign body and move it more distally. In the rare cases in which the patient cannot be ventilated after the measures above, needle cricothyroidotomy may be a temporizing life-saving procedure.

Those patients without complete airway obstruction or severe respiratory distress should be placed in a quiet room in a position of comfort until rigid bronchoscopy may diagnose and relieve the obstruction. Bronchoscopy should be performed if foreign body aspiration is suspected, even if radiographic studies are normal. This should be performed under general anesthesia in a controlled setting such as the operating room. Depending on the institution, bronchoscopy may be performed by an otolarnyngologist, pulmonologist, or surgeon. Bronchoscopy complication rates are very low, ranging between 1-10% and the majority of patients are discharged within 24 hours of the procedure.

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Foreign Body Aspiration: Nurses’ Role

Check x-ray report for the location of the foreign body
Educate caregiver on safe storage of toys and keeping small objects safely stored away from children
Assess the mental status of the child
Monitor for airway swelling, increased secretions, infection or difficulty breathing after the foreign body is removed

Conners et al., 2022

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Case Study

A 2 year old child is being discharged after treatment for an aspiration of a peanut.

What information should be reinforced with the child’s parents as part of discharge planning?

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Acute Respiratory Distress Syndrome (ARDS)

Severe lung condition where alveoli fill with fluid
Characterized by hypoxemia, radiographic opacities, decreased functional residual capacity, increased physiologic dead space, and decreased lung compliance
May develop at any age
A significant cause of mortality and morbidity in critically ill children
May develop over a few days, or may worsen quickly
Complications may include blood clots, infections, additional lung problems, or organ failure

National Heart, Lungs and Blood Institute, 2022

Hon et al., 2021

Orloff et al., 2019

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ARDS: Causes

Primarily caused by damage to the tiny blood vessels in the lungs
May be triggered by various pathologies, including trauma, pneumonia and sepsis
Direct causes of lung injury include pneumonia, aspiration, inhalational lung injury, lung contusion, chest injury and submersion injury
Indirect causes include sepsis, shock, pancreatitis, trauma, cardiopulmonary bypass, transfusion-related ALI, burns and increased intracranial pressure

Hon et al., 2021

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ARDS: Symptoms

Shortness of breath
Rapid, shallow breaths, crackles
Tachycardia
Productive cough
Cyanosis
Extreme tiredness
Fever
Chest pain, especially when trying to breathe deeply
Low blood pressure
Confusion

National Heart, Lungs and Blood Institute, 2022

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ARDS: Diagnosis

Medical history and thorough physical examination
Bronchoscopy
Chest X-ray and CT scan to create detailed images of the lungs
Laboratory testing including haematology, Sputum culture, and blood chemistry to identify the potential involvement of other organ systems
Arterial blood gas analysis to determine severity of hypoxemia or PaO2 level
Ultrasonography to assess pleural effusions, transudative and exudative fluid

National Heart, Lungs and Blood Institute, 2022

Hon et al., 2021

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ARDS: Treatment

Oxygen therapy
Breathing support: Noninvasive ventilation, ventilator
Medicines: Antibiotics, acid reducing medicines, muscle relaxants, sedatives
Additional treatment as indicated:

Feeding tube and fluid management
Blood transfusion
Physical therapy
Lying face down
Extracorporeal membrane oxygenation (ECMO)

National Heart, Lungs and Blood Institute, 2022

Hon et al., 2021

Orloff et al., 2019

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ARDS: Nurses’ Role

ICU care with continuous monitoring.
Manage nutrition
Prevent aspiration by keeping the head of the bed elevated before feeding.
Treating the underlying cause or injury
Improve oxygenation with mechanical ventilation
Suction oral cavity
Give antibiotics

Diamond, et al., 2022

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ARDS: Nurses’ Role

Deep venous thrombosis prophylaxis
Stress ulcer prophylaxis
Observe for barotrauma
Monitor blood chemistry and fluid levels
Coordinate care for nutritional support, chest physiotherapy, treatment for sepsis if present
Educate the family or care providers about the disorder
Provide emotional supports to the child and the parents

Diamond, et al., 2022

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Critical Thinking Question

Why is it important to position the child with ARDS to maintain a semi recumbent position with the head of the bed at a 30 or 45 degree angle?

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Pneumothorax

Happens when air leaks out of the lung
Air gets trapped in the space between the outside of the lung and the ribcage
The air may squash the lung and cause some or all of the lung to collapse
Pneumothorax may be spontaneous, iatrogenic, and traumatic in both neonatal and juvenile patients

Cömert, 2021; Goldman, 2020

The Children’s Hospital of Philadelphia, n.d.b

University of Rochester Medical Center

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Pneumothorax: Causes

May occur in infants with other lung diseases such as respiratory distress syndrome
Infants on a mechanical ventilator
Premature babies (due to fragile lung tissue)
Infants with meconium aspiration

Cömert, 2021; Goldman, 2020

The Children’s Hospital of Philadelphia, n.d.b

University of Rochester Medical Center

Contact info: info@nursesinternational.org

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Pneumothorax: Signs and Symptoms

Varies with age
May be quite mild; healthy babies may not have any symptoms or distress
Irritability and restlessness (due to pain or breathing difficulty)
Rapid breathing
Grunting
Nostril flaring
Chest wall retractions
Pale or bluish skin color

Cömert, 2021; Goldman, 2020

The Children’s Hospital of Philadelphia, n.d.b

University of Rochester Medical Center

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Pneumothorax: Diagnosis

History
Physical exam (area affected will have diminished or no lung sounds)
Chest X-ray
Ultrasound of chest

Cömert, 2021; Goldman, 2020

The Children’s Hospital of Philadelphia, n.d.b

University of Rochester Medical Center

Contact info: info@nursesinternational.org

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Pneumothorax: Treatment

Oxygen supplementation
Careful observation in the hospital
May require placement of a chest tube do decompress lung
Series of chest X-rays to monitor the pneumothorax (Improvement or deterioration)
Follow up care after the discharge

Cömert, 2021; Goldman, 2020

The Children’s Hospital of Philadelphia, n.d.b

University of Rochester Medical Center

Contact info: info@nursesinternational.org

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Pneumothorax: Nurses’ Role

Assess and manage pain
Administer oxygen as prescribed
A thorough respiratory assessment
Watch for the signs of infections, respiratory distress
Ensure nutrition and hydration
Ensure proper placement and patency of the chest tube
Pad banding sites with gauze or tape
High fowler's or semi fowler's position
Administer oxygen as prescribed
Proper discharge planning and teaching

RN Pedia, n.d.

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Critical Thinking Question

How might a nurse describe a pneumothorax and its treatment to the parents of a symptomatic newborn admitted to the NICU with a meconium aspiration?

Contact info: info@nursesinternational.org

A pneumothorax is an air leak in the lungs. It’s when air from the lungs leaks into the chest area. The leak may start suddenly or may develop slowly. It often occurs in the first 24 to 36 hours after birth. A cause may be from a meconium aspiration when the baby is still in the mother’s uterus and breathes in its first stool (meconium). Air may then become trapped, causing the lungs to expand too much. This may lead to air leaks. Due to the child being hospitalized for air leaks with symptoms, treatment may include: Giving oxygen to the child may help heal the air leak more quickly, and removing the collected air by placing a syringe or a thin tube (catheter) through the chest wall into the air space. The air may be removed with the syringe. Or the tube may be connected to a drainage system to help remove the air until the leak may seal.

Reference: https://www.cedars-sinai.org/health-library/diseases-and-conditions---pediatrics/p/pneumothorax-in-children.html

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Red Flags

Increased rate and/or depth of respirations
Retractions
Abnormal lung sounds; rales, ronchi, wheezes
Diminished lung sound in either lobes
Apnea
Pale skin colour
Excessive coughing, labored breathing
Asymmetric rise and fall of chest
Decreasing oxygen saturation/increased O2 requirement
Change in LOC or decreased level of consciousness CIRCU

Best-Brandt, 2019

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs may influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur
Health customs: In some cultures family members play a large role in health care decision-making
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations

AHRQ, 2020

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Cultural Considerations (con.):

Religion, culture, beliefs, and ethnic customs may influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

Contact info: info@nursesinternational.org

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References

Andrews, M.M., Boyle, J.S. & Collings, J. W. (2020). Transcultural Concepts in Nursing Care (8th Ed.). Wolters Kluwer, Philadelphia, PA.

Best-Brandt, T. (2019, August). Mary Bridge Children’s Hospital. Pediatric Assessment & Red Flags. https://www.marybridge.org/file_viewer.php?id=344&title=Peds+Assessment+and+Red+Flags

Cömert, H. S. Y. (2021, March 24). Pneumothorax in Children. Pleura - a Surgical Perspective [Working Title]. IntechOpen, 2021. 10.5772/intechopen.100329.

Conners, G. P., Mohseni, M., Wallace, D. (2022, April 30). Pediatric Foreign Body Ingestion (Nursing). StatPearls Publication. https://www.ncbi.nlm.nih.gov/books/NBK568742/?report=reader#_NBK568742_pubdet_

Cramer, N., Jabbour, N., Tavarez, M. M., et al. (2022, May 2). Foreign Body Aspiration. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK531480/

Contact info: info@nursesinternational.org

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References

Diamond, M., Peniston, H.L., Sanghavi, D., et al. (2022, February 26). Acute Respiratory Distress Syndrome (Nursing). StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK568726/#!po=5.00000

Goldman R. D. (2020). Spontaneous pneumothorax in children. Canadian family physician Medecin de famille canadien, 66(10), 737–738.

Hon, K. L., Leung, K., Oberender, F., & Leung, A. K. (2021). Paediatrics: how to manage acute respiratory distress syndrome. Drugs in context, 10, 2021-1-9. https://doi.org/10.7573/dic.2021-1-9

Orloff, K. E., Turner, D. A., & Rehder, K. J. (2019). The Current State of Pediatric Acute Respiratory Distress Syndrome. Pediatric allergy, immunology, and pulmonology, 32(2), 35–44. https://doi.org/10.1089/ped.2019.0999

National Heart, Lungs and Blood Institute. (2022, March 24). Acute Respiratory Distress Syndrome. https://www.nhlbi.nih.gov/health/ards

Contact info: info@nursesinternational.org

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References

RN Pedia. (n.d.). Pneumothorax Nursing Care Plan & Management. https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/pneumothorax/

The Children’s Hospital of Philadelphia. (n.d.a). Foreign Body Aspiration. https://www.chop.edu/conditions-diseases/foreign-body-aspiration

The Children’s Hospital of Philadelphia. (n.d.b). Spontaneous Pneumothorax. https://www.chop.edu/conditions-diseases/spontaneous-pneumothorax

University of Rochester Medical Center. (n.d. ). Pneumothorax in Children. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=90&contentid=p02397

Vijayasekaran S. (2020). Pediatric Airway Pathology. Frontiers in pediatrics, 8, 246. https://doi.org/10.3389/fped.2020.00246

Contact info: info@nursesinternational.org

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