Dr. Areefa AlbahriDr. Areefa Albahri

Variations in Pediatric Anatomy and Variations in Pediatric Anatomy and

PhysiologyPhysiology : : Respiratory dysfunction in children tends to Respiratory dysfunction in children tends to

be more severe than in adults. Several be more severe than in adults. Several differences in the infant’s or child’s differences in the infant’s or child’s respiratory system account for the increased respiratory system account for the increased severity of these diseases in children severity of these diseases in children compared with adults. compared with adults.

Such differences, as example, are: Newborns Such differences, as example, are: Newborns are obligatory nose breathers until at least4 are obligatory nose breathers until at least4 weeks of age. The young infant cannot weeks of age. The young infant cannot automatically open his or her mouth to automatically open his or her mouth to breathe if the nose is obstructed and the breathe if the nose is obstructed and the airway lumen is smaller in infants and children airway lumen is smaller in infants and children than in adults. than in adults.

Respiratory distress syndrome Respiratory distress syndrome “Hyaline Membrane Disease“Hyaline Membrane Disease””

Is a syndrome of immature infants Is a syndrome of immature infants that is characterized by a that is characterized by a progressive and frequently fatal progressive and frequently fatal respiratory disorder resulting from respiratory disorder resulting from atelectasis and immaturity of the atelectasis and immaturity of the lungs.lungs.

It should be noted that some It should be noted that some situations result in the acceleration situations result in the acceleration of surfactants (steroid therapy and of surfactants (steroid therapy and heroin addicted mother). RDS is heroin addicted mother). RDS is common in preterm babies. common in preterm babies.

The exact etiology of RDS is not The exact etiology of RDS is not clearly defined but resulting from clearly defined but resulting from decreased pulmonary surfactant. decreased pulmonary surfactant.

Contributing factors (that decrease Contributing factors (that decrease surfactant): surfactant):

a) Prematurity and immature alveolar a) Prematurity and immature alveolar lining cells. lining cells.

b) Acidosis. c) Hypothermia. b) Acidosis. c) Hypothermia. c) Hypoxia. e) Hypervolemia f) Diabetes. c) Hypoxia. e) Hypervolemia f) Diabetes.

Etiology:

Altered physiologyAltered physiology : :

11. Immature lung. Immature lung:: 2. Sequence of events resulting in hyaline 2. Sequence of events resulting in hyaline

membrane disease:membrane disease: a) a) Deficient surfactant Deficient surfactant b) b) Alveolar instabilityAlveolar instability: : c) c) HypoxemiaHypoxemia and pulmonary vascular and pulmonary vascular

pressure lead to ischemia in the alveoli pressure lead to ischemia in the alveoli 3. RDS is usually a self-limited disease 3. RDS is usually a self-limited disease

and symptoms peak in about 3-4 days, at and symptoms peak in about 3-4 days, at which time surfactant synthesis begins to which time surfactant synthesis begins to accelerate and pulmonary function and accelerate and pulmonary function and clinical appearance begins to improve. clinical appearance begins to improve.

Clinical manifestationClinical manifestation : :

Symptoms are usually observed soon Symptoms are usually observed soon after birth. after birth.

Primary signs and symptoms: Primary signs and symptoms: 1. Expiratory grunting or whining (when 1. Expiratory grunting or whining (when

infant is not crying). infant is not crying). 2. Substernal and intercostal retractions. 2. Substernal and intercostal retractions.

Clinical manifestationClinical manifestation : :

3. Inspiratory nasal flaring, Tachypnea, 3. Inspiratory nasal flaring, Tachypnea, Hypothermia and cyanosis when child is in Hypothermia and cyanosis when child is in room air (in severe cases may be cyanotic room air (in severe cases may be cyanotic even with oxygen given). even with oxygen given).

4. Decrease breath sound and dry 4. Decrease breath sound and dry sandpaper breath sound. sandpaper breath sound.

Secondary signs and symptoms: Secondary signs and symptoms: 1. Hypotension. 2. Peripheral edema. 1. Hypotension. 2. Peripheral edema. 3. Absent bowel sound. 4. Decreased 3. Absent bowel sound. 4. Decreased

urinary output.urinary output.

Diagnostic evaluation: Diagnostic evaluation: 1. laboratory test: PCO2 elevated, PO2 1. laboratory test: PCO2 elevated, PO2

low, and Blood pH low low, and Blood pH low 2. Chest x-ray 2. Chest x-ray Nursing and medical management: Nursing and medical management:

(supportive therapy) (supportive therapy) Maintenance of oxygenation PaO2 at Maintenance of oxygenation PaO2 at

60-80 mmHg to prevent hypoxia. 60-80 mmHg to prevent hypoxia.

Maintenance of respiration with ventilatory Maintenance of respiration with ventilatory support if necessary. support if necessary.

Maintenance of thermoneutral state (to Maintenance of thermoneutral state (to prevent hypothermia). prevent hypothermia).

Maintenance of fluid, electrolyte and acid-Maintenance of fluid, electrolyte and acid-base balance. base balance.

Maintenance of nutrition. Maintenance of nutrition. Antibiotic is indicated only when hyaline Antibiotic is indicated only when hyaline

membrane disease cannot be differentiated membrane disease cannot be differentiated from early onset of sepsisfrom early onset of sepsis. .

Tonsillitis Tonsillitis Inflammation of the tonsils. Tonsils are Inflammation of the tonsils. Tonsils are

masses of lymphoid tissue located in the masses of lymphoid tissue located in the pharyngeal cavity. pharyngeal cavity.

Causes: May be viral or bacterial usually Causes: May be viral or bacterial usually associated with pharyngitis. 20% of acute associated with pharyngitis. 20% of acute tonsillitis and pharyngitis are caused by tonsillitis and pharyngitis are caused by group A b-hemolytic streptococci (GABHS). group A b-hemolytic streptococci (GABHS).

Clinical Manifestations:- Clinical Manifestations:- Difficulty swallowing or breathing, as Difficulty swallowing or breathing, as

the tonsils enlarged from edema ( Kissing the tonsils enlarged from edema ( Kissing tonsils meet in the midline). tonsils meet in the midline).

Breathing through the mouth leads to Breathing through the mouth leads to offensive mouth odor and frequent offensive mouth odor and frequent drooling drooling

Impaired sense of smell and taste and Impaired sense of smell and taste and change of voice. change of voice.

Therapeutic Therapeutic managementmanagement -: -:

Diagnosis is established from visual Diagnosis is established from visual examination of the throat. examination of the throat.

Throat culture positive for bacterial Throat culture positive for bacterial infection, antibiotic indicated. infection, antibiotic indicated.

If viral tonsillitis, treatment is symptomatic. If viral tonsillitis, treatment is symptomatic. Throat cultures positive for GABHS infection Throat cultures positive for GABHS infection warrant antibiotic treatment. warrant antibiotic treatment.

The majority of children with tonsillitis The majority of children with tonsillitis respond to medical treatment others undergo respond to medical treatment others undergo surgical intervention. surgical intervention.

Therapeutic Therapeutic managementmanagement -: -:

Surgical Treatment; Surgical Treatment; Tonsillectomy (removal of the tonsils). Tonsillectomy (removal of the tonsils).

Tonsillectomy is recommended for Tonsillectomy is recommended for recurrent streptococcal infections and recurrent streptococcal infections and massive hypertrophy. massive hypertrophy.

Tonsillectomies are reserved for Tonsillectomies are reserved for children >3 years of age due to excessive children >3 years of age due to excessive blood loss and a potential for the tonsils blood loss and a potential for the tonsils to grow back. to grow back.

Nursing considerationsNursing considerations : :

Provide soft to liquid diet. Provide soft to liquid diet. Cool mist vaporizer to keep mucous Cool mist vaporizer to keep mucous

membranes moist. membranes moist. Warm salt - water gargles. Warm salt - water gargles. Analgesic and antipyretic drugs. Analgesic and antipyretic drugs.

Nursing considerationsNursing considerations : :

Post-operative care: Post-operative care: Place child on abdomen or side to Place child on abdomen or side to

facilitate drainage of secretion. facilitate drainage of secretion. Suction if needed. Suction if needed. Discouraged from coughing frequently. Discouraged from coughing frequently. Observe for bleeding and calms and Observe for bleeding and calms and

reassure child and relieve pain. reassure child and relieve pain. Cool water, crushed ice or dilute fruit Cool water, crushed ice or dilute fruit

juice is given first after child is awake juice is given first after child is awake

Otitis Media (O.M)Otitis Media (O.M)

Otitis Media: is an Inflammation of the middle Otitis Media: is an Inflammation of the middle ear. ear.

Classification: Classification:

AA) ) Acute or chronic OMAcute or chronic OM: bacteria or viruses : bacteria or viruses cause a purulent exudate to form behind cause a purulent exudate to form behind tympanic membrane in the middle ear space. tympanic membrane in the middle ear space.

B) Serous otitis media – non purulent: sterile B) Serous otitis media – non purulent: sterile fluid accumulates due to blocked Eustachian fluid accumulates due to blocked Eustachian tubes. tubes.

Several factors cause children to develop Several factors cause children to develop Otitis media:- Otitis media:-

. Eustachian tube, short, wide, . Eustachian tube, short, wide, straight, easy entry of organism. straight, easy entry of organism.

b. Cartilage lining of E.T b. Cartilage lining of E.T underdeveloped, open more easily. underdeveloped, open more easily.

c. lying down position of infant. c. lying down position of infant.

Clinical manifestation: Clinical manifestation:

1. 1. Pain: infant pull at earsPain: infant pull at ears 2. Temperature 2. Temperature 3. Lymph node swollen 3. Lymph node swollen 4. Vomiting. 4. Vomiting. 5. Diarrhea 6. Anorexia. 5. Diarrhea 6. Anorexia. 7. Rupture tympanic membrane, 7. Rupture tympanic membrane,

relief of pain and purulent discharge relief of pain and purulent discharge in external ear canal. in external ear canal.

8. On otoscopy the tympanic 8. On otoscopy the tympanic membrane appears red bright and membrane appears red bright and bulging. bulging.

TreatmentTreatment-:-:

1. Administration of antibiotics 1. Administration of antibiotics especially ampicillin. especially ampicillin.

2. Analgesic and antipyretic drugs to 2. Analgesic and antipyretic drugs to reduce pain and fever. reduce pain and fever.

3. Myringotomy: incision of the ear 3. Myringotomy: incision of the ear drum for drainage of secretion. drum for drainage of secretion.

Nursing considerationNursing consideration -: -:

1. Pain relief analgesic. 1. Pain relief analgesic. 2. If ear drainage occurs, clean 2. If ear drainage occurs, clean

external ear canal with sterile cotton external ear canal with sterile cotton swaps soaked in H2O2. swaps soaked in H2O2.

3. Facilitate drainage place the child 3. Facilitate drainage place the child on the affected side. on the affected side.

4. Parent education: correct 4. Parent education: correct administration of antibiotics administration of antibiotics

PneumoniaPneumonia

Definition: Inflammation of the lung Definition: Inflammation of the lung tissue. Inflammation of the alveoli tissue. Inflammation of the alveoli results in atelectasis. Atelectasis is results in atelectasis. Atelectasis is defined as a collapsed or airless defined as a collapsed or airless portion of the lung, so gas exchange portion of the lung, so gas exchange becomes impaired. The inflammatory becomes impaired. The inflammatory response further impairs gas response further impairs gas exchange. exchange.

EtiologyEtiology -: -:

1. Viruses such as RSV (respiratory 1. Viruses such as RSV (respiratory syncytiale viruse). syncytiale viruse).

2. Bacteria 2. Bacteria 3. Mycoplasma 3. Mycoplasma 4. Fungi. 4. Fungi. 5. Aspiration of foreign substances. 5. Aspiration of foreign substances. 6. Ingestion of kerosene may cause 6. Ingestion of kerosene may cause

pneumonia, in this condition never pneumonia, in this condition never induce vomiting. induce vomiting.

Clinical manifestationClinical manifestation -: -:

1.1. History of upper respiratory tract History of upper respiratory tract infection infection

2. Shaking chills. 2. Shaking chills. 3. High fever, cough 3. High fever, cough 4. Hacking, unproductive cough 4. Hacking, unproductive cough 5. Chest pain, children usually 5. Chest pain, children usually

report abdominal pain. report abdominal pain. 6. Drowsiness. 6. Drowsiness. 7. dyspnea7. dyspnea 8. Cyanosis. 8. Cyanosis.

Diagnosis: is based on physical findings and Diagnosis: is based on physical findings and a sputum culture. Chest x-ray demonstrates a sputum culture. Chest x-ray demonstrates the extent and location of the involvement. the extent and location of the involvement.

treatment:treatment: 1. Antibiotics: penicillin, ampicillin, 1. Antibiotics: penicillin, ampicillin,

chloramphenicol, erythromycin. chloramphenicol, erythromycin. 2. Bed rest to conserve energy 3. Fluid as 2. Bed rest to conserve energy 3. Fluid as

tolerated. tolerated. 4. Humidified air to reduce labored breathing 4. Humidified air to reduce labored breathing

and reduce hypoxemia and reduce hypoxemia ♣ ♣ The objective of treatment is effective The objective of treatment is effective

ventilation and prevention of dehydration ventilation and prevention of dehydration

Complications: Complications: are rare but may include are rare but may include worsening respiratory distress, hypoxia. worsening respiratory distress, hypoxia.

Treatment and nursing Management: Treatment and nursing Management: Croup is usually managed on an outpatient Croup is usually managed on an outpatient basis cases requiring hospitalization in basis cases requiring hospitalization in cases of progressive stridor. cases of progressive stridor.

High humidification with oxygen. High humidification with oxygen. Increase fluid intake ―good hydration‖. Increase fluid intake ―good hydration‖. Minimal handling. Minimal handling. Monitor vital signs. Monitor vital signs. Teach parents home management of croup. Teach parents home management of croup. Epinephrine nubilizer, Syrup of ipecac Epinephrine nubilizer, Syrup of ipecac

(reducing coughing). (reducing coughing).

EpiglottitisEpiglottitis : : Causative agent: caused mainly by H. Causative agent: caused mainly by H.

Influenza. Other agents include Influenza. Other agents include pneumococci, Beta hemolytic streptococci pneumococci, Beta hemolytic streptococci and staph aureus. and staph aureus.

Age: 3-10 years with seasonal variations Age: 3-10 years with seasonal variations Clinical manifestations: Clinical manifestations: High fever, aphonia, drooling and High fever, aphonia, drooling and

inspiratory stridor. inspiratory stridor. Irritability with hyperextended neck. Irritability with hyperextended neck. Cherry red epiglottis. Cherry red epiglottis. Refusal to eat. Refusal to eat. Intercostal retraction. Intercostal retraction.

Diagnostic evaluationDiagnostic evaluation:: History and physical examination. History and physical examination. Leukocytosis Leukocytosis X-Ray neck ―epiglottic edema. X-Ray neck ―epiglottic edema. Treatment and nursing management: Treatment and nursing management: Antibiotic therapy ―ampicilline, Antibiotic therapy ―ampicilline,

chloromphenicol I.V. 7-10 days‖. chloromphenicol I.V. 7-10 days‖. Quite room, cool humidified oxygen and Quite room, cool humidified oxygen and

bed rest and increase fluids. bed rest and increase fluids. Teach parents home care Teach parents home care

―tracheostomy‖. ―tracheostomy‖. Observe for signs of respiratory distress. Observe for signs of respiratory distress. Medical emergency ―endotracheal Medical emergency ―endotracheal

intubation‖. intubation‖.

Bronchial AsthmaBronchial Asthma

Asthma is a recurrent and reversible Asthma is a recurrent and reversible condition of chronic inflammatory condition of chronic inflammatory airway disorder characterized by airway disorder characterized by airway hyper responsiveness, airway airway hyper responsiveness, airway edema, and mucus production. edema, and mucus production.

It’s the most common chronic It’s the most common chronic illness of childhood and affects 9 illness of childhood and affects 9 million American children million American children

Causes: allergic reaction to plants, Causes: allergic reaction to plants, pollens, foreign body in the air way. pollens, foreign body in the air way.

Bronchial AsthmaBronchial Asthma 1. 1. Spasmodic: Spasmodic: sporadic in nature, with sporadic in nature, with

varying intervals of freedom from difficulty varying intervals of freedom from difficulty and with precipitating factors often readily and with precipitating factors often readily defined. defined.

2. 2. Continuous: Continuous: no outward signs or no outward signs or symptoms of Asthma, but there is some symptoms of Asthma, but there is some shortness of breath on occasion, transitory shortness of breath on occasion, transitory wheezing on strenuous exercise and wheezing on strenuous exercise and wheezy rales heard during deep wheezy rales heard during deep inspiration. inspiration.

3. 3. Intractable: Intractable: persistent wheezingpersistent wheezing 44. Status Asthmaticus. Status Asthmaticus: severe attack in : severe attack in

which the patient deteriorates in spite of which the patient deteriorates in spite of adequate treatment with sympathomymetic adequate treatment with sympathomymetic drugs. drugs.

Clinical manifestationClinical manifestation : :

Usually begin with a hashing paroxysmal, Usually begin with a hashing paroxysmal, irritative, and non- productive cough and irritative, and non- productive cough and then when condition progress cough become then when condition progress cough become productive. productive.

Shallow irregular and short breathing with Shallow irregular and short breathing with prolonged expiratory phase. prolonged expiratory phase.

Expiratory wheezes (The sound of air being Expiratory wheezes (The sound of air being pushed through constricted bronchioles). pushed through constricted bronchioles).

Neck veins distended and cyanosis caused Neck veins distended and cyanosis caused by CO2 retention. by CO2 retention.

TreatmentTreatment::

Current goals of medical therapy Current goals of medical therapy are avoidance of asthma triggers are avoidance of asthma triggers

Corticosteroides; anti-inflammatory Corticosteroides; anti-inflammatory to reduce mucosal edema. to reduce mucosal edema.

Bronchodilator, Bronchodilator, β-β-adrenergic adrenergic agonist(ventoline, albuterol) and agonist(ventoline, albuterol) and expectorants expectorants

Hydration with oral and I.V fluids. Hydration with oral and I.V fluids.

Cystic FibrosisCystic Fibrosis Cystic fibrosis (CF) is an inherited Cystic fibrosis (CF) is an inherited

autosomal recessive trait disorder that autosomal recessive trait disorder that affects the exocrine glands of the body. The affects the exocrine glands of the body. The condition is characterized by an alteration condition is characterized by an alteration in sweat, electrolytes, and mucus in sweat, electrolytes, and mucus production that leads to multisystem production that leads to multisystem involvement. involvement.

The exocrine glands of the body produce The exocrine glands of the body produce extremely thick, tenacious mucus. The extremely thick, tenacious mucus. The sweat glands produce a larger amount of sweat glands produce a larger amount of chloride, leading to a salty taste of the skin chloride, leading to a salty taste of the skin and alterations in electrolyte balance and and alterations in electrolyte balance and dehydration. dehydration.

Lab tests: Lab tests: Sweat test the child sweats at normal Sweat test the child sweats at normal

rate but it is very high in sodium chloride. rate but it is very high in sodium chloride. A quantitative sweat chloride test > 60 A quantitative sweat chloride test > 60

mEq/L. mEq/L. Chest radiography, pulmonary Chest radiography, pulmonary

involvement. involvement. Stool fat and enzyme analysis, absence Stool fat and enzyme analysis, absence

of pancreatic enzymes. of pancreatic enzymes.

Pancreatic in sufficiency: thick mucus Pancreatic in sufficiency: thick mucus obstruct pancreatic duct and make atrophy for obstruct pancreatic duct and make atrophy for the pancreatic cells, blocking the secretion of the pancreatic cells, blocking the secretion of pancreatic enzymes (lipase for digestion, pancreatic enzymes (lipase for digestion, trypsine for protein,amylase for trypsine for protein,amylase for carbohydrates). Food is then not broken down carbohydrates). Food is then not broken down and absorbed. and absorbed.

Symptoms of pancreatic insufficiency. Symptoms of pancreatic insufficiency. 1. Bulky, floating, greasy, foul - smelling stools.1. Bulky, floating, greasy, foul - smelling stools.

(steatorrhea) (steatorrhea) 2. Inability to utilize vitamins, fat soluble vitamins 2. Inability to utilize vitamins, fat soluble vitamins

A, D, E, and K. A, D, E, and K. 3. Malabsorption symptoms (4. seems very hungry. 3. Malabsorption symptoms (4. seems very hungry. 5. Absence of pancreatic enzymes in stool. 5. Absence of pancreatic enzymes in stool. 6. Meconium ileus in newborn (obstruction in 6. Meconium ileus in newborn (obstruction in

intestine so during 24hr no passage of meconium) intestine so during 24hr no passage of meconium)

Pulmonary infectionsPulmonary infections:: thick mucus obstruct alveoli, decreasing O2 - CO2 thick mucus obstruct alveoli, decreasing O2 - CO2

exchange and trapping air, over inflating the lungs exchange and trapping air, over inflating the lungs result in the following symptoms:- result in the following symptoms:-

1. Cough, tenacious mucus. 1. Cough, tenacious mucus. 2. Worsening respiratory distress (increased pulse, 2. Worsening respiratory distress (increased pulse,

retractions, flaring nares, dyspnea, and cyanosis). retractions, flaring nares, dyspnea, and cyanosis). 3. Symptoms due to retained air in alveoli 3. Symptoms due to retained air in alveoli

(respiratory acidosis, barrel chest). 77 | P a g e (respiratory acidosis, barrel chest). 77 | P a g e 4. Clubbing of fingers due to chronic inadequate O2, 4. Clubbing of fingers due to chronic inadequate O2,

inadequate peripheral tissue perfusion. inadequate peripheral tissue perfusion. 5. Repeated lung infection, related to pooling of 5. Repeated lung infection, related to pooling of

secretions. secretions.

6. Complications: Pneumothorax (air 6. Complications: Pneumothorax (air collected in the pleural cavity from collected in the pleural cavity from ruptured alveoli), atelectasis (collapse of ruptured alveoli), atelectasis (collapse of lung alveoli with obstruction, no air lung alveoli with obstruction, no air enter and residual air absorbed), and enter and residual air absorbed), and pneumonia. pneumonia.

♣ ♣ Management of cystic fibrosis focuses Management of cystic fibrosis focuses on minimizing pulmonary complications, on minimizing pulmonary complications, promoting growth and development, and promoting growth and development, and facilitating coping and adjustment of the facilitating coping and adjustment of the child and family. child and family.

Nursing Interventions: Nursing Interventions: 1. Lung (most emphasized) 1. Lung (most emphasized) a. Postural drainage and chest a. Postural drainage and chest

physiotherapy. physiotherapy. b. Antibiotics for infections. b. Antibiotics for infections. c. Expectorants,nebulizers,bronchodilators. c. Expectorants,nebulizers,bronchodilators. d. Humidified O2. d. Humidified O2. e. Mist or croup tents. e. Mist or croup tents. f. Force fluids to liquify secretions. f. Force fluids to liquify secretions. g. I & O chart. g. I & O chart. h. Monitor symptoms of respiratory distress and h. Monitor symptoms of respiratory distress and

lung infections. lung infections.

2. Intestines: 2. Intestines: a. Give pancreatic enzymes with (or before a. Give pancreatic enzymes with (or before

each meal) to promote adequate digestion and each meal) to promote adequate digestion and absorption of nutrients and optimize absorption of nutrients and optimize nutritional status.. nutritional status..

b. Daily weight. b. Daily weight. c. Monitor stools, should appear more normal. c. Monitor stools, should appear more normal. d. Water- soluble forms of fat soluble vitamins. d. Water- soluble forms of fat soluble vitamins.

Low fat, high protein, high CHO diet. Low fat, high protein, high CHO diet.

Thank You AllThank You All

Any Question ??????Any Question ??????