CHAPTER 10 – RESPIRATORY SYSTEM First Nations and Inuit Health Branch (FNIHB) Pediatric Clinical Practice Guidelines for Nurses in Primary Care. The content of this chapter has been revised August 2011. Table of Contents GENERAL INFORMATION .....................................................................................10–1 ASSESSMENT OF THE RESPIRATORY SYSTEM ...............................................10–1 History of Present Illness and Review of Systems ...........................................10–1 Physical Examination of the Respiratory System ............................................10–1 COMMON PROBLEMS OF THE RESPIRATORY SYSTEM..................................10–4 Asthma .............................................................................................................10–4 Asthma, Acute (Exacerbation) ...................................................................10–4 Asthma, Chronic ........................................................................................10–8 Bronchiolitis ....................................................................................................10–11 Mild Bronchiolitis ......................................................................................10–12 Moderate to Severe Bronchiolitis .............................................................10–13 Community-Acquired Pneumonia (CAP) .......................................................10–14 Croup (Laryngotracheitis; Laryngotracheobronchitis) ....................................10–18 Foreign Body causing wheezing ....................................................................10–21 Persistent Cough ...........................................................................................10–22 Reactive Airway Disease ...............................................................................10–24 Upper Airway Disorders Comparison .............................................................10–26 Upper Respiratory Tract Infection (URTI) .......................................................10–26 EMERGENCY PROBLEMS OF THE RESPIRATORY SYSTEM .........................10–28 Epiglottitis .......................................................................................................10–28 Neonatal Resuscitation ..................................................................................10–30 SOURCES ............................................................................................................10–34 Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2011 Respiratory System 10–1 GENERAL INFORMATION Respiratory illnesses in children are one of the most housing and those who are exposed to cigarette or common causes of nursing station visits and hospital wood smoke. Because of the contagious nature of admissions among Aboriginal children. Such illnesses many of the viral illnesses, outbreaks are common. are more common in children who live in crowded Careful assessment is necessary to prevent morbidity. ASSESSMENT OF THE RESPIRATORY SYSTEM1,2,3,4,5,6,7,8 HISTORY OF PRESENT ILLNESS PHYSICAL EXAMINATION OF AND REVIEW OF SYSTEMS THE RESPIRATORY SYSTEM GENERAL Use the IPPA approach: The history varies according to the child’s age. – I for inspection – P for palpation – Onset of illness (sudden, gradual) – P for percussion – Symptoms (acute, chronic, pattern over time) – A for auscultation – Fever – Runny nose Some of these techniques (specifically palpation and percussion) are difficult to perform on infants and – Sore throat toddlers, and may not yield useful information. – Chest pain or tightness (older children may complain of this symptom) VITAL SIGNS – Dyspnea (appearance of increased work of – Respiratory rate (see normal range in Table 1, breathing; complaints of shortness of breath in “Normal Pediatric Heart Rate, Blood Pressure and older children) Respiratory Rate By Age”) – Cough (timing [for example, night cough, exercise- – Fever can increase the respiratory rate in induced], frequency, productive/nonproductive, children as much as 10 breaths per minute per characteristics [for example, barking, whooping]) degree of temperature (see Table 2, “Types of Cough and Most Likely Illness”) – A sustained respiratory rate in the upper end of normal in a resting child may suggest – Stridor respiratory illness or an increased metabolic rate – Wheeze (for example, fever) – Cyanosis – A very rapid respiratory rate suggests lower – Fatigue airway disease – Pallor – Newborn rate may go up to 80 breaths per – Previous similar episodes minute if infant is crying or stimulated – History of respiratory illness/conditions (for – Respiratory rhythm and depth example, asthma, premature birth, previous – Heart rate (elevated with increased work of intubation) breathing, fever) (see normal range in Table 1, – Other medical history (for example, cardiac, “Normal Pediatric Heart Rate, Blood Pressure and conditions causing immunocompromise) Respiratory Rate By Age”) – Family medical history (for example, asthma) – Pulse rates for a sleeping child may be 10% lower – Allergies – Heart rate may be elevated with increased work – Medications of breathing Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2011 10–2 Respiratory System – Temperature; see “Temperature Measurement in Children” in chapter 1 for measurement methods and normal temperature ranges according to age Table 1 – Normal Pediatric Heart Rate, Blood Pressure and Respiratory Rate By Age (Adapted from9,10,11) Heart Rate Range Lower Limit of Systolic Respiratory Rate Range Age (beats/minute [mean]) Blood Pressure (mm Hg) (breaths/minute) Birth to < 6 months 80–180 [140] 60 30–60 6 months to < 12 months 70–150 [130] 70 30–50 1 year to < 3 years 90–150 [120] 72–76 24–40 3 years to < 5 years 65–135 [110] 76–80 22–34 5 years to < 12 years 60–120 [85–100] 80–90 16–30 12 years to adult 60–100 [80] 90 12–20 INSPECTION – Voice changes (muffled with epiglottitis, hoarseness with laryngeal inflammation Signs of Mild Respiratory Illness [for example, croup]) – Nasal discharge, sniffing – Prolonged expiration (may indicate asthma or – Discharge at inner canthus of eyes bronchiolitis) – Skin chafing around nose, upper lip – Asymmetry of chest movements (asymmetry may – Voice changes indicate pneumonia) – Coughing – Nasal flaring (especially in infants) – Grunting (especially in infants) Table 2 – Types of Cough and Most Likely Illness – Accessory muscle use for breathing (indrawings): Nature of Cough Likely Type of Illness – Supraclavicular – retractions at the sternal Paroxysmal, whooping Pertussis notch, use of sternocleidomastoid muscles Loose, productive URTI, bronchitis – Substernal – intercostal retractions, abdominal Sharp, barky Croup, foreign body muscle use (lower airway symptoms) Tight, productive Pneumonia, bronchiolitis – Positioning (for example, sitting forward with Chronic Asthma, bronchiectasis, head tilted back slightly to extend neck [sniffing tuberculosis position] with airway obstruction [epiglottitis]); sits upright, leaning forward resting on extended arms Signs of Moderate to Severe with asthma Respiratory Distress – Silent chest – Child appears acutely ill (may indicate lower – Tachycardia (see normal range in Table 1, respiratory infection, bacterial infection) “Normal Pediatric Heart Rate, Blood Pressure and Respiratory Rate By Age”) – Decreased activity, interaction – Tachypnea (see normal range in Table 1, “Normal – Irritability to decreased mental alertness Pediatric Heart Rate, Blood Pressure and (suggests hypoxemia) Respiratory Rate By Age”) – Pallor – Cyanosis of nails and mucous membranes Signs of Chronic Disease (late sign) – Clubbing (may indicate bronchiectasis, cystic – Drooling: sign of upper airway disease fibrosis) (for example, epiglottitis) – Eczema (often associated with asthma) – Difficulty swallowing: acute upper airway inflammation (for example, epiglottitis) – Hyperinflation 2011 Pediatric Clinical Practice Guidelines for Nurses in Primary Care Respiratory System 10–3 PALPATION Localized Crackles Not useful in children < 3 years old, although it may – Pneumonia be useful in older, cooperative children. Allows further – Bronchiectasis assessment of respiratory excursion. Diffuse Crackles PERCUSSION – Severe pneumonia Useful only in older children (> 2 years). – Bronchiolitis – Resonance is normal – Pulmonary edema (congestive heart failure, fluid – Dullness to percussion over areas of fluid or solid overload) tissue is present in lobar pneumonia, pleural Crackles that disappear after coughing usually have effusion and collapsed lung no significance. You may not hear crackles if the child – Increased resonance over areas of hyperinflation is breathing shallowly. Try to have the child take deep (sounding like percussion of a puffed-out cheek) breaths. Some children with pneumonia may not have is present in bronchiolitis, asthma, foreign body crackles or any respiratory signs other than tachypnea. with obstruction to the lung that is obstructed and pneumothorax Wheezes – May be inspiratory or expiratory AUSCULTATION – Suggests asthma or bronchiolitis – Quality of breath sounds (tracheobronchial, bronchovesicular, vesicular) Stridor – Volume of air entry (good air entry or decreased air – Inspiratory entry, identify area) – Suggests croup, epiglottitis – Ratio of inspiration to expiration – Adventitious sounds: crackles, wheezes, pleural Pleural Rub rub, stridor, bronchial breathing – Sounds like two pieces of leather being rubbed In infants and small children,