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Neonatal breathing pattern

Preferential nose breathers for first month of life. Nasal congestion can lead to airway obstruction and oxygen deprivation.

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Reasons for airway obstruction in the neonate.

- nasal congestion - tongue is large in proportion to the mouth so it is capable of obstructing airway - trachea is high and fairly close to the top of the esophagus which increases risk of aspiration - airways are small and short do obstruction by mucous secretions is frequent and severe - resp. Infections so common in young children, freq. cause nasal x

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Neonatal/Pedatric Respiratory Differences

  • Neonates are nose breathers for the first four weeks of life so nasal congestion can lead to airway obstruction and oxygen deprivation
  • The tongue of the neonate is quite large in proportion to the mouth so it is capable of obstructing the airway
  • The trachea is high and fairly close to the top of the esophagus which increases the risk of aspiration of foods and fluids into the airway
  • The airways are small and short in young children so obstruction by mucous secretions is frequent and can be severe
  • Respiratory infections that are common in young children cause nasal congestion which eventually leads to significant airway obstruction.
  • Young children and infants are more susceptible to respiratory infections as their immune systems are immature
  • Most toddlers and infants have a 6-9 respiratory infections per year with infants under 6 months being especially vulnerable
  • By age 6 the incidence of infections decreases to about 4 or 5 per year
  • The chest area is smaller size and developmental immaturity can affect respirations
  • The intercostal muscles that aid respirations are not fully developed until about school age, therefore respirations depend more on the diaphragm (by the 7th year the shared effort is like that in an adult)
  • Anything that compromises diaphragmatic function of the young child, such as external pressure on the abdomen, can lead to respiratory difficulty.
  • The chest is small and thus easily compromised by abdominal distention which can cause elevation of the diaphragm. The chest wall of a young child is thin so any prssure or restraint over the chest area can interfere with respiratory efforts as well
  • Thin chest wall allows normal breath sounds to be heard even over areas of pnemothorax or atelectasis. Such pathology often produces a change in the pitch rather than the intensity of the breath sounds over the involved areas. Thus, both sides of the infant's chest must be auscultated for comparison to locate areas of diminished air exchange, which even then may not be evident
  • Cartilage or the ribs and sternum is softer and more flexible than that of the adult. This factor along with the thin chest wall and poorly developed intercostal muscles, accounts for retraction or inward movement of the chest during inspiration if respiratory effect is increased.

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Basics of Respiratory Assessment

  1. Inspect the nose for patency, inflammation, deformities, symmetry, and discharge
  2. Evaluate cough for nature, frequency, character, and productivity
  3. Chest x-ray, thoracentesis, PFTs, and ABGs are examples of diagnostic tests
  4. ALTE is the clinical presentation of apnea of infancy, including some combination of changes in color, muscle tone, and choking or gagging
  5. Wheezing, crackles, and rhonchi are examples of adventitious lung sounds
  6. Inspect mouth for color, lesions, masses, and bleeding in the mouth and pharynx
  7. Inspect the neck for symmetry and prescence of tender or swollen areas
  8. Changes in LOC, dyspnea, tachypnea, retractions, and audible changes in breathing are all signs of respiratory distress
  9. Assessment of the thorax and lungs includes inspection, palpation, percussion, and auscultation
  10. Respirations should be assessed for rate, depth, rhythm, and ease

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Chest Retractions

The vidible sinking in of the soft tissues of the chest between and around the firmer tissue of the cartilaginous and bony ribs, as occurs with increased inspiratory effort or obstruction at some level of the respiratory tract. Retraction begins in the intercostal spaces. If increased effort is needed to fill the lungs, supraclavicular and infraclavicular retraction may be seen. In infants, sternal retraction occurs with only a slight increase in respiratory effort, the result of the pliability of their chests

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Pulmonary Function Tests (PFTs)

Measure lung volumes and the flow of air. In a testing situation, patients are asked to move that air quickly and forcefully. The speed and volume of the air are measured, while the nurse or respiratory therapist verbally encourages or coaches the patient to exhale quickly and fully. Pulmonary function tests (spirometry testing) can be don ein a doctor's office, clinic, or even at the patient's beside.

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FEV1

The forced expiratory volume 1. The amount of air exhaled in the first second of a quick and forceful expiration. FEV1 provides a valuable clue to the nurse regarding the severity of the patient's airway obstruction. This measurement is then compared to values which are predicted for a person of the patient's age, gender, height, and weight. Additional calculations and comparisons can be made which will help to determine whether a patient's pulmonary dysfunction is due to obstructive causes (mucus in airway, asthma, emphysema, cystic fibrosis, chronic bronchitis) or restrictive causes (head injury, muscular dystrophy, spinal curvatures, obesity)

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Peak Expiratory Flow Rate (PEFR)

Method of measuring maximal airflow during expiration, using a small, inexpensive device, which the nurse can teach the patient to use at home

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Purposes of pulmonary function testing

  1. Diagnose pulmonary disease
  2. Monitor disease progression
  3. Evaluate disability
  4. Evaluate response to bronchodilators

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Do pulmonary function tests provide information regarding the amount of oxygen in the blood?

PFTs measure lung volumes and speed of airflow. They do NOT measure gas exchange.

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What tests can provide information regarding the amount of oxygen in the blood?

Arterial blood gases and pulse oximetry provide information about the presence and degree of hypoxia.

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What is the difference/similarities betwen FEV1 and PEFR measurements?

Both measure airflow during expiration as well as provide information about airflow obstruction. FEV1 is measured in the hospital or clinic setting while PEFR is measured in the home.

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Thoracentesis

Description of Procedure: Insertion of a large-ore needle through the chest wall into the pleural space

Purpose of Procedure: Diagnostic test of pleural fluid, To remove pleural fluid, To instill medicaiton

Pre Procedure Nursing Considertions:

  1. Explain procedure to patient
  2. Check informed consent has been obtained
  3. Obtain baseline VS
  4. Ensure patient voids

During Procedure Nursing Considerations:

  1. Assist patient to sit upright and lean forward over a beside table
  2. Instruct patient not to talk or cough
  3. Obtain VS and SpO2
  4. Observe closely for any signs of R. distress

Post Procedure Nursing Considerations:

  1. Check bandage for drainage
  2. Observe closely for any signs of R. distress
  3. Verify breath sounds in all fields after procedure
  4. Encourage deep breaths to expand lungs
  5. Send labeled specimens to lab

Complications: Rapid removal of high volumes can result in hypotension, hypoxia, or pulmonary edema. A follow-up chest x-ray should be done to check for possible pneumothorax.

 

**Instead of thoracentesis, persistent pleural effusions can also be treated by insertion of a chest tube**

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Peak Expiratory Flow Rate (PEFR) Procedure

Description of Procedure: A handheld device is used to determine how well air moves out of the lungs. The patient blows forcefully and quickly into the device after taking a deep breath. Very beneficial in patients with asthma and a key component in asthma action plan.

Purpose of Procedure: Determines airway narrowing before other systems, Helps to determine medication regimen, Helps to decide when to go to the MD or ED

Nursing Considerations:

  1. Peak flow zones will be set by the health care provider
  2. Personal best peak flow number is determined over a 2-3 weeks period
  3. Measurements should be check at the same time each day
  4. Measurements from two different meters cannot be compared
  5. Measurements should be recorded and brought to health care provider during follow-up visits

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Ventilation-Perfusion Lung Scan Procedure

Description of Procedure: Photographs are taken after:

  1. patient receives an IV radioisotope injection for the perfusion portion of the test.
  2. patient inhales a radioactive gas for the ventilation portion of the test

Purpose of Procedure: To identify areas of the lung not receiving airflow or blood flow. Ventilation without perfusion suggests the probablity of a pulmonary embolism.

Nursing Considerations:

  1. Instruction patient to undress to waist, put on gown, and remove any metal between neck and waist
  2. Ventilation component requires patient cooperation

Post Procedure Precautions Needed? No. The gas and isotope transmit radioactivity for only a brief interval

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Tapering Oxygen According to Pulse Oximeter Readings

  1. When a patient's oxygen dose is being titrated up or weaned (decreased) the nurse's most important responsibilities are assessment and patient safety.
  2. Patient must be observed for signs of hypoemia and hypercapnia
  3. Obtaining and documenting VS and the pulse oximeter reading are only part of the full assessment. Subjective and objective data must be noted, documented, and communicated within the multidisciplinary team.
  4. Procedure:
    1. Verify physician orders pertaining to oxygen dose and route of delivery
    2. The rate at which oxygen is weaned will vary based on patient presentation, illness, level of activity, medications, and type of oxygen delivery device
    3. Collaborate with respiratory therapy as needed
    4. Assess patient within 5-15 minutes of any change in oxygen therapy

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Respiratory Failure

A clinical state characterized by

  • Inadequate elimination of carbon dioxide
  • Inadequate oxygenation of the blood

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What does respiratory failure result from?

  1. Intrinsic lung or airway disease
  2. Inadequate effort caused by head injury

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Respiratory Distress

A compensated state of respiratory dysfunction with increased rate and effort of breathing

The increased effort is adequate to maintain:

  1. Adequte oxygenation of blood
  2. Elimination of carbon dioxide

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Assessment of Children with Respiratory dysfunction

  1. Level of consciousness and interaction with the environment
  2. Respiratory rate
  3. Respiratory mechanics and "work of breathing"
  4. Color of skin and mucous membranes

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Auscultation of the infant

Should be performed over peripheral lung fields. Because the pedatric chest is so small, breath sounds are readily transmitted from one side of the chest to the other. TO minimize this transmission, listen along the midaxillary lines and proceed toward the back.

Normal: soft, tubular breath sounds on inspiration and minimal to no breath sound son expiration

 

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Stridor

Inspiratory high pitched sounds secondary to obstruction beetween the supraglottic space and the lower trachea

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Wheezing

Prolonged expiration indicates obstruction of the intrathoracic airway. ex. small bronchi and bronchioles in asthma and bronchitis

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Grunting

Premature closure of the glottis during active expiration in an attempt to increase end expiratory pressure. Diseases associated with grunting respirations are:

  • Pulmonary edema
  • Pneumonia
  • Atelectasis
  • Acute Respiratory Distress Syndrome

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Retractions

An inspiration due to upper airway obstruction or conditions causing decreased pulmonary compliance

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Four clinical signs for respiratory assessment

  1. LOC
  2. RR
  3. Respiratory effort and mechanics
  4. Skin and mucous membrane color

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Why are infants and children more prone than adults to developing respiratory distress?

  1. Anatomic differences between children and adults
  2. Small size of airways in pediatric patients: trachea is 1/3 size of adult trachea
  3. Thorax: ribs an dsternum are too pliable to use the intercostals, so infants use thier diaphragm to breathe, moving it down for inspiration and up for exhalation. Diaphragmatic breathing progressively declines until approximately 7 years of age.
  4. Orientation of ribs in children is horizontal and already maximally oriented in the anterior-posterior direction
  5. The immature anatomy of children decreases their ability to compensate during respiratory distress
  6. Paradoxical chest movements are abnormal
  7. Infant lungs have fewer alveoli (20 million compared with 300 million in adults)
  8. Infants have an increased metabolic demand and consumption of oxygen, therefore respiratory rates are increased:
    1. Neonates 30-60/minute
    2. Infants 25-55/minute
    3. 5 year olds 14-22/minute

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Signs of severe respiratory distress

  • Decreased responsiveness of environment
  • Air hunger
  • Dusky mucous membranes and soles of feet
  • Grunting
  • Head bobbing
  • Stridor
  • Wheezing
  • Low oxygen saturation
  • Poor distal breath sounds
  • Acidosis/respiratory failure

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What is the difference between tachypnea and hyperventilation?

Tachypnea: rate of breathing is fast and abnormally rapid

Hyperventilation: Rate and depth of respiration increased. Hyperventilation often causes lower CO2 levels, because CO2 is being rapidly blown off.

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Central Nervous System signs of respiratory distress

  1. Change in LOC
  2. Anxiety, restlessness, hypoxia
  3. Lethargy, somnolence (hypercapnia), increase CO2 in blood

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Respiratory System signs of respiratory distress

  1. Change in breathing that includes:
    1. Increased RR then decreased RR (muscles tire, late sign)
    2. SOB/dyspnea
    3. Audible change in breathing
      1. Wheezing
      2. Stridor
      3. Grunting
    4. Change in lung sounds
      1. Diminished
      2. Wheezing
      3. Crackles
      4. Rhonchi
    5. Increased WOB (work of breathing)
      1. Nasal flaring
      2. Retractions
    6. Decreased O2 sats or other change in ABGs
    7. Change in sputum (amount, color, odor) or cough
    8. Presence of pain (pleuritic)
    9. Positioning of patient (tripod)
    10. Unexplained fatigue

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Cardiovascular System signs of respiratory distress

  1. Tachycardia
  2. Change in BP (hypotension OR hypertension)
  3. Dysrhythmias
  4. Change in skin color/temperature (cyanotic, cool, clammy, mottling)
  5. Diaphoresis
  6. Unexplained fatigue

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Audible expiratory grunt

Found on inspection.

Attempt to increase end expiratory pressure by premature closure of the glottis

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Tripod Position

Found on inspection.

Body position, indicates moderate to severe respiratory distress (AKA orthopneic position)

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Cyanosis

Found on inspection.

Hypoxia

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Barrel Shaped Chest

Found on inspection.

Anterior-posterior diameter is equal to lateral

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Retractions

Found on Inspection

Use of accessory muscles to aid inspiration due to airway obstruction or decreased pulmonary compliance

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Tracheal Deviation

Found on palpation/percussion.

Medical emergency if due to tension pneumothorax

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Rhonchi

Found on auscultation

Rumbling sound due to obstruction of large airways by secretions

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Fine Crackles

Found on auscultation

Sound of alveoli suddenly snapping open, heard late in inspiration secondary to atelectasis, pulmonary edema, pneumonia (AKA rales)

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Stridor

Found on auscultation

Continuous, monophonic, high pitched wheeze, sign of partial airway obstruction, associated with croup, epiglottitis and post extubation

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Right middle lobe

Found on ausculation

Right midaxilliary line

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Thoracentesis Diagnostic Study

A catheter or needle is positioned in the pleural space to remove fluid. Monitor breath sounds post procedure.

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V/Q Diagnositc Study

Two part test used to assess pulmonary ventilation and perfusion: useful to diagnose pulmonary emboli

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PEFR Diagnostic Study

Maximum airflow rate during forced expiration, monitor degree of bronchoconstriction

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FEV1 Diagnostic Study

Amount of air exhaled in first second of FVC; best measure of airway secretions

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