Lower respiratory tract infection: BRONCHITIS, BRONCHIOLITIS, PNEUMONIA IN CHILDREN, ASTHMA IN CHILDREN,

Lower respiratory tract infection: BRONCHITIS, BRONCHIOLITIS, PNEUMONIA IN CHILDREN, ASTHMA IN CHILDREN: INTRODUCTIO, DEFINITION, CAUSES, PATHOPHYSIOLOGY, MANAGEMENT, NURSING DIAGNOSIS.

1. Lower respiratory tract infection

2. BRONCHITIS DEFINITION It is defined as inflammation of one or more bronchi that is characterized by dry cough ( which is worst at night ) and wheezing.

3. Incidence and etiology Especially in children less than 4 years of age usually associated with previous URI. Acute bronchitis may be bacterial or viral in origin. V iral infection: adenovirus, RSV, Rhinovirus Bacterial infection: mycoplasma pneumoniae Chemical agents/ allergens: dust, allergens, strong fumes etc.

4. Clinical features Runny nose Malaise Chills Fever Back and muscle pain Sore throat Wheezing Shortness of breath Fatigue Coughing

5. Diagnostic evaluation History and physical examination X ray Sputum culture

6. Management Antibiotics: in case of the bacterial infection and to prevent secondary infection. Cough expectorant : An expectorant to loosen and thin mucus so it can be more readily discharged. Antipyretics medicines: if the child is suffering from the fever Steam inhalation Nebulization can be done with normal saline or bronchodilators. Broncodilators : these will open the bronchial tubes and clear out mucus. E.g.: salbutamol, salmeterol Mucolytics : these will thin and loosen the mucus in the airway. E.g. : Guaifenesin Anti-inflammatory medicines

7. BRONCHIOLITIS

8. INTRODUCTION Bronchiolitis is lower respiratory tract infection caused by viral infection mainly and is seasonal, peaking in winters. The major cause of the bornchiolitis is RSV ( respiratory synticial virus)

9. Definition Bronchiolitis is a serious illness characterized by inflammation of bronchioles, causing sever dyspnea. Common under infant under age of 6 months. Common in winter and early spring. Viral: RSV, adenovirus , influenza virus. Bacteria: influenzae , pneumococcus and streptococcus hemolyticus Incidence and etiology

10. Pathophysiology

11. Clinical manifestations Dyspnea Nasal flaring Cyanosis Intercoastal , subcoastal . supracoastal retractions Diminished breath sounds Crackles sound Wheezing

12. History and physical examination. Chest x ray: shows areas of collapse. Pulse oxymetry should be recorded on all patients. Cultures may be performed if sepsis suspected Blood gases may be useful if advanced respiratory support is being considered. Clinical manifestations

13. MANAGEMENT Children with less severe symptoms : antipyretics, adequate hydration. Hospitalization is warranted for children on severe distress : oxygen therapy, critical monitoring of vital signs and blood gas level and ventilatory support be necessary.

14. Management Supportive Management Oxygenation: aim to keep oxygen saturation > 92%. • humidified head box oxygen should be used if physically possible. Apnoea Monitoring Feeding: intravenous fluids should be reserved for severe illness with severe respiratory distress or when nasogastric feeds are not tolerated. Nebulised Hypertonic Saline: 4ml of 3% sodium chloride & 2.5mg salbutamol eight hourly via nebuliser can be given. Bronchodilators: salbutamol, ipratropium should be administered to dilate the bronchioles. Inhaled / Oral Corticosteroids can be administered to relieve inflammation. Physiotherapy

15. Nursing diagnosis Ineffective airway clearance related to Increased mucus and nasal discharge Interventions: Assess airway for patency . Assess breath sounds by auscultation . Monitor the vital signs: SP02, temperature, respiratory rate, pulse rate. Elevate head of bed : semi fowlers position. Encourage fluid intake at frequent intervals over 24-h time periods. Assist to perform deep breathing and coughing exercises in child. Nebulization should be done as prescribed by the dr. Administer oxygen as prescribed. Administer medication as prescribed by the dr. : antipyretic, bronchodilaters , antibiotics

16. Cont …. Ineffective breathing pattern related to Increased mucus and nasal discharge Impaired gas exchange related to Hypoxemia. Disturbed sleep pattern related to difficulty in breathing. Knowledge deficit related to treatment and prognosis about the diseases.

17. PNEUMONIA IN CHILDREN

18. Definition An inflammation of the lung parenchyma (the respiratory bronchioles and the alveoli) is known as Pneumonia”. Pneumonia is mainly caused by microorganisms which enter the lower respiratory system and cause infection. The microorganism includes bacteria, mycobacteria, mycoplasma, fungi, parasites, and viruses.

19. CLASSIFICATION According to the causative organisms Viral pneumonia :- Rhinovirus , coronaviruses, influenza virus, respiratory sncytial virus(RSV), adenovirus and parainfluenza . Bacterial pneumonia: it may be caused by pneumococcus, streptococcus, staphylococcus etc. Fungal pneumonia :- Fungal pneumonia caused by histoplasmosis , blastomycosis , candidiasis . Parasitic pneumonia :- Parasitic pneumonia (caused by protozoa, nematodes, platyhelminthes ); common organism is Pneumocystis ( carinii ).

20. Cont … According to the areas of the lung involved/affected Lobar pneumonia Multilobar pneumonia Bronchial pneumonia Interstitial pneumonia

21. Cont … Miscellaneous types: Aspiration pneumonia: it is caused by aspiration of amniotic fluid, food etc. Loffler’s pneumonia: it is a kind disease in which eosinophils accumulates in lungs in response to parasitic infection. Hypersensitivity pneumonitis: it is an inflammation of alveoli within the lungs caused by hypersensitivity to inhaled drugs. Hypostatic pneumonia: it results from collection of fluid in dorsal region of lungs and occurs in bed ridden patient.

22. P athophysiology

23. CLINICAL MANIFESTATION Late symptoms: Convulsions Drowsiness Chest indrawing Wheezing Hoarsness of voice Cyanosis Pleural pain: referred to shoulder and abdomen. Fever with chills Cough with thick sputum Tachypnea Anorexia Nasal flaring Malaise Irritability Running nose Grunting

24. Diagnostic evaluation History of the child Chest x-ray: patchy consolidation can be seen Culture of sputum: shows causative organisms. \ Blood test: increased WBC Bronchoscopy Pleural fluid culture Pulse oximetry CT-scan

25. Management Mild cases: some children with no retractions are treated at home with: Antipyretics Bed rest Adequate diet and fluid intake Propped up position In severe cases: hospitalization is required: Initiation of antibiotics Comfortable position Oxygen inhalation Adequate diet and fluid intake

26. Management 1. Pneumonococcal pneumonia Penicillin 2. Pneumonia by klebsiella and haemophilus Cephalosporin, amoxicillin and clavulanic acid 3. Mycoplasm pneumonia Erythromycin, clarithromycin, azithromycin 4. Anti fungal therapy Amphotericin Flucanozole sulphonamides

27. Supportive care Antipyretics ( paracetamol 10- 15mg/kg/dose every 4-6hrs. Oxygen administration (oxygen hood, mask, nasal prongs) Hydration: Provide adequate fluid to meet the increased needs of the body. Chest physiotherapy Nutrition: Give high caloric and liquid diet. And if the client is having breathing difficulty do not give any feed as there are chances of aspiration is more.

28. Nursing care Assessment of a child and determine the causative organism. Control of fever : antipyretics and tepid sponging. Maintain patent airway Provision of high humidified oxygen. Positioning : semi fowlers position Monitor respiratory status and vital signs. Administration of antibiotics as prescribed by the dr. Promotion of rest Provision of appropriate and adequate fluids and nutrition Support and education to parents Prevention of complication.

29. Nursing diagnosis Ineffective airway clearance related to inflammation and accumulations of secretions as evidenced by cough with sputum productions. Impaired gas exchange related to alveolar capillary membrane changes as evidenced by tachycardia and restlessness. Hyperthermia related to inflammatory process as evidenced by increased body temperature. Risk for fluid volume deficit related to inadequate oral intake, fever, as evidenced by poor skin turgor. Imbalanced nutrition less than body requirement related to disease condition as evidenced by refusal of food by child.

30. Cont …. disturbed Sleeping pattern related to hyperthermia and cough as verbalized by mother’s concern for rest and sleep. Knowledge deficient about the conditions, prognosis, and treatment of pneumonia as evidenced by less knowledge about pneumonia management.

31. ASTHMA IN CHILDREN

32. Definition Asthma is defined as a reversible, characteristized by an increased responsiveness of the airways to various stimuli, manifest by wide spread narrowing of the airways causing paroxysmal dyspnea, cough and wheezing. Basically, Any of these stimuli can trigger a hyperactive allergic response which produces: Inflammation of the respiratory tract Bronchoconstriction, and Hypersecretion of mucus Asthma is a chronic inflammatory disorder of the airways characterized by recurring symptoms, airway obstruction, and bronchial hyperresponsiveness (National Asthma Education and Prevention Program [NAEPP], 2007 ).

33. Etiology Extrinsic asthma Intrinsic asthma Also called as allergic asthma: in this the symptoms are induced by the hyper-immune response to the inhalation of a specific allergen like pollen, dust, smoke, powder Non allergic asthma refers to same manifestation s of airway obstruction but in response to an unidentified or non specific factor in the environment. Can be triggered by: Exercise Aspirin Change in temperature Viral respiratory infection Emotional stress Excitement

34. Pathophysiology

35. Clinical manifestation Wheezing Dyspnea Cough Retractions Nasal flaring Stridor Tachypnea Restlessnesss Abdominal pain Fatigue due to shortness of breath Cyanosis

36. Diagnostic evaluations History taking Family history Passive cigarettes, smoking Exposure to triggering factors Socio-economic status Stressful condition Physical examination Sputum culture Chest x-ray: shows air trapping Blood examination shows eosinophilia Pulmonary function test: Pulmonary function tests (PFTs) are noninvasive tests that show how well the lungs are working. The tests measure lung volume, capacity, rates of flow, and gas exchange . RAST test or radioallergosorbent test

37. Management

38. Medical management Short acting bronchodilators : causes relaxation of bronchiol smooth muscle. E.g.: albuterol,terbutaline Anticholinergic: ipratropium bromide Mast cell inhibitors: cromolyn sodium: an NSAIDS prevents asthma by blocking of mast cell mediators. Corticosteroids: prednisolone decreases airway inflammation. Leukotriene blockers: zileuton diminish the mediator action of leukotrienes . Antibiotics Oxygen therapy: oxygen can be administered through oxygen masks and cannula.

39. Cont … Magnesium sulphate : IV administration of drug have shown bronchodilating effect. Heliox : a mixture of helium and oxygen can be given in case of breathing difficulty. Methylxanthines : such as theophylline: it works by relaxing the muscles around the airway.

40. Nursing management Nursing assessment: history and physical examination. Ineffective airway clearance related to bronchospasm and mucosal edema. Monitor respiratory rate, effort, color, heart rate. Administer humidified oxygen at ordered flow rate. Nebulization with normal saline or bronchodilaters . Positioning: upright position Keep NPO if respiratory distress is there. Maintain IV line. Administer medication as prescribed.

41. Nursing diagnosis Ineffective Airway Clearance related to bronchoconstriction, increased mucus production, ineffective cough, possible bronchopulmonary infection . Ineffective Breathing Pattern related to chronic airflow limitation. Impaired Gas Exchange related to chronic pulmonary obstruction abnormalities due to destruction of alveolar capillary membrane. Risk for Infection related to compromised pulmonary function, retained secretions, and compromised defense mechanism.

42. Imbalanced Nutrition: Less Than Body Requirements related to increased work of breathing, air swallowing, drug effects with resultant wasting of respiratory and skeletal muscles. Activity Intolerance related to compromised pulmonary function, resulting in shortness of breath and fatigue. Disturbed Sleeping Pattern related to hypoxemia and hypercapnia .