Respiratory Review

Fall 2022
Sinead Sheehan
  Respiratory Assessment
 Respiratory Illnesses
 Bronchiolitis
 Croup
 Pneumonia
Overview  Asthma
 Respiratory Equipment
 HHFNC
 Questions?
  What are we looking for?
 Respiratory rate and rhythm
 Work of breathing
Respiratory  Position of comfort
Assessment  Colour
 Oxygen saturation
 Level of consciousness
 Signs of any obstruction (such as secretions)
  What are we listening for?
 Air entry: should be equal bilaterally to the bases
Respiratory  Airway sounds: stridor, grunt, gurgle
 Auscultation sounds
Assessment  Clear
Continued  Wheeze
 Crackles
 • Suction equipment-
nasal, oral or NP
• Oxygen- prongs or non-
What rebreather
respiratory • BVM- support
ventilations
equipment do • Code Pink button/ call
bell
you have that
you can use in Not in the picture…
• Monitoring equipment
an emergency? • Meds (inhalers, nebs)
• Other people: RNs, RT,
MD

**Ensure safety check at start of shift**

Respiratory Illnesses
Bronchiolitis, Croup, Pneumonia, Asthma
  Most common cause of hospitalization
in kids under 1 year
 Diagnosis made by history, physical
exam and respiratory swab
 Most often caused by RSV but can be
caused by other respiratory viruses
 RSV
Bronchiolitis  Highly transmissible- can live on
surfaces- commonly transmitted in
schools/ daycares.
 Older kids/ teens/ adults can transmit
but likely only mild illness
 RSV season: November- April **
 Lasts 7-10 days- cough may last longer
  Virus (such as RSV) enters nasal
tract and infects epithelial cells
in the upper respiratory system.
 These cells are sloughed and
aspirated= moves to lower
respiratory.
What is  Virus replication leads to
inflammation, edema,
happening in increased mucous secretion,
etc.
**Infant airways most susceptible

bronchiolitis?  Leads to obstructions in small

as smaller/ less alveoli, smaller
airways and increased metabolic
airways, localized atelectasis demand**
and trapped air.
 May see increased respiratory
rate/ effort and dropping
oxygen saturation.
  Early symptoms:
 Nasal congestion/ discharge
 Mild cough (dry)
 Fever
 Sneezing
 Decreased appetite

Signs and  Worsening symptoms:

 Tachypnea
Symptoms of  Increased work of breathing

Bronchiolitis 
Persistent cough (may be productive)
Wheezing (sometimes crackles)
 Problems feeding (related to congestion/ tachypnea)= risk of dehydration
 Lower oxygen saturation
 Poor feeding
 Increased irritability/ lethargy

**Under 2 months of age= may have apnea**

  On Tues Nov 2nd, Baby X developed a wet cough and rhinorrhea.
Wet cough is persistent, non-croupy and non-productive; no
hemoptysis.
 Symptoms progressed to mild respiratory distress, which mother
describes as rapid breathing with abdominal movements
 Baby was feeding more but only 5 min/feed- overall reduced
breast feeding volume;
Case Example-  No fever, vomiting, diarrhea, ear tugging, or rash.
2a patient  Lives with parents and 2 y.o. sister who started w/ URTI the
preceding Wed, self-resolved. Sister attends daycare. Currently,
mother experiencing new cough and father recently experienced
sore throat. No recent travel.
 Respiratory: mild increased WOB w/ subcostal retractions and
some intermittent abdo breathing (no nasal flaring, intercostal
indrawing). Intermittent expiratory wheeze in all auscultated lung
fields. Thick nasal secretions.
  Prevent RSV
 Palivizumab (monthly IM injection during season)
 Handwashing, avoid exposure, and don’t smoke
 Treatment of bronchiolitis= manage symptoms
 Monitor work of breathing
 Provide oxygen (as needed)
Management  Monitor/ maintain hydration
 Treat fever
 Bronchodilators (if wheezing)
 Nasal drops and nasal suctioning as needed
 May need Heated High-Flow Nasal Cannula
(HHFNC)
**Higher risk for severe disease: born premature, less than 3 months,
cardiopulmonary disease or immunodeficiency, downs etc.**
  Usually lasts about
1 week.
Croup  Cough and
breathing are
Viral infection of upper
airway which worse during the
obstructions breathing first 1-3 days-
and causes a especially at night
characteristic barking  Bark due to
cough.
swelling of larynx,
trachea and
bronchi.
 Croup often begins as typical
cold but changes with
increased inflammation
 Hoarse voice
 Barking cough
Symptoms  Stridor (mild= when upset,
severe= at rest)
 Increased work of breathing
 Runny/ stuffy nose
 Fever
  Dexamethasone (0.6 mg/kg):
 Takes a few hours to work but effect lasts 24-36
hours. Usually only 1 or 2 doses are needed.
 Nebulized/ inhaled epinephrine:
Management  Effect lasts 4 hours so may need more than once.
of Croup  Oxygen therapy/ suctioning as needed
 Cool, humid air helps
 Cool night air
 Humidifier/ hot shower in bathroom
  May be caused by
virus, bacteria or fungi
 Air sacs may fill with
fluid or purulent
Pneumonia material causing cough
with phlegm/ pus,
Infection deep in the fever, chills and
lungs difficulty breathing
 In kids under 3 years
old: usually viral, in
older kids/ teens:
usually bacterial cause.
  High fever (persistent)
 Cough
 Tachypnea
 Increased work of breathing
Signs and  Crackles in lungs
Symptoms  Loss of appetite
 Vomiting (post coughing episode)
 Feeling unwell
 Abdo/ chest pain
  Bacteria in the
bloodstream
(bacteremia)
 Difficulty breathing,
Pneumonia: decreased oxygen
Complications saturation
 Fluid accumulation
around the lungs
(pleural effusion)
 Lung abscess

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 Antibiotic Therapy
Amoxicillin PO
Ampicillin IV
 Antibiotics Non-
Severe
Cefuroxime IV
Clarithromycin PO
Pneumonia Azithromycin IV
** Medication education**
 Treat fever Ceftriaxone IV
Vancomycin IV (if critically ill)
 Keep hydrated
Management Severe If atypical Pneumonia (over 5
Pneumonia years)
 Suction, oxygen and Clarithromycin PO
bronchodilators as Azithromycin IV
needed Aspiration
Ceftrizone IV

Pneumonia If abscess suspected

Clindamycin IV
  Narrowing of airways +
inflammation + mucous
Asthma production in response to a
trigger
 Most common chronic
Chronic lung disease condition in kids
where the airways get  Can be a lifelong condition, but
narrow and swollen good asthma control can allow
and are blocked by kids to live a normal life
excess mucus  Symptoms include: coughing,
wheezing and trouble
breathing
 Early Warning Signs:
 Daytime coughing or wheezing
 Breathing problems:
 Breathing faster than normal
 Feeling short of breath
 Feelings of chest tightness or a heavy chest
Asthma:  Any other difficulty breathing

Signs &  Nighttime waking due to coughing, wheezing or

breathing problems.
Symptoms  Coughing/ trouble breathing with physical activity
Late Warning Signs:
 Reliever puffer lasting less than 3 hours
 Shortness of Breath
 Continuous coughing and wheezing
 Difficulty talking
 Use of intercostal muscles
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 Risk factors for asthma include:
 history of allergies and eczema
 family history of allergies and allergic
Asthma: disorders like asthma and eczema
 being exposed to tobacco smoke
Causes, Risk before birth and during childhood
Factors,  a respiratory infection called
Prevalence respiratory syncytial virus (RSV) during
childhood
 low birth weight

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 The
Paediatric Respiratory
Assessment Measure
(PRAM) is a 12-point
scoring system to
objectively assess
asthma severity and
PRAM Scores response to treatment
in an acute care setting.

0-3= mild
4-7= moderate
8-12= severe

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 1. Controllers
(such as Fluticasone) to
decrease inflammation and
mucous in the airways

Treatment 2. Relievers
(such as Ventolin) for quick relief
during an episode to
bronchodilate the airways.
 Increasing
Severity….

 Steroids
Treatment: I.e. dexamethasone (po) or
hydrocortisone (iv)
Acute Asthma  Oxygen therapy
Episode/  Salbutamol nebulizer
Refractory  Magnesium Sulfate
Asthma  IV Salbutamol
 1. Shake the MDI
2. Attach to Aerochamber
Inhalers: 3. Firmly hold mask onto child’s face covering nose and
Metered Dose mouth

Inhaler with 4. Release puff into Aerochamber and hold for 10 breaths

Aerochamber and 5. Wait 30-60 seconds minimum between breaths

Mask 6. Have child rinse mouth after use

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 1.Shake the MDI
2.Breath Out
3.Place mouthpiece between teeth and
tongue is flat and close lips around
Inhalers: mouthpiece
Metered Dose 4.Breath in slowly and press canister until
Inhaler with you have completed your breath
Aerochamber and 5.Hold breath for 10 seconds
Mouthpiece 6.Wait 30-60 seconds minimum between
breaths
7.Have child rinse mouth after use

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  Used to measure and monitor how well air is moving
through the lungs.
 Colour- coded: green, yellow and red
 To be used:
 Before/ after giving a reliever

Peak Flow  During an asthma episode

 1-2 times daily
Meters  Tricky to use so child needs to be able to follow
directions well
 Can help tell:
 If child if having difficulty with asthma
 If the medications are helping
 If the child is getting better after an asthma episode
Paediatric
Asthma
Education
Checklist

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My Asthma
Action Plan

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 HHFNC is an oxygen delivery device that delivers a heated and humidified mixture of
air and oxygen at a flowrate that meets or exceeds the patient’s peak inspiratory
flow.
• Requires a physician order (RT can initiate HHFNC without an order if
required).
• Continuous cardio-resp monitoring
AIRVO: • Team huddle 60 minutes post HHFNC initiation to re-evaluate patient status.
Should be documented in an EPIC note.
Heated High Flow • Patient NPO initially- reassess based on patient’s tolerance of therapy.
Nasal Cannula • RN to observe first oral feed on AIRVO (if feeds restarted)
• Patients on flow rates greater than or equal to 2 L/kg/min and/or 0.60 FiO2
(HHFNC) require consideration for transfer to tertiary centre

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 ROLE OF PAEDIATRICIAN:
 Consult RT Re: initiation of HHFNC
 Enter order for HHFNC
 60 minute huddle post HHFNC initiation

AIRVO:
ROLE OF RT:
Heated High Flow
 Initiating and titrating HHFNC therapy in all clinical areas.
Nasal Cannula
 Q2-4 and PRN assessments
 RT or MRP may adjust flow rate

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 ROLE OF RN
 Assessment of HR, BP, RR, SPO2, resp
assessment and PEWS score:
 Pre-initiation of HHFNC
 On initiation: Q1H x 4, then Q2H x2 then if stable,
Q4H
 If any increase in oxygen or flow: go back to Q1H x

AIRVO: 4, Q2h x 2, Q4H

 PRN based on patient’s condition
Heated High Flow  Abdominal Girth: check Qshift
Nasal Cannula  Equipment checks Q1H- ensure:
 Tubing connected with no blockages
 Nasal cannula in place
 Water inhalation bag not empty
 Correct settings on AIRVO

 Adjust oxygen concentration to maintain

ordered SPO2 levels

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Questions?
 Sick Kids. Asthma Learning Hub, About Kids Health. Retrieved from https://www.aboutkidshealth.ca/asthmahub

Sick Kids. RSV Learning Hub, About Kids Health. Retrieved from https://
www.aboutkidshealth.ca/article?contentid=764&language=english

Sick Kids. Pneumonia Learning Hub, About Kids Health. Retrieved from https://
www.aboutkidshealth.ca/Article?contentid=784&language=English

Pneumonia. Mayo Clinic. Retrieved https://www.mayoclinic.org/diseases-conditions/pneumonia/symptoms-causes/syc-

20354204

References
Sick Kids. Croup Learning Hub, About Kids Health. Retrieved from
https://www.aboutkidshealth.ca/article?contentid=17&language=english

Croup. Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/croup/symptoms-causes/syc-

20350348

Sick Kids. Bronchiolitis Learning Hub, About Kids Health. Retrieved from
https://www.aboutkidshealth.ca/Article?contentid=765&language=English

Bronchiolitis. Mayo Clinic. Retrieved from https://

www.mayoclinic.org/diseases-conditions/bronchiolitis/symptoms-causes/syc-20351565

Respiratory syncytial virus. Mayo Clinic. Retrieved from https://

www.mayoclinic.org/diseases-conditions/respiratory-syncytial-virus/symptoms-causes/syc-20353098 34
MDI and Spacer. Breathe: the Lung Association. Retrieved from MDI Spacer - Preschooler | Canadian Lung Association