PRESENTED BY-
JAYESH SONI
MSc. N. (PEDIATRICS)

ASTHMA

BRONCHIAL ASTHMA
DEFINITION : Bronchial asthma is a chronic
inflammatory disorder of the lower airway is
characterized by bouts of dyspnea
(predominantly “expiratory”), as a result of
temporary narrowing of the bronchi by
bronchospasm, mucosal edema and thick
secretions.

Types
Mainly 3 types:
(1) Allergic or Extrinsic asthma- It produce by hyper immune
(IgE) response to the inhalation of specific allergen
(pollen, duct etc..)
Children with extrinsic asthma usually have positive
skin test to offending allergen or positive family history of
allergy
(2) Non-allergic or Intrinsic asthma- It is produce in response
to unidentified or non-specific factors(triggers) of
environment
No hyper immune response produced, may be positive
family history
Child have irritable & hyper-reactive airway
(3) Mixed type- Or both Allergic & Non-allergic

ETIOLOGY
The obstructive processes are secondary to an increased responsiveness of the
bronchi to any one or a combination of a diverse group of factors referred to as
‘triggers’
• Allergy to certain foreign substances: Inhalants like smoke, dust and powder,
Foods like egg, meat, wheat, and chocolate.
• Food additives
• Drugs like aspirin and morphine
• Respiratory infection
• Emotional disturbances
• Exhaustion during exercise
• Change of climate/weather
• Release of airborne allergens in the environment
• Loss of heat and water from the lower airways
• Puberty changes : Endocrinal changes enhances the symptoms of asthma
Predisposing factors
• Heredity
• Childhood infections like measles and pertusis

PATHOPHYSIOLOGY
Triggers
Activation of mast cells, T cells and epsinophil
Infiltration of mucosa and epithelium
Mast cells releases the mediators of inflammation (leukotriens)
Damage the wall of the airway
Epithelial shedding and mucus secretion
Bronchospasm involving smooth muscles
Bronchial hyperactivity
Symptoms such as wheezing and respiratory distress
Asthma
Collapse and emphysema Bronchiectasis

CLINICAL MANIFESTATIONS:
The onset of asthmatic paroxysm is usually sudden and often occurs at night.
A typical attack of asthma is characterized by
 Dyspnoea
 Wheezing (expiratory)
 Cough with or without sputum
 cyanosis
 Pallor
 Sweating
 Exhaustion
 Restlessness
 Tightness in the chest
 Paroxysmal cough
• Generally recurrent asthmatic attacks last over 2-10 days with the interval
of few days to few months.
• Children with severe bronchial asthma over a prolonged period may
develops a barrel shaped chest deformity.

DIAGNOSTIC EVALUATION:
History -
– Family
– Environmental
– Disease characteristics.
• Physical Examination
• PEER (Peak Expiratory Flow Rate) meter test: The
child is made to stand and breathe in deeply.
Then he breathes out quickly and hard right in to
PEER meter. Repeat for three times. If the reading
is low it indicates Asthma.
• Chest X – ray
• Pulmonary function test (Spirometry )

COMPLICATIONS
• Emphysema
• Collapse
• Pnemothorax
• Bronchiectasis
• Tuberculosis in patients on prolonged steroid therapy
MANAGEMENT:
• Allergen control
• Prevention of exacerbation by avoidance of triggers, avoidance of allergens
and use of medications.
• Drug therapy: Asthma medications are categorized into two-
• Long term control medications i.e Corticosteroids, cromolyn sodium,
nedocromil sodium.
• Quick relief medications i.e. anti-cholinergics, systemic corticosteroids
• Chest physiotherapy including breathing exercises and physical training
• Many asthma medications are given by inhalation with a nebulizer or a
Metered-Dose Inhaler (MDI).

NURSING MANAGEMENT:
Providing emotional support
Positioning
Continuous evaluation of respiratory status.
Oxygen therapy
Administer fluid therapy
Providing rest
Supporting family members
Providing Health education
NURSING DIAGNOSIS:
 Ineffective airway clearance related to inflammation and constriction of
bronchi.
 Activity intolerance related to imbalance between oxygen supply and
demand
 Disturbed sleep pattern related to severe cough and respiratory distress.
 Imbalanced nutritional status less than body requirement related to
anorexia.
 Anxiety related to prognosis of disease and hospitalization.
 Deficient knowledge regarding the treatment and follow up care

ATELECTASIS
Presented By-
Jayesh Soni
HOD Pediatric Nursing

ATELECTASIS
• Atelectasis is defined as the collapse or closure of the lung
resulting in reduced or absent gas exchange. It may affect part
or all of one lung or Atelectasis is the collapse of alveoli or
lung tissue.
• It develops when the alveoli becomes airless from absorption
of their air without replacement of the air with breathing.

Types
Mainly 3 types observed in children-
1- Obstructive: Complete/Partial lung airway obstruction due to cause
include airway foreign body, blood clot, mucus plug, and tumor
2- Resorptive: Child with neuromuscular weakness, who lack the ability to
reinflate the collapsed area of lung. Child with respiratory muscle weakness
or spinal cord injury are at increased risk for mucus plugging, atelectasis,
and pneumonia.
3- Compressive: it is caused by
space-occupying masses within
the chest. Eg- large cysts,
overinflated lobes, Cardiomegaly,
or congenital lobar emphysema
that can compress and collapse
adjacent lung tissue.

Etiology
1. Congenital/primary atelectasis- Preterm or LBW baby.
- due to immaturity of respiratory of muscle, alveolar ducts
abnormality, any pulmonary disorders.
2. Acquired or secondary atelectasis:
• Bronchial obstruction due to foreign body
• Excessive secretions
• Mucus plugs
• Tumors
• Enlargement of lymph nodes or heart
• Pleural effusion
• Pneumothorax, tension cyst
• Prolonged anesthesia or
abdominal surgery.

Congenital/primary atelectasis Acquired or secondary atelectasis
Immaturity of respiratory of muscle Bronchial obstruction due to foreign body
or alveolar ducts in Premature/LBW Mucus plugs, tumor or any cause
Baby
Reduce ventilation or Blockage
Obstruction of passage of air
Trapped alveolar air absorbed into bloodstream
But outside air cannot replace the absorbed air due to blockage
Affected portion of alveoli becomes airless
Excessive pressure on the lung tissue
Restricts normal lung expansion on inspiration
Alveoli collaps (Atelectasis)
Pathophysiology

Clinical Manifestation
Rapid bronchial occlusion with a large area of lung
collapse causes;
 chest pain on the affected side,
 Retraction
 Coughing
 Sputum production and low-grade fever
 Marked respiratory distress
 Dyspnea,
 tachycardia,
 Tachypnea,
 pleural pain and central cyanosis
 Difficulty breathing in the supine position

Assessment and Diagnostic Findings
• Chest x-ray : patchy infiltrates or
consolidated areas.
• Pulse oximetry: (SpO2) (less than 90%)
or a (PaO2).
• Physical examination: Decreased breath
sounds and crackles are heard over the
affected area.
• Complete Blood count
• CT scan to check for infections or
blockages, such as a tumor in your lung
or airway
• Bronchoscopy -which involves inserting
a camera, located on the end of a thin,
flexible tube, through nose or mouth
and into lungs

Prevention
• Frequent turning, early mobilization,
Strategies to expand the lungs and to manage
secretions.
• Deep-breathing maneuvers (at least every 2
hours)
• The use of incentive spirometry or voluntary
deep breathing
• Directed cough, suctioning, aerosol nebulizer
treatments followed by chest physical
therapy
• Postural Drainage and chest percussion, or
bronchoscopy
• Change position frequently, especially from
supine to upright position, to promote
ventilation and prevent secretions from
accumulating.
• Encourage appropriate deep breathing and
coughing to mobilize secretions and prevent
them from accumulating.
Incentive Spirometry
Aerosol Nebulization

Management
• The goal in treating the patient with
atelectasis is to improve ventilation and
remove secretions
• In patients who do not respond to first-
line measures or who cannot perform
deep-breathing exercises, other
treatments such as positive expiratory
pressure (PEP therapy )
• If the cause of atelectasis is bronchial
obstruction from secretions, the
secretions must be removed by
coughing or suctioning to permit air to
re-enter that portion of the lung
• Chest physical therapy (chest
percussion and postural drainage)

• Nebulizer treatments with a bronchodilator
• Medication or sodium bicarbonate may be used to assist in
the expectoration of secretions.
• Thoracentesis, removal of the fluid by needle aspiration, or
insertion of a chest tube if cause is compression
• If respiratory care measures fail to remove the obstruction, a
bronchoscopy is performed.
• Endotracheal intubation and mechanical ventilation may be
necessary for respiratory failure

Surgical management
If atelectasis is chronic and cannot re-expands of
lungs, than removal of the involvement part of lungs
via lobectomy or segmental resection may be
done..if needed

EMPYEMA
• Empyema is also called pyothorax or purulent pleuritis. It’s a
condition in which pus gathers in the area between the lungs
and the inner surface of the chest wall. This area is known as
the pleural space.
• Pus is a fluid that’s filled with immune cells, dead cells, and
bacteria.
• Pus in the pleural space can’t be coughed out. Instead, it needs
to be drained by a needle or surgery.
• The two most common bacteria
Streptococcus pneumoniae
and Staphylococcus aureus are
responsible in children.

Symptoms
Simple empyema
• Simple empyema occurs in the
early stages of the illness. A child
has this type, if the pus is free-
flowing.
The symptoms of simple empyema
include:
• shortness of breath
• dry cough
• fever
• sweating
• chest pain when breathing that
may be described as stabbing
• headache
• confusion
• loss of appetite
Complex empyema
• Complex empyema occurs in the later
stage of the illness. In complex
empyema, the inflammation is more
severe. Scar tissue may form and
divide the chest cavity into smaller
cavities. This is called loculation, and
it’s more difficult to treat.
• If the infection continues to get
worse, it can lead to the formation of
a thick peel over the pleura, called a
pleural peel. This peel prevents the
lung from expanding. Surgery is
required to fix it.
Other symptoms in complex empyema
include:
• difficulty breathing
• decreased breath sounds
• weight loss
• chest pain

Diagnosis
• Chest X-rays and CT scans will show whether or not there’s
fluid in the pleural space.
• An ultrasound of the chest will show the amount of fluid and
its exact location.
• Blood tests can help check white blood cell count, look for the
C-reactive protein, and identify the bacteria causing the
infection. White cell count can be elevated if have an
infection.
• During a thoracentesis, a needle is
inserted through the back of your
ribcage into the pleural space to
take a sample of fluid. The fluid is
then analyzed under a microscope
to look for bacteria, protein, and
other cells.

Treatment/Management
• Treatment is aimed at removing the pus and fluid
from the pleura and treating the infection.
Antibiotics are used to treat the underlying infection.

There are different types of surgery for this:
• Percutaneous Thoracentesis - A needle can be inserted into
the pleural space to drain the fluid.
• Thoracostomy: In this procedure, a plastic tube inserted into
chest between two ribs. Then they’ll connect the tube to a
suction device and remove the fluid. They may also inject
medication to help drain the fluid.

EMPHYSEMA
• Emphysema affects the air spaces
distal to the terminal bronchiole. It
is characterized by abnormal
permanent enlargement of lung air
spaces with the destruction of their
walls without any fibrosis and
destruction of lung parenchyma
with loss of elasticity. this lung
condition causes severe shortness
of breath.
• In very rare cases, children can develop emphysema, can be
develops due to an congenital abnormality.
• It is a progressive lung disease, is a form of chronic obstructive
pulmonary disease (COPD).

Types of emphysema in children
Alpha-1 antitrypsin deficiency
• Alpha-1 antitrypsin deficiency – this protein
protects the alveoli (air sacs in the lungs) from
damage due to a certain enzyme in the body. This
damage to the air sacs of the lungs can lead to
emphysema.
Lobar emphysema (congenital alveolar overdistension)
• Lobar emphysema – a rare respiratory condition
in which air enters the lungs but cannot escape,
leading to over-inflation of the lungs

Causes
• A hereditary (passed down in families) gene
mutation causes emphysema in children.

Signs and symptoms
• Breathing very quickly (respiratory distress)
• Difficulty breathing
• Bluish tint to the skin (due to decreased
oxygen in the blood)
• Enlarged chest (Barrel shaped)
• Underdevelopment of the cartilage that
supports the bronchial tube (the passages
through which air flows in and out of the
lungs)

Diagnosis
Physical examination for symptoms-
• Decreased breath sounds through the stethoscope
• Rounded fingertips (clubbing)
• Pursed-lip breathing (to counteract alveolar collapse)
• Hypoxia or Hypoxemia
• Hypercarbia: High levels of carbon dioxide in the blood.
Chest X-ray- A chest X-ray of someone with emphysema may show
abnormally large lungs
CT scan of chest - A CT scan in someone with emphysema may show
small pockets of air throughout the lung
Pulmonary function tests (PFTs) – is a simple test that measures
airway obstruction.
Complete blood count (CBC)- ABG, Hematocrit, Serum Bicarbonate
level..

Treatment
• Mainly focuses on improving emphysema symptoms
• Smoking cessation (active/passive)
• Medications are usually prescribed to widen the airways
(bronchodilators) -albuterol
• Anti-inflammatory drugs to reduce swelling in the airways
(such as steroids)
• Antibiotics (to treat lung infections)
Supportive management-
• Oxygen therapy
• Lung volume reduction surgery - Surgical removal of large
areas of damaged lung
• Pulmonary rehabilitation
• Lung transplantation - This is the most drastic of emphysema
treatments

Plural effusion
Each pleura has two parts:
– Parietal layer : which lines the
thoracic wall
– Visceral layer : which completely
covers the outer surfaces of the
lungs
Parietal pleura divide the according to
the region:
Costal pleura lines the inner
surfaces of the ribs, the costal
cartilages, the intercostal spaces.
Diaphragmatic pleura covers the
thoracic surface of the diaphragm.
Mediastinal pleura covers and
forms the lateral boundary of the
mediastinum.

Plural effusion
• Pleural effusion, a collection of fluid in the pleural space, is
rarely a primary disease process but is usually secondary to
other diseases.
• The pleural space normally contains only about 10-20 ml of
serous fluid. Pleural fluid normally seeps continually into the
pleural space from the capillaries lining the parietal pleura and
is reabsorbed by the visceral pleural capillaries and lymphatic
system.
• Any condition that interferes
with either secretion or drainage
of this fluid leads to pleural
effusion.

Classification
Transudative effusions
Transudative effusions also known as
hydrothoraces , occur primarily in
non-inflammatory conditions; is an
accumulation of low-protein, low cell
count fluid.
Cause
• Increase hydrostatic pressure found
in heart failure ( most common
cause of pleural effusion)
• Decrease oncotic pressure ( From
hypoalbuminemia) found in cirrhosis
of liver or renal disease.
• In this condition, fluid movement is
facilitated out of the capillaries and
into the pleural space
Exudative effusions
Exudative effusions occur in an area of
inflammation; is an accumulation of
high-protein fluid.
An exudative effusion results from
increased capillary permeability
characteristic of inflammatory reaction.
This types of effusion occurs secondary
to conditions such as pulmonary
malignancies, pulmonary infections and
pulmonary embolization.
Cause
• Disseminated cancer (particularly lung
and breast), lymphoma
• Pleuro-pulmonary infections
(pneumonia)
• Heart failure
• cirrhosis, nephrotic syndrome
• Other conditions sarcoidosis,
• systemic lupus erythematosus (SLE)
• Peritoneal dialysis

Pathophysiology
Transudative pleural effusions:
Increased Hydrostatic pressure
&
Decreased Oncotic pressure
Unable to remain the fluid with
in a intravascular space
Fluid shift interstitial space
Effusion

Pathophysiology
Exudative pleural effusions:
Invasion of microbes
Initiation of inflammatory reaction
Vasodilation increase capillary permeability
leak of plasma protein
decrease oncotic pressure
fluid shift into interstitial space

Clinical Manifestations
Usually the clinical manifestations are those caused by
the underlying disease and severity of effusion
• Pneumonia causes fever, chills, and pleuritic chest pain
• malignant effusion may result in dyspnea and coughing
• When a small to moderate pleural effusion is present,
dyspnea may be absent or only minimal.
• Pleuritic chest pain,
• Dullness or flatness to percussion
• Decreased or absent breath sounds

Diagnostic Evaluation
The diagnosis of pleural effusion is based on both
medical history and physical examination
• Chest X-ray or ultrasound detects presence of fluid,
in which the pleural effusion appears as an area of
whiteness on a standard posteroanterior chest X-ray.
• Thoracentesis biochemical, bacteriologic, and
cytologic studies of pleural fluid indicates cause.

Management
• The objectives of treatment are to discover the
underlying cause, to prevent reaccumulation of
fluid, and to relieve discomfort, dyspnea, and
respiratory compromise.
General-
• Treatment is aimed at underlying cause (heart
disease, infection).
• Thoracentesis is done to remove fluid, collect a
specimen, and relieve dyspnea

For Malignant Effusions -
• Chest tube drainage, radiation, chemotherapy,
surgical pleurectomy, pleuroperitoneal shunt,
or pleurodesis
• Pleurectomy:
a type of surgery in which part of the pleura
is removed.

Nursing Assessment-
 Obtain history of previous pulmonary
condition
 Assess child for dyspnea and tachypnea
 Auscultate and percuss lungs for
abnormalities
Nursing Diagnosis
Ineffective Breathing Pattern related to
collection of fluid in pleural space

RESPIRATORY DISTRESS
SYNDROME
JAYESH SONI
HOD
CHILD HEALTH NURSING

RESPIRATORY DISTRESS
SYNDROME
Definition
• Acute lung disease of the newborn caused by
developmental insufficiency of surfactant
production and structural immaturity of the
lungs.

INCIDENCE & CAUSES OF RDS
• Approximately 50% of the neonates born at 26-28
weeks of gestation develop RDS.
Contributing factors:
• Neonates younger than 33-38 weeks
• Weight less than 2500g
• Maternal diabetes
• Cesarean delivery without preceding labor
• Fetal asphyxia
• Second of twins

PATHOPHYSIOLOGY
Etiology
Deficient surfactant production in
newborn
Hypo inflation of alveoli
Forceful inflation to inflate
alveoli
Pulmonary resistance
Shunting of blood through
foramen ovale and ductus
arteriols
Poor lung perfusion
Hypoxia
Anaerobic metabolism
Lactic acid and increased co2
levels
Alveolar collapse
Respiratory failure

Respiratory
signs and symptoms:
1. Tachypnea
2. Dyspnea
3. Intercostal retraction
4. Audible expiratory grunt
5. Flaring of the nares
6. Cynosis

CLINICAL MANIFESTATIONS
• At the disease progress
1. Apnea
2. Flaccidity
3. Unresponsiveness
4. Diminished breath sounds
• Severe Disease associated with:
1. Shock
2. Diminished cardiac return and bradycardia.
3. Low arterial blood pressure.

Silverman score

Score- 0-3 = mild distress
4-6 = moderate distress
>6 = impeding respiratory failure

Chest retraction
When the upper airway (trachea) or
the small airways of the lungs
(bronchioles) become partially
blocked, air flow is restricted.
As a result, the intercostal muscles
are sucked inward, between the ribs.
This sucking in of the chest muscles
is a sign of airway obstruction.
Diseases or conditions that cause
restriction of the airway will cause
intercostal retraction.

Nasal flaring
• Nasal flaring is the
enlargement of the opening
of the nostrils during
breathing. It is often a sign
that increased effort is
needed to breathe
Expiratory grunt
• quick, sharp sound created
by a forced expiration

Diagnosis
• History of premature delivery
• Concentration of lecithin in amniotic fluids
• Ratio of lecithin/sphingomyelin
• Lecithin indicate lung maturity
• L/S ratio 2:1 indicate lung maturity
Post natal diagnosis
• Clinical findings
• Shake test – to identify surfactant deficiency
• Chest X-ray
• Blood gas measurement.

Treatment of RDS
• Oxygen
• Surfactant
• Arterial blood gases
• Chest X-ray
• Infection control
Oxygen:
 Maintain Pao2 - 50-80mmHg
 Spo2- 88-92%
 Nasal cannula
 if >25% oxygen is required
Mechanical ventilation

Treatment of RDS
Supportive treatment
• Temperature regulation: prevent hypothermia.
• Fluids, metabolism, and nutrition: closely monitor and
maintain blood glucose, electrolytes, acid balance,
calcium, phosphorous, renal function, and hydration.
• Once the infant is stable, intravenous nutrition with
aminoacids and lipid.
• After the respiratory status is stable, initiate small
volume gastric feeds (preferably breast milk)

Other Supportive treatment
• Circulation and anemia: monitor heart rate, peripheral
perfusion, and blood pressure. Blood or volume expanders
may be required.
• Antibiotics: start antibiotics in all infants who present with
respiratory distress at birth after obtaining blood cultures.
Discontinue antibiotics after three to five days if blood
cultures are negative.
• Support of parents and family: keep the parents well
informed. Encourage parents

Prevention of RDS
• Intubation of infant born at or before 30 weeks
gestation in the delivery
• Prophylactic natural surfactant therapy is
administrated through the ET as soon as the infant is
stable after intubation
• Do not delay surfactant for CXR
• No CXR is necessary to confirm
• Antenatal Steroids should be given to any pregnant
women at 24 to 34 weeks of gestation with intact
membranes at high risk for preterm delivery.

PNEUMOTHORAX
Presented By-
Jayesh Soni
HOD - Pediatrics
CHRONIC RESPIRATORY DISEASE

Introduction
• Occurs when air collects between the pleural
layers causing the lung to collapse.
• If blood collects in the pleural space, it is
called a hemothorax and if blood and air
collect, it is called pneumothorax.
62
• Pneumothorax - air leaks into the space
between the chest wall and the outer tissues of
the lungs.
• Pneumomediastinum - air leaks into the
mediastinum (the space in the thoracic cavity
behind the sternum and between the two
pleural sacs containing the lungs).

DEFINITION
• Pneumothorax is a
lung disorder in
which air in the lungs
leaks out through
holes in the lung
tissue into the spaces
outside the lung
airways.
• It is also called air
leak syndrome.
63

Mainly 3 Types:

Causes
• Air leaks occur when the alveoli (tiny air sacs) become
over distended and burst.
• Pressure of the air delivered by mechanical ventilators
(breathing machines) is the most common cause.
• Meconium aspiration (inhalation of the first stools passed
in utero) can also trap air and lead to over distention (the
lungs expand too much) and air leaks.
• Air leaks often occur in the first 24 to 36 hours when lung
disease is at its peak.
• Other causes includes- family history, smoking
• Baby have infections like COPD, TB, Asthama, Bacterial
Pneumonia etc..
• Or any trauma

Risk factors
• babies with other lung diseases such as hyaline
membrane disease (HMD)
• babies on mechanical ventilators
• premature babies whose lung tissues are more
fragile
• babies with meconium aspiration because the
meconium plugs the airways and can weaken the
tissues

Signs and symptoms
• increasing respiratory distress, including rapid
breathing, grunting, nostril flaring, and chest wall
retractions
• difficulty hearing breath sounds when listening
with a stethoscope
• change in the location of heart or lung sounds when
the organs are moved by the presence of air
• changes in arterial blood gas levels

diagnosis
• chest x-rays - X-rays may
show the following:
–air in places outside the
normal lung airways
–collapse of the lung
–movement or shifting of
other organs in the chest
away from the air leak
side
68

Contd..
Transillumination - a fiber optic
light probe placed on the baby's
chest wall (the side of the chest
with the air leak transmits
brighter light). This procedure
is often used in an emergency.
69
https://youtu.be/Xe3h2gSTHlA

Treatment
Specific treatment for pneumothorax and air leak syndrome
will be determined by baby's physician based on:
• baby's gestational age, overall health, and medical history
• extent of the condition
• baby's tolerance for specific medications, procedures, or
therapies
• expectations for the course of the condition
70

Contd..
Treatment for pneumothorax may include:
• supplemental oxygen
• removal of the collected air by insertion of a
chest tube (a needle or catheter placed through
the chest wall into the air space). The air may be
withdrawn with a syringe or the tube connected
to a drainage system to help remove the air until
the leak can seal. 71

NURSING DIAGNOSIS
• Impaired gas exchange related to altered oxygen
supply secondary to ventilation perfusion mismatch.
• Ineffective breathing pattern related to decreased
lung expansion secondary to malfunction of chest
drainage system.
• Acute pain related to impaired pleural integrity or
presence of chest tube.
• Risk for infection related to insertion of chest tube.