Mais conteúdo relacionado


Respiratory system dis. By Jayesh sir.pptx

  3. 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.
  4. 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
  5. 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
  6. 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
  7. 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.
  8. 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 )
  9. 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).
  10. 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
  11. ATELECTASIS Presented By- Jayesh Soni HOD Pediatric Nursing
  12. 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.
  13. 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.
  14. 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.
  15. 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
  16. 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
  17. 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
  18. 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
  19. 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)
  20. • 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
  21. 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
  22. 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.
  23. 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
  24. 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.
  25. 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.
  26. 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.
  27. 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).
  28. 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
  29. Causes • A hereditary (passed down in families) gene mutation causes emphysema in children.
  30. 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)
  31. 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..
  32. 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
  33. 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.
  34. 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.
  35. 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
  36. 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
  37. 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
  38. 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
  39. 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.
  40. 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
  41. 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.
  42. 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
  44. RESPIRATORY DISTRESS SYNDROME Definition • Acute lung disease of the newborn caused by developmental insufficiency of surfactant production and structural immaturity of the lungs.
  45. 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
  46. 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
  47. Respiratory signs and symptoms: 1. Tachypnea 2. Dyspnea 3. Intercostal retraction 4. Audible expiratory grunt 5. Flaring of the nares 6. Cynosis
  48. 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.
  49. Silverman score
  50. Score- 0-3 = mild distress 4-6 = moderate distress >6 = impeding respiratory failure
  51. 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.
  52. 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
  53. 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.
  54. 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
  55. 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)
  56. 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
  57. 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.
  59. 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).
  60. 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
  61. Mainly 3 Types:
  62. 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
  63. 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
  64. 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
  65. 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
  66. 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
  67. 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
  68. 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
  69. 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.