Children's Respiratory Nursing

Janice Mighten, Janice Mighten

• Publisher: Wiley-Blackwell
• Year: 2012
• ISBN:
  9781118278277
• Edition: 1
• Topic: Medicina
• Subtopic: Enfermería pedriática

Children's Respiratory Nursing is a comprehensive, patient-centred text providing up-to-date information about the contemporary management of children with respiratory conditions. It looks at acute and chronic respiratory conditions in both primary and secondary health care sectors and explores the subject from a child- and family-focused perspective. Children's Respiratory Nursing isdivided into four user-friendly sections:

• The first section provides a general background for children's respiratory nursing
• Section two explores the various investigations that aid diagnosis and treatment, such as assessment of defects in airflow and lung volume, oxygen therapy, and long term ventilation
• Section three looks at respiratory infection and provides an overview of the common infections in children with reference to national and local guidelines
• The final section considers the practical issues that impact on children's nurses - the transition from children to adult services, legal and ethical issues and the professional communication skills needed for dealing with children and their families

This practical text is essential reading for all children's nurses who have a special interestin respiratory conditions and would like to develop a greater level of understanding of the management required.

Special Features

• Examples of good practice provided throughout
• Includes evidence-based case studies
• Explores care in both hospital and community settings
• A strong practical approach throughout

Section III

Respiratory conditions

Chapter 8

Management of lung infection in children

Alan R. Smyth

Professor of Child Health, School of Clinical Sciences, University of Nottingham; Honorary
Consultant in Paediatric Respiratory Medicine, Nottingham Children’s Hospital

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Learning objectives

After studying this chapter, the reader will:

• understand the range of pathogens causing lung infection in children
• be aware of strategies to prevent serious lung infection in children and to prevent cross-infection in the hospital setting
• understand the diagnostic difficulties which may arise
• be familiar with the emergency management of paediatric lung infection
• be familiar with the specific antimicrobial therapies available and ways of improving ­effectiveness through increased adherence.

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Introduction

Respiratory infections in children are common. One-third of all preschool children will be seen in primary care at least once a year because they are coughing (Hay et al. 2005). Respiratory ­infections are one of the most common reasons for children to be admitted to hospital; respiratory syncytial virus (RSV) infection alone is estimated to account for 20% of hospital admissions in preschool children in the US (Hall et al. 2009). The cost to the UK National Health Service of treating acute cough in preschool children has been estimated at over £30 million per year (Hollinghurst et al. 2008).

Respiratory symptoms (such as poor feeding, cough and difficulty breathing) may indicate a ­self-limiting upper respiratory infection or the early stages of a severe lower respiratory ­infection (such as bronchiolitis, croup or pneumonia). Careful nursing observations will ensure effective ­triage and assessment, as well as guiding the supportive treatment which is the ­cornerstone of care.

Bronchiolitis

Acute bronchiolitis is one of the most common causes of hospital admission in children in the UK, during the months of November through to the end of February. In other parts of the world, different seasonal peaks occur and, in many tropical countries, the peak in admissions corresponds with the rainy season.

Bronchiolitis is most commonly caused by RSV but other important causes are human ­metapneumovirus, parainfluenza virus type 3, influenza and adenovirus. The clinical syndrome is the same, irrespective of the virus responsible, with the exception of some forms of adenovirus which have the capacity to cause severe pneumonia and a form of permanent lung damage known as ­obliterative bronchiolitis. Infants have smaller airways than older children and these are more likely to become blocked (leading to air trapping) when inflammation, due to virus infection, ­produces inflammatory secretions and oedema. A 1 mm rim of oedema in an airway of 4 mm in diameter will increase airways resistance 16-fold. Much of the inflammation in bronchiolitis is caused by ­neutrophils and an excessive response by the infant’s immune system (McNamara and Smyth 2002).

Bronchiolitis is primarily a condition of the first year of life. It is a clinical syndrome, characterised by coryza, cough and a chest which appears hyperinflated (air ‘trapped’ in the chest). When a stethoscope is applied, crackles are heard at the lung bases. In North America, the term bronchiolitis may be applied to young children with episodic (viral) wheeze.

In most cases the infant’s mother will report poor feeding. In the early stages of infection, this may be due to coryza, causing nasal obstruction. As infection progresses over several days, poor feeding may be related to tachypnoea. Where this is severe, infants are at risk of aspiration. Infants under 6 weeks of age with RSV infection are at risk of central apnoea.

There is no active immunisation against RSV infection. Infants with chronic lung disease of ­prematurity who are receiving home oxygen, those with some forms of congenital heart disease and severe immune deficiency are at greater risk of severe bronchiolitis. Passive immunisation with palivisumab (a monoclonal antibody against RSV) should be offered to these children (JCVI 2004). This is expensive and needs to be administered at monthly intervals usually in five doses over the winter period.

Viral diagnostic tests may help with measures to prevent cross-infection in hospital, e.g. nurs­ing infants with RSV infection in cubicles or cohorting larger groups with RSV infection in ‘­bronchiolitis bays’ (SIGN 2006). Each institution will have its own infection control policy, which should be followed. Nasopharyngeal aspirates can be analysed by direct immunofluorescence but increasingly polymerase chain reaction (PCR, see Glossary) methods are used. A chest x-ray is rarely helpful, unless a complication such as aspiration is suspected.

The treatment of viral bronchiolitis is supportive. Babies who are feeding poorly should have nasogastric feeds (SIGN 2006). However, if the infant is very tachypnoeic (>60 breaths per minute), consider nil by mouth and intravenous fluids for a short period to avoid aspiration of feeds. Supplementary oxygen should be administered if the oxygen saturation is consistently <92%. This is best given through nasal cannulae. A small proportion of infants, often those with a known risk factor for severe disease (see above), may require ventilatory support. There is as yet no evidence that the use of nasal continuous positive airway pressure (nasal CPAP), in a deteriorating infant, will avoid intubation and mechanical ventilation (Palanivel and Anjay 2009). Many infants require a ‘trickle’ of oxygen to maintain normal oxygen saturations levels for several days after their ­respiratory symptoms have settled.

A borderline saturation in air, in an otherwise well baby, is not a reason to keep them in hospital. Simple nursing measures, such as gentle suction of nasal secretions, may also be helpful. One ­specific therapy has been shown to be of benefit in recent years – nebulised hypertonic saline (Zhang et al. 2008). This is administered as a 3% solution (usually 4 mL nebulised very 8 h) and in randomised controlled trials has improved clinical score and shortened hospital stay by ­approximately 24 h.

Ribavirin is an antiviral agent which is effective against RSV and may be given in nebulised form. It can cause genetic abnormalities in pregnancy, it is also difficult to administer and there is little evidence of benefit (Ventre and Randolph 2007). Bronchodilators, steroids and antibiotics are of no benefit in most infants with bronchiolitis and should not be used (although they frequently are) (Calogero, Sly 2007; Gadomski, Bhasale 2006; Spurling et al. 2007). Young children who are admitted with acute bronchiolitis may go on to have recurrent episodes of wheezing in the coming months. There is no effective preventive treatment for this complication (Blom et al. 2007). Even at 10 years of age, children who were admitted with bronchiolitis in infancy will wheeze more ­frequently than matched controls (Noble et al. 1997).

Pneumonia

Pneumonia is the most common cause of death in children under 5 years worldwide, accounting for 2 million deaths (19% of all deaths) (Bryce et al. 2005). In 2000, 42 countries accounted for 90% of deaths from pneumonia and over half the children in these countries failed to get the antibiotic they needed (WHO 2005). In the developed world there are few deaths and the incidence of ­pneumonia in children under 5 is around 36 cases per 1000 children per year, just under half ­requiring admission to hospital (Jokinen et al. 1993).

In the UK, infection with some of the organisms which can cause pneumonia may be prevented through the primary immunisation schedule. These include pneumococcus and pertussis (UK Immunisation Schedule 2010). Children in at-risk groups should also be given specific immunisations, e.g. influenza immunisation for children with chronic respiratory disease, such as cystic fibrosis, and 25-valent pneumococcal vaccine for children with sickle cell disease (Department of Health 2010).

Infants with pneumonia may present with non-specific symptoms such as poor feeding, lethargy and fever. There may be specific respiratory signs such as grunting and tachypnoea. However, in children under a year, the presentation may be one of ‘sepsis’ with a respiratory cause only apparent once an infection ‘screen’ has been undertaken and antibiotics started. Even in older children, symptoms may be misleading – abdominal pain is seen as well as chest pain and cough may be a late feature. In young infants, respiratory examination may reveal tachypnoea and chest ­indrawing. In older children classic physical signs such as a dull sound when the chest is percussed (tapped) and bronchial (harsh) breathing are more likely to be present and may allow the affected lung (and lobe) to be determined (Smyth 2001).

In younger children, viral infection (such as RSV) is the most common cause of pneumonia. Bacterial organisms are more common in older children, most commonly Streptococcus pneumoniae (‘the pneumococcus’), followed by Haemophilus influenzae, Mycoplasma pneumoniae and Chlamydia pneumoniae. The pneumococcus is transmitted through droplet spread (close prolonged contact) and some forms can live in the nasopharynx without causing symptoms. Young children are at greater risk of pneumococcal infection than adults, particularly children with poor splenic function (e.g. sickle cell disease) or immune deficiency. Staphylococcus aureus is an uncommon cause of pneumonia. Children appear much sicker, and may develop complications such as ­pneumatocoele (thin-walled cavities on chest x-ray). If Staph. aureus is suspected, intravenous flucloxacillin should be given. As with bronchiolitis, a nasopharyngeal aspirate may help to identify the causative virus in infants.

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