Management of Respiratory Issues in the School Setting Toni B. Vento, MS, RN, NCSN Supervisor of Health Services Medford Public Schools Pediatric Indicators of High Risk Anatomic features of the immature airway Age related developmental issues Developmental delay Infectious disease susceptibilities Facts about Pediatric Respiratory Failure Respiratory failure leads to hypoxemia and acidosis Precursor of full cardiopulmonary arrest Leading cause of preventable death in pediatric emergencies is failure to adequately manage the airway Key to success in pediatric resuscitation is managing the airway 1
Pediatric Assessment Triangle First Impression Appearance Mental Status, Muscle Tone Body Position Breathing Visible movement, effort Circulation Color Tools of Nursing Assessment Physical appearance: use of accessory muscles, color, demeanor, body position Auscultate lungs: air entry, quality of breath sounds, symmetry Respiratory Rate and Pulse oximetry Peak flow values: determine change from baseline. Use as a guide to onset of exacerbation and to evaluate effectiveness of bronchodilator Symptoms of Respiratory Distress Abnormal Respiratory Rate Increased work of breathing Preferred position of comfort Change in heart rate Change in color Altered mental status 2
Clinical Red Flags Physical Appearance Child leans forward as position of comfort Accessory muscles used in neck, intercostal area, sternum Looks distressed, anxious or agitated Quality of Breath Sounds Lack of wheezing Shortness of breath, difficulty speaking Tachypnea or Bradypnea Pulse oximetry < 95% Peak flow < 50% of personal best, no increase after medication is given Unreliable during acute episode The Center for Pediatric Emergency Medicine (CPEM), Teaching Resource for Instructors in Prehospital Pediatrics. Illustrations by Susan Gilbert. 3
Causes of Respiratory Distress Upper Airway Disease Allergic rhinitis and sinusitis Obstruction of Large Airways Foreign body Vocal cord dysfunction Vascular ring, laryngeal web Laryngotracheomalacial, tracheal stenosis Enlarged lymph nodes, tumor Obstruction of small airways Viral bronchiolitis, pneumonia, croup, pertussis Cystic fibrosis Bronchopulmonary dysplasia Heart disease Other Causes GERD with aspiration Anaphylaxis Pneumothorax What was your most frightening respiratory emergency at school? Asthma Most common chronic condition in US with estimated 22 million people (2010) Approximately 7 million children (2010) Approximately 9 people die from asthma each day In 2008, 3300 people died from asthma 4
Asthma is expensive According to the CDC, in 2009: Asthma costs $56 billion per year Average yearly cost for a child with asthma was $1039 Estimated 10.5 million lost school days/year Estimated 14.2 million lost work days/year 479,300 hospitalizations 1.9 million emergency department visits 8.9 million doctor visits Nearly 1 in 5 children with asthma went to an emergency department for care Pathophysiology Chronic inflammatory disorder hyperresponsiveness of airways airflow limitation respiratory symptoms disease chronicity Persistent changes may occur (Remodeling) Basement membrane fibrosis Mucous hypersecretion Epithelial cell injury Smooth muscle hypertrophy Angiogenesis 5
Pathogenesis Genetic Factors Cytokine response profiles AGE Altered Innate and Adaptive Immune Responses Lower Airway Targeting Environment Allergens Pollution Infections Microbes Stress Lower Respiratory Infection RSV/Para influenza Adenovirus Chlamydia Mycoplasma Persistent wheezing and asthma National Institute of Health, 2007 Diagnosis Assessment of impairment and risk to determine severity is made through a detailed history Physical exam Standardized questionnaires such as Asthma Control Test and Childhood Asthma Control Test Gold standard is spirometry measurements Assessment of response to therapy # ED visits # medication side effects # of nighttime awakenings # days absent from school # times/week student used inhaler at school Was student able to return to physical activities WHAT HAPPENS DURING AN ASTHMA ATTACK? VIDEO 6
Clinical Guidelines Severe Respiratory Distress EMERGENT Give Albuterol by nebulizer If little to no response in 5 min, call 911 Moderate Respiratory Distress URGENT Give Albuterol by nebulizer Consider repeat of Albuterol if ordered by MD Mild Respiratory Distress NON URGENT Give Albuterol by MDI using spacer Exemplary Practice: Prevention Identify high risk students with asthma Obtain medical orders for Albuterol to be given by nebulizer and MDI Use aerochamber with MDI Obtain Asthma Action Plan Incorporate into Individual Health Care Plan Develop 504 plan if needed Collaborate with parents and teachers to minimize triggers Exemplary Practice: Evaluation Post treatment assessment: Appearance Breath sounds O2 saturation Respiratory rate Peak flow Student should not leave the health office unless there is improvement in symptoms. 7
Case Study #1 Mary is a 2 nd grade student with a history of asthma and allergies to strawberries and bee stings. She is sent to the nurses office at 2:20p for respiratory distress. What s next? Upon physical exam, Mary is using her suprasternal muscles, RR 50 s and she has audible wheezing, almost stridorous. She reports she was wheezy after recess. You proceed to check O2 saturation: 96% Peak flow: 150 (Her personal best is 200) Breath Sounds: wheezing on expiration in all lobes Mary has medical orders for ProAir inhaler and Albuterol solution by nebulizer. 8
Post treatment You decide to give Albuterol by nebulizer because her RR is elevated, she is retracting and her IHCP states her recovery after treatment is slow. The nebulizer treatment ends and you notice that it is now 2:35, dismissal time. Exemplary practice Call parent and work out alternate dismissal Wait 10 minutes to evaluate Mary Compare pre and post treatment assessment Collaborate with parent to update treatment plan, identify asthma triggers and arrange alternate transportation plans Collaborate with teacher in order to review student symptoms and indications for school nurse assessment Use Mary s health office visits as teaching time Case Study #2 Eric is a 3 rd grade student with a known history of asthma. He comes to the health office complaining of can t breathe after lunch/recess. The school nurse listens to his lungs, gives him a drink of cool water and lets him rest in her office. 9
Eric doesn t have an inhaler at school so when he is dismissed, the school nurse encourages his mother to bring an inhaler to school and gives her the medication forms for her physician. 2 days later, Eric presents to the health office with wheezing. His school nurse hears diminished breath sounds with expiratory wheezing in the upper lobes. His O2 sat is 98%. While waiting for his mother, EL s shortness of breath acutely increases and his O2 sat falls to 91%. His color is pale and he is using his suprasternal muscles. Exemplary Practice Reassure student Encourage a position of comfort Avoid oral intake Activate 911 Monitor respiratory symptoms, vital signs and O2 sat Seek assistance to notify parent and watch other students in health office Collaborate with physician to obtain medical orders for inhaler and nebulizer at school Field Trip Management Obtain physician orders for inhaler and aerochamber Establish plan for field trip with parent Fragile asthma: encourage parent to chaperone Determine student s readiness to identify symptoms and self administer medication Develop Emergency Care Plan and review with teacher (including when to call 911) Assess prior to departure for field trip 10
Role of School Nurse Education Prevention Advocacy and Case Management Choking Usually sudden onset of respiratory distress If student is able to cough, cry or speak then airway is partially obstructed DO NOT INTERFERE! Let student try to clear his/her own airway Call 911 and prepare for a full airway obstruction Provide reassurance Exemplary practice Always activate 911 and refer student to the emergency room Monitor for post choking stridor, drooling, change in consciousness Aspiration Teaching 11
Sickle Cell Disease: Acute Chest Pain Causes: Sickle cells block the pulmonary blood vessels and cause infarction Diffuse pain of pain crisis Myocardial infarction Pneumonia Pulmonary hypertension Younger ages (2 4 yrs) fever cough Children and Adults chest pain shortness of breath chills productive cough Symptoms Nursing Interventions Monitor Vital Signs, O2 saturation, work of breathing Ibuprofen as ordered for fever Position of comfort Notify parent Activate 911 12
Spontaneous Pneumothorax Sudden onset of a collapsed lung without any apparent cause, such as a traumatic injury to the chest or a known lung disease. Risk factors Primary SP Age Stature Risk Factors Secondary SP Connective tissue disease Airway disease Congenital lung disease Infectious disease Symptoms Sharp chest pain, made worse by a deep breath or a cough Shortness of breath Chest tightness Easy fatigue Rapid heart rate Bluish color of the skin caused by lack of oxygen Nasal flaring Chest wall retractions Nursing Interventions Position of comfort Monitor Vital Signs, O2 sat Notify parent Activate 911 13
http://www.aafa.org Resources http://www.asthmapact.org http://www.lung.org/associations/states/color ado/asthma/asthma action plan.html http://www.nhlbi.nih.gov/files/docs/guideline s/asthsumm.pdf References Blood: 89 (5) March 1, 1997; E. Vichinsky et al. Acute Chest Syndrome in Sickle Cell Disease: Clinical Presentation and Course. www.scinfo.org/problem oriented clinicalguidelines/specific problems chest pain andchest syndrome Eur Respir Rev: 19 (117) September 1, 2010; M. Noppen 14