Week 3: Acute and Chronic Respiratory Conditions in the Pediatric Client

Normal Pediatric Respiratory Anatomy and Physiology

• Upper respiratory tract components (as summarized in the transcript): nasal passages, nasopharynx, epiglottis, larynx. These structures contain smooth muscle and mucous glands.

  • Transient upper airway sounds are heard

  • Infants aiway cartilage is soft

  • outh breather

  • Airway diameter is smaller

  • Difficult to ausculate due to a narrower airway and the presence of secretions, which can lead to challenges in diagnosing respiratory conditions effectively.

• Lower respiratory tract components: trachea, carina, bronchi, bronchioles, alveolar space.

• Alveoli: air sacs where oxygenation occurs via capillaries; alveolus structure supports gas exchange.

• Visual cues on the slides included a cross-sectional view showing the airway from nasal/oral entry through bronchioles to alveoli; emphasis on airway mucous production and smooth muscle affecting patency.

• Infant vs adult anatomy notes (e.g., tongue size and airway considerations) highlighted in the slide sequence; these influence airway patency in pediatrics.

  • Tongue is larger and can cause obstruction.

Respiratory Assessments and Manifestations

• Key assessment domains: Respirations, Oxygenation, Observation, Auscultation.

• Early manifestations vs later manifestations of respiratory distress should be differentiated; the dehydration status should be considered during assessment.

  • Signs of respiratory distress, such as tachypnea, retractions, and nasal flaring, may appear initially, while later signs can include cyanosis, altered mental status, and exhaustion.

    • Early manifestation: fuzzy or irritative, pallor.

    • Later: lethargic, tachypnic, and tachycardic, expect adventitious breath sounds, cyanosis.

      • Also, beware of their position (tripod), head bobbing (super concerning), and nasal flaring.

      • Higher retractions, more distressed. Shoulder usage.

    • Assess for skin color, pulse ox, and work of breathing to evaluate the severity of respiratory distress and to guide further intervention.

    • Children under 3 years of age are not able to blow their nose; therefore, suction is necessary.

    • First suction, then put them on oxygen in their nares (nasal cannula 4 L max), then if nothing changes, call the provider.

  • Are they dehydrated? Assessing hydration levels is crucial, as dehydration can exacerbate respiratory conditions and influence the overall clinical picture (such as crying with minimal tears)

  • Respiratory rate>60 is concerning, and the child would be NPO.

• Pulse oximetry is a useful adjunct in infant assessment (image reference in slide).

  • Rotate sight to prevent skin ulcers.

Retractions and Severity of Respiratory Distress

• Retractions: higher retractions denote greater airway compromise; observing and documenting severity is important.

      

  

• Important nursing note: if an infant is not allowed to eat (NPO) and has a respiratory rate > 60 breaths per minute, this indicates SEVERE distress.

Acute Epiglottitis (Medical Emergency)

• Etiology: Bacterial, usually Haemophilus influenzae type b (Hib influenzae).

• Health Promotion/Maintenance considerations: Vaccination status relevant (Hib vaccine); Droplet precautions until stabilized.

• Age/Onset: typically 2–5 years; progresses rapidly.

• Expected findings: stridor, drooling, muffled voice, dysphagia; tripod position; chin protrusion; mouth open; tongue protruding; inflamed, large cherry-red epiglottis; respiratory distress; high fever.

  • Keep upright, in an undisturbed, comfortable position.

  • Do not put anything in their mouth or tongue to prevent obstructing their airway. NOTHING IN THEIR MOUTH.

  • Likely intubated.

  • No spontaneous cough, as they can’t clear their airway.

• Therapeutic procedures/meds: possible endotracheal intubation or tracheostomy in severe cases; lateral neck X-ray; antibiotics; droplet precautions for 24 hours after IV antibiotics; corticosteroids; IV fluids; humidified oxygen.

• Nursing interventions:

  • Do not insert anything in the mouth.

  • Position the child for comfort; provide calm reassurance to the caregiver and child.

  • Maintain droplet precautions.

  • Monitor vital signs and oxygenation status.

  • Have intubation equipment readily available at the bedside.

Acute Laryngotracheal Bronchitis (Croup)

• Etiology: Viral (RSV, influenza A & B), mycoplasma pneumonia, measles, parainfluenza types 1–3.

  • Health promotion and maintenance, educate the client on vaccines.

• Age/Onset: Infants and children <2 years; gradual onset.

• Expected findings: inspiratory stridor, barky/brassy cough, hoarseness, restlessness, irritability, retractions, low-grade fever.

• Therapeutic procedures/meds: cool air outside or cool mist (shocks the airway); steroids (oral/IV); racemic epinephrine (nebulized); nebulized budesonide.

• Nursing interventions: frequent VS monitoring; be alert for airway obstruction/distress; provide reassurance; stay calm; caregiver support; hold child as needed.

  • Supportive care: oxygenation, fluids, and suctioning.

• Hear stridor, give steroids and racemic epenephrine!

Acute Spasmodic Laryngitis

• Etiology: Viral, possibly allergy-related.

• Age/Onset: 1–3 years.

• Pattern: child awakens at night with sudden dyspnea and barking metallic cough; stridor; hoarseness; restlessness; symptoms typically disappear during the day and recur.

• Therapeutic procedures/meds: cool mist (shocks the airway); steroids; racemic epinephrine (nebulized); supportive care.

• Nursing interventions: Often managed at home; use a cool mist vaporizer; encourage quiet activities at home.

Bronchitis and Bronchiolitis (RSV)

• Bronchitis/Bronchiolitis often involves lower respiratory tract infection with cough and airway inflammation.

  • Bronchitis is common in kids under the age of 2, while bronchiolitis primarily affects infants and young children under 12 months.

• Important note: cough suppressants may hinder clearance of secretions; care focuses on supportive management.

Bronchiolitis: Etiology and Assessment

• Common etiologies: RSV (most common cause), parainfluenza, adenovirus.

• Risk factors: males are more often affected; peak incidence is <7 months; under 2 years; prematurity; crowding; chronic disease; daycare; secondhand smoke exposure.

• Expected findings: fever, cough, rhinorrhea/pharyngitis, irritability, respiratory distress, copious secretions, wheezing or crackles; possible eye/ear infections; dehydration signs.

  • Mental status change, adventitious breath sounds, tachypnea and tachycardia, lethargy.

• Diagnostics/Labs: NP viral panel/NP wash; ABGs; electrolytes; rapid antigen testing (IF/ELISA).

  • Swab their nares for labs.

• Therapeutic procedures: bronchodilators are generally not recommended; supportive care; ribavirin (for RSV as indicated); corticosteroids (sometimes); palivizumab (Synagis) for prevention in high-risk groups (premies from getting RSV).

  • Suction before feeds to prevent aspiration.

• Nursing interventions: droplet and contact precautions; suction, repositioning, supplemental oxygen as needed; limit visitors; assign to RN with no other at-risk visitors; encourage fluids; avoid chest physiotherapy (not proven to be effective); education on handwashing, avoiding smoke exposure, suction technique with bulb syringe.

Otitis Media (Acute Otitis Media, AOM)

• Contributing factors: age < 24 months; Cleft lip/palate; daycare exposure; passive smoke exposure; bottle propping; recent URI; allergies; enlarged lymph nodes; winter/spring season; incomplete immunizations; Down syndrome.

• Expected findings: ear pain, fever, enlarged lymph glands, bulging tympanic membrane, inconsolable crying, poor appetite/sleep, purulent drainage if rupture; transient hearing loss.

• Diagnostics/Meds/Therapeutic procedures: otoscopy, acoustic reflectometry, tympanometry; antibiotics (if bacterial infection), antipyretics/analgesics; topical anesthetics; myringotomy with tympanostomy tubes (BMTs) in select cases (to help drain).

• Nursing interventions/education: explain pinna rationale; apply heat to affected ear; maintain dry ear with WET ear care; monitor for hearing loss; promote vaccine adherence; avoid bottle propping; avoid passive smoking; encourage breastfeeding; seek care when symptoms occur; BMT care includes keeping water out of the ear and notifying the provider when tubes extrude.

Tonsillitis and Tonsillectomy

• Contributing factors: often in younger children.

  • Due to an underdeveloped immune system.

• Expected findings: halitosis, snoring, nasal-sounding voice, mouth breathing, hearing difficulties, throat pain with swallowing, fever, persistent cough, breathing/swallowing difficulties.

• Diagnostics/Therapeutics: throat culture; CBC; clotting times; antibiotics if strep positive; antipyretics; antiemetics; topical anesthetics; tonsillectomy if indicated.

• Nursing interventions: diet considerations (soft/liquids); cool-mist vaporizer; warm saline gargles.

• Tonsillectomy pre-operative care: consent, bleeding risk, URI symptoms, loose teeth; baseline VS.

  • Take note of CBC and clotting times.

• Post-operative care: monitor for excessive bleeding (signs of swallowing difficulty, frequent throat clearing); airway assessment; elevate head of bed; NPO transitioning to clear/soft; around-the-clock analgesia; ice collar; patient education on discharge and when to seek help for bleeding, persistent cough, ear pain, or fever.

  • Complications: bleeding, pain, and dehydration.

    • Reposition for drainage.

  • Monitor for frequent clearing of the throat or swallowing.

    • If you see a child constantly coughing or clearing their throat, this is alarming and can be a sign of bleeding.

  • Avoid gargling and vigorous tooth brushing.

  • Avoid red dyes in their diet.

Pneumonia and Related Considerations

• Pneumonia can be viral or bacterial; discuss possible complications and preventive strategies.

  • Upper respiratory infection

  • Risk of bacterial infection

    • Abrupt and suspect viral infection

    • If bacteria use antibiotics

    • Hib vaccine is a preventative measure.

• In clinical notes, there is emphasis on infection control and monitoring for respiratory status changes.

Chronic Pulmonary Conditions in the Pediatric Client: Asthma and Cystic Fibrosis (CF)

• Endocrine dysfuntion

Asthma: Pathophysiology and Course

• Pathophysiology: chronic inflammatory process with IgE-mediated responses; involvement of mast cells, eosinophils, and T-lymphocytes leading to vascular congestion; bronchiolar hyperreactivity to irritants; intrinsic vs extrinsic triggers; bronchospasm and mucus production cause air trapping and hypoxemia.

  • Respiratory failure is the key thing you’re worried about.

  • Dehydration could be a factor.

• Clinical course: exposure to environmental factors provokes airway inflammation; coughing, wheezing, chest tightness, and breathlessness may progress to airway hyper-responsiveness and obstruction, potentially leading to hypoxemia and respiratory failure if severe.

• Key concepts: Chronic inflammation, airway remodeling, and variability in symptoms.

Asthma Classification (Four Categories)

• Intermittent: Findings frequency 0-2 times per week; nighttime findings none for ages 0–4 years old or none or infrequent for older children; activity limitations none.

• Mild Persistent: Frequency greater than intermittently but not daily; nighttime findings 1–2 times per month (0–4 years) or 3–4 times per month (5–11 years); minor activity limitations.

• Moderate Persistent: Daily symptoms; nighttime findings more frequent (3–4 times per month for 0–4; frequent for older children); some activity limitations.

• Severe Persistent: Continuous symptoms; nighttime findings frequent (more than once/week, but not daily for 0–4; frequent for older children); extreme activity limitations.

• Use of Short-Acting Beta-Agonists (SABA) as rescue medication increases with greater severity.

  • Should not be used daily or multiple times a day. Need steroids to deal with it better.

    

Triggers of Asthma

• Extrinsic triggers (allergens): pollen, dust mites, mold, animal dander, cockroaches, etc.

  • Know to keep children away from this.

• Intrinsic triggers (nonallergic): exercise, cold air, irritants (smoke, strong odors), viral infections, irritants in the environment.

  • An increase in women due to hormonal changes during menses.

Asthma Expected Findings and Diagnostics

• Typical symptoms: dyspnea, cough, inspiratory and/or expiratory wheeze; decreased air movement is a concern even if wheezing is absent.

• Diagnostics: age-appropriate assessment plus tests such as chest X-ray, pulmonary function tests (PFTs), Peak Expiratory Flow Rate (PEFR), CBC, and pulse oximetry.

• PEFR details: PEFR measures the maximum flow of air that can be forcibly exhaled in one second. Measured using a peak expiratory flow meter (PEFM) in L/min. Each child should establish their personal best, measured over 2-3 weeks when asthma is stable.

• A chronic cough with no infection or expiratory wheezing can support a diagnosis.

Therapeutic Procedures / Medications (Asthma)

• Bronchodilators:

  • Short-Acting Beta-2 Agonists (SABA)

    • Heart and lungs

    • Tachycardia

  • Long-Acting Beta-2 Agonists (LABA)

    • Controllers

  • Distinguish rescue meds from long-term control meds.

• Cholinergic antagonists (anticholinergics).

• Allergen control strategies.

• Anti-inflammatory agents (e.g., corticosteroids).

• Leukotriene modifiers.

• Mast cell stabilizers.

  • Good controllers for allergies.

• Monoclonal antibodies.

• Combination medications.

• Emergency measures: Magnesium sulfate (need to call a rapid response, bolus of fluid needed due to low BP that could happen); Oxygen; IV fluids; ABGs; BMP; high potassium diet (note: referenced in slide as part of emergency management).

• Complications to monitor: Status asthmaticus (medical emergency), respiratory failure.

• Nursing interventions/education:

  • Frequent assessments before and after treatments.

    • Auscultate the heart and respiratory rate before and after treatment.

    • If the child is very tachycardic, then spread out treatment to address this.

  • Use of spacers with metered-dose inhalers (MDIs).

  • Rinse the mouth after inhaled steroids or other inhaled meds to prevent candidiasis.

Review Questions and Clinical Scenarios (Asthma)

• Example ER scenario: In a 10-year-old with acute asthma exacerbation, worsening condition is indicated by increased wheezing vs decreased wheezing, among other signs. (Slide prompts to distinguish signs of worsening.)

• Poster/presentation review questions address inflammation, airway swelling, and the timing of bronchial narrowing during bronchospasm; most children with chronic asthma have allergies is a common statement in review prompts.

• Controller therapy teaching: when a child is instructed after taking controller medication, suggest actions such as rinsing the mouth after inhaler use.

Cystic Fibrosis (CF): Pathophysiology and Systems Involved

• CF is a multi-system disease characterized by thick, sticky mucus production due to defective chloride transport in sweat glands and exocrine glands.

• Contributed factors: family history, which is seen heavily amongst Caucasian clients.

  • Higher risk for sepsis!

  • Decreased immune system, increased chances of infection.

    • PICC line or VAC for IV antibiotic meds.

• Organs affected (cross-sectional view):

  • Lungs: thick mucus buildup, bacterial infections, widened airways; risk of bronchiectasis, bronchitis, bronchiolitis, pneumonia, atelectasis, pneumothorax, bronchial obstruction due to mucus.

  • Sinuses: sinusitis, nasal polyps.

  • Liver: hepatic steatosis, portal hypertension, biliary cirrhosis, neonatal obstructive jaundice, cholelithiasis.

  • Pancreas: blocked pancreatic ducts leading to malabsorption and fat-soluble vitamin deficiency; pancreatitis; insulin deficiency.

  • intestines: meconium ileus in newborns, distal intestinal obstruction syndrome, rectal prolapse, malabsorption issues.

  • Reproductive: infertility (aspermia or absent vas deferens in males; amenorrhea and delayed puberty in females).

• Skin: sweat glands produce salty sweat; tears/saliva also high in sodium and chloride.

• Growth and nutrition: poor weight gain, failure to thrive due to malabsorption; fat-soluble vitamin deficiencies (A, D, E, K).

CF Diagnostics

• Nutritional panel (fat-soluble vitamin levels A, D, E, K)

• Sputum culture, chest and abdominal X-rays

• DNA testing, Sweat chloride testing

• Pulmonary function tests (PFTs)

• Stool analysis

CF Therapeutic Procedures and Medications

• Respiratory and supportive care:

  • Oxygen, IV fluids, feeding tube as needed.

  • High-protein, high-calorie diet.

  • Chest physiotherapy (CPT) for airway clearance; airway clearance therapy (ACT) 2x daily or more as ordered; CPT is performed to loosen mucus.

    • May use a vest chest PT, do not eat after use, as there is the chance of emesis.

  • Vaccines and RSV prevention: Palivizumab.

  • Pancreatic enzyme replacement within 30 minutes of meals.

  • Dornase alfa (DNase) to decrease mucus viscosity.

  • Multivitamins; fat-soluble vitamin supplementation; antibiotics/antifungals.

  • H2 blockers and PPIs as needed; stool softeners as needed.

  • Transplant options (lung, heart, pancreas) in end-stage disease; liver transplant in some CF-related situations; also consideration of bowel transplant in select cases.

CF Nursing Interventions

• Frequent respiratory assessments; daily weight checks.

• Involve the child and caregiver in care planning.

• Airway clearance therapy (ACT) 2x daily or more as ordered; CPT as prescribed.

• Maintain a high-protein, high-calorie diet with snacks; moderate aerobic exercise.

• Monitor glucose for CFRD (CF-related diabetes).

• Education and psychosocial support for the patient and family.

  • Educate the family on having their child meet their caloric needs, the definition of the disease process, and how to react to it (when to give meds, non-therapeutic methods).

• Dietary counseling and coordination of care.

CF Complications and General Manifestations

• Respiratory: bacterial/fungal colonization, bronchiectasis, recurrent infections, pneumothorax, atelectasis, hemoptysis, bronchiolitis, bronchitis, etc.

• Hematologic/vascular: pulmonary hypertension, cor pulmonale in advanced disease.

• Liver and biliary: hepatic steatosis, portal hypertension, biliary cirrhosis.

• Gastrointestinal and nutrition: meconium ileus in neonates, pancreatic insufficiency with malabsorption, and malnutrition.

• Growth and developmental: failure to thrive, growth delays.

  • Daily weight due to the failure to thrive.

CF Diet and Nutrition Counseling

• CF patients require high-calorie, high-protein diets with adequate salt intake to offset salt losses in sweat.

• Salt intake considerations: sweat and tears can be salty; ensure electrolyte balance is maintained.

Diet and Education Scenarios (CF Nutrition Question)

• Typical exam question: A CF patient should be advised to consume foods high in calories and protein to meet higher energy needs; salt intake should be managed to prevent hyponatremia in sweat-rich states.

Practical Nursing Implications and Distinguishing Features

• Early recognition of distress in pediatric respiratory conditions is critical for timely intervention.

• Infection control measures (droplet and contact precautions) are essential in epiglottitis, bronchiolitis, and other infectious etiologies.

• Family education is central: suction techniques, hand hygiene, vaccination adherence, avoidance of tobacco smoke, and recognition of warning signs of deterioration.

• For CF, multi-system involvement requires coordinated care focusing on nutrition, airway clearance, infection control, and monitoring for CFRD and liver/pancreatic complications.