Medication Instructions: Clear, step-by-step, written
When to Seek Care:
Worsening symptoms
Breathing difficulty
Lethargy
Include Child in Care
Age appropriate participation improves understanding
KEY TERM: Aspiration → Inhaling foreign object into airway
High Risk:
Toddlers (especially males)
Prevention Education:
Avoid small objects
Age-appropriate foods
No putting objects in mouth
NCLEX HIGH-YIELD SUMMARY
ARIs = most common pediatric illness
Spread by: Contact, Droplets
Incubation: 1–3 days
Duration: 4–10 days
Most are viral
Children: Get sicker faster; show more severe symptoms
Early signs: Nasal congestion, cough
Late/severe signs: Retractions, cyanosis, LOC changes
Green mucus ≠ always bacterial
Testing: Not routine unless severe
Vaccines prevent serious infections
Hand hygiene = BEST prevention
Teach BEFORE child gets sick
MASTER CONCEPT
In pediatrics, respiratory illness can go from mild to life-threatening VERY quickly
CROUP — OVERVIEW
What is Croup?
Croup is not just one single illness; it is a group of disorders affecting the upper and middle airway that cause:
Swelling
Narrowing of the airway
Restricted airflow
It is especially associated with:
A barky cough
Hoarseness
Stridor
Airway Structures Involved in Croup
Croup mainly affects:
Larynx
Supraglottic structures
Trachea
Some sources may also include:
Epiglottis
Bronchi
KEY TERM DEFINITIONS
Croup: A group of inflammatory disorders of the upper airway causing swelling, barking cough, hoarseness, and inspiratory stridor.
Supraglottic structures: Structures above or around the vocal cord area, including tissues near the larynx.
Stridor: A high-pitched sound, usually heard on inspiration, caused by airflow through a narrowed upper airway.
Coryza: Inflammation of the nasal mucosa causing runny nose, nasal congestion, cold-like symptoms.
Parainfluenza virus: A common respiratory virus and the most common cause of viral croup.
Epiglottitis: Inflammation and swelling of the epiglottis that can rapidly cause life-threatening airway obstruction.
Orthopnea / tripod position: A position in which the child sits upright and leans forward to improve breathing.
Intercostal retractions: Inward pulling of the muscles between the ribs during breathing, showing increased work of breathing.
Laryngeal spasm: Sudden involuntary closure/spasm of the laryngeal structures that can obstruct the airway.
Mechanical ventilation: A life-support intervention that helps or completely takes over breathing.
PATHOPHYSIOLOGY
Basic Pathophysiology of Croup
Croup happens when an irritant causes inflammation and swelling in the upper airway.
Possible irritants include:
Viruses
Allergens
Bacteria
Most common cause: Virus
Because the affected structures are in the upper airway, the swelling narrows the airway and makes it harder for air to move in, especially during inspiration.
This is why croup causes:
Inspiratory stridor
Barky cough
Hoarseness
Important feature: Croup is usually:
Short in duration (around 2 days)
Self-limiting
Usually not an emergency, though it can become severe
TYPES OF CROUP
1. Viral Croup
Cause: Usually caused by:
Parainfluenza virus
Structures involved:
Larynx
Subglottic/supraglottic airway structures
Trachea
Clinical pattern:
Often follows a viral upper respiratory illness
Usually includes:
Fever
Coryza
Barky cough
Hoarseness
Stridor
Key pattern:
Usually does not recur repeatedly once a child recovers from infection
2. Spasmodic Croup
Associated with:
Allergens
History of allergies
Key features:
More often occurs at night
Usually:
Sudden onset
Short duration
Resolves quickly
May recur
Fever?: Usually no fever
Coryza?: May have mild coryza symptoms only
Difference from viral croup:
Spasmodic croup is more associated with:
Edema/swelling rather than the same inflammatory pattern seen in viral croup
ACUTE EPIGLOTTITIS
Why it is grouped with croup disorders
Because the epiglottis is closely related anatomically to the:
Larynx
Supraglottic airway
Why it is dangerous
The epiglottis can swell so severely that it:
Completely blocks airflow into the trachea
This makes epiglottitis a medical emergency
PATHOPHYSIOLOGY OF EPIGLOTTITIS
How Inflammation Develops
Infectious agent usually enters through the:
Nasopharynx
It then invades tissue lining the epiglottis and causes:
Rapid inflammation
Marked swelling
Severe upper airway narrowing
Other noninfectious causes:
Trauma
Smoke inhalation
Chemical inhalation
Heat injury
Hot foods
Hot liquids
Vaping / e-cigarette exposure
Heated illicit drug devices
Progression of Epiglottitis
As swelling worsens:
Stridor develops
Airflow decreases
Child may initially have a barky cough
Critical Warning Sign
If the cough disappears, this may indicate:
Near-complete airway obstruction
This is an emergency because:
Complete occlusion can occur
Cardiopulmonary arrest may follow without immediate intervention
ETIOLOGY AND EPIDEMIOLOGY
Viral Croup
Most commonly follows exposure to a respiratory virus, especially:
Parainfluenza virus
The virus enters through:
Nasal passages
Pharynx
Laryngeal structures
This causes inflammation of airway linings.
Spasmodic Croup
Usually not due to the same infectious inflammatory pattern.
More commonly associated with:
Allergic triggers
Airway edema
Nighttime recurrence
Epiglottitis
Traditionally most commonly caused by:
Haemophilus influenzae type B (Hib)
Because of vaccination, epiglottitis in young children has greatly decreased.
Other infectious causes:
Other bacteria
Viruses
Fungi
Other noninfectious causes:
Trauma
Burns
Smoke
Chemicals
Hot food/drink
Vaping
Heated drug inhalation
Modern Epidemiology
Because of widespread Hib vaccination:
Epiglottitis is now seen more often in:
Older children
Adolescents
Adults
RISK FACTORS
For Croup
Croup is most common in:
Children 6 months to 3 years old
More often in males
Fall and early winter
Additional risk factors:
Family history of croup
Small pediatric airway diameter
Prior nasal drainage / URI symptoms
Allergies, especially for spasmodic croup
Smoke exposure in the home
For Epiglottitis
Risk factors include:
Incomplete vaccination
Not up to date on Hib vaccine
Exposure to airway trauma
Smoke or chemical inhalation
Thermal injury to airway
CLINICAL PRESENTATION
Viral Croup Presentation
Typical Progression
Early phase:
Often starts with:
1–2 days of:
Coryza
Nasal drainage
Congestion
Around day 3:
The child may develop:
Fever
Barky cough
Hoarseness
Inspiratory stridor
As swelling worsens:
The child may develop:
Faster respirations
Longer inspiratory phase
Increased work of breathing
Stridor on inspiration and expiration
Decreased breath sounds
Intercostal retractions
Anxiety
Agitation
Why anxiety matters:
Anxiety and crying can worsen airway obstruction by increasing work of breathing, oxygen demand, and aggravating swelling and distress.
Spasmodic Croup Presentation
Often may have:
Sudden onset
At night
Recurrent
Little or no fever
May resolve before treatment is needed
Epiglottitis Presentation
In Younger Children
Children younger than 5 with epiglottitis may show:
More severe respiratory distress
Refusal to lie down
Preference for upright or tripod position
Drooling
Difficulty swallowing
Stridor
Important Difference from Croup
Epiglottitis often has:
Little or no cough
Excessive drooling
More severe appearance
In School-age Children/Adolescents
They may show
More throat pain
Difficulty swallowing
Drooling
Less dramatic respiratory symptoms at first
DIFFERENTIATING CROUP VS EPIGLOTTITIS
Croup:
Barky cough present
Hoarseness
Stridor
Often follows URI/coryza
Usually viral
Usually self-limited
Epiglottitis:
Drooling
Difficulty swallowing
Child prefers sitting upright
Often no cough
More toxic/severe appearance
Medical emergency
Airway can close rapidly
LAB TESTING AND DIAGNOSTIC STUDIES
Croup
Usually diagnosed by: Clinical presentation
Sometimes: Airway x-rays may be obtained; CBC may be done if child is stable and diagnosis is unclear
Epiglottitis
Usually diagnosed by: Clinical presentation
Critical nursing safety point:
Do NOT inspect the throat directly in a child with suspected epiglottitis because touching or irritating the throat can cause laryngeal spasm and complete airway occlusion.
Additional important point: Painful procedures may be avoided initially because agitation can worsen obstruction.
Airway emergency readiness: Airway tools must remain with the child during diagnosis and treatment.
TREATMENTS AND THERAPIES
Treatment Depends on:
Cause
Severity
Respiratory status
Possible treatments include:
Nebulized medications
Oral steroids
Injectable steroids
Airway support
Mechanical ventilation in severe cases
CORTICOSTEROIDS
A major treatment for croup is the use of corticosteroids to reduce airway swelling.
Commonly used:
Prednisolone
Dexamethasone
MEDICATION: PREDNISOLONE
Class: Corticosteroid
Action: Acts like synthetic cortisol to:
Suppress immune response
Decrease inflammation
Therapeutic use: Inflammatory disorders, including airway swelling
Severe cases may need nebulized meds, airway support, mechanical ventilation
Parent Teaching
Croup often improves with steam, cool air, hydration; epiglottitis always needs emergency care.
Vaccination
Prevents many epiglottitis cases; avoid cigarette smoke exposure
BRONCHITIS & RSV — PART 1: BRONCHITIS OVERVIEW
What is Bronchitis?
Bronchitis is inflammation of the larger airway branches that come off the trachea, meaning the bronchi.
Key Term Definitions
Bronchitis: Inflammation of the bronchi, usually causing cough, mucus production, and sometimes fever or abnormal lung sounds.
Bronchi: Large airway branches extending from the trachea into the lungs.
Edema: Swelling caused by fluid accumulation in tissues.
Pathophysiology of Bronchitis
When the bronchi become inflamed:
The lining becomes swollen (edematous)
Mucus production increases
The child develops a cough
Airflow may become more difficult, especially in children because their airways are already small
Etiology and Epidemiology of Bronchitis
Most Common Cause
Bronchitis in children is most often caused by viruses (Influenza, RSV, COVID-19).
Less common cause: Bacterial bronchitis can occur, but it is not common.
Chronic bronchitis: Children with chronic bronchitis often have underlying chronic conditions, such as cystic fibrosis.
RISK FACTORS
Children at higher risk include:
Infants younger than 2 years
Premature infants
Low birth weight infants
Children with heart disease
Children with lung disease
Immunocompromised children
CLINICAL PRESENTATION OF BRONCHITIS / BRONCHIOLITIS
Children often present with symptoms of an upper respiratory infection, then progress to lower respiratory symptoms.
Early symptoms: Coryza, congestion, cold-like symptoms
Common manifestations: Cough, fever, tachypnea, wheezing, crackles
More serious progression: Difficulty breathing, retractions, hypoxia
LAB TESTING AND DIAGNOSTIC STUDIES FOR BRONCHITIS
Typical Diagnosis
Bronchitis is usually diagnosed by clinical manifestations, history, and physical exam.
TREATMENT OF BRONCHITIS
Main Treatment
Bronchitis in children is treated primarily with supportive care: hydration, fever control with antipyretics, nasal drops, bulb suctioning for infants.
Important Point
The underlying respiratory infection causing bronchitis also needs to be managed; antibiotics are NOT used routinely.
IMPACT ON OVERALL HEALTH — BRONCHITIS
Psychosocial Impact
Commonly seen in infants and early toddlers. These children may become distressed because: nasal congestion interferes with sucking.
CONSIDERATIONS OF THE PEDIATRIC CLIENT
Health Promotion and Disease Prevention — Bronchitis
Focus areas: Prevent viral URIs, good hand hygiene, avoid sick contacts, immunizations, avoid smoke exposure.
Parents can help prevent bronchitis by practicing respiratory hygiene, keeping the child away from sick contacts, keeping immunizations current, avoiding smoke exposure.
PLAY — BRONCHITIS
Children with bronchitis often do not want to play during the acute illness, but as they improve, play is encouraged matching the age and developmental level.
PART 2: RESPIRATORY SYNCYTIAL VIRUS (RSV) OVERVIEW
What is RSV?
Respiratory Syncytial Virus (RSV) is a common RNA virus that infects the respiratory tract and is one of the most important causes of bronchiolitis, lower respiratory tract infection, and hospitalization in infants and young children.
KEY TERM DEFINITIONS
RSV: Respiratory Syncytial Virus, a common respiratory virus that often infects infants and young children.
RNA virus: A virus that uses ribonucleic acid as its genetic material.
Mucous membranes: Moist tissue linings, such as those in the nose and eyes.
PATHOPHYSIOLOGY OF RSV
How RSV Spreads
RSV is transmitted mainly through:
Contact with contaminated surfaces and touching the nose or eyes and droplets in the air.
Survival and contagious period:
Lives for hours on surfaces
Incubation period: 4 to 6 days
Viral shedding: up to 11 days, making RSV highly contagious.
What Happens in the Body
Virus enters through nasal or eye mucous membranes
Replicates in the nasopharynx
Spreads down the respiratory tract
Settles in the bronchioles
Invades epithelial cells of bronchioles
Spreads into alveolar pneumocytes
Lower Respiratory Involvement
Lower airway infection usually begins within the first 3 days.
Effects on Airway
The virus causes:
Cell death (necrosis)
Shedding/sloughing of epithelial cells
Increased mucus production
Neutrophil infiltration
These result in airway occlusion, air trapping, increased airway resistance, and may cause wheezing, crackles, respiratory distress, and sometimes apnea.
ETIOLOGY AND EPIDEMIOLOGY OF RSV
Seasonal Pattern
RSV occurs most often: Fall to early spring, with peaks often in the first 2 months of the year.
Lifetime Exposure
Most people get RSV at some point in life.
Important Fact: Only about 10% of children escape RSV before age 2.
Immunity is not strong or long-lasting, thus reinfection is common, but reinfections are often less severe as the person gets older.
RISK FACTORS FOR RSV
Children at highest risk include:
Infants younger than 6 months
Premature infants
Infants born in autumn or early winter
Low birth weight infants
Children with Down syndrome, lung disease, heart disease, or who are immunocompromised.
Daycare attendees, children with older siblings, exposure to secondhand smoke, low socioeconomic status.
These factors increase risk for: infection, severe disease, complications, and hospitalization.
CLINICAL PRESENTATION OF RSV
Clinical Presentation Depends on:
Age of child
Underlying health problems
Whether infection is primary or repeat infection
Upper Respiratory Symptoms
Older children may present with more upper respiratory symptoms such as:
Coryza
Cough
Nasal congestion
Nasal drainage
Conjunctivitis
Lower Respiratory Symptoms
Most cases in infants/young children involve the lower respiratory tract.
Structures most affected:
Bronchi
Bronchioles
Alveoli
This causes:
Restricted airflow
Increased mucus
Mucus stasis
Expected findings: wheezing, crackles, altered respiratory rate, altered breathing pattern, apneic episodes, severe coughing from bronchospasm, and hypoxia.
LAB TESTING AND DIAGNOSTIC STUDIES FOR RSV
Gold Standard
A nasal secretion sample is used; best collection method is a nasal washing, but a nasal swab is acceptable.
Best Test: PCR is preferred, while an acceptable alternative is the rapid antigen detection test (RADT).
TREATMENT OF RSV
Main Treatment
Treatment is mainly supportive, similar to bronchitis and includes:
Hydration
Fever management
Bulb suctioning
Monitoring respiratory status
Infection Control
RSV spreads by contact and droplets, thus everyone entering the room should use a surgical mask, gown, and gloves.
When the child leaves the room:
Child should wear a surgical mask if able.
RSV PREVENTION WITH MONOCLONAL ANTIBODIES
New Developments
There are now two antibody products mentioned:
Nirsevimab
Clesrovimab
These provide passive immunization and protection for about 5 months.
Who Can Receive Them?
Infants less than 8 months who are at high risk for severe illness or death from RSV.
Dosing Information
Nirsevimab
Single 50 mg or 100 mg injection for infants <8 months
For infants 8–24 months: two 100 mg injections.
Clesrovimab
Single 105 mg injection; only for infants <8 months.
MEDICATION: NIRSEVIMAB
Class: Monoclonal antibody
Action: Binds to RSV F protein, stopping the spread of RSV virus
Therapeutic use: Prevents RSV in:
Infants entering first RSV season
Immunocompromised infants entering second RSV season
Because RSV occurs mostly in infants, the psychosocial effects are primarily on parents and caregivers; infants may become upset due to nasal congestion interfering with sucking (comfort).
Nasal congestion can lead to distress and crying, impacting bonding and attachment.
Developmental Impact
If infection is severe and hospitalization is prolonged, developmental delays may occur due to interference with normal developmental experiences.
HEALTH PROMOTION AND DISEASE PREVENTION — RSV
Parent Education
Focus on prevention measures for:
Infants younger than 6 months
Premature infants
Infants born in autumn or early winter
Important Prevention Measures
Avoid crowds during RSV season
Stay home when possible with very young/high-risk infants
Hand hygiene
Avoid exposure to sick people
Important Point: No vaccine for RSV currently, so prevention depends on reducing exposure, good hygiene, and antibody prevention for select infants.
PROTECTING THE CHILD WHO HAS RSV
Key Priorities
Airway: Top hospital safety priority is airway management.
Transmission: Prevent spread by isolation, hand hygiene, correct PPE use.
Oxygen: If oxygen is needed, provide humidified oxygen; monitor pulse oximetry; titrate oxygen as prescribed.
Fluids: If the child receives IV fluids, monitor carefully for fluid overload, including lung sounds, edema, intake/output, and daily weights, as infants can easily become fluid overloaded.
Parents can prevent RSV by understanding how it spreads, who is at highest risk, and how to reduce exposure.
If the child is otherwise healthy and stable, care can often continue at home with close monitoring and adherence to provider instructions.
PLAY — RSV
Children with RSV usually do not want to play during the acute phase, but as they improve, play should be encouraged with caution regarding exposure to others.
Hospital play (if hospitalized) can be used for: diversion, comfort, and continued development.
COMMUNICATION — RSV
No special communication differences compared with other respiratory illnesses.
Use parent teaching, age-appropriate explanation, calm reassurance, and clear instructions to reduce anxiety and support understanding.
HIGH-YIELD SUMMARY
Bronchitis
Inflammation of bronchi, usually viral; causes cough, mucus, fever, wheezing/crackles; treated with hydration, fever control, and suctioning.
Bronchiolitis
Inflammation of bronchioles, usually in children <2; most commonly caused by RSV; can block small airways and collapse alveoli.
RSV
RNA virus, spread by contact and droplets; incubation: 4–6 days; shed up to 11 days; common in infants; presents with wheezing, crackles, apnea, hypoxia.
Pneumonia
Infection of lung tissue, often begins as an upper respiratory infection; types include viral, bacterial, atypical, and neonatal; diagnostic gold standard is chest X-ray.
Treatment
Supportive care for all, antibiotics for bacterial, antivirals for some viral causes, oxygen if needed, hydration, fever and pain control.
Influenza
Common contagious viral illness; prevent with annual influenza vaccination; major complication is secondary pneumonia.
Acute Viral Nasopharyngitis
Most common cause is rhinovirus; symptoms include rhinorrhea, nasal congestion, cough; usually diagnosed clinically, treated with comfort measures.
Streptococcal Pharyngitis
Caused by Group A Streptococcus; distinguishing feature includes abrupt sore throat; diagnostic gold standard is throat swab; treatment includes antibiotics.
Tonsillitis
Inflammation of tonsils, can progress to peritonsillar abscess; bacterial tonsillitis requires antibiotics.
Pertussis
Communicable bacterial illness requiring immunization; has three stages; requires droplet precautions; treatment includes antibiotics.
Asthma
Most common chronic respiratory disease; characterized by airway inflammation, narrowing, and mucus production; requires trigger identification and management plan.
Cystic Fibrosis
Genetic disorder causing thick mucous leading to respiratory issues; airway clearance therapy is priority along with nutritional support.