Chapter 15 Notes

Developmental Aspects of the Respiratory System

●Newborn airway is narrow and more easily occluded
●Children younger than the age of 6 are abdominal-breathers
●Growth and development considerations for a child with a respiratory condition
●Anatomical di erences in infants and children?
DEVELOPMENTAL ASPECTS OF THE RESPIRATORY SYSTEM
The airway of the newborn is narrow and more easily occluded than that of an adult. Newborns
are obligatory nose breathers; they do not use their mouths for breathing. The cough of a
newborn is usually nonproductive because young infants pro- duce little respiratory mucus.
Because they lack this cleansing function, they are more susceptible to respiratory infections.
Newborns have a highly developed sense of smell, and the mucous membranes are highly
vascular. The ethmoid and maxillary sinuses are present at birth, though the frontal and
sphenoidal sinuses are not fully developed until the child is 6 to 8 years of age. The lymphoid
tissues, or tonsils, are absent at birth and grow more rapidly in the child than any other tissue. By
age 7, the tonsils present at adult size.
Children younger than the age of 6 are abdominal-breathers instead of thoracic-breathers. The
intercostal muscles are too weak to facilitate respiration, causing the child to rely on the use of
the diaphragm for inspiration. As the diaphragm moves downward, negative pressure is created,
expanding the alveoli and lling the lungs with air. The downward movement of the diaphragm
places pressure on the abdominal contents. With increased airway resistance, the weak
musculature of the thorax is pulled inward, causing retractions, as if sucking on a collapsed
straw.
Retractions are a pulling in of the soft tissue of the chest wall with inspiration and occur when
the accessory muscles are used for breathing. This is an abnormal nding and requires the nurse
to conduct a more thorough respiratory assessment. In the chest, common sites for retractions
include suprasternal, supraclavicular, intercostal, subcostal, and substernal areas.
The respiratory system of the toddler expands to hold a greater volume. This also increases the
distances between the structures of the respiratory tract, decreasing the risk of infections. The
tonsils and adenoids of the toddler are increasing in size. The eustachian tubes remain short and
horizontal during the toddler and preschool-age years, providing easier access for nasal bacteria
to enter the ear.
The epiglottis is long and accid among children ages 8 and younger, making it more susceptible
to swelling that can lead to airway occlusion. The epiglottis is small and does not close properly,
and the larynx and the glottis are higher in the younger child’s neck, which makes the child more
prone to aspiration. The thyroid, cricoid, and tracheal cartilages are immature and easily collapse
with exion of the neck. The child’s neck has fewer functional muscles than that of the adult.
The increased amount of soft tissue makes the younger child more susceptible to infection and
edema.
The trachea in children is shorter and narrower in diameter than in adults. To compare, the
trachea of a newborn is approximately 4 mm in diameter, about the diameter of a drinking straw.
By age 6, the diameter of the trachea is approximately 12 mm, while an adult’s trachea is from
18 to 20 mm in diameter. A child’s trachea bifurcates (separates into two branches) at the third

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 thoracic vertebra, but an adult’s trachea bifurcates at the sixth thoracic vertebra. In addition to the
higher level of bifurcation, the angle of the right bronchus (one of the two large branches of the
trachea) is much sharper in children. Because of the narrow lumen of the trachea, excess mucous
production can easily produce a greater degree of swelling that can lead to an obstruction and
severe respiratory distress.
The right bronchus is shorter, wider, and more vertical than the left; therefore, inhaled foreign
bodies more often lodge in the right bronchus. The bronchioles of the infant are little more than a
thin layer of muscle elastic-lined with ciliated epithelium. Lung tissue is also immature at birth
and continues to develop until about age 12. Children have less alveolar surface for gas exchange
than adults. The surface area increases ninefold by age 12. The alveoli increase in number from
25 to 300 million during this time, along with increasing in size and functionality. The maturity
of the alveoli enhances ventilation and respiration, promoting more effective gas exchange.
Because of the differences in a child’s airway, the force needed for ventilation is greater.
Increased friction and resistance make it more dif cult to generate ventilation in the presence of
airway edema that may result from hypersensitivity reactions or infectious processes.
The average full-term infant has 20 to 50 million alveoli at birth. Rapid growth and maturation of
alveoli occurs during the toddler and preschool ages. This expansion improves ventilation;
respiratory rates decrease signi cantly from those of the newborn. The alveoli continue to
increase in number during the school-age period, reaching approximately 300 million by 8 years
of age. Lung development is complete by 5 to 6 years of age. The respiratory structures of the
adolescent are of approximately adult size and capacity.

UPPER AIRWAY DISORDERS

Stridor, barking cough, snoring, hoarseness
^^^^

Pharyngitis
● In ammation of the mucosa of the pharynx that frequently results in sore throat
● Most commonly occurs in the winter and spread by close contact
● Signs and symptoms
● Fever, sore throat, di culty swallowing, headache, abdominal pain, in amed,
red, enlarged pharynx and tonsils
● Diagnosis- throat culture
● Treatment
● Bacterial- antibiotics
● Viral- supportive care
● Education
Pharyngitis Common cold
Pharyngitis is an in ammation of the mucosa of the pharynx that frequently results in sore throat.
It occurs most commonly in winter and is spread by close contact. The incidence is high among
children and declines in late adolescence and adulthood. Most sore throats are viral in nature,
most commonly caused by adenovirus. About a quarter of cases of pharyngitis are caused by
group A beta-hemolytic streptococci (GABHS).
Pharyngitis can either be a short illness with no symptoms or result in severe, life-threatening
illness. In cases of the latter, the causative agent is group A beta-hemolytic streptococci, which
may lead to acute rheumatic fever, scarlet fever, or acute glomerulonephritis. Colonization of the

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 pharynx by GABHS may produce either asymptomatic or acute infection. The M protein is the
major virulence factor of GABHS and facilitates resistance to phagocytosis by
polymorphonuclear neutrophils. Type-speci c immunity develops during infection and provides
protective immunity to subsequent infection with that particular M serotype.
Signs and Symptoms
▪ Often an abrupt onset
▪ Fever
▪ Sore throat
▪ Dif culty swallowing
▪ Headache
▪ Abdominal pain
▪ In amed, red, and enlarged pharynx and tonsils, often covered with exudates
▪ Anterior cervical lymphadenopathy
▪ The presence of petechiae on the palate; a ne, red, sandpaper-like rash on the trunk or
abdomen; and a strawberry tongue are common ndings with a group A streptococcus
infection
Viral pharyngitis is usually self-limiting, with symptoms subsiding in 3 to 5 days unless
superimposed by sinusitis or parapharyngeal or peritonsillar abscess.
Diagnosis
Throat culture remains a good way to diagnose streptococcal pharyngitis (Fig. 15-5). A false-
positive culture can occur if other organisms are misidenti ed as GABHS, and children who are
streptococcal carriers may have positive cultures. False-negative cultures are attributed to a
variety of causes, including an inadequate throat swab specimen and a patient’s covert use of
antibiotics (Smith, 2020). Diagnostic test kits with rapid identi cation of GABHS are available
for use at the of ce or clinic settings. These rapid tests have high speci city. Therefore, a
positive result generally does not need a throat culture con rmation. The throat culture does give
information about susceptibility of the organism to speci c antibiotics.
Medical Care?
Viral pharyngitis is generally treated with supportive care as needed, which includes pain and
fever relief with acetaminophen or ibuprofen. Most untreated cases of streptococcal pharyngitis
resolve in a few days. The objective of antibiotic therapy is to hasten clinical recovery and
prevent acute rheumatic fever. Antibiotics may be started immediately without culture. Oral
penicillin is the prescribed treatment of choice. Oral penicillin is inexpensive and is given two or
three times a day for 10 days. Oral amoxicillin (Amoxil) is suitable for children because it is
available as chewy tablets or as a suspension. Oral erythromycin (Erythrocin) is indicated in
children allergic to penicillin.
Education/Discharge Instructions
For children who are cared for at home, it is important that the nurse instruct the parents to give
the full dose of the antibiotic prescribed even after the child shows signs of improvement. This is
a very important aspect in the management of pharyngitis to prevent valvular damage of the
heart. Instruct parents on methods used to provide pain and fever relief, such as administering
acetaminophen (Children’s Tylenol) or ibuprofen (Children’s Advil) and use of a cool-mist
humidi er.

Tonsilitis

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 ● In ammation of the tonsils

● Often occurs with pharyngitis
● Treatment
● Recurrent/ chronic- tonsillectomy
● Nursing Care
● After surgery
● Side-lying position
● Promote comfort and limit activities that cause bleeding
● Education
● Bleeding

Tonsillitis
In ammation of the tonsils often occurs with pharyngitis, which may lead to the diagnosis of
tonsillitis or tonsillopharyngitis. Tonsillitis is an in ammation of the tonsils, which are masses of
lymphoid tissue located within the pharynx. Tonsils protect the respiratory and alimentary tracts
from infection by inducing secretory immunity and regulating the production of secretory
immunoglobulin. Tonsils normally enlarge progressively between 2 and 10 years of age and
reduce progressively during preadolescence, so tonsils of children larger than those of adults.
Nearly all children in the United States experience at least one episode of tonsillitis. Viruses and
group A beta-hemolytic streptococcus are the most common cause of infection in tonsillitis.
Surgical Care
Tonsillectomy (surgical removal of the tonsils) is used for recurrent or chronic tonsillitis. The
American Academy of Otolaryngology and Head and Neck Surgery suggests the occurrence of
three or more treated infections per year as suf cient to necessitate a surgical intervention.
Surgery is performed 6 weeks after an acute infection has been resolved.
After the surgery, children are kept on their side to facilitate drainage of secretions. Providing
comfort and reducing activities that may aggravate bleeding are the priorities. Coughing, clearing
the throat, and blowing the nose are to be avoided. Secretions and vomitus are checked for fresh
blood. Because the throat is sore after surgery, the nurse can apply ice packs and an ice collar to
provide relief. Food and uids are offered when the child is alert, initially cool water, crushed
ice, and avored ice pops. However, red-or brown-colored uids are not given so the nurse is
able to distinguish the drainage, which might be fresh or old blood. As the child begins to
tolerate food, items such as gelatin, cooked fruit, sherbet, soup, and mashed potatoes are offered.
Foods to avoid include milk, ice cream, and pudding because they coat the mouth and throat and
cause the child to clear the throat, which may cause bleeding.
Education/Discharge Instructions
The nurse should teach the parents to:
• Keep the child away from highly seasoned food and “sharp” foods (e.g., nacho chips) for a
period of 2 weeks. The scab is most likely to be dislodged at 8 to 12 days
• Have the child avoid gargling and vigorous tooth brushing
• Instruct the child that he or she should not cough or clear the throat
• Limit the child’s activities that may result in bleeding

Croup
● Viral agents are the most common cause of croup
● Signs and symptoms

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 ● “Seal bark,” inspiratory stridor

● Treatment
● Cool air/ mist; steroids
Croup
Croup is a generic term encompassing a heterogeneous group of illnesses affecting the larynx,
trachea, and bronchi. The lateral walls of the trachea below the level of the vocal cords are
marked by swelling and erythema. Croup is described according to the main anatomical area
affected. Epiglottitis, supraglottitis, laryngitis, laryngotracheobronchitis, and bacterial tracheitis
encompass croup syndrome. Croup commonly affects children between 3 months and 5 years of
age, most often around age 2. The incidence is higher in boys, and it is most frequent during the
winter months. The incidence of epiglottitis has dramatically decreased since the introduction of
the Hib vaccine in the late 1980s.
Viral agents, particularly the parain uenza viruses (types 1, 2, and 3), and RSV are the most
common cause of croup and account for the majority of cases. Streptococcus pyogenes, S
pneumoniae, and Staphylococcus aureus are the common causes of epiglottitis while
Haemophilus in uenzae, S aureus, and Corynebacterium diphtheriae are involved in bacterial
tracheitis.
Signs and Symptoms
The symptoms of croup can be explained in terms of the child’s anatomical structure. The
subglottic region of the larynx is held within the rigid ring of the cricoid cartilage. Symptoms are
related to the extent of upper airway involvement and the infectious agent responsible for the
croup. Croup can lead to obstruction because children have a narrow larynx, such that a decrease
in airway diameter causes a decrease in air ow, leading to the symptoms of croup.
Acute laryngotracheitis is characterized by these signs and symptoms:
▪ Usually viral (parain uenza, adenovirus, RSV)
▪ Peak age is 3 to 36 months
▪ Gradual, acute onset during the night
▪ URI symptom
▪ Seal-bark cough
▪ Mild to moderate dyspnea
▪ Symptoms worse at night
▪ Low-grade fever
▪ Respiratory rate less than 50
Spasmodic croup typically has these manifestations:
▪ Usually viral
▪ Peak age is 3 to 36 months
▪ Generally no preceding illness, though may have coryza
▪ Sudden onset, often at night Fever variabl
▪ Barky coug
▪ Hoarseness
Epiglottitis displays the following characteristics:
▪ Peak age is 1 to 5 years
▪ Rapid onse
▪ Sore throa
▪ Dysphagia
▪ Anxiety related to inspiratory distress

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 ▪ Droolin
▪ Muf ed speec
▪ Toxic appearance
▪ Tripod positionin
▪ Marked distres
▪ High fever ranging from 101.8°F to 104°F (38.8°C to 40°C)
Croup is characterized by these ndings:
▪ Usually caused by Staphylococcus aureus
▪ Peak age is 3 to 36 month
▪ Acute onse
▪ Hoarseness
▪ Barky coug
▪ Inspiratory strido
▪ Toxic appearance
▪ Purulent sputu
▪ Marked distres
▪ High fever 102.2°F (39°C)
Bacterial tracheitis symptoms include the following:
▪ Considered a bacterial complication of a viral disease
▪ Can lead to a life-threatening airway obstruction severe enough to cause respiratory arres
▪ Preceded by upper respiratory tract infection
▪ “Croupy” coug
▪ Stridor unaffected by position
▪ Toxic appearin
▪ High feve
▪ Strido
▪ Hoarsenes
▪ Dyspne
▪ Retractions and nasal aring
▪ Thick purulent tracheal secretions
Laryngitis typically has these characteristics:
▪ More common in older childre
▪ Usually caused by a viru
▪ Hoarsenes
▪ May have upper respiratory symptoms including coryza, sore throat, and nasal congestion
▪ Malaise
▪ Low-grade fever
▪ Headache
▪ Myalgi
Medical Management Vital = no antibiotics
Corticosteroids are the mainstay of therapy for croup, regardless of clinical severity. A single
dose of dexamethasone (0.15 to 0.60 mg per kg usually given orally) is recommended in all
patients with croup, including those with mild disease. Nebulized epinephrine is an accepted
treatment in patients with moderate to severe croup. Dexamethasone and inhaled budesonide
relieve croup symptoms as early as 3 hours after treatment. Based on historical data, nebulized
adrenaline in children with severe croup substantially reduces the number requiring an arti cial

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 airway. Adrenaline reduces respiratory distress within 10 minutes of administration and lasts
longer than 1 hour.

Acute Epiglottitis
● A medical emergency presenting as a sudden, potentially lethal condition
characterized by high fever, sore throat, dyspnea, and rapidly progressing respiratory
obstruction
● Signs and symptoms
● Classic sign- tripod position with chin thrust out (sni ng position)
● Diagnosis- history, imaging
● Treatment
● Possible intubation or tracheostomy, antibiotics, steroids, humidi ed O2, IV
uids
● Nursing Care
● Do not put anything into the mouth
● Education
● Prevention
Acute Epiglottitis 4 D's: Dysphonia, Dysphasia, Drooling, and Distressed respirations
Acute epiglottitis or supraglottitis is a medical emergency presenting as a sudden, potentially
lethal condition characterized by high fever, sore throat, dyspnea, and rapidly progressing
respiratory obstruction. Acute epiglottitis is a serious obstructive in ammatory condition that
requires immediate attention.
Diagnosis
Diagnosis of croup is based on the signs and symptoms along with history, and treatment takes
priority over testing because of the severity of respiratory distress. Soft tissue imaging of the
neck and chest demonstrates the classic presentation of subglottic narrowing or the “steeple
sign.” When epiglottitis is suspected, blood cultures are ordered to identify the causative
organism. A radiograph of the lateral neck may present with the “thumb sign,” which describes
the x-ray appearance of the epiglottis. The diagnosis of a bacterial cause for croup, such as in the
case of bacterial tracheitis and laryngotracheobronchitis (LTB), can be con rmed by an elevated
white blood cell count, which includes leukocytosis with a left shift. Bacterial tracheitis can be
differentiated from epiglottitis by a slower onset, the absence of the thumb sign, and classic
symptoms presented in epiglottitis.
H. influenzie is the caustive organism
Prevention
Routine immunization with Hib provides primary prevention of epiglottitis. Good hand washing,
proper tissue disposal, and covering the nose and mouth when coughing are effective methods of
preventing spread of infection.
Collaborative Care
NURSING CARE
In mild croup, a child may present with only a croupy cough and may just require parental
guidance and reassurance, given alertness, baseline minimal respiratory distress, proper
oxygenation, and stable uid status.
The nursing care measures for croup depend on the various causative organisms. The most
important goal in the treatment of children with croup is maintaining the airway and providing
adequate respiratory exchange. The nurse stays at the child’s side to reduce child and parent
anxiety, observes for worsening symptoms, and helps the child maintain a position that supports

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 Don't put anything in the mouth, can cause a spasm and close the airway

maximum airway and respiratory exchange. Key areas of nursing responsibility include
maintaining the airway, providing rest and humidi cation, monitoring uid balance, and
administering medications as prescribed. Changes in condition are based on observations and
assessment of the child’s response to therapy, including careful observation of the child’s
response to their surroundings (changes in level of consciousness).
Urgent care or emergency department treatment of croup depends on the patient’s degree of
respiratory distress:
• Corticosteroids. Corticosteroids are bene cial due to their anti-in ammatory action; their use
decreases both laryngeal mucosal edema and the need for salvage nebulized epinephrine;
corticosteroids may be warranted even in those children who present with mild symptoms.
• Epinephrine. Patients who receive nebulized racemic epinephrine in the emergency department
should be observed for at least 3 hours after last treatment because of concerns for a return of
bronchospasm, worsening respiratory distress, and/or persistent tachycardia; patients can be
discharged home only if they demonstrate clinical stability with good air entry, baseline
consciousness, no stridor at rest, and have received a dose of corticosteroids.
• Heliox. Heliox is a gas that contains a mixture of helium and oxygen (with not less than 20%
oxygen); delivery to the patient is via nasal cannula, face mask, or hood; it has low viscosity
and low speci c gravity, which allows for greater laminar air ow through the respiratory tract;
helium facilitates the movement of oxygen through the airways and decreases the mechanical
work of respiratory muscles; this clinical response reduces respiratory distress.
As previously mentioned, current treatment approaches for patients with croup are
corticosteroids and nebulized epinephrine; steroids have proven bene cial in severe, moderate,
and even mild croup.
▪ Corticosteroids. Steroids are thought to decrease airway edema via their anti-
in ammatory effect; corticosteroids have been shown to reduce hospitalization rates by
86%, and in mild disease, they have been proven to reduce the number of children
returning to the ED for further treatment.
▪ Epinephrine. Epinephrine stimulates alpha receptors and beta2 receptors; it constricts the
precapillary arterioles, thus decreasing airway edema; because
of the potential adverse effects of tachycardia and hypertension, it is reserved for children
with moderate to severe disease.
MEDICAL CARE
Mild cases of croup are commonly treated with cool mist. A high-humidity, cool air vaporizer
may be used at home in the child’s room. In the hospital setting, oxygen hoods for infants and
oxygen tents for toddlers are used. Cool mist is thought to moisten airway secretions to facilitate
clearance, soothe in amed mucosa, and provide comfort and reassurance to the child, thereby
lessening anxiety. Nebulized racemic epinephrine (Micronefrin or Vaponefrin) (0.25 to 0.5 mL in
3 mL of a normal saline solution) or l-epinephrine (5 mL of 1:1,000 solution) are equally
effective to cause mucosal vasoconstriction and consequently decrease subglottic edema, thus
relieving the symptoms. This treatment is indicated for those with moderate to severe stridor at
rest or when stridor does not respond to cool mist. Observe the child after nebulization to assess
the airway and side effects of the delivered medication.
Corticosteroids are also given to children to decrease the edema in the laryngeal mucosa through
their antiin ammatory action. IM dexamethasone (Decadron) and nebulized budesonide
(Pulmicort) are widely used.
Antibiotic therapy is indicated for epiglottitis and bacterial tracheitis. Combinations of ampicillin

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 and sulbactam (Unasyn) are the drugs most often prescribed. Antibiotics are not used in the
management of viral croup.
Education/Discharge Instructions
Parents are instructed on the use of cool-mist humidi cation, as well as the use of a steamy
bathroom to help modify respiratory symptoms. If the child has been hospitalized and discharged
on medications, the parents also need information about the importance of compliance and the
proper administration and dosage of medications. Parents are also instructed on symptoms of
potential side effects of the medications and the symptoms of a worsening condition (e.g.,
speci cally increased signs of respiratory distress, restlessness, and confusion).

LOWER AIRWAY DISORDERS

Decreased air movement, prolong expiration, wheezing
^^^^

Bronchitis
● Nonspeci c bronchial condition in which the bronchial tubes are in amed
● Signs and symptoms
● Dry, hacking cough that becomes productive
● Symptoms usually worse at night
● Treatment
● Supportive
● Nursing care
● Chronic bronchitis in adolescents- screen for tobacco/ THC use
Bronchitis
Bronchitis is a nonspeci c bronchial condition in which the bronchial tubes are in amed. It is
unusual for children to be diagnosed with bronchitis alone; other associated upper and/or lower
respiratory tract conditions are likely to be involved because of the proximity of the respiratory
tract structures. Tracheobronchitis is a more common term used when the trachea is prominently
involved.
Bronchitis may be acute or chronic. Acute bronchitis is commonly preceded by a viral upper
respiratory tract infection and may last for 1 to 3 weeks. The incidence of acute bronchitis is
highest during the winter months. Children are usually affected in their rst 4 years of life.
Chronic bronchitis lasts for months or years and is more common among adults, particularly
smokers. The incidence of chronic bronchitis in children is also more often associated with
cigarette smoking or the presence of secondhand smoke, as well as with the presence of another
chronic condition such as allergies, asthma, or CF.
Viruses are usually the causative organism. The tracheobronchial epithelium is invaded by the
infectious agent, and this leads to activation of in ammatory cells and release of cytokines,
giving way to the occurrence of symptoms. If the tracheobronchial epithelium becomes
signi cantly damaged or hypersensitized, then a protracted cough may last for 1 to 3 weeks.
Signs and Symptoms
▪ Dry, hacking cough that becomes more productive and purulent over time and worsens at
night
▪ Rhinorrhea occurring 3 to 4 days after onset of a cough
▪ Signs of nasopharyngeal infection and conjunctivitis
▪ Coarse breath sounds, rhonchi, and coarse, changing rales
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 ▪Low-grade or no fever
▪Low substernal discomfort or burning in the chest
▪A productive cough lasting more than 3 months with chronic bronchitis
Diagnosis
Because a virus is usually the causative organism, bronchitis is diagnosed based on the child’s
symptoms. In children older than 6, M pneumoniae is a common cause, and bronchitis can be
determined by the identi cation of this bacterium.
Prevention
Good hand washing, covering the nose and mouth when coughing, and care in avoiding touching
eyes and nose can help prevent the spread of the organisms that cause bronchitis. Instruct parents
on the avoidance of secondhand smoke, dust exposure, known allergens, air pollution, crowded
places during u seasons, and contact with persons known to have bronchitis.
Collaborative Care
NURSING CARE
Nursing care is generally directed toward providing supportive care and adequate air exchange.
To provide oxygenation, the nurse must ensure that the airway is open and free of obstruction.
The airway can be opened by administering prescribed bronchodilators. The nurse encourages
the child to clear the airway from secretions by coughing. Use of a cool-mist humidi er at the
bedside may help liquefy secretions, which promotes expectoration when coughing. Secretions
are disposed of in sealed plastic bags.
MEDICAL CARE
For acute bronchitis, care is primarily supportive. Symptom relief may include use of
antipyretics, analgesics, and humidity. Cough suppressants are administered with caution
because they interfere with clearance of secretions. The condition is self-limiting, and antibiotics,
though often prescribed, do not hasten improvement in uncomplicated cases. The treatment for
chronic bronchitis depends on the cause or underlying condition.
Education/Discharge Instructions
Home care may include instructing the parents on using a cool-mist humidi er, providing
suf cient uids and nutrition, and encouraging the child to expectorate secretions. Parents are
instructed to avoid exposing the child to secondhand smoke, environmental pollutants, and
known allergens.

Bronchiolitis and Respiratory Syncytial Virus

● An in ammation of the bronchioles and small bronchi
● RSV is a common virus that can be serious, especially for infants
● Signs and symptoms
● Diagnosis- nasopharyngeal secretions +RSV antigen
● Treatment- Hydration, fever control, oxygenation
● Nursing Care – droplet/ contact precautions
● Education
● Handwashing, suction in bulb syringe, saline drops/ spray, discontinue
smoking in the home
Bronchiolitis and Respiratory Syncytial Virus (RSV)
Bronchiolitis is an in ammation of the bronchioles and small bronchi. Bronchiolitis causes lower
respiratory tract obstruction because of in ammation and edema, which may lead to

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 bronchospasms. Bronchiolitis is usually caused by viral pathogens, such as RSV, adenovirus, and
parain uenza virus (types 1, 2, and 3), among others. Respiratory syncytial (sin-SISH-uhl) virus,
or RSV, is a common respiratory virus that usually causes mild, cold-like symptoms. Most
people recover in a week or two, but RSV can be serious, especially for infants. In fact, RSV is
the most common cause of bronchiolitis (in ammation of the small airways in the lung) and
pneumonia (infection of the lungs) in children younger than 1 year of age in the United States.
By the age of 2, nearly every child has been exposed to the virus.
RSV peaks in the winter, generally beginning as early as September or October and continuing
through April or May. Bronchiolitis is common among children age 2 years and younger. Nearly
80% of the cases of bronchiolitis occur in children younger than 1 year of age. Bronchiolitis is
highly contagious and spreads by direct contact with respiratory secretions or from particles on
contaminated objects. Bronchiolitis is easily spread from hand to eye, nose, and mucous
membranes.
The peak period for a child to acquire RSV is December through March. RSV most often begins
as an infection in the nasal epithelial cells. The RSV virus then replicates in the host cell. The
host cell is destroyed, and virus particles are released to propagate the infection. The infection
results in the destruction of the epithelial cells of the respiratory tract. Exposure to RSV triggers
a humoral immune response. Primary RSV infection results in only a weak antibody response
with IgM, IgG, and IgA produced. This response is not enough to destroy the virus completely or
to prevent upper respiratory tract replication of the virus. Consequently, an upper respiratory
tract illness develops. High levels of neutralizing antibodies are required to prevent the
progression of infection from the upper respiratory tract to the lower respiratory tract.
Signs and Symptoms
■ Upper respiratory infection (URI) symptoms of cough, coryza, and rhinorrhea lasting 3 to 7
days
■ Respiratory distress marked by noisy, raspy breathing and cyanosis
■ Audible wheezing
■ Retractions
■ Rales and prolonged expiratory phase of respirations
■ Tachypnea
■ Low to moderate fever up to 102°F (38.9°C)
■ Decreased appetite and poor feeding
■ Pharyngitis
■ Depending on the duration of symptoms and oral intake, dehydration may be manifested by
poor tearing, dry mucous membranes, and poor skin turgor
■ Thick mucus, exudate, and mucosal edema obstruct the smaller airways (bronchioles) leading
to a reduction in expiration, air trapping, and hyperin ation of the alveoli
■ The obstruction interferes with gas exchange, possibly leading to hypoxemia (decreased
oxygen) and hypercapnia (increased carbon dioxide in the blood), which in turn leads to
respiratory acidosis
■ May be accompanied by otitis media and conjunctivitis
■ May result in hospitalization
Diagnosis

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 Positive identi cation of RSV is accomplished from nasal secretions or nasopharyngeal

washings. These are tested for the virus or for the antibodies the virus makes.
Prevention
Proper hand washing, reducing exposures to and transmission of RSV, and avoiding secondhand
smoke are the best means of prevention. The monoclonal antibody palivizumab (Synagis) is
given IM to high-risk infants and shown to be effective in reducing the complications of RSV,
hospitalization, and associated morbidities as prophylaxis for high-risk infants.
Collaborative Care
NURSING CARE
RSV is treated symptomatically through maintenance of hydration, fever control, oxygenation,
and keeping the mucous membranes clear of mucus. Children may be managed at home.
Hospitalization is recommended for children who have some other underlying illness or are in a
debilitated state. In the hospital, nursing care includes head elevation of 30 to 40 degrees, oxygen
saturation monitoring, and cool-mist therapy combined with oxygen administered by hood or
tent in concentrations suf cient to alleviate dyspnea and hypoxia. The nurse administers IV
uids until the child shows signs of improvements.
Strict isolation is required for patients infected with RSV virus because it is easily spread from
hand to eyes or nose and other mucous membranes. The nurse emphasizes hand washing and that
contact precautions such as the use of gown, gloves, and masks are required (Fig. 15-6). Parents
need to know that the rst 24 to 72 hours is the critical time and in most cases children recover
completely.
dropplet
MEDICAL CARE
The clinical goal is to return the child to a normal respiratory status. Medical therapy is aimed at
relief of respiratory distress, improvement in oxygenation, and alleviation of airway obstruction.
Education/Discharge Instructions
Educate parents on the importance of watching for signs of worsening conditions, such as signs
of respiratory distress and dehydration, and on when to seek care. Instruct parents on the use of
cool-mist humidi cation, providing uids, and fever control. Parents can be instructed to manage
rhinitis with saline drops and nasal suctioning.

Pneumonia
● A lower respiratory tract infection of the pulmonary parenchyma
● Classi ed as:
● Lobar
● Bronchopneumonia
● Interstitial
● Signs and symptoms- productive cough, chest pain, n/v/d, fatigue, fever, h/a, chills,
fussiness
● Diagnosis- CXR, sputum culture, CT, pulse ox, blood work
● Treatment- uids, cool mist humidi er, acetaminophen, cough medications, nebulizer,
oxygen, antibiotics, suctioning
● Nursing care
● Education- handwashing, prevention
Pneumonia
Pneumonia is a lower respiratory tract infection of the pulmonary parenchyma. It is more
common in infancy and early childhood and may occur as a primary infection or secondary to

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 another illness or infection. Pneumonias are classi ed as lobar, bronchopneumonia, and

interstitial. Lobar pneumonia involves lobes of the lungs. Viral pneumonia, a more common
form, involves RSV infection in infants and parain uenza and adenoviruses in older children,
whereas Streptococcus pneumoniae is the common pathogen causing bacterial pneumonia. Viral
pneumonia accounts for 45% of pneumonia cases (Redjal, 2020). A viral infection can have a
secondary bacterial infection 6 to 8 days after initial onset because of viral insult of protective
mechanisms.
Aspiration pneumonia may occur as a result of aspiration of foreign material into the lower
respiratory tract.
Collaborative Care
NURSING CARE?
Nursing care is primarily directed toward providing supportive care and educating the family
about the illness and management. Supportive care includes ensuring adequate hydration, which
will help in thinning secretions. Oxygen administration via nasal cannula with cool mist, CPT,
and postural drainage are initiated for patients requiring hospitalization. Supplemental oxygen
may be necessary with children experiencing signi cant respiratory distress and who would be
easily fatigued by activities. IV uids help prevent dehydration. Elevating the head of the bed
will promote improved air exchange of the lungs.
MEDICAL CARE
Most cases of pneumonia can be treated at home with rest and uids and symptomatic
management with analgesics and antipyretics. Antibiotics are given for bacterial pneumonia and
not for viral pneumonia. If antibiotics are given, the drugs may range from amoxicillin (Amoxil)
to the third generation cephalosporins, depending on the severity of the condition.
Bronchodilators also might be used. Analgesics may reduce the pain associated with coughing.
Education/Discharge Instructions
Treatment of a child with pneumonia is supportive depending on the severity of the symptoms.
Education includes instructing the parents on the importance of adhering to the prescribed
antibiotic regimen. Parents of infants may need to be instructed to continue frequent, small
feedings because the child may tire easily. Inform the parents that complete recovery from
pneumonia may occur in about 2 weeks. Even if the child is feeling better after treatment,
gradual return to normal activities like school and play are encouraged.
HIB and pneumococcal vaccine is recommended
In uenza
● A common infection of the respiratory system caused by viruses
● Infants and children are most vulnerable
● Signs and symptoms
● Fever, chills, headache, myalgia, malaise, n/v/d, cough, dry, sore throat
● Diagnosis- swab for in uenza
● Nursing care- supportive care; oseltamivir (Tami u)- start within rst 48 hours to
decrease severity and duration of illness
● Education- prevention, u vaccine is recommended starting at 6 months
In uenza
In uenza, or u, is a common infection of the respiratory system caused by viruses. Infants and
children are most vulnerable to the in uenza virus. It is estimated that children are 3 times more
likely to become ill with in uenza than adults are. The American Lung Association notes that in
the United States in uenza and its related complications result in an estimated 226,000

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 hospitalizations and anywhere from around 3,000 to 49,000 deaths annually, particularly among
older individuals and those with chronic medical conditions. The disease rapidly spreads
worldwide in seasonal epidemics. In uenza is most common during the winter months.
Three types of virus cause in uenza. In uenza types A and B are the major in uenza pathogens
and cause epidemics. These viruses mutate and create different strains. In uenza type C causes
mild symptoms and does not cause epidemics. Regular H1N1 and H3N2 are categorized under
type A in uenza and are included in the seasonal u vaccine. Type B viruses are generally not
found in humans, although they can cause illness with less severe symptoms. Type C viruses
cause mild illness in humans and are not typically included in the seasonal u vaccine. In uenza
is spread through droplets when an infected person coughs, sneezes, or speaks. Indirectly, articles
contaminated by nasopharyngeal secretions may spread the infection. Infected individuals shed
the virus for 1 to 2 days before symptoms appear and may continue to shed the virus in
increasing amounts for as long as 2 weeks. In uenza causes a lytic (cellular destruction)
infection of the respiratory epithelium with loss of ciliary function, decreased mucus production,
and desquamation of the epithelial layer. These changes may permit secondary bacterial invasion
directly from the epithelium or through the middle ear space.
Signs and Symptoms
▪ Abrupt onset of fever
▪ Facial ushing
▪ Chills
▪ Headache
▪ Myalgia
▪ Malaise
▪ Diarrhea, nausea, and vomiting
▪ Cough
▪ Coryza
▪ Dry or sore throat
▪ Photophobia, tearing, burning, and eye pain may occur
▪ Complications include severe viral pneumonia, encephalitis, and secondary bacterial
infections such as otitis media, sinusitis, or pneumonia
▪ Flu symptoms in children are similar to that of adults, except that children have higher
degrees of fever of up to 105.1oF (40.6oC)
Diagnosis
The diagnosis of u is based on the child’s signs and symptoms and epidemiological
considerations. In the presence of a known epidemic, a child who has symptoms of fever,
malaise, and respiratory illness may easily be diagnosed. Laboratory tests may also isolate the
virus from the nasopharynx if done early in the course of illness. Rapid in uenza diagnostic tests
are available, although they have varying degrees of sensitivity. Results may be obtained within
15 minutes, but their routine use should be considered based on whether the results would
change the clinical care. Nasopharyngeal swabs or aspiration taken within 72 hours of the onset
of the symptoms can isolate and con rm the virus in 2 to 6 days.
Prevention
Prevention includes frequent hand washing, covering the mouth and nose when sneezing or
coughing, properly disposing of used tissues, and avoiding close contact with persons who may
have become infected. In uenza vaccines are now widely used for prevention. There are two
routes for the vaccines: IM and nasal spray. Vaccination is recommended annually to populations

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 at risk because the u virus is continuously changing. Current guidelines recommend that all
children ages 6 months to 18 years be immunized with 2 doses being administered during the
rst year of immunization. In addition, health-care providers should receive a yearly in uenza
vaccine to protect themselves and prevent spread to patients and their families.
Collaborative Care
NURSING CARE
Because in uenza is a self-limiting condition, nursing care is supportive. Depending on the
severity of in uenza, the child recovers within 1 to 2 weeks. The nurse must emphasize to the
parents the importance of adequate rest and sleep. When the child has the u, more uids are
offered. An electrolyte solution is recommended. The nurse can reiterate the importance of
having an annual vaccination.
MEDICAL CARE?
In uncomplicated cases, in uenza is treated symptomatically because symptoms usually recede
in 48 to 72 hours. Adequate rest and uid intake are important components of the regimen. For
fever and pain, acetaminophen (Children’s Tylenol) or ibuprofen (Children’s Advil) is given.
Antiviral drugs such as oseltamivir (Tami u), amantadine (Symmetrel), and rimantadine
(Flumadine) are currently used to manage in u- enza. These medications are usually given in the
rst 48 hours to decrease the severity and duration of the illness. Antibiotics are given when
there is evidence of a superimposed bacterial infection, like prolonged fever and deterioration of
the condition.
Education/Discharge Instructions
Parents can be instructed to ensure adequate rest, hydration, and nutrition as well as provide
fever control as necessary. Continued education includes a reminder of the importance of
receiving the in uenza vaccine as well as frequent hand washing, covering the mouth and nose
when sneezing or coughing, properly disposing of used tissues, and avoiding close contact with
persons who may have become infected. Cold v. Flu: swab for flu and covid, do multiple swabs
and determine what would be the treatment
Acute Respiratory Distress Syndrome (ARDS)
● Life-threatening condition characterized by increased pulmonary capillary
permeability and pulmonary edema
● Signs and symptoms- respiratory distress
● Treatment- ICU- respiratory and cardiac care
● Nursing care
● IV uids, IV nutrition, positioning, pain and anxiety control, infection control
Acute Respiratory Distress Syndrome (ARDS)
ARDS is a life-threatening condition characterized by increased pulmonary capillary
permeability and pulmonary edema, which leads to hypoxemia, reduced lung compliance, and
alveolar in ltrates. An acute underlying illness or injury such as sepsis, viral pneumonia, smoke
inhalation, aspiration of gastric contents, hydrocarbon ingestion or aspiration, or near-drowning
may progress to ARDS. Infection is the most common cause, often associated with respiratory
syncytial virus (RSV) in children. Indirect lung injury, such as with pancreatitis, shock, burns,
trauma, drug overdoses, and blood transfusions, may also precipitate ARDS. The underlying
disease or disorder in uences the mortality rate. Mortality in adults can be as high as 90% with
underlying liver disease and as low as 10% in children with RSV. The average mortality rate
overall is 40%. Multisystem organ failure is a frequent complication of ARDS, has a major effect
on the prognosis, and is the leading cause of death in both adults and children.

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 As the disease progresses, the alveolar-capillary membrane becomes more permeable. As
exudate enters the alveolar spaces, the lung becomes less compliant and susceptible to
pulmonary edema. This further leads to decreased surfactant production, which exacerbates
alveolar instability. Swelling leads to atelectasis, and gas diffusion is impaired. As a result,
decreased oxygen enters the bloodstream, which may lead to multisystem organ damage.
Signs and Symptoms
Respiratory distress results when breathing does not match the body’s metabolic demand for
oxygen due to failure of oxygenation and/or ventilation. Respiratory distress is typically
characterized by signs of increased work of breathing, such as tachypnea, use of accessory
muscles, and/or retractions. Head bobbing, nasal aring, and grunting are additional signs more
commonly seen in very young children. A respiratory rate that is inappropriately slow for the
clinical condition may also be a sign of respiratory distress and may be more important than
impending respiratory arrest. An abnormal pattern of respiration is a sign of respiratory distress
that may offer clues to etiology.
ARDS is usually diagnosed in a patient who is in the hospital from a critical illness such as
shock, sepsis, or other trauma. Diagnostic tests may include:
▪ Arterial blood gases
▪ Chest x-ray
▪ Other blood tests that can nd an infection that may be causing ARDS
▪ CT scan of the lung
▪ Electrocardiogram and echocardiogram to rule out cardiac causes
Prevention
The incidence of ARDS may be decreased through primary prevention of traumatic injuries by
use of child car restraints, bicycle helmets, and protective sports gear. Some infectious illnesses
primarily affecting the respiratory tract may be prevented through compliance with
recommended immunizations and good hand washing hygiene. RSV pas- sive immunization
with immunoglobulins can inhibit more serious illness in vulnerable patients.
Collaborative Care
NURSING CARE
Caring for children with ARDS requires advanced training and technical skills along with
vigilant nursing assessment and monitoring of vital signs. The nurse must accurately record and
report signi cant changes in vital signs to the physician. Calories and uids are provided
intravenously; therefore, the nurse monitors exact intake and output. In addition, the child with
ARDS requires supportive care. The child will be placed in intensive care, and both the
respiratory and cardiovascular status will be monitored closely. Care includes positioning, pain
and anxiety control, maintenance of nutrition, and infection control practices. Ventilator support
may be required as the disease progresses and requires the nurse to be sensitive to the
psychological support of both the child and family. Education should include an explanation of
procedures and assisting the family to understand test results and evidence of disease progress.
MEDICAL CARE
Medical management is directed at improving oxygenation and ventilation and often includes the
use of mechanical ventilation with attention to positive end-expiratory pressure (PEEP).
Monitoring includes continuous blood pressure measurements, central venous pressure
monitoring, and ABS analysis to assess for adequate oxygenation, ventilation, uid volume, and
cardiac functioning. Fluids may be restricted to reduce intravascular volume because of the
potential for pulmonary edema related to increased pulmonary capillary permeability.

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 Most people with ARDS will need mechanical ventilator assistance with a low tidal volume. Use
of a high tidal volume can overdistend the lungs, leading to lung in ammation and ventilator-
associated lung injury. For milder symptoms, oxygen may be delivered using a properly tting
face mask. PEEP is considered an essential component of ventilation. Use of PEEP helps expand
alveoli and increases lung volume.
Prone positioning has been demonstrated to improve postural drainage and ventilation of
collapsed portions of the lungs. Use of inhaled nitric oxide, which causes pulmonary vasodilation
increasing blood ow, has been found to improve oxygenation, though research has not
demonstrated an overall signi cant improvement in survival rates. Surfactant therapy has been
studied as a potential treatment for ARDS, though consistent bene ts in children have not been
identi ed. Use of extracorporeal membrane oxygenation (ECMO), which removes the blood
from the body and then returns it, has also been used in adults, though according to Cheifetz,
limited data addresses its use in children. Though ECMO is a life-saving therapy, it is also
considered invasive with a high risk of bleeding.
Education/Discharge Instructions
Parents need to be instructed about the need for that longterm care follow-up and monitoring of
the pulmonary system. In addition, parents need to understand the importance of maintaining a
smoke-free environment, providing proper nutrition, avoiding infections, and ensuring
compliance with immunizations.

CHRONIC LUNG DISEASES

^^^^

Asthma
● Characterized by bronchial smooth muscle spasm, in ammation and edema of the
bronchial mucosa, and production and retention of thick secretions
● Pathophysiology: in ammatory response/hyperresponsive airways
● acute bronchoconstriction, edema, and mucus plugging, tissue damage
● Signs and symptoms-
● Recurrent wheezing, SOB, nonproductive cough, exercise intolerance, chest
pain or tightness
● Diagnosis- clinical presentation, history and physical, labs
Asthma
Asthma is the most common chronic disease in childhood and is characterized by the triad
symptoms of bronchial smooth muscle spasm, in ammation and edema of the bronchial mucosa,
and production and retention of thick, tenacious, pulmonary secretions leading to airway
obstruction. Asthma is the most common chronic condition among children, currently affecting
an estimated 6.7 million children under 18 years, of which 3.5 million suffered from an asthma
attack or episode in 2016. Prevalence and mortality rates are higher and continue to rise among
minority and inner-city children. Risk factors include environmental factors, such as air
pollutants, allergen exposure, exposure to tobacco smoke, and strong chemical odors. Other
factors include low socioeconomic status and health-care disparities. An asthma episode is a
series of events that result in narrowed airways. These include swelling of the airway lining,
tightening of the muscle surrounding the airways, and increased secretion of mucus inside the

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 airway. The narrowed airway causes dif culty breathing and the familiar “wheeze.” The term
status asthmaticus is used to refer to persistent and intractable asthma exacerbation in which the
child does not respond to therapy and is a medical emergency.
Genetic, environmental/extrinsic, and intrinsic factors predispose the child to develop asthma.
Although allergens play an important role in asthma, 20% to 40% of children with asthma have
no evidence of allergic disease. Among the extrinsic factors are allergens such as dust, pollen,
animal hairs, chemical sprays, perfumes, baby powder, molds, and foods such as nuts,
chocolates, oranges, and chicken. Conditions such as changes in weather, pollution, and smoke
may also trigger an attack. Intrinsic factors include exercise, anxiety, strong emotions such as
fear and laughter, and infections.
When any of the factors trigger an asthma attack, the response comes in 10 to 20 minutes. The
allergen/antigen binds to the allergen-speci c immunoglobulin E (IgE) surface, causing
activation of resident airway mast cells and macrophages. Proin ammatory mediators, such as
histamine and leukotrienes, are released. They provoke contraction of the airway’s smooth
muscles, increased mucus secretion, and vasodilation. Consequently, microvascular leakage and
exudation of plasma into the airway walls cause them to become thickened and edematous with
subsequent lumen constriction.
Signs and Symptoms
▪ Recurrent wheezing
▪ Shortness of breath
▪ Nonproductive cough Atopic dermatitis, allergies, and asthma all go
▪ Chest tightness or pain together
▪ Exercise intolerance
▪ Prolonged expiratory phase of respirations
▪ Tachypnea
▪ Retractions and nasal aring nighttime cough
▪ History of allergies
▪ History of atopic dermatitis
▪ Nasal polyps
▪ History of nighttime cough
▪ Family history of atopy (asthma, allergic rhinitis, or atopic dermatitis)
Diagnosis
The asthma diagnosis for the child is based on clinical symptoms, history, physical examination,
and to a lesser extent, laboratory tests. Diagnostic studies may include pulse oximetry to measure
oxygen saturation, blood gases to determine carbon dioxide retention and hypoxemia, complete
blood count, pulmonary function tests to assist in determining the degree of disease, peak
expiratory ow rate, allergy testing, and chest radiography to evaluate hyperin ation and the
potential for coexisting infection.

Asthma Treatment
● There are four types of asthma medicines and treatments:
● Quick-relief medicines –work quickly to relieve sudden symptoms; take at the rst
sign of symptoms.
● Controller medicines –correct the underlying changes in the airways, like swelling and
excess mucus; can be used alone or in combination

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 ● Combination of quick-relief and controller medicines – used for short-term relief and
control. (recommended in the current asthma clinical guidelines but have not yet been
approved to be used in this way by the FDA.)
● Biologics –targets a cell or protein to prevent swelling inside the airways; for people
with certain types of persistent asthma and are given by injection or infusion.
Prevention
Prevention is directed toward day-to-day management of asthma. This includes educating the
parents and child on the importance of identifying environmental factors that trigger an attack;
compliance with medication; and how to use and clean inhalers, spacer devices, or aerosol
equipment as needed. In addition, parents and children need to understand how to manage
asthma in settings away from home, how to recognize when there is a need to seek additional
assistance, and the importance of regular follow-up.
Collaborative Care
NURSING CARE
Nursing care for children with asthma involves assisting with relief of symptoms and providing
health education to patients and family. Asthma attacks are frightening and stressful both for the
child and family; therefore, the nurse has a calm approach in its initial management.
Administering quick-relief medications without delay is important (Fig. 15-8). Essential nursing
interventions include giving medications on time, liquefying secretions through adequate
hydration, positioning the child properly (head of bed elevated 30 degrees) to provide comfort,
and lung expansion. The side-lying and semiprone positions are also recommended. It is vital
that the nurse reports and records the child’s respiratory assessment and responses to medications
so that appropriate management may be initiated immediately. The nurse can also ensure that
respiratory treatments happen in a timely manner and that ordering a prn (as needed) treatment
may be necessary.
MEDICAL CARE
Treatment consists of early relief of symptoms through drug therapy and prevention of further
attacks through allergen control, environmental manipulation, health education, and attainment
of self-management skills. The goal is to enable the child to have as regular a life as possible by
keeping the lung function within normal limits. The nurse provides adequate health education
about the use of a peak ow meter to help the parents increase their capacity to care for the child.
Drug therapy depends on the level of severity of the disease. There are two approaches to this
therapy: (1) the quick-relief or rescue medications and (2) the long-term control medications.
The U.S. Department of Health and Human Services, the National Asthma Education and
Prevention Program, expert panel give guidelines for the diagnosis and management of asthma
via revised age-related classi cation schemes for asthma severity (Table 15-2, Table 15-3, and
Box 15-1).
The guidelines recommend daily anti-in ammatory agents to control the levels of persistent
asthma, with increasing doses of medication as necessary. The use of low-dose control
medications, such as inhaled steroids, cromolyn sodium (Intal), nedocromil (Tilade), or an
antileukotriene agent such as a montelukast sodium (Singulair) tablet is recommended for
children with mild, persistent asthma (Fig. 15-9). A higher dose of steroids with the addition of
long-acting beta antagonists may be needed for moderate and severe persistent asthma. For quick
relief of bronchospasm and for children with asthma, short-acting inhaled beta antagonists are
recommended
Asthma Action Plan

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 The Asthma Action Plan (Fig. 15-10) is an educational communication tool used between the
health-care provider and the patient, along with their family and caregivers, to properly manage
asthma and respond to asthma episodes. The Asthma Action Plan is completed by the child’s
primary care provider. It includes the symptoms and management for each color zone including
peak ow measurements appropriate for each color zone. Nurses can provide adequate
instructions on how to use, interpret, and complete the form.
A peak ow meter (Fig. 15-11), which can be purchased over the counter, is an essential
companion for the Asthma Action Plan for children older than 6 years. The peak ow meter is a
portable handheld device that is used to measure the ability to push air out of the lungs. To
determine the child’s zone for children younger than 6 years, the symptoms alone are used. The
“personal best” peak ow is determined when the child is symptom free. A peak ow meter
package usually contains a form where peak ow readings are recorded regularly. A personal
best normal may be obtained from measuring the patient’s own peak ow rate. Therefore, it is
important for the patient, parents, and the doctor to discuss what is considered “normal.”
Education/Discharge Instructions
Asthma education is critical and is directed at addressing activities discussed in the section on
prevention. The community nurse can offer health education to families that emphasizes
correctly adhering to the treatment regimen, preventing infection, and avoiding asthma triggers.
Nurses are in the best position to provide health education because they are in contact with the
patients and the parents most of the time.

Asthma Delivery Devices

● Metered dose inhalers
● Dry powder inhalers
● Breath actuated inhalers
● Soft mist inhalers
● Nebulizers
● Injectables (biologics)
^^^^

Asthma Management Guidelines

● Mild asthma: Well-controlled with as-needed reliever medication alone or with low-
intensity controller treatment such as low-dose inhaled corticosteroids (ICSs),
leukotriene receptor antagonists, or chromones.
● Moderate asthma: Well-controlled with low-dose ICS/long-acting beta2-agonists
(LABA).
● Severe asthma: Requires high-dose ICS/LABA to prevent it from becoming
uncontrolled, or asthma that remains uncontrolled despite this treatment (Morris,
2019).
The most common problems that need to be excluded before a diagnosis of severe
asthma can be made are the following (Morris, 2019):
● Poor inhaler technique
● Poor medication adherence
● Incorrect diagnosis of asthma, with symptoms due to alternative conditions such as
upper airway dysfunction, cardiac failure, or lack of tness

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 ● Comorbidities and complicating conditions such as rhinosinusitis, gastroesophageal

re ux, obesity, and obstructive sleep apnea
● Ongoing exposure to sensitizing or irritant agents in the home or work environment
^^^^

Asthma Meds
Corticosteroids
Beclomethasone
● Actions & Uses: long term management asthma
● Administration alerts: not for acute
● Pharmacokinetics: onset 1-4 wk
● Adverse e ects: toxicity w/ intranasal
● Pediatric considerations: long term use growth issues
Leukotriene receptor antagonist Montelukast
● Actions & Uses: prevents airway in ammation & edema-
● Administration alerts: not for acute, 2 hr prior exercise
● Pharmacokinetics-Onset rapid
● Adverse e ects: headache, GI increased ALT, symptoms- rare depression, SI,
hallucinations
^^^^

Asthma Meds
● Short acting beta-adrenergic agonist
● Albuterol
● Rescue inhaler-bronchodilator
● Long-acting beta-adrenergic agonist
● Salmeterol
● NOT used to terminate an acute attack/ preventive
● Anticholinergics
● Ipratropium
● Actions & uses relieve and prevent bronchospasm
● Administration: inhalation
● Pharmacokinetics: onset 5-15 min
● Adverse e ects: dry mouth, cough, tremors, irritability, insomnia
● Contraindications: sensitivity soybeans, peanuts
Cystic Fibrosis
● Inherited autosomal-recessive disorder that causes the production of thick mucus
that a ects several body systems
● Diagnosis- clinical presentation, family history, sweat chloride test
● Signs and symptoms
● GI
● Respiratory
● Complications
● Airways complications, chronic infections, nutritional de ciencies, electrolyte
imbalances, liver disease, infertility

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 ^^^^

Cystic Fibrosis
● Treatment-
● Ensure respiratory function
● Enhance nutrition
● Promote Growth and Development
● Prevent respiratory infections and malnutrition
● Nursing care
● Nutrition
● Medication compliance
● Handwashing
● Avoid sick contacts
● Education
● Chest physiotherapy
● Postural drainage
● Resources mucous glands
Cystic Fibrosis
Cystic brosis (CF) is an inherited autosomal-recessive disorder of the exocrine glands that
causes the production of thick mucus that affects several body systems, including respiratory,
gastrointestinal (GI), and reproductive. CF is the most common cause of chronic respiratory
disease in children and is accompanied by multiple, severe respiratory infections. CF is the most
common autosomal recessive disease in the Caucasian population, occurring in approximately
1/3,500 births. The increased mucus production in the airways causes obstruction and stasis of
uid, providing a rich habitat for bacterial growth. In addition, the pancreatic ducts are often
blocked by mucus, prohibiting the secretions of pancreatic enzymes necessary for the
metabolism of food nutrients. In later childhood, the reproductive system is affected because
ovarian ducts and the vas deferens may be occluded, leading to infertility. An increased loss of
sodium causes salt depletion in children with CF.
Most patients become symptomatic at birth or soon after birth. Respiratory infections and poor
weight gain are the most frequent presentation. These symptoms coupled with pancreatic
insuf ciency usually signify a diagnosis of CF. Other classic disease manifestations are excessive
salt loss via sweat and male infertility. Respiratory disease is the most severe manifestation and
the most frequent cause of death or lung transplant in early adult life. While CF is part of the
normal newborn screening tests in the U.S., it can be sometimes missed. If CF is suspected, a
sweat chloride test is performed; a sweat chloride concentration above 60 mmol/L is diagnostic
for CF.
Prevalent CF pathogens leading to chronic lower lung infections include Staphylococcus aureus
and Pseudomonas aeruginosa; while later in the disease course, some patients become infected
with more unusual and dif cult to treat pathogens like Burkholderia cepacia Achromobacter
xylosoxidans, Stenotrophomonas maltophilia, and mycobacteria. However, complications can
occur in nearly every organ and increase with age, including liver disease, CF-related diabetes,
nasal polyps, and intestinal obstructions.
CF is transmitted as an autosomal-recessive trait, which means that a child can receive a
defective gene from either parent. When both parents carry the defective gene, the child has a
75% chance of inheriting one CF gene from each parent and manifesting the disease. There is a

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 50% chance that the child will inherit one defective gene and one normal gene from each parent
and become a carrier of the disease. There is a 25% chance that the child will inherit only normal
genes and be free of CF.
The CF genes have been found on chromosome 7, which encodes CF transmembrane conductor
regulator (CFTR) protein. CFTR normally regulates the chloride channel and facilitates the
activity of other chloride and sodium channels at the cell surface. Abnormal functions of CFTR
cause a disruption of sodium ion transport across the exocrine and epithelial gland cells and
make the cell walls impermeable to chloride ions. This causes an excess of sodium and chloride
found in the sweat of children affected by CF. In addition, the loss of sodium and water from the
airways increases the viscosity of the mucus and disrupts the ciliary mechanism (hairlike
process) that is intended to clear the airways, predisposing the child to recurrent respiratory
infections.
A similar transport defect occurs in the pancreatic and bile ducts. With inadequate excretion of
pancreatic enzymes for food breakdown, children experience varying levels of protein and fat
absorption. Reduced protein and fat absorption leads to weight loss and failure to thrive,
requiring an affected child’s diet to be high in protein and calories. Fat is excreted in the stool,
resulting in abnormal bowel patterns, including steatorrhea, diarrhea, and abdominal pain.
The mucus gland produces thin, free- owing secretions, but in CF it produces thick mucus that
accumulates and obstructs organs. In newborns, thick secretions may plug the small intestine and
lead to failure in passing meconium (the rst feces of a newborn infant, which is greenish black,
odorless, and tarry). In the GI system, thick secretions impair the digestive system and lead to
malnutrition in childhood.
Signs and Symptoms
CF affects the vital organs of the body, and children with the condition show a wide range of
signs and symptoms. The severity of the symptoms also varies. Because CF is a multisystem
disease (failure of two or more organ systems), the symptoms are presented according to the
body system affected.
Gastrointestinal tract symptoms include:
▪ Meconium ileus
▪ Prolonged jaundice
▪ Steatorrhea
▪ Rectal prolapsed
Respiratory symptoms include:
▪ Crackles
▪ Wheezes
▪ Diminished breath sounds
▪ Productive cough
▪ Tachypnea, hypoxia, and cyanosis
Integumentary symptoms include:
▪ Salty-tasting tears and skin
Secondary consequences include:
▪ Dehydration
▪ Secondary respiratory infections, namely bacterial pneumonia
▪ Malnutrition
▪ Intestinal atresia
▪ Idiopathic pancreatitis

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 ▪ Biliary cirrhosis
▪ Cholestasis
▪ Emphysema and atelectasis
▪ Prolonged hypoxia
▪ Hemoptysis
▪ Diabetes
▪ Anemia
▪ Failure to thrive
▪ Osteoporosis
Common characteristics include a child who:
▪ Is thin and underweight (classi ed as less than or equal to 10th percentile for height and
weight on a standardized growth chart)
▪ Has a barrel chest
▪ Has a protuberant abdomen and distention
▪ Has wasted buttocks
▪ Has thin extremities
▪ Is listless and lethargic
▪ Has delayed development of secondary sex characteristics and infertility
▪ Has occlusion of the vas deferens in males Recessive - both parents need to be carriers for
▪ Has occlusion of the ovarian ducts in females the kid to get CF
Diagnosis Test sweat for chloride levels to dx CF
The diagnosis of CF is based on the child’s signs and symptoms, including a positive family
history of the disease, absence of pancreatic enzymes, increase in the electrolyte concentration of
sweat, and chronic pulmonary involvement. Chest x-ray lms show patchy atelectasis and
obstructive emphysema. A quantitative sweat chloride test is performed on sweat obtained by
iontophoresis of pilocarpine. The results of the sweat chloride test are determined differently
depending on the age of the child.
Prevention
CF is currently not preventable. In families with a known history of CF, identi cation of carriers
may assist the parents in family planning decisions.
Collaborative Care
NURSING CARE
The goal of treatment is to ensure respiratory function, enhance nutrition, promote growth and
development, and encourage independence in an individual child and family. The potential for
the complications related to respiratory infection and malnutrition can be reduced or prevented
by instructing the parents on proper nutrition, medication compliance, good hand washing, and
avoiding contact with persons with respiratory infections.
MEDICAL CARE
Airway clearance and antibiotic use are the key treatment modalities for lung disease related to
CF. Ensuring respiratory function in children entails controlling infection and improving
aeration. These care measures are achieved via medicated aerosol therapy, chest physiotherapy
(CPT; percussion and postural drainage), and antibiotic therapy (Fig. 15-4). Some children with
CF have a central venous access device for frequent antibiotic administration. Evidence-based
medications routinely used in the treatment of CF include inhaled mucolytic agents, recombinant
human DNAse (Pulmozyme), inhaled hypertonic saline, and medication for chronic
pseudomonas infections, which include inhaled tobramycin (TOBI) and oral azithromycin.

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 Most children with CF have a complete loss of pancreatic function and inadequate digestion of
fats and protein; therefore, replacing pancreatic enzymes is an important aspect of management.
Enzyme replacement is administered with meals and snacks, so the digestive enzymes are mixed
with food in the duodenum.
Education/Discharge Instructions
It is essential that the nurse teach parents how to care for their child at home. After the diagnosed
and acute phase of illness, the family is prepared for home management and assists in promoting
child growth and development with limitations.
▪ Teach the family about the nature of the disease and prepare them to manage day-to-day
minor complaints.
▪ Assist the family in arranging for the portable suction machine and about the proper
suctioning technique at home.
▪ Instruct the family to do the respiratory therapy before a meal because CPT may induce
vomiting of thick mucus.
▪ Teach the family different techniques used for CPT and postural drainage and coughing
exercises based on the child’s age. The child needs to be suctioned, followed by CPT and
inhalation to liquefy the thick secretions.
▪ Teach the family about preferred meal plans, high- caloric diet, and mixing pancreatic
enzyme with meals.
▪ Instruct the family to monitor the child’s weight to ensure proper growth patterns.
▪ Teach the family how to administer medications properly.
▪ Inform the family how to access community resources and how to contact their home
health nurse.
Nursing Interventions
1. Wash hands or use approved alcohol-based hand rubs, before and after providing care.
Appropriate hand hygiene helps prevent infection outbreaks, reduces transmission of
antimicrobial-resistant organisms, and reduces overall infection rates.
2. Monitor temperature every 4 hours. Report a single temperature greater than 101.3°F
(38.5°C) or three temperatures greater than 100°F (38°C) in 24 hours to the care provider.
Fever is often the rst indication of infection.
3. Observe for and report additional signs of infection such as increased mucus production,
persistent cough, tachypnea, dif culty breathing, or cyanosis. Increased mucus production in
the airways causes obstruction and stasis of uid, providing a rich habitat for bacterial
growth. Early detection of infection allows for prompt and appropriate intervention.
4. Monitor and report laboratory values as ordered, such as complete blood count with
differential, serum protein, serum albumin, and cultures. Laboratory values are correlated
with the child’s history and physical examination to provide a global view of the patient’s
immune function and nutritional status.
5. Encourage uid intake and a high-calorie balanced diet, emphasizing proteins, fatty acids,
and vitamins. Nutrients bene ting the immune system include essential amino acids, linoleic
acid, vitamin A, folic acid, vitamin B6, vitamin B12, vitamin C, vitamin E, Zn, Cu, Fe, and
Se. Ef cient immune function may be affected by de ciencies in one or more of these
nutrients.
6. Instruct the child and parents on principles of medication management: prophylactic
antibiotics, medicated aerosol therapy, CPT, and deep breathing and cardiovascular exercise.
Instruction empowers the child and family to manage care. Medicated aerosol therapy, CPT,

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 and deep breathing exercises help reduce atelectasis and risk for infection and promote
healing.
7. Encourage use of community resources, such as the Cystic Fibrosis Foundation. The use of
community resources may help support the family to nd ways to prevent infection and
increase the possibility of a positive adjustment to the condition.
The nurse must help the parents understand that caring for a child with CF can be challenging.
There are suf cient resources and help lines that can assist parents, and the nurse uses these
resources to provide adequate health education to parents and older children.

Dornase alfa (Pulmozyme)

● Enzyme that hydrolyzes the DNA in sputum, reducing sputum viscosity in children
with cystic brosis
● Administered via nebulizer
● Monitor for dysphonia and pharyngitis.
^^^^

Acetylcysteine (Mucomyst)
● Exerts mucolytic activity and lowers mucous viscosity of pulmonary secretions
● Administer aerosolized bronchodilator 10-15 minutes before administering
acetylcysteine via nebulization
● Adverse e ects (most common): mouth sores, Nausea and vomiting, Fever and runny
nose, Drowsines.s Unpleasantly wet or sweaty skin, Chest tightness
????

Chest Tubes
● Provides removal of air, uid, or blood from the pleural, pericardial, or mediastinal
spaces.
● The purpose of closed chest suction is to remove air and uid from the thoracic
cavity and to improve postoperative lung re-expansion, as well as to treat
pneumothorax.

Chest tube must be at least 1 foot below the levels of the lungs. What is the drainage of the chest tube? Is the tubing
clear, make sure it is not clamped or kinked. Encourage to cough and deep breathe. Do NOT milk the tube, causes
negative pressure in the lungs and can damage them.

Should be a gentle and continuous bubbling in the suction chamber, air leak = continuous bubbling in the air leak
chamber.

Air leak = clamp closest to the patient and call provider.

Tube pops out of patient (dislodged) = cover with sterile occlusive dressing and THEN call surgeon - emergency.
Tube pops off of the chest tube (disconnected) = Tape the end and place it in a bottle of sterile saline and get a new
system in there and fix it.
Tube gets kinked = dyspnea, tachypnea, etc. Weird patient presentation = check the tubing and make sure it is not
kinked.

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