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Course: Pediatric Nursing

Topic: Nursing Care of Child with Respiratory Disorder (Part IV)

The Nurses International Community

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Module Goals

Learners will be able to:

Identify common respiratory conditions in children (croup, RSV, pneumonia, bronchitis).
Identify risk factors associated with respiratory illnesses in children.
List common diagnostic procedures for respiratory conditions and nursing implications.
Describe nursing management of children experiencing respiratory disorders.

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Croup

Acute inflammation of the upper and lower respiratory tracts
Most commonly caused by parainfluenza virus type 1 infection
Characteristic brassy, ‘barking’ cough and inspiratory stridor
May cause breathing problems
Seen more often in the winter

Bhatia,2022

Cedars- sinai, n.d.

Contact info: info@nursesinternational.org

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Croup: Causes

Most common pathogens: Parainfluenza viruses, especially type 1
Less common causes:

Respiratory syncytial virus (RSV)
Adenovirus
Influenza viruses A and B
Enterovirus
Rhinovirus
Measles virus
Mycoplasma pneumoniae

Bhatia,2022

Cedars- sinai, n.d.

Contact info: info@nursesinternational.org

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Croup: Risk Factors

Young children 3 months to 5 years
The peak time for croup to occur is 2 years old

Risk is higher due to smaller airways
A small amount of swelling may make it very hard for a baby or young child to breathe

Bhatia,2022

Cedars- sinai, n.d.

Contact info: info@nursesinternational.org

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Croup: Sign and Symptoms

Symptoms of croup vary as it moves from nose to lungs
Symptoms may improve in the morning and worsens at night
Child may wake due to respiratory distress, tachypnea, retractions
General Symptoms:

A ‘runny’ nose, a ‘stuffy’ nose, and slight cough
A cough that turns into a “seal’s bark”
Loses voice (laryngitis)
Fever
‘Creaking’ or stridor

Bhatia,2022

Cedars- sinai, n.d.

Contact info: info@nursesinternational.org

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Croup: Diagnosis

Clinical presentation (eg, ‘barking cough’, inspiratory stridor).
Anteroposterior (AP) and lateral neck x-rays as needed.
AP and lateral x-rays of the neck and chest show subepiglottic narrowing (steeple sign) seen on AP neck x-ray and supports the diagnosis.

Bhatia,2022

Contact info: info@nursesinternational.org

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Croup: Treatment

For outpatients: Cool humidified air and possibly a single dose of a long-acting corticosteroid
For inpatients: Humidified oxygen, racemic (equal parts) epinephrine, and corticosteroids
Mildly ill child may be cared for at home with hydration, antipyretics and humidification (vaporizer or humidifier)
Hospitalization may be needed for respiratory distress, tachycardia, fatigue, cyanosis, hypoxia, dehydration

Bhatia,2022

Contact info: info@nursesinternational.org

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Croup: Management at Home

Hydration: Provide plenty of fluids/breastfed frequently
Smoke free environment
Maximum comfort:

Raise the head of the bed
Prop an older child up in bed with extra pillows
emotional comfort (sing child’s favourite song or offer toy)

Remain with the child initially: sleep in the same room as the child
Remain calm: If a child sees a care provider frightened, it will increase their anxiety and lead to increased breathing difficulty
Humidify: Put a humidifier in the child’s room

Cedars- sinai, n.d.

Contact info: info@nursesinternational.org

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Croup: Nurses’ Role

Monitor oxygen saturation ( pulse oximeter)
Provide oxygen to maintain O2 saturation above 92%
Measure co2 retention via ABGs
Provide nebulization with epinephrine 5 to 10 mg in 3 mls of saline every 2 hours
Administer dexamethasone IM or orally per order
Antibiotics are rarely indicated

Bhatia,2022

Contact info: info@nursesinternational.org

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What Would the Nurse Do?

A nurse is taking care of a 2-yr-old who presents with a barking cough and inspiratory stridor. Upon assessment, the nurse notes moderate intercostal retractions, a respiratory rate of 44, and oxygen saturation of 90%.

What should the nurse do next?

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Respiratory Syncytial Virus (RSV)

A common respiratory virus
Usually causes mild, cold-like symptoms
May be serious, especially in infants and younger children
Leading cause of bronchiolitis and pneumonia in children younger than 1 year of age in the USA

CDC, 2020

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RSV: Risk Factors

Premature infants
Very young infants, 6 months and younger
Younger children with chronic lung disease or congenital heart disease
Children with weakened immune systems
Children with neuromuscular disorders, including those who have difficulty swallowing or clearing mucus secretions

CDC, 2020

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RSV: Symptoms

May not be severe initially
May become more severe as it progresses
Early symptoms include:

‘Runny’ nose
Decreased appetite
Cough, which may progress to wheezing

CDC, 2020

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RSV: Symptoms in Very Young Children (Less Than 6 Months Old)

Irritability
Decreased activity
Decreased appetite
Apnea (pauses while breathing)
Fever may not always occur with RSV infections

CDC, 2020

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RSV: Diagnosis

For infants and young children: Real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) and antigen detection tests.
For older children and adolescents: Highly sensitive rRT-PCR assays.

CDC, 2020

Contact info: info@nursesinternational.org

For Infants and Young Children

Both rRT-PCR and antigen detection tests are effective methods for diagnosing RSV infection in infants and young children in the respiratory samples (i.e form throat, nose or oropharyngeal swabs). The RSV sensitivity of antigen detection tests generally ranges from 80% to 90% in this age group. Healthcare providers should consult experienced laboratorians for more information on interpretation of results.

For Older Children, Adolescents, and Adults

Healthcare providers should use highly sensitive rRT-PCR assays when testing older children and adults for RSV. rRT-PCR assays are now commercially available for RSV. The sensitivity of these assays often exceeds the sensitivity of virus isolation and antigen detection methods. Antigen tests are not sensitive for older children and adults because they may have lower viral loads in their respiratory specimens. Healthcare providers should consult experienced laboratorians for more information on interpretation of results.

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RSV: Treatment

No specific treatment
Most RSV infections are self-limiting and resolve in a week or two
No vaccine available
Palivizumab is a monoclonal antibody recommended by the American Academy of Pediatrics (AAP) to be administered to high-risk infants and young children
Treat symptoms

CDC, 2020

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RSV: Education: Relieve The Symptoms

Manage fever and pain with over-the-counter analgesics and antipyretics (acetaminophen or ibuprofen)
Fluids: To prevent dehydration (loss of body fluids)
Consult healthcare provider before giving non prescription cold medicines; Some medicines contain ingredients that are not good for children

CDC, 2020

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RSV: (Education) Prevention

Frequent hand washing
Avoid touching face
Avoid close contact with sick people
Cover coughs and sneezes
Clean and disinfect common surfaces
Stay home when not feeling well

CDC, 2020

Contact info: info@nursesinternational.org

Wash hands often: Wash hands often with soap and water for at least 20 seconds, and help young children do the same. If soap and water are not available, use an alcohol-based hand sanitizer. Washing hands will help protect from germs.
Keep the hands off the face: Avoid touching eyes, nose, and mouth with unwashed hands. Germs spread this way.
Avoid close contact with sick people: Avoid close contact, such as kissing, and sharing cups or eating utensils with people who have cold-like symptoms.
Cover coughs and sneezes: Cover mouth and nose with a tissue or upper shirt sleeve when coughing or sneezing. Throw the tissue in the trash afterward.
Clean and disinfect surfaces: Clean and disinfect surfaces and objects that people frequently touch, such as toys, doorknobs, and mobile devices. When people infected with RSV touch surfaces and objects, they may leave behind germs. Also, when they cough or sneeze, droplets containing germs may land on surfaces and objects.
Stay home when sick: If possible, stay home from work, school, and public areas when someone is sick. This will help protect others from catching illness.

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RSV: Nursing Management

Humidify room: a cool-mist humidifier or vaporizer may moisten the air and help ease congestion and coughing
Ensure hydration
Encourage good hygiene habits
Administer medications as prescribed
Evaluate the child response to the interventions and treatment provided

Nurses Lab, 2021

Contact info: info@nursesinternational.org

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Critical Thinking Question

A nurse is taking care of a 5-month-old diagnosed with RSV after two days of coughing, fever, and nasal congestion. The infant's symptoms are currently mild so they are being discharged home.

What education should the nurse provide the family prior to discharge?

Contact info: info@nursesinternational.org

This infant was brought for evaluation early in their course of illness. RSV may start with mild symptoms that become more severe as the illness progresses. Because of this and the fact that this is a very young infant (at a higher risk for severe illness from RSV) the nurse should educate the family on signs of worsening illness and respiratory distress that would require them to bring the infant back in (for example, retractions, lethargy, pallor, tachypnea, inability to feed). The nurse should also provide information about how to manage the infant's symptoms at home with rest, hydration, medications for fever, and humidified air to loosen congestion. The nurse should teach the family to avoid giving over-the-counter cold medications as they often have ingredients that are not good for children. Lastly, the nurse should teach the family strategies for preventing the spread of the illness, such as keeping other children away from the infant and frequent hand washing.

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Pneumonia

An acute respiratory infection/inflammation that is caused by bacteria, viruses, or chemical irritants
May be viral or bacterial
The alveoli of lungs fill with purulent fluid making breathing painful and limits oxygen intake
Contagious and may be spread through airborne particles (a cough or sneeze)
May spread through other fluids, like blood during childbirth, or from touching contaminated surfaces and then nose or mouth

The Children’s Hospital of Philadelphia, n.d.

WHO, 2021

Unicef, 2020

Contact info: info@nursesinternational.org

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Pneumonia: Causes

Caused by infectious agents i.e. viruses, bacteria and fungi

Streptococcus pneumoniae – Most common cause of bacterial pneumonia in children
Haemophilus influenzae type b (Hib) Second most common cause of bacterial pneumonia
Respiratory syncytial virus- most common viral cause of pneumonia
HIV, Pneumocystis jiroveci is the most common cause in infants
Other pneumonias: Caused by food, liquid(aspiration) gases, dusts or fungi

The Children’s Hospital of Philadelphia, n.d.

WHO, 2021

Unicef, 2020

Contact info: info@nursesinternational.org

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Types of Pneumonia

Bacterial pneumonia

Caused by Group B streptococcus, Staphylococcus aureus, Group A streptococcus
May have acute onset
Symptoms

Productive cough
Chest pain
Vomiting or diarrhea
Low or no appetite
Fatigue

The Children’s Hospital of Philadelphia, n.d

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Types of Pneumonia (Continued)

Mycoplasma Pneumonia

Generally causes mild infections
May affect all ages
Does not start with a cold
Fever and cough develop first
Persistent cough may last for 3-4 weeks
Severe cough (may be productive)

**Other pneumonias: Caused by food, liquid(aspiration) gases, dusts or fungi

The Children’s Hospital of Philadelphia, n.d

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Types of Pneumonia (Continued)

Viral Pneumonia

Caused by Influenza virus, parainfluenza virus, Adenovirus, RSV
Early symptoms are like those of bacterial pneumonia
Wheezing may occur
Cough may worsen
May cause child to be susceptible to bacterial pneumonia

The Children’s Hospital of Philadelphia, n.d

Contact info: info@nursesinternational.org

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Pneumonia: Risk Factors

Compromised Immune system
Pre-existing illnesses (HIV infections and measles)
Environmental factors:

Indoor air pollution caused by cooking and heating with biomass fuels (such as wood or dung)
Living in crowded homes
Smoking environment

The Children’s Hospital of Philadelphia, n.d.

WHO, 2021

Unicef, 2020

Contact info: info@nursesinternational.org

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Pneumonia: General Signs and Symptoms

Fever
Chest or stomach pain
Decrease in appetite
Chills
Rapid and labored breathing
Vomiting
Headache
General malaise (not feeling well)
Fussiness

The Children’s Hospital of Philadelphia, n.d.

WHO, 2021

Unicef, 2020

Contact info: info@nursesinternational.org

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Pneumonia: Diagnosis

Chest X-ray
Blood tests: Arterial blood gas to analysis CO2 level in blood
Sputum culture
Pulse oximetry: To determine oxygen level in the blood
Chest CT scan
Bronchoscopy
Pleural fluid culture

The Children’s Hospital of Philadelphia, n.d.

Contact info: info@nursesinternational.org

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Pneumonia: Treatment

Treatment depends upon:

Child's age, overall health, and medical history
Severity of illness
Cause of the illness
Child's tolerance for specific medications, procedures, or therapies
Expectations for the course of the condition

The Children’s Hospital of Philadelphia, n.d.

WHO, 2021

Unicef, 2020

Contact info: info@nursesinternational.org

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Pneumonia: Treatment

Antibiotics for bacterial and mycoplasma pneumonia
No clear treatment for viral pneumonia
Other treatment include:

Proper diet
Enough hydration
Humidification and nebulization
Antipyretics for fever and discomfort
Antitussives or expectorants for cough

The Children’s Hospital of Philadelphia, n.d.

WHO, 2021

Unicef, 2020

Contact info: info@nursesinternational.org

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Pneumonia: Nurses’ Role

Supportive and routine monitoring and assessment of respiratory status, oxygenation, fluid status, and sepsis risk
Monitor O2 level and provide supplemental oxygen if required
Administer Intravenous or oral antibiotics, fluids as prescribed
Careful monitor intake and output for a fluid deficit

Ebeledike, 2022

Contact info: info@nursesinternational.org

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Pneumonia: Nurses’ Role

Routine monitoring for fever and risk of sepsis
Frequent suctioning of the child's nose and mouth to clear airways
Nebulizer treatments, as ordered
Encourage parents to vaccinate their children according to recommended guidelines

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Critical Thinking Question

What risk factors for pneumonia are modifiable?

Why is understanding modifiable risk factors important for the pediatric nurse?

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Bronchitis

A condition in which bronchial tubes, become inflamed and cause coughing, and may cause production of mucus.
The causative agents irritate and inflame the bronchial tubes.
Bronchitis may be acute (short-term) or chronic (long-term).
Causative agent depends upon the type of bronchitis; usually caused by viral infections (RSV).

National Heart, Lungs, and Blood Institute, 2022

CDC 2019

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Bronchitis: Types and Causes

Acute bronchitis:

Acute onset and last for few days to week
Usually caused by viral infections like cold/flu and rarely by bacterial infection

Chronic bronchitis:

Ongoing cough for several months and may relapse 2 or more times a year
Productive cough
Caused by long-term exposure to irritants (chemicals, fumes, smoke)

National Heart, Lungs, and Blood Institute, 2022

Contact info: info@nursesinternational.org

Acute bronchitis is very common. Viral infections, such as the cold or flu, are usually the cause, and most people recover after a few days or weeks. Occasionally, acute bronchitis may be caused by a bacterial infection.

Chronic bronchitis is an ongoing cough that lasts for several months and comes back 2 or more years in a row. The cough is productive, meaning it brings up mucus. In chronic bronchitis, the lining of the airways is constantly inflamed. This causes the lining to swell and make more mucus, which may make it hard to breathe. Chronic bronchitis is often part of a serious lung disease called chronic obstructive pulmonary disease (COPD). Both chronic bronchitis and COPD are most often caused by cigarette smoking.

Those who are older, have been exposed to fumes or secondhand smoke, have a family history of lung disease, have a history of childhood respiratory diseases, or have gastroesophageal reflux disease (GERD), are also at higher risk of getting chronic bronchitis.

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Bronchitis: Signs and Symptoms

‘Hacking’ cough, which may produce clear, yellow-grey or greenish mucus (phlegm)
Sore throat
Headache
‘Runny’ or ‘blocked’ nose
Generalized aches and pains
Fatigue

NHS, 2019

Contact info: info@nursesinternational.org

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Bronchitis: Diagnosis

Physical exam, auscultation of chest and lung sounds
Medical history
Symptoms
Blood test to identify infection
Chest X-ray to assess the lungs and bronchial tubes and rule out pneumonia

National Heart, Lungs, and Blood Institute, 2022

Contact info: info@nursesinternational.org

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Acute Bronchitis: Treatment

Usually resolves without treatment
Rest, comfort, hydration
Over-the-counter (OTC) medicines (above 6 years old)
NSAIDs
Tea or water with teaspoons of honey (no honey for children younger than a year old due to bacteria)
Humidified air
Saline nasal spray or drops to relieve a ‘stuffy’ nose; rubber suction bulb to clear mucus
Antibiotics if prescribed

NHS Inform, 2022

National Heart, Lungs, and Blood Institute, 2022

Contact info: info@nursesinternational.org

Acute bronchitis often goes away on its own without treatment by the doctor. However, few steps at home may feel relieve the discomfort:

Get plenty of rest
Drink lots of fluids – this helps prevent dehydration and thins the mucus in the lungs, making it easier to cough up
Use over-the-counter (OTC) medicines that loosen mucus.
Take a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen or paracetamol to treat headaches, fever, and aches and pains – although ibuprofen is not recommended if a child has asthma and should not be given to the children younger than 6 years of age (The Medicines and Healthcare Products Regulatory Agency (MHRA) has recommended that over-the-counter cough medicines should not be given to children under the age of six).
Drink tea or water with a couple of teaspoons of honey; no honey for children below a year old as it may cause botulism
Keep a humidifier nearby of in the room of the child

Doctors typically prescribe antibiotics only if they find that a child has a bacterial infection, which is more common in young children. If a child is taking any prescribed medicines, or have other diseases, talk to the doctor before taking any OTC medicines.

Babies under 12 months should not be given honey, because honey contains bacteria that an infant’s developing digestive system can’t handle. Eating honey may cause a baby to become ill with a condition called infant botulism .

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Chronic Bronchitis: Treatment

Medicines to clear airways (bronchodilators)
Oxygen therapy
Pulmonary rehabilitation: breathing techniques such as pursed-lip breathing
Therapy to facilitate breathing; abdominal or diaphragmatic breathing

NHS Inform, 2022

National Heart, Lungs, and Blood Institute, 2022

Contact info: info@nursesinternational.org

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Bronchitis: Nurses Role

Provide oral hydration
Auscultate lungs, monitor oxygenation, monitor signs of pneumonia
Assess vital signs
Monitor intake and output
Education

smoking cessation and avoid exposure to secondhand smoke
Encourage influenza and pneumococcal vaccines

Justice et al, 2021

Singh et al, 2022

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Red Flags

Increased rate and/or depth of respirations
Retractions
Abnormal lung sounds; rales, ronchi, wheezes
Diminished lung sound in either lobes
Apnea
Pale skin colour
Excessive coughing, labored breathing
Asymmetric rise and fall of chest
Decreasing oxygen saturation/increased O2 requirement
Change in LOC or decreased level of consciousness CIRCU

Best-Brandt, 2019

Contact info: info@nursesinternational.org

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs may influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur
Health customs: In some cultures family members play a large role in health care decision-making
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations

AHRQ, 2020

Contact info: info@nursesinternational.org

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Cultural Considerations (con.):

Religion, culture, beliefs, and ethnic customs may influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

Contact info: info@nursesinternational.org

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References

Andrews, M.M., Boyle, J.S. & Collings, J. W. (2020). Transcultural Concepts in Nursing Care (8th Ed.). Wolters Kluwer, Philadelphia, PA.

Bhatia, R. (2022, January). Croup (Laryngotracheobronchitis). https://www.msdmanuals.com/professional/pediatrics/respiratory-disorders-in-young-children/croup

CDC-Centre for Disease Control And Prevention. (2021, July 01). Bronchitis. https://www.cdc.gov/antibiotic-use/bronchitis.html

CDC- Centre for Disease Control and Prevention. (2020, December 18). RSV in Infants and Young Children. https://www.cdc.gov/rsv/high-risk/infants-young-children.html

Cedars-Sinai. (n.d. ). Croup in Children. https://www.cedars-sinai.org/health-library/diseases-and-conditions---pediatrics/c/croup-in-children.html

Contact info: info@nursesinternational.org

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References

Ebeledike C, Ahmad T, Martin SD. (Updated 2022 May 8). Pediatric Pneumonia (Nursing). StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK568682/

Justice, N. A., Le, J. K., Doerr, C. ( 2021, July 29). Bronchiolitis (Nursing). StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK568705/

National Heart, Lungs, and Blood Institute. (2022, March 24). Health Topic: Bronchitis. https://www.nhlbi.nih.gov/health/bronchitis

NHS. (2019, August 07). Bronchitis. https://www.nhs.uk/conditions/bronchitis/

NHS Inform. (2022, October 28). Lung and Airways: Bronchitis. https://www.nhsinform.scot/illnesses-and-conditions/lungs-and-airways/bronchitis#about-bronchiti

Contact info: info@nursesinternational.org

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References

Nurses Lab. (2021, February 11). Respiratory Syncytial Virus. https://nurseslabs.com/respiratory-syncytial-virus/

RN Pedia. (n.d.). Pneumothorax Nursing Care Plan & Management. https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/pneumothorax/

Singh, A., Avula, A., Zahn, E. (2022, May 8). Acute Bronchitis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448067

The Children’s Hospital of Philadelphia. (n.d.). Pneumonia in Children. https://www.chop.edu/conditions-diseases/pneumonia-children
Unicef. (2020, November 11). Childhood pneumonia: Everything you need to know. https://www.unicef.org/stories/childhood-pneumonia-explained
WHO. (2021, November 11). Pneumonia. https://www.who.int/news-room/fact-sheets/detail/pneumonia#:~:text=In%20children%20under%205%20years,the%20chest%20expands%20during%20inhalation).

Contact info: info@nursesinternational.org

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