The upper respiratory tract, or upper airway, consists of the oronasopharynx, pharynx, larynx, and upper part of the trachea.
The lower respiratory tract consists of the lower trachea, mainstem bronchi, segmental bronchi, subsegmental bronchioles, terminal bronchioles, and alveoli.

Respiratory tract infections account for the majority of acute illnesses in children.
The etiology and course of these infections are influenced by the age of the child, the season, living conditions, and preexisting medical problems.

Infants under 3 months of age may be susceptible to pertussis

Conditions that weaken defenses of the respiratory tract and predispose children to infection also include allergies (e.g., allergic rhinitis), preterm birth, bronchopulmonary dysplasia (BPD), asthma, history of RSV infection, cardiac anomalies that cause pulmonary congestion, and cystic fibrosis (CF). Daycare attendance and exposure to secondhand smoke increase the likelihood of infection.

“Infants and young children, especially those between 6 months and 3 years of age, react more severely to acute respiratory tract infections than older children.”

assessment should include respiratory rate, depth and rhythm, heart rate, oxygenation, hydration status, body temperature, activity level, and level of comfort. Special attention should also be given to the components and observations listed in Box 23-2.

Signs/Symptoms: Fever
May be absent in newborn infants
Greatest at 6mos-3yrs
may reach 103-105 even in mild infections
often appears as first sign
may lead to listlessness and irritability
tendency to devp high temps w/infection in certain families
may precipitate febrile sz

Signs/Symptoms: Poor feeding Anorexia
common in infants during breastfeeding or bottle feeding
common w/most childhood illness
fq initial evidence of illness
persists to greater or lesser degree throughout febrile stage of illness

Signs/Symptoms: vomiting
Common in small children with illness

Clue to onset of infection

May precede other signs by several hours

Usually short lived but may persist during the illness

signs/symptoms: diarrhea
Usually mild, transient diarrhea but may become severe

Often accompanies viral respiratory infections

Frequent cause of dehydration

Signs/Symptoms: abdominal pain
Common complaint

Sometimes indistinguishable from pain of appendicitis

May be caused by mesenteric lymphadenitis

May be linked to muscle spasms from vomiting, especially in nervous, tense child

Signs/Symptoms: nasal blockage
Small nasal passages of infants easily blocked by mucosal swelling and exudation

Can interfere with respiration and feeding in infants

May contribute to the development of otitis media and sinusitis

signs/symptoms: nasal discharge
Frequent occurrence

May be thin and watery (rhinorrhea) or thick and purulent

Depends on the type or stage of infection

Associated with itching

May irritate upper lip and skin surrounding the nose

signs/symptoms: cough
Common feature

May be evident only during acute phase

May persist several months after a disease

signs/symptoms: respiratory sounds
Sounds associated with respiratory disease:

• Cough

• Hoarseness

• Grunting

• Stridor

• Wheezing


• Wheezing

• Crackles

• Absence of breath sounds (movement of air)

signs/symptoms: sore throat
Frequent complaint of older children

Young children (unable to describe symptoms) may not complain even when highly inflamed

Often accompanied by refusal to take oral fluids or solids

Signs/Symptoms: Meningismus
Meningeal signs without infection of the meninges

Occurs with abrupt onset of fever

Accompanied by:

• Headache

• Pain and stiffness in the back and neck

Subsides as body temperature decreases

One of the cardinal signs that the child is feeling better is the increase in activity; this may, however, be temporary if a high fever returns after a few hours of increased activity.

(difficult breathing except in upright position), associated with intercostal or substernal retractions (inspiratory “sinking in” of soft tissues in relation to the cartilaginous and bony thorax)

pulsus paradoxus
(blood pressure falling with inspiration and rising with expiration), nasal flaring, head bobbing (head of sleeping child with suboccipital area supported on caregiver’s forearm bobbing forward in synchrony with each inspiration), grunting, wheezing, or stridor

For older infants and children who can tolerate decongestants, vasoconstrictive nose drops may be administered 15 to 20 minutes before feeding and at bedtime. Two drops are instilled, and because this shrinks only the anterior mucous membranes, two more drops are instilled 5 to 10 minutes later.

Adequate fluid intake is encouraged by offering small amounts of favorite fluids (clear liquids if vomiting) at frequent intervals.
Oral rehydration solutions, such as Infalyte or Pedialyte, should be considered for infants, and water or a low-carbohydrate (≤5 g per 8 oz) flavored drink should be considered for older children.

In the hospital, diapers are weighed to assess output, which should be at least 1 ml/kg/hr up to 30 kg in weight. Then it should be at least 30 ml per hour in patients weighing more than 30 kg. The practitioner should be notified if the urine output is low.

Acute nasopharyngitis, or the equivalent of the “common cold,” is caused by the rhinovirus, RSV, adenoviruses, enteroviruses, influenza virus, and parainfluenza virus.
Younger Kids: fever, irritability, restlessness, poor feeding, dec fluid, sneezing, abundant mucus (mouth breathing), vomiting/diarrhea
Older Kids: dryness, irritation of nose and throat, nasal d/c=mouth breathing, sneezing, chilling, muscle aches, cough

Acute nasopharyngitis
Therapeutic MGMT
Children with nasopharyngitis are managed at home. There is no specific treatment, and effective vaccines are not available. Cough suppressants containing dextromethorphan should be used with caution (cough is a protective way of clearing secretions) but may be prescribed for a dry, hacking cough, especially at night. Over-the-counter cold preparation such as pseudoephedrine and some antihistamines are not appropriate for the treatment of the common cold in infants and toddlers; these may cause serious side effects in such children and have been associated with death in infants

Acute nasopharyngitis
Nasopharyngitis is so widespread in the general population that it is impossible to prevent. Children are more susceptible because they have not yet developed resistance to many viruses.

Early evidence of Respiratory complications. Call med provider if not resolved in 2-3 days
refusal to take oral fluids & dec urination, earache, resp >50-60 in toddler/older child, fever >101, listlessness, confusion,increasing irritability, persistent or exacerbating cough, wheezing, restlessness and poor sleep

Acute Streptococcal Pharyngitis
GABHS infection of upper airway=strep throat
Onset is abrupt- will see headache, fever, abdominal pain, tonsils and pharynx may be inflamed/covered w/exudate @ second day

Streptococcal Pharyngitis Therapeutic mgmt
oral penicillin is prescribed in a dose sufficient to control the acute local manifestations and to maintain an adequate level for at least 10 days. Oral erythromycin is indicated for children who are allergic to penicillin.

If an injection is required, it must be administered deep into a large muscle mass (e.g., vastus lateralis or ventrogluteal muscle).
To prevent pain, application of a topical anesthetic cream such as EMLA (an eutectic mixture of lidocaine and prilocaine) over the injection site 2.5 hours before the injection or LMX4 (4% lidocaine) over the site 30 minutes before the injection is helpful

Tonsillitis often occurs with pharyngitis. Because of the abundant lymphoid tissue and the frequency of URIs, tonsillitis is a common cause of illness in young children. The causative agent may be viral or bacterial
manifestations of tonsillitis are caused by inflammation… difficulty swallowing and breathing…Nursing care involves providing comfort and minimizing activities or interventions that precipitate bleeding

Influenza is spread from one individual to another by direct contact (large-droplet infection) or by articles recently contaminated by nasopharyngeal secretions. There is no predilection for a specific age group, but attack rates are highest in young children who have had no previous contact with a strain
1- to 3-day incubation period. Affected persons are most infectious for 24 hours before and after the onset of symptoms.

The influenza vaccine is now recommended annually for children 6 months to 18 years of age (completed). Influenza vaccine (trivalent inactivated influenza vaccine [TIV]) may be given to healthy children 6 months old and older.

Otitis media is one of the most prevalent diseases of early childhood. Its incidence is highest in the winter months. Many cases of bacterial OM are preceded by a viral respiratory infection. The two viruses most likely to precipitate OM are RSV and influenza

Standard Terminology for Otitis Media
Otitis media (OM)—An inflammation of the middle ear without reference to etiology or pathogenesis
Acute otitis media (AOM) —An inflammation of the middle ear space with a rapid onset of the signs and symptoms of acute infection—namely, fever and otalgia (ear pain)
Otitis media with effusion (OME)—Fluid in the middle ear space without symptoms of acute infection

Clinical Manifestations of Otitis Media
Acute Otitis Media
Follows an upper respiratory tract infection
Otalgia (earache)
Fever—may or may not be present
Purulent discharge (otorrhea)—may or may not be present
Infants and Very Young Children
Fussiness, restlessness, irritability, especially on lying down
Tendency to rub, hold, or pull affected ear
Rolling head from side to side
Difficulty comforting child
Loss of appetite, refusal to feed

Older Children
Crying or verbalizing feelings of discomfort
Loss of appetite

Chronic Otitis Media
Hearing loss
Difficulty communicating
Feeling of fullness, tinnitus, or vertigo may be present

Myringotomy, a surgical incision of the eardrum, may be necessary to alleviate the severe pain of AOM. A myringotomy is also performed to provide drainage of infected middle ear fluid in the presence of complications (mastoiditis, labyrinthitis, or facial paralysis) or to allow purulent middle ear fluid to drain into the ear canal for culture.
Parents are encouraged to reduce risk factors for AOM by breastfeeding infants for at least the first 6 months of life, avoid propping the bottle, decrease or discontinue pacifier use after 6 months, and prevent exposure to tobacco smoke

Nursing objectives for children with AOM include (1) relieving pain, (2) facilitating drainage when possible, (3) preventing complications or recurrence, (4) educating the family in care of the child, and (5) providing emotional support to the child and family.
acetaminophen (all ages) and ibuprofen (6 months of age and older) are used to treat mild pain. For more severe pain, the AAP (2004a) guidelines recommend a stronger analgesic such as codeine

Croup is a general term applied to a symptom complex characterized by hoarseness, a resonant cough described as “barking” or “brassy” (croupy), varying degrees of inspiratory stridor, and varying degrees of respiratory distress resulting from swelling or obstruction in the region of the larynx.
Croup syndromes can affect the larynx, trachea, and bronchi.

acute epiglottitis, or acute supraglottitis, is a medical emergency. It is a serious obstructive inflammatory process that occurs predominantly in c hildren 2 to 5 years but can occur from infancy to adulthood. The obstruction is supraglottic as opposed to the subglottic obstruction of laryngitis
Onset is abrupt, can rapidly progress. C/o sore throat and pain on swallowing. Fever and appears sicker, insists on tripod position. Three clinical observations that are predictive of epiglottitis are absence of spontaneous cough, presence of drooling, and agitation.
Throat inspection should be attempted only when immediate endotracheal intubation can be performed if needed.
The child who is suspected of having epiglottitis should be examined in a setting where emergency airway equipment is readily available. Examination of the throat with a tongue depressor is contraindicated until experienced personnel and equipment are available to proceed with immediate intubation or tracheostomy in the event that the examination precipitates further or complete obstruction

Nursing MGMT Epiglottitis
The child is allowed to remain in the position that provides the most comfort and security, and the parents are reassured that everything possible is being done to obtain relief for their child.

When epiglottitis is suspected, the nurse should not attempt to visualize the epiglottis directly with a tongue depressor or take a throat culture but should refer the child for medical evaluation immediately.

Acute Laryngotracheobronchitis
most common croup syndrome. mostly kids under 5. Cause is viral. usually preceded by URI. Characterized by gradual onset of low grade fever, wakes up with barky brassy cough.

Acute Laryngotracheobronchitis
Therapeutic mgmt
medical management is maintaining the airway and providing adequate respiratory exchange.
Nebulized epinephrine w/severe dz-causes mucosal vasoconstriction
Oral steroids also effective in croup

Acute Laryngotracheobronchitis
Nursing Care
continuous observation and accurate assessment of respiratory status. Pulse oximetry is used for monitoring oxygenation status
Early signs of impending airway obstruction include increased pulse and respiratory rate; substernal, suprasternal, and intercostal retractions; flaring nares; and increased restlessness.

Bronchitis: inflammation of large airways (trachea and bronchi)…fx associated with URI.
Primary cause is viral…dry hacking cough. tx is usually analgesics, antipyretics and humidity.

Respiratory Syncytial Virus and Bronchiolitis (RSV)
acute viral infection @ bronchiolar level. Usually winter/early spring. RSV is most fx cause of hx in children under 1. can be precursor to asthma. Transmitted from exposure to contaminated secretions.

Signs/Syptoms RSV
Incubation: 5-8 days
Initial: rhinnorrhea, pharyngitis, cough, sneeze, wheeze, ear/eye drainage, fever.
Progression: increased cough/wheeze, tachypnea and retractions, cyanosis
Severe: tachypnea >70bpm, listlessness, apnea, poor air exchange, poor breath sounds

Apnea may be the first recognized indicator of RSV infection in very young infants (younger than 1 month old).
Dx Eval: Elisa, DFA, hyperinflation of lungs seen on chest xr

RSV: mgmt
humidified o2, fluid intake, airway maintenance, meds. Most are managed at home. Antibiotics are not part of the treatment of RSV unless there is a coexisting bacterial infection such as OM
Ribavirin, an antiviral agent (synthetic nucleoside analog), is the only specific therapy approved for hospitalized children
The only product available in the United States for prevention of RSV is palivizumab

Nursing care mgmt of RSB
usually separate rooms or w/other RSV kids. Contact and standard precautions.
Encourage breastfeeding mothers to continue feeding or to pump and store for later use. No meds are appropriate for infants.
monitor o2.

Viral pneumonias, which occur more frequently than bacterial pneumonias, are seen in children of all ages and are often associated with viral URIs

The child with bacterial pneumonia usually appears ill. Symptoms include fever, malaise, rapid and shallow respirations, cough, and chest pain
Antibiotic therapy, rest, liberal oral intake of fluid, and administration of an antipyretic for fever are the principal therapeutic measures. Hospitalization is indicated when pleural effusion or empyema accompanies the disease, when respiratory distress occurs, in situations in which compliance with therapy is estimated to be poor, in infants younger than 1 month old, and when there are chronic illnesses such as congenital heart disease or BPD

Pneumonia nursing care
supportive and symptomatic but necessitates good respiratory assessment. Lying on the affected side if the pneumonia is unilateral (“good lung up”) splints the chest on that side and reduces the pleural rubbing that often causes discomfort

TB: second leading cause of death from infectious dz
The following groups have the greatest rates of latent TB infection: immigrants, international adoptees, refugees from or travelers to high-prevalence regions (Asia, Africa, Latin America, and countries of the former Soviet Union), homeless individuals, and inmates of correctional facilities

The child in severe distress (1) cannot speak, (2) becomes cyanotic, and (3) collapses. These three signs indicate that the child is truly choking and requires immediate action. The child can die within 4 minutes.

Treatment of children with smoke inhalation injury is largely symptomatic. The most widely accepted treatment is placing the child on humidified 100% oxygen as quickly as possible and monitoring for signs of respiratory distress and impending failure.
Nursing care of the child with inhalation injury is the same as that for any child with respiratory distress. Vital signs and other respiratory assessments (oxygenation, work of breathing, acid-base status) are performed frequently, and the pulmonary status is carefully observed and maintained

Asthma prevalence, morbidity, and mortality are increasing in the United States, especially among African Americans

Because the bronchi normally dilate and elongate during inspiration and contract and shorten on expiration, the respiratory difficulty is more pronounced during the expiratory phase of respiration.
The classic manifestations of asthma are dyspnea, wheezing, and coughing

Therapeutic mgmt of Asthma
continuous care: reg. visits
prevent exacerbations & avoid triggers
Reduce underlying inflammation
pt education, environmental control, pharm mgmt,

long term & rescue inhalers
Inhaled corticosteroids, cromolyn sodium and nedocromil, long-acting β2-agonists, methylxanthines, and leukotriene modifiers are used as long-term control medications.
Short-acting β2-agonists, anticholinergics, and systemic corticosteroids are used as quick-relief or rescue medications.

used tx asthma mostly in er when child not respond to other rx. need therapeutic levels

A child with asthma who sweats profusely, remains sitting upright, and refuses to lie down is in severe respiratory distress. Also, a child who suddenly becomes agitated or an agitated child who suddenly becomes quiet may have serious hypoxia and requires immediate intervention.
when symptoms are severe and numerous, when symptoms have been present for a long time, and when there is a family history of allergy, there is a greater likelihood of a poor prognosis.

Nursing tx
One of the major emphases of nursing care is outpatient management by the family. Parents are taught how to prevent exacerbations, to recognize and respond to symptoms of bronchospasm, to maintain health and prevent complications, and to promote normal activities.

Cystic Fibrosis
inherited as an autosomal recessive trait; the affected child inherits the defective gene from both parents, with an overall risk of one in four if both parents carry the gene.

cystic fibrosis clinical features
clinical features, which are increased viscosity of mucous gland secretions, a striking elevation of sweat electrolytes, an increase in several organic and enzymatic constituents of saliva, and abnormalities in autonomic nervous system function

Goals of CF therapeutic management are to (1) prevent or minimize pulmonary complications, (2) ensure adequate nutrition for growth, (3) encourage appropriate physical activity, and (4) promote a reasonable quality of life for the child and the family
In CF patients, characteristic signs of pulmonary infection—fever, tachypnea, and chest pain—may be absent; therefore, a careful history and physical examination are essential. The presence of anorexia, weight loss, and decreased activity alerts the practitioner to pulmonary infection and the need for an antibiotic regimen.

Blood streaking of the sputum is usually associated with increased pulmonary infection and often requires no specific treatment. Hemoptysis greater than 250 ml/24 hr for an older child (less for a younger child) indicates a potentially life-threatening event and needs to be treated immediately.

CF Gastrointestinal mgmt
The principal treatment for pancreatic insufficiency is replacement of pancreatic enzymes, which are administered with meals and snacks to ensure that digestive enzymes are mixed with food in the duodenum

Children with CF require a well-balanced, high-protein, high-caloric diet (because of their impaired intestinal absorption). In fact, they often require up to 150% of the recommended daily allowances to meet their needs for growth
Nursing assessments, including observation of respiratory pattern, work of breathing, and lung auscultation, are vital assessments.
Gentle coaxing, positive reinforcement, and frank negotiation may be required to enlist cooperation for effective medication compliance.
One of the most important aspects of educating parents for home care is teaching techniques for the removal of mucus (ACT, vest, forced expiration) and breathing exercises.

respiratory insufficiency is applied to two situations: (1) when there is increased work of breathing but gas exchange function is near normal and (2) when normal blood gas tensions cannot be maintained and hypoxemia and acidosis develop secondary to carbon dioxide retention.
Respiratory failure is defined as the inability of the respiratory apparatus to maintain adequate oxygenation of the blood with or without carbon dioxide retention.

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