Pediatric Respiratory Disorders

Hallmark Assessment Findings:

• Barky, seal-like cough — classic distinguishing feature
• Inspiratory stridor — worse with crying or agitation
• Hoarse voice from laryngeal involvement
• Low-grade fever; gradual onset over 1–2 days
• Worse at night; child may appear relatively well during daytime

Nursing Priorities:

• Keep child calm — agitation worsens stridor and increases oxygen demand
• Keep parent at bedside — separation increases anxiety and airway work
• Administer racemic epinephrine (nebulized) for moderate-severe croup per order — observe for rebound (return of symptoms 2–4 hours after treatment)
• Administer corticosteroids (dexamethasone) as ordered — reduces subglottic edema
• Cool mist or humidified air — traditional management; evidence for benefit is mixed but commonly used
• Monitor for worsening stridor at rest, cyanosis, or fatigue — escalate immediately

Hallmark Assessment Findings (4 Ds):

• Dysphagia — inability to swallow; drooling (refuses to swallow)
• Dysphonia — muffled "hot potato" voice; NOT hoarse (distinguishes from croup)
• Drooling — unable to manage secretions
• Distress — toxic appearance, high fever (39–40°C), anxious, sitting upright in tripod position
• Sudden onset over hours (vs. croup's gradual onset)

Nursing Priorities:

• Do NOT: examine throat with tongue depressor, agitate the child, place in supine position, attempt IV access without immediate airway support available
• Allow child to remain in position of comfort — typically sitting forward, tripod position
• Keep parent at bedside to minimize agitation
• Prepare for emergent intubation or surgical airway — notify provider, anesthesia, OR immediately
• Administer IV antibiotics as ordered once airway is secured
• Provide humidified oxygen without disturbing the child

Assessment Findings:

• URI symptoms precede lower airway involvement (rhinorrhea, low-grade fever)
• Expiratory wheezing — lower airway obstruction
• Tachypnea, intercostal retractions, nasal flaring
• Poor feeding — hypoxia and tachypnea impair coordinated suck-swallow
• Crackles on auscultation; prolonged expiratory phase
• SpO₂ may drop, especially during feeding

Nursing Priorities:

• Supportive care is primary — bronchiolitis is viral; antibiotics are not indicated
• Maintain airway patency — bulb suction or nasopharyngeal suction to clear secretions
• Supplemental oxygen to maintain SpO₂ ≥90–95%
• Small, frequent feedings or NG feeding if respiratory distress impairs oral feeding
• Monitor hydration status — tachypnea increases insensible losses
• High-flow nasal cannula (HFNC) or CPAP for moderate-severe cases
• Palivizumab (Synagis) prophylaxis for high-risk infants (premature, chronic lung disease, congenital heart disease)

Assessment Findings — Acute Exacerbation:

• Wheezing, dyspnea, chest tightness, cough (especially nocturnal)
• Tachypnea, tachycardia, accessory muscle use
• Silent chest = severe obstruction — no air movement; immediately life-threatening
• Peak expiratory flow rate (PEFR) <50% predicted = severe attack
• Hypoxia: SpO₂ <92% = severe; cyanosis = impending respiratory arrest

Nursing Priorities:

• Position upright (High-Fowler's) to maximize diaphragm excursion
• Supplemental oxygen for SpO₂ <94%
• Administer short-acting beta-2 agonist (albuterol) via nebulizer or MDI with spacer — first-line for acute exacerbation
• Ipratropium (anticholinergic) added for moderate-severe attacks
• Systemic corticosteroids for moderate-severe attacks — reduce inflammation
• IV magnesium sulfate for severe refractory attacks in the ED setting
• Teach proper inhaler technique with spacer for all ages; peak flow monitoring
• Identify and document triggers; develop asthma action plan