Respiratory- 12

Smaller nares & narrow nasal passages. Newborns- nasal breathers. Small oral cavity & large tongue. Infant- soft tracheal cartilage. Rapid tonsil growth. Long floppy epiglottis. Higher trachea;

short & narrow. All risks for airway occlusion!

Increased airway resistance. Risk for increased airway resistance with edema & swelling

Infant – cartilaginous ribs/flexible . Risk for inefficient ventilation.

Respiratory tract grows until about age 12. 

The child’s upper airway is short and narrow, which increases the potential for obstruction. 

There is an inverse relationship between airway diameter and resistance: The narrower the 

airway is, the greater the airway resistance. The bronchial division is higher and at a different angle than the adult. Newborns: obligatory nose breathers up to 2-3 months (coordination of mouth breathing is controlled by maturing neurologic pathways; opening the mouth to breath is not automatic.)

The lower airway also develops throughout childhood. 

The alveoli change size and shape and increase in number until puberty, which increases the area available for gas exchange.

The smooth muscles of the bronchi and bronchioles develop during the first year of life. Newborn doesn’t have enough smooth muscle to trap airway invaders. By 5 months, infant has 

enough muscles to react to irritants 

The intercostal muscles are immature and the diaphragm is the primary muscle used for ventilation until about age 6.

The ribs are cartilaginous and flexible, which causes retractions that worsen during respiratory 

distress. Pediatric ET Tube Sizing- A child’s little finger is a good estimate for the diameter of the airway. Respiratory Assessment- VISUALIZING THE CHEST WHEN PERFORMING A RESPIRATORY

ASSESSMENT IS OF UTMOST IMPORTANCE!

Pulse oximetry, Cardiopulmonary monitoring, Respirations, Respiratory effort: retractions, nasal 

flaring, Breath Sounds, Preferred position, Responsiveness. Looking – Listening – Feeling Patient as a WHOLE. Never just depend on the monitors to tell you if a patient is in RDS.

Normal Respiratory Rates in Children Birth to 6 months 30-60/min . Progressively slows down. Birth to 6 months-abd breathing; hard to count. Infants have periodic breath which is an irregular rhythm and may have pauses up to 20 seconds.

This breathing pattern is not apnea.

Apnea is the cessation of respirations lasting longer than 20 seconds or any pause in breathing 

associated with cyanosis.

Signs of Respiratory Distress Color - Mucus membranes, Nail beds, Skin 

Cough - Productive, Forceful or weak?, Brassy, Croupy Behavior - Irritability, Restlessness, responsiveness

Positioning- Tripod position Vital Signs- Tachypnea Breath Sounds - Adventitious sounds, Diminished or absent sounds

Respiratory Effort- Labored breathing, Nasal flaring, Stridor, Difficulty talking, Weak cry, Retractions, Accessory muscle use, Paradoxical breathing

Mild Respiratory Distress- Intercostal Retractions

Moderate Respiratory Distress- Intercostal retractions, Substernal, Subcostal

Severe Respiratory Distress- Intercostal retractions, Substernal, Subcostal, Supraclavicular, Suprasternal. Severe Respiratory Distress the use of accessory muscles – the sternocleidomastoid and trapezius muscles – are used and we see supraclavicular and suprasternal retractions.

As severity increases retraction sites increase. Higher up=more RDS. Pulse Oximetry - >95%, below can indicate hypoxemia. Placement- finger, foot, ear. Use a light 

barrier to reduce interference from bright lights. Confirm heart rate matches the heart rate detected by the monitor. Interference from shivering; vasoconstriction; poor capillary refill; hypothermia; intravenous dyes; and electromagnetic interference can result in a false low 

reading. Anemia may result in a false high reading. Rotate sites, can cause a burn

Arterial Blood Gases (ABG)- Assesses gas exchange, ventilatory control, acid-base balance, 

monitors respiratory therapy. Normal values similar to adults. Nursing Considerations- Painful, 

Small sample size, Coping mechanisms, Praise, Comfort Acid-base balance

Respiratory Acidosis- pH<7>26 mEq/L, PaCO2 > 45 mmHg. Causes- CNS depression, 

Asphyxia, Hypoventilation. S&S- Diaphoresis, Headache, Tachycardia, Confusion, Restlessness, 

Apprehension, Flushed face

Respiratory Alkalosis- pH >7.45, HCO3 <22>

Hypoxia, Gram-negative bacteria. S&S- Rapid deep respirations, Paresthesia, Light-headedness, Twitching, Anxiety, fear Croup Syndromes : Laryngotracheobronchitis, Epiglottitis (Supraglottitis), Bacterial Tracheitis. 

Airway changes with croup - Upper airway tissues respond to the virus with inflammation and 

edema. Epiglottis swells, which can occlude the airway and trachea swells against the Cricoid 

cartilage which narrows the airway. From there, copious secretions (like with most viruses) 

increase RDS and can completely obstruct the airway. Signs & Symptoms- Inspiratory Stridor, Barking Cough, Hoarseness WARNING- No throat cultures, No visual inspection of the throat, LARYNGOSPASMS, Close the 

larynx and can cause complete airway obstruction!

Minor Viral Illness (Most Common )- Acute spasmodic laryngitis (spasmodic croup), 

Laryngotracheal bronchitis

Bacterial illness (Most Serious )- Acute epiglottitis, Bacterial tracheitis Viral Illness - Spasmodic Croup- swelling below vocal cords

Laryngotracheal bronchitis (LTB)- swelling above & below vocal cords

Assessment- Barking Cough, Stridor, Worst during sleep

Treatment- Humidified air, Keep Calm, Warm oral fluids, ED – labored breathing or stridor

Bacterial Tracheitis- Cough, Retractions, Stridor, Hoarseness, Fever, Toxic Appearance (look like they don’t feel good), Child may prefer to lie flat 

Cause : Staph; Strep A; H. influenza Diagnosis : Blood Cultures often treated as LTB; condition worsens after treatment Hospitalization in Pediatric ICU. This is secondary infection following LTB Diagnosis- blood cultures Treatment : Antibiotics 10–14-day course, Mechanical Suctioning, Oxygen, Intubation

Epiglottitis- EMERGENCY, rarely seen after 7, vaccines have decreased

Assessment- Dyspnea, Drooling (hallmark), Dysphonia (hoarse), Dysphagia

Causes - narrow airway increases risk. Bacteria (flu, pneumonia, staph)

Nursing Considerations - Keep Calm, Do not examine throat or obtain throat cultures, Have 

intubation and tracheostomy trays immediately available. Tx - airway mgmt, abx, antipyretics, hydration, emotional support

Bronchitis- Inflammation of trachea and bronchi, Most common in winter months

Sx- Dry, hacking cough that increases at night, +/- productive, May swallow sputum and vomit, 

Chest/Rib soreness, Breath Sounds course with fine crackles Treatment : Palliative, May need abx with secondary infection 

Nursing Considerations - Support respiratory function: Rest, Humidification, Hydration, 

Symptomatic Treatment (fever, pain)

Bronchiolitis- Cause-Viral/Bacterial organism causes inflammation and obstruction of 

bronchioles. RSV leading cause. Increased incidence of reactive airway disease/asthma. Epidemic

from October-March. Transmitted through direct contact/contaminated surfaces Virus shed 3-8 days, Incubation period 2-8 days. Virus invades mucosal cells lining small bronchi. Virus bursts from cell to adjacent cells. Invaded cells die. Membranes of infected cells fuse with 

adjacent cells. Cause “syncytia” 

Debris clogs/obstructs bronchioles, Airway lining swells, Production of excessive mucous, Cycle repeated in lungs

Assessment- Rhinitis, Cough, Fever, Wheezing, Tachypnea, Poor Feeding, Vomiting, Diarrhea, 

Dehydration 

Diagnostic: Radiographs- Shows Hyperinflation, Atelectasis, Inflammation. ELISA test Tx - No effective therapy, Humidified Oxygen, Hydration, Antipyretics RSV – Respiratory Syncytial Virus- More prominent <24>

have needed medicine within 6 months of start of RSV season, <24>

life, Infants born at 29-32 weeks gestation up to 6 months, Infants born at 32-35 weeks gestation

with 2+ risk factors including childcare attendance, exposure to air pollutants, school-age 

siblings, congenital abnormalities of the airway, severe neuromuscular disease Pneumonia- Acute inflammation/infection of bronchioles and alveolar spaces of lungs. May be 

viral, mycoplasma or bacterial or caused by foreign body aspiration. Bacteria circulates through 

bloodstream to lungs. Damage cells, causing inflammation and edema 

Cellular debris and mucus cause airway obstruction. 

Consider unilateral lobar pneumonia. Virus enters through upper respiratory tract. Infiltrate alveoli nearest bronchi of one/both lungs. Virus invades cell, replicates and bursts out. Kills cells 

and sends out cell debris. Adjacent areas invaded, distributed in a scattered, patchy pattern Newborns: Grunting, Nasal Flaring, Irritability, Lethargy, Decreased Appetite 

Sx- Fever, Rhonchi, Crackles, Wheezes, Cough, Dyspnea, Tachypnea, Restlessness, Decreased 

breath sound 

Clinical Therapy: Pain Control, Fever Control, Airway Mgmt, Fluids, Rest, Antibiotics 

Diagnostic: Radiograph, WBC, History, Physical Findings

Smoke-Inhalation Injury- Airway obstruction, Carbon monoxide poisoning,