Chapter 21: Respiratory Dysfunction in Children

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Welcome back to the Deep Dive.

I am so glad you are here with us today because we are tackling um a monster of a topic.

We really are.

This is one of those subjects that if you are planning to work in pediatrics or frankly anywhere in healthcare involving kids, you simply cannot avoid.

We are cracking open chapter 21 of Wong's Essentials of Pediatric Nursing titled The Child with Respiratory Dysfunction.

It is a massive topic, you're right, but calling it a monster is actually pretty accurate in terms of its impact.

If you look at the data,

respiratory issues are the absolute number one reason children are hospitalized.

The number one reason.

By far.

It is the bread and butter of pediatric nursing.

You will see this on the medsered floor, in the ER, in the ICU, and definitely in primary care.

It's everywhere.

Exactly.

And our mission today is pretty specific.

We aren't just going to read the textbook to you.

That would be a cure for insomnia and we want you awake for this.

We want to bridge that gap between the theory on the page and safe, effective clinical practice.

We want to help you, the listener, spot the subtle signs before they turn into a code blue.

That is the whole goal.

Because with children,

respiratory distress can be incredibly deceptive.

They have this amazing physiological reserve where they compensate and compensate and compensate.

Right up until the edge of a cliff.

Until they can't and then they crash.

Hard and fast.

So we're going to take a 30 ,000 foot view of this chapter to start and then we're going to drill down into the details.

Okay.

So walk us through the roadmap.

What are we covering today?

So we'll start with the foundational stuff, the anatomy and physiology, literally why a child's airway is so different from yours or mine.

It's the key to everything else.

Okay.

Then we'll move into the acute infections, the things that hit hard and fast like RSV and croup.

Then we'll transition into the long haul stuff,

the chronic management of asthma and cystic fibrosis, which is, you know, a whole different ball game requiring different nursing skills.

Then the grand finale.

The grand finale, yeah.

Yeah.

We will wrap up with emergency management, recognizing respiratory failure and the basics of pediatric CPR.

But through all of this, I want you to keep one thing in mind.

Mastering this chapter is about patient safety.

It's about decoding the signs the child is giving you.

So let's unpack this.

Let's start with the basics.

Section one, the pediatric difference.

Why is a kid not just a small adult when it comes to breathing?

I mean, they have lungs, a trachea, a nose.

It's all the same parts, right?

Same parts, but very, very different mechanics.

It really comes down to what the book calls the size factor.

It sounds obvious, but the clinical implications are huge.

How so?

The diameter of a young child's airway is significantly smaller than an adult.

I'm talking tiny.

I've heard the analogy of breathing through a drinking straw versus like a paper towel roll.

That's a great way to visualize it because the airway is so narrow, about four millimeters in an infant, which is the width of a piece of spaghetti.

Even a tiny amount of swelling or mucus creates a massive obstruction.

Four millimeters.

That's nothing.

It's nothing.

So think about the physics of it.

In an adult, a millimeter of swelling is an annoyance.

You might feel a bit stuffy, right?

Right.

You take some decongestant and you're fine.

Exactly.

In an infant, that same one millimeter of swelling reduces the airway diameter by 50 % or more.

Wow.

50%.

Yes.

It increases the resistance to airflow exponentially.

So the infant has to work much, much harder to pull air through that narrow tube.

That's why a little cold in a baby can look like severe respiratory distress.

So when we see a baby with a stuffy nose, we shouldn't just brush it off as, oh, they're congested.

Never.

For them, it's a major work of breathing issue.

And here is where the anatomy gets even more critical.

The distance between the structures in the respiratory tract is shorter.

Okay.

What does that mean in practice?

It means organisms, bacteria, viruses can move rapidly down the tract.

What starts as a sniffle in the nose can become a lower respiratory infection, like bronchiolitis or pneumonia, much, much faster than in an adult.

There's just less real estate to travel.

And speaking of anatomy, the text makes a big point about the ears.

Why does it seem like every toddler I know has had at least one ear infection?

Is that related?

Completely related.

It's the Eustachian tubes.

In adults, these tubes are longer and angled downward so they drain fluid nicely from the ear into the back of the throat.

Okay.

That makes sense.

But in infants and young children, those tubes are relatively short.

They're wider and they lie almost perfectly horizontally.

So they don't drain.

Exactly.

There's no help from gravity.

It allows pathogens extremely easy access to the middle ear, especially when they're lying down drinking from a bottle.

It's essentially a flat open highway for bacteria to travel from the throat to the ear.

Okay.

So structurally, they are just set up for trouble.

What about their immune system?

The text talks about an immunity timeline.

I found this graph in the chapter really interesting.

It is fascinating, isn't it?

If you look at the infection rate curve, you see a really specific pattern.

Infants younger than three months actually have a lower infection rate.

Which seems counterintuitive.

You'd think they are the most vulnerable because they are the smallest and newest.

They are definitely vulnerable if they get sick, but they are protected by maternal antibodies they received in utero.

It's like a starter pack of immunity from their mom.

Ah, okay.

But here is the catch.

Those antibodies start to fade.

From three to six months of age.

That is what the book calls the danger zone.

The danger zone.

Yes.

The maternal antibodies are disappearing, but the infant's own antibody production hasn't fully kicked in yet.

They're in an immunity gap.

So that three to six month window is where we see infection rate spike.

So if a form of bolt comes into the clinic with a fever, our antenna should go up a little higher than for a two month old.

Absolutely.

And then as they hit the toddler in preschool years, the viral infection rate remains high, but for different reasons entirely.

Daycare.

Daycare, socialization, and the fact that toddlers put everything in their mouths.

They're just constantly exposed to new germs before their immune system has a full library of defenses built up.

It's a germ factory out there.

Now the text also mentions seasonal patterns.

I feel like we all know flu season, but is there more to it than just it's cold outside?

Definitely.

The season helps you play detective, really.

Winter and spring are typically when we see epidemics of RSV and other common respiratory pathogens like influenza.

Okay, that's what we'd expect.

But interestingly, mycoplasmal infections, the ones that can cause walking pneumonia, they tend to hit in autumn and early winter.

So knowing the season can actually give you a clue as to what bug you might be dealing with before you even get the swab results back.

That's a great clinical pearl.

Okay, so we know the setup.

They're anatomically and immunologically vulnerable.

Now let's talk about the assessment.

Section two, the art of assessment.

The text has these huge boxes, box 21 .1 and 21 .2, listing clinical manifestations.

If I'm a student, I'm looking at these lists and thinking, do I have to memorize all this?

What am I actually looking for?

This is the core of the chapter.

You have to be able to decode the signs.

Don't just memorize the list.

Understand what the list is telling you about the child's physiology.

Let's start with the generalized signs.

Fever.

Right.

Fever in small children can be alarming for parents.

It can reach 103 to 105 degrees Fahrenheit, even with a mild illness.

105?

That sounds terrifying to a parent.

My kid has a fever of 105.

I'm panicking.

It is, but in pediatrics, the height of the fever doesn't always correlate with the severity of the illness.

A kid can have 104 fever with a simple virus and be running around playing.

Another kid can have a 101 fever and be lethargic and septic.

The key is to treat the child, not the number on the thermometer.

Look at the whole picture.

Always.

The text also mentions anorexia, vomiting, and diarrhea.

Now vomiting,

I usually associate that with a stomach bug.

Why is it in the respiratory chapter?

Yeah, that's what I was thinking.

It's a common confusion.

But think about it.

Children swallow a lot of mucus.

They don't know how to spit it out or blow their nose effectively.

So it all goes down.

It all goes down.

And that mucus irritates the stomach lining.

Also, the muscle spasms from severe coughing can trigger the gag reflex and cause vomiting.

And sometimes abdominal pain is actually referred pain from pneumonia.

Wait, referred pain from the lungs to the stomach.

Yes.

If a child has pneumonia in the lower lobes of the lungs, the irritation of the diaphragm and surrounding nerves can be felt in the abdomen.

So a kid clutching their tummy might actually have a lung issue.

That is a key takeaway for assessment.

Don't get tunnel vision.

Absolutely.

Now let's look at the respiratory effort, the work of breathing.

This is where you really need to use your eyes.

What are we looking for regarding rate?

So techicnea, or fast breathing, is a primary compensation mechanism.

If you can't get enough oxygen per breath, your body's solution is to take more breaths.

But you need to look deeper than just the number.

Look for retractions.

Retractions.

That's when the skin sucks in between the ribs, right?

Yes.

It's the sinking in of soft tissue.

It means the child is generating huge negative pressure inside their chest just to pull air in against resistance.

You might see it above the sternum, that's suprasternal, or between the ribs intercostal.

The deeper the retraction, the harder they're working.

And is one spot worse than another?

Yes.

If you see suprasternal retractions, that child is in serious trouble.

They're using every accessory muscle they have just to take a breath.

They're fighting for every single molecule of air.

And what about the sounds?

We aren't just listening for clear breath.

We're listening for the noise of obstruction.

Clear breath is the ideal.

But you're listening for what's wrong.

And you're categorizing the noise.

Grunting is an ominous sign.

It sounds exactly like it is.

A rhythmic grunting noise on expiration.

It sounds painful just listening to you describe it.

It's physiological.

It's the child trying to keep their alveoli open.

They're closing their glottis at the end of the breath to create positive end -expiratory pressure, or PEEP.

It's a last -ditch effort to improve oxygenation.

If you hear grunting, that child is in trouble.

That is a sign of impending failure.

OK.

That is a critical sound to recognize.

What about stridor versus wheezing?

I feel like students often mix those two up.

They do.

But it's an easy distinction if you think location and timing.

Stridor is a high -pitched inspiratory sound.

It happens when breathing in.

It usually means upper airway obstruction, like in croup.

It's the sound of air being forced through a narrow larynx or trachea.

OK.

So stridor is upper breathing in.

Right.

Wheezing is usually musical and expiratory happening when breathing out.

It indicates lower airway issues like asthma or bronchiolitis.

It's the sound of air being squeezed through tiny, constricted bronchioles.

So stridor up top, wheezing down low.

That's a good way to remember it.

Generally, yes.

But here is a critical nursing priority that the text emphasizes.

And it is so important.

A quiet chest is not always a good chest.

What do you mean?

If a child comes in wheezing like a freight train, and then suddenly the chest goes silent, you do not celebrate.

Why?

Wouldn't that mean the wheeze is gone and they're better?

It often means the obstruction is so severe that air is no longer moving at all.

If there is no air moving, there is no sound.

That is a silent chest.

And it is a sign of imminent respiratory arrest.

Yeah.

You need to act immediately.

That child is about to stop breathing.

That is a terrifying nuance.

Silence can be deadly.

Wow.

OK.

Let's move geographically down the airway.

Section three, upper respiratory tract infections, the common cold, or nose pharyngitis.

Right.

The most common thing you'll see in any pediatric setting.

The management is largely supportive.

There's no magic pill for a virus.

But the nursing care is vital, especially for infants.

The text mentions saline drops and bulb suction.

Why is that emphasized so much?

Is it just for comfort?

It's for survival.

That sounds dramatic.

But for a baby, it's true.

Because infants are obligate nose breathers.

For the first few months of life, they don't know how to breathe through their mouths comfortably, especially when feeding.

So if their nose is blocked?

If their nose is clogged with mucus, they literally cannot eat and breathe at the same time.

They will try to latch onto the breast or bottle, suck a few times, then pull away gasping for air.

They get exhausted and dehydrated very quickly.

So suctioning before feeds is a nutrition intervention as much as a respiratory one.

Exactly.

You clear the airway so they can take the bottle.

And a safety alert from the text regarding humidity,

discouraged steam vaporizers.

Really?

My grandma swore by those.

The tent over the boiling pot.

It's a huge burn risk.

A curious toddler pulls a pot of boiling steam onto themselves.

It happens way too often.

Cool mist humidifiers are much safer and just as effective for soothing inflamed mucus membranes.

That is a great practical piece of advice.

Let's move to the throat.

Pharyngitis is a sore throat.

How do we distinguish between just a virus and strep?

You really need a throat culture or a rapid strep test to be sure, but it's a critical distinction to make.

Viral pharyngitis is self -limiting.

It resolves on its own.

But GAP -EHS group, a beta hemolytic streptococcus, needs antibiotics.

And not just to make the throat feel better, right?

We are preventing something worse down the line.

Precisely.

We treat strep to prevent the sequelae, the dangerous after effects.

Untreated strep can lead to rheumatic fever, which damages the heart valves and joints, or acute glomerulonephritis, which is a serious kidney disease.

That's a heavy consequence for a skipped antibiotic.

Now, if the tonsils get too big, we're talking tonsillitis.

The text has this vivid image of kissing tonsils.

It is descriptive, isn't it?

When the tonsils are so enlarged they touch in the midline of the throat, they can block the airway and make swallowing difficult.

If a child has repeated infections or develops sleep apnea from the obstruction, they might get a tonsillectomy.

And post -op care for tonsillectomy seems to be a favorite topic for nursing exams.

What is the number one thing to watch for?

Bleeding, hemorrhage.

But it's not always obvious, like bright red blood on the pillow.

The most subtle early sign of hemorrhage is frequent swallowing.

Frequent swallowing?

Yeah.

Even while sleeping?

Yes.

Especially while sleeping.

The child is swallowing blood that's trickling down the back of their throat.

Even if they are asleep, if you see that repetitive gulping motion, you need to wake them up and check with a flashlight.

They could be losing a significant amount of blood into their stomach before you ever see it.

That is a pro tip.

And what about diet after the surgery?

Cool fluids, crushed ice, popsicles.

Things that are soothing.

But, and this is important, avoid red or brown fluids.

Because it looks like blood if they vomit.

Exactly.

You don't want to be panicking over red food punch.

And avoid citrus orange juice burns a raw throat.

Also,

discharge teaching is crucial.

The risk of bleeding isn't just in the first 24 hours.

It can happen until 10 days post -op when the scab, the escher, sloss off.

So parents can't let their guard down a week later.

Got it.

Let's shift ears to the ears.

Otitis media.

We talked about the anatomy, but what can we do about it?

Prevention is really key here.

The text highlights a few things.

Breastfeeding reduces the risk because of the immune transfer and the positioning.

And the positioning matters.

It matters a lot.

You should never, ever prop a bottle for a baby lying flat.

Why is that?

Gravity.

Yeah.

If they drink while supine, milk can reflux right up those short, open eustachian tubes into the middle ear.

It pulls there and becomes a perfect growth medium for bacteria.

It's a direct setup for an infection.

So always hold the baby in a semi -upright position for feeds.

Always.

And of course, eliminate tobacco smoke.

Secondhand smoke paralyzes the cilia, the little hairs that are supposed to clear the ear and respiratory tract.

So fluid just sits there.

OK, so hold the baby upright and put out the cigarette.

Now, section five, croup syndromes.

These are the ones that sound really scary.

They do.

The classic one is acute laryngotrichia bronchitis or LTB.

That is a mouthful.

Let's stick to croup for now.

What does the classic presentation look like?

This is usually a toddler.

They have a mild cold, maybe a low grade fever.

They go to bed and then they wake up in the middle of the night with this terrifying barking cough.

It sounds like a seal.

And they have that high -kitched inspiratory sound, the stridor, right?

The subglottic airway, the area just below the vocal cords,

is swelling up.

We treat it with cool mist to soothe the airway.

But medically, we use nebulized epinephrine.

Epinephrine, like for a severe allergic reaction?

Same drug, but a different mechanism here.

When it's inhaled, it causes vasoconstriction.

It shrinks the swollen blood vessels in the airway.

It opens the airway very quickly, but the effect can be short -lived.

We also use corticosteroids like dexamethasone to knock down the inflammation for a longer lasting effect.

But there is a more dangerous cousin to croup, right?

Epiglottitis.

Yes, and this is a true medical emergency.

It's much rarer now because of the Hive vaccine, but you have to recognize it.

Unlike LTB, which is gradual, epiglottitis is abrupt.

The child looks toxic.

They have a high fever and they look absolutely terrified.

What are the telltale signs?

You have to remember the four D's.

Drooling, dysphagia, which means they can't swallow, dysphonia, which is a muffled hot potato voice, and distress.

Why are they drooling?

Because it hurts too much to swallow their own saliva.

Their throat is so swollen and painful, the saliva just runs out of their mouth.

And they sit in a very specific way to keep their airway open.

The tripod position.

Exactly.

Sitting upright, leaning forward, chin out, mouth open.

They're physically aligning their airway to get every possible bit of air in.

Now here's the big red flashing light from the text.

The huge warning.

What should a nurse never do?

Never, ever, under any circumstances, put a tongue depressor in their mouth.

Do not attempt to examine the throat unless you have an anesthesiologist and intubation equipment right there, ready to go.

Why?

It seems like you'd want to see what's wrong.

The epiglottis, that little flap that covers the trachea, is so inflamed and swollen it's like a big cherry in the back of the throat.

Stimulating it with a tongue blade can trigger a complete laryngospasm.

The airway shuts down completely and you cannot bag mask ventilate them.

You have lost the airway.

That is intense.

It is.

So your job is to keep the child calm.

Do not start an IV.

Do not draw blood.

Do not make them cry.

Let them sit on their parents' lap until the airway is secured in the operating room.

Keep them calm.

Don't look in the throat.

Got it.

Let's move down to the lungs.

Section 6.

Lower respiratory infections.

RSV and pneumonia.

RSV, or respiratory syncytial virus, causes bronchiolitis.

It's a huge problem in the winter.

The virus attacks the small airways, the bronchioles.

They get obstructed by mucus and edema.

Air gets in but gets trapped.

Trapped.

How does that work?

Yes.

It acts like a check valve.

Air can get forced in on inspiration, but on expiration the airway collapses slightly and the mucus plug blocks the exit, so the lungs get hyper -insulated with trapped air.

The text makes a big deal about contact precautions.

Because RSV lives on surfaces for hours.

Hand washing is paramount.

You can pick it up from a crib rail, a stethoscope, a door handle, and then transmit it to the next baby.

It spreads like wildfire in hospitals and daycares.

And the management?

It's largely supportive.

There's no cure.

It's all about hydration and suctioning.

The suction priority is key here.

Just like with the common cold, but even more critical.

These infants cannot eat or breathe well with clogged noses.

Suctioning before feeds is a non -negotiable nursing intervention.

Is there a vaccine for it?

Not a traditional vaccine for everyone yet.

No.

Yeah.

But for high -risk infants,

we're talking preemies, kids with congenital heart defects, there is a monthly injection of monoclonal antibodies called syniagists or Pallivizumab to prevent severe RSV disease during the peak season.

Now regarding pneumonia, I found a very specific point in the text about positioning that surprised me.

I always heard good lung down.

Right.

That's the common teaching for adults to improve V -Q matching.

But the source text here, Wong's, specifically discusses unilateral pneumonia in children.

It says, lying on the affected side splints the chest.

So if the right lung is sick, you lay them on the right side.

According to this text, yes, it can reduce the pleural rubbing pain.

The theory is, if they are in less pain, they'll breathe more effectively.

Though generally, keeping the head of the bed elevated, a semi -erect position is almost always best for overall oxygenation.

Interesting.

Okay.

Moving on to the chronic conditions.

Section seven, asthma.

This is a huge one.

Asthma is the leading cause of chronic illness in children.

You have to understand the triad of what's happening in the airway.

Inflammation, mucus production, and muscle spasm or bronchoconstriction.

All three are happening.

And how do we track it at home?

The text talks about a traffic light system.

Right.

This uses a peak expiratory flow meter or PEFM.

It's a simple device that measures how fast a child can blow air out.

You find their personal best when they're healthy, and then use that as a baseline.

And my colors.

Green is 80 to 100 percent of their personal best.

All clear.

They're good to go.

Yellow is 50 to 79 percent.

This is a caution zone.

The airways are narrowing.

They need to use their rescue medication.

Red is below 50 percent.

This is a medical alert.

Severe narrowing is happening.

They need to use their rescue meds and seek help immediately.

It's a great tool for objective assessment.

Speaking of reds, we have rescue versus controller meds.

Albuterol is your rescue inhaler.

It's a beta -adrenergic agonist, a bronchodilator.

It relaxes the muscle spasm quickly, but it doesn't fix the underlying swelling.

So that's where the controller comes in.

Exactly.

That's usually an inhaled corticosteroid like fluticasone.

This is the medication that reduces the inflammation in the airway.

It has to be taken every day, even when the child feels fine, to prevent attacks.

And what about side effects we should teach parents about?

Albuterol makes kids jittery and tachycardic.

They're heart races.

Parents need to expect that so they don't get scared.

With the inhaled steroids, the big patient education point is to rinse the mouth out with water after use to prevent thrush, which is a yeast infection in the mouth.

Okay, let's tackle the other major chronic condition.

Cystic fibrosis, or CF, this is genetic, correct?

Yes, it's an autosomal recessive trait.

Both parents have to carry the gene.

It's a mutation of the CFTR gene, and the result is the body produces thick, sticky mucus that clogs ducts everywhere.

So it's not just a lung disease?

Not at all.

That's a huge misconception.

In the lungs, that thick mucus traps bacteria, leading to chronic infections, inflammation, and eventually permanent lung damage.

And what about the pancreas?

In the pancreas, the mucus blocks the ducts that are supposed to release digestive enzymes into the stomach.

So they can't digest their food?

Correct.

They have severe malabsorption of fats and proteins.

They can eat a ton of food and still be malnourished and fail to gain weight.

That's why they need to take pancreatic enzymes with every meal and snack.

Every single snack?

Every single time they eat, within 30 minutes of eating.

And they need high -protein, high -calorie diets,

often 150 % of the normal recommended daily allowance.

They also need to supplement fat -soluble vitamins A, D, E, and K because they can't absorb them from food.

How is it diagnosed?

Nowadays, most cases are caught on newborn screening.

But the gold standard for diagnosis is the sweat chloride test.

Why sweat?

Because the faulty gene also affects how salt moves through cells.

Kids with CF have a very high concentration of sodium and chloride in their sweat.

It's the basis for the old saying that a baby who tastes salty when kissed is destined to have a short life.

Wow.

And for the lungs, how do they manage all that mucus?

With airway clearance therapies or ACTs, this can be manual chest percussion or more commonly now, they wear a special vibrating vest that shakes the mucus loose so they can cough it out.

They have to do this at least twice a day, every day for life.

That is an incredible amount for a family to manage.

Okay, finally, section nine,

respiratory emergencies.

We've touched on respiratory failure, but what about foreign bodies?

Foreign body aspiration is most common in ages one to three.

They're exploring their world with their mouth and their airway is small.

The usual suspects.

Hot dogs, grapes, peanuts, exactly.

The signs are a sudden onset of choking, gagging or unilateral wheezing.

Prevention is really the key here, cutting food into appropriate sizes and keeping small objects out of reach.

No latex balloons for toddlers.

And if a child's condition worsens and they progress to respiratory failure, what is the cardinal sign we should be looking for?

Restlessness.

Before their oxygen stats drop, before they turn blue, they get agitated.

If a child is hypoxic, their brain is not getting enough oxygen and they don't sit still.

They get anxious and restless.

If a quiet, tired child suddenly becomes agitated, checks their oxygen saturation immediately.

So restlessness is a major red flag and if they rest, CPR, what's the key difference in PEDs?

The sequence is still C -A -B.

Compressions, airway, breathing.

Don't delay compressions to fiddle with the airway.

And the depth.

Push hard and fast.

One third the depth of the chest.

In practice, that's about four centimeters in infants and five centimeters in children.

And the ratio of compressions to breaths.

If you're a single rescuer, it's 30 compressions to two breaths, just like in adults.

But if you're a healthcare provider and there are two of you, the ratio for children and infants changes to 15 compressions to two breaths.

15 to two.

Got it.

Okay, we have covered a massive amount of ground here.

We really have.

From the tiny four millimeter airway of an infant, all the way to the complex lifelong care of cystic fibrosis.

When you think about this entire chapter, what is the final most important takeaway for a nursing student?

The nurse's role is observation.

Vigilant observation.

A child can compensate for a long, long time and look okay -ish.

And then they crash.

They fall off that cliff.

Watching for the subtle signs of increased work of breathing and that key sign of restlessness saves lives.

Catching it early is everything.

That is a powerful message.

Your eyes are your most important assessment tool.

Thank you so much for walking us through this.

My pleasure.

It's a critical topic.

For everyone listening, go back and look at those tables and care plans in chapter 21.

Review the asthma action plans and the CF enzyme instructions.

They will absolutely show up in your practice.

From the last minute lecture team, stay curious and stay safe out there.