Learning Objectives

At the end of this session, you will be able to:

• Respiratory Infections
 Learning Objectives
At the end of this session, you will be able to:
• Discuss the anatomy and physiology of the
respiratory system
• Differentiate between upper and lower
respiratory tract infections
• Demonstrate the assessment, management
and ongoing care of common upper and lower
respiratory tract infections
 Agenda
• Let’s get thinking
• Respiratory Tract Infections
– Croup
– Diphtheria
– Epiglottitis
– Pertussis
– Bronchiolitis
– Asthma
– Tuberculosis
– Pneumonia
– Influenza
– Covid -19

• Nursing Priorities/Interventions
• Suctioning
 Let’s Get Thinking!
What are some of the
differences in
paediatric vs. adult What are the
respiratory system? differences between
upper and lower
respiratory infections?

What are the ways

respiratory disease
presents in
children?
 Upper vs Lower Respiratory Tracts:
Refresher
• Upper Respiratory Tract
– Consist of the airways
from the nostrils to the
larynx.
– Includes the middle ear.
• Lower Respiratory Tract
– Consists of the airways
from the trachea and
bronchi to the bronchioles
and the alveoli.
 Inside the Lungs

Bronchi
Bronchioles
Terminal Bronchioles

Respiratory Bronchioles
Alveolar Ducts
Alveoli
 Paediatric Respiratory System
• What is the difference?
• What are the clinical implications?

Adult airway Paediatric airway

Respiratory Tract Infections
 Acute Respiratory Infections:
Incidence
• Respiratory infections(ARI)
account for 6% of the total global
disease burden, according to the
World Health Organization (WHO).

• Every year, approximately 6.6

million under-five-year-old
children die worldwide; 95
percent of them are from low-
income countries.
• ARI accounts for one-third of all
deaths
Tazinya et al., 2018
 Group Discussion

• Infants under 3 months have a lower infection

rate…Why??
 Acute Respiratory Infections:
Risk Factors
• Early weaning of breastfeeding
• Poor socio-economic status
• Poor nutritional status
• Rainy season
• Structural abnormalities
• Lack of immunization
• HIV incidence
• Parental smoking
• Parasitic infection

Brian Wolf 2011

(WHO, 2005)
 Upper Respiratory Infections
• URIs are the most common infectious diseases.
• Vast majority have viral etiology – 90%.
– Rhinoviruses account for
25 -30 % of URIs.
– Respiratory syncytial viruses (RSVs), parainfluenza
and adenoviruses for 25-35%.
• Most URIs are self-limiting.
• Acute viral infections predispose children to
bacterial infections of sinuses and middle ear.

(Cotton et al., 2008)

Upper Respiratory Tract Conditions
Rhinitis
(common Sinusitis Viral Croup
cold)

Epiglottitis Pertussis Diphtheria

Influenza COVID-19
 Croup
• Causes:
– Parainfluenza virus
– RSV
– Rhinovirus
– Influenza A
• Signs and Symptoms:
– Gradual onset
– ‘Barking’ cough
– Stridor
– Increased work of breathing
– Hoarse voice
• Most common 6 mon – 3
years

An acute viral infection causing partial upper airway

obstruction
 Croup
• Monitoring
– Monitor vital signs, O2 sat
• Medications
– Dexamethasone IV/oral prednisone
– Inhaled Epinephrine
• Short ½ life (1hr), need to monitor for relapse
• Tests/Procedures
– Blood work to rule out malaria or other infections may be
necessary.
– Neck X-ray (if severe)
• May show “steeple sign” → tracheal narrowing
• Reassessment/Disposition
– Usually go home after medication management and observation.
 Diphtheria
• Causes:
– Bacterium Corynebacterium diphtheriae (C
diphtheriae)
• May involve any mucous membrane.
• Incubation period 2-5 days
• Death occurs in 5-10%
• Signs and Symptoms:
– Infection in larynx or trachea causes stridor and
obstruction.
– Infection of nose and throat causes a grey, scaly
membrane.
– Pharyngeal diphtheria may have swollen
neck (enlarged neck lymph nodes) “bull neck.”

Great care is needed when examining the throat as this may

precipitate complete obstruction of the airway
 Diphtheria
• Monitoring
– Oxygen to keep sats > 90%.
– Encourage feeding to meet child’s maintenance fluids.
• If difficulty swallowing may need ng insertion – insert cautiously.
• Medications
– Give diphtheria antitoxin (IM or IV) immediately.
– Antibiotics – Amoxicillin (Amoxycillin)
– Paracetamol for fevers.
• Tests/Procedures
– Clinical features
• Great care when examining throat – may precipitate obstruction of airway.
• Reassessment
– Keep child in position of comfort.
– Avoid invasive interventions which may upset the child.
• Prevention
– Vaccination
 Epiglottitis
• Cause:
C:\Users\kathy boehmer\Desktop\Epiglottitis-Laryngoscopy.jpg

– Most common Haemophilus

influenza
• Occurs most often in under-
immunized and those too young to
receive vaccine.
• Signs and symptoms:
– Drooling
– Dysphagia
– Dysphonia
– Distress
Normal epiglottis Severe epiglottitis

Acute bacterial infection where the epiglottis tissue gets

inflamed. Can lead to upper airway occlusion over a relatively
short period of time.
 Epiglottitis
• Monitoring
– Monitor vital signs, O2 sat
– Provide O2
• Medications
– Antibiotics – Cefuroxime or Ceftriaxone
– Corticosteroids are given to reduce swelling in throat.
– Give IV fluid for nutrition and hydration.
• Tests/Procedures
– Blood work
– Neck X-ray
• Reassessment/Disposition
– Keep child in position of comfort.
– Avoid invasive procedures until airway is stabilized.
– Prep for transport to OR for intubation.
 Pertussis (Whooping Cough)
• Causes:
– Bacterium Bordetella pertussis
• Occurs most often in children Highly contagious
too young to have completed
full vaccinations (< 6 months) Thick mucus
• Signs and Symptoms: accumulates inside
– Early signs resemble common the airways, causing
cold, first 7 - 10 days
– Fever uncontrollable
– Later signs: Severe hacking coughing.
cough followed by high-pitched
intake of breath
 Pertussis
Monitoring
• Oxygen to keep sats > 90%.
• Encourage feeding to meet child’s maintenance fluids.
Medications
• Antibiotics – Erythromycin or Azythromycin drug of choice
• Paracetamol for fevers
Tests/Procedures
• Nasopharyngeal swab or aspirate
Reassessment/Disposition
Keep child in position of comfort during coughing
spells.
Avoid invasive procedures. If suctioning needed,
perform gently….can cause spasm.
Prevention
Vaccination
Doune Porter GAVI Alliance 2011
 Influenza
Causes:
• Influenza types A , B and C (Type A&B cause
widespread illness /epidemics)
Mode of transmission
• direct contact with infected individuals
• Indirect contact with contaminated objects
(called fomites, such as toys, doorknobs) and
• inhalation of virus-laden aerosols
Incubation
1-4 days

Influenza or flu, is a contagious viral infection that can cause

mild to severe symptoms and life-threatening complications,
including death, even in healthy children.
(CDC,2022)
 Influenza
Signs and symptoms:A child can become suddenly ill with any or
all of these symptoms:
• Very high Fever, which may be as high as 39.4°C to (40.5°C)
• Body aches, which may be severe
• Headache
• Sore throat
• Cough that gets worse
• Tiredness
• Runny or stuffy nose
• Nausea
• Vomiting
• Diarrheoa
Cold and Flu have different symptoms. Cold is usually mild and often goes away
after a few days. Flu can cause severe symptoms and lead to problems such as
pneumonia, croup and even death
 Influenza - Management

Psychological support Fever management-

• Reassure client and caregiver • Serve prescribed antipyretics
• Incorporate appropriate • Remove excess clothing
developmentally strategies. • Ensure adequate ventilation
Monitoring- Fluid intake
• Monitor vital signs, • Ensure adequate fluid intake
• SPO2 • Encourage breastfeeding for
• Give O2 PRN breastfed babies
Rest and sleep
• Adequate rest to conserve
energy and promote recovery
 Influenza - Management cont’d
Nutrition
• Serve light nourishing diet in bit at regular interval of time.
Medication
• Paracetamol for fever management
• Antiviral medicine. This may help to ease symptoms, and
shorten the length of illness.
• Antibiotics – Are not effective against viral infections, so
they should not be prescribed. However, they may be
used, if the child develops bacterial pneumonia.
Prevention
• Vaccination
• Clean and disinfect surface.
• Hand hygiene
• Limit child’s contact with infected person
 Acute Lower Respiratory Infections
• Leading cause of death • Respiratory syncytial
among children under 5 virus (RSV) is the most
years of age. common pathogen.
• Leading reason for • The age group mainly
hospitalization in affected by RSV in
children in Africa. developing countries is
children under 6 months
of age.
• RSV-ALRI is slightly
more common in boys
than in girls.
(Williams, 2002)
WHO: 3 Principle Signs of Lower
Respiratory Infection

Lower
respiratory
infection

Rapid breathing
Chest indrawing
Inability to feed

(Hart & Cuevas, 2007)

Lower Respiratory Tract Infections

Pneumonia Bronchiolitis

Asthma
(inflammatory not Tuberculosis
infectious)
 Bronchiolitis
C:\Users\kathy boehmer\Desktop\Bronchiolitis_anatomy_PI.jpg

• Causes:
– RSV
– Causes bronchioconstriction and mucus
plugging
• Usually < 2 yrs – typically 2-6 months
– Risk factors: prematurity, daycare/school,
immunocompromised, maternal smoking
• Presentation:
– Cough
– Tachypnea
– Low-grade fever
– Wheezing/crackles
– Retractions
– Decreased air entry

Lower respiratory tract infection causing destruction of the

lining of the bronchioles.
 Bronchiolitis
• Monitoring
– Monitor vital signs, O2 sat.
• Medications
– Supplemental O2 to keep sats > 90%
– Ventolin (trial of Ventolin - only continue if effective)
– Epinephrine if effective
– Hydrocortisone
• Tests/Procedures
– Diagnosed based on the history and physical exam.
• Reassessment/Disposition
– Encourage small frequent feeds or IV if respiratory distress.
– Observation &/or admission.
 Asthma
• History of:
– Frequent cough at night
– Recurrent wheezing
– Recurrent chest tightness
– Fatigue
– Triggers
• Signs and Symptoms:
– Wheezing
– Prolonged expiratory phase
– Retractions
– Tachypnea
– Retractions Chronic inflammation disorder of the airways
– Inability to complete sentences characterized by airway hyperactivity,
bronchiospasm and inflammation and reversible
– Silent chest in older children small airway obstruction

https://www.youtube.com/watch?v=7EDo9pUYvPE
https://www.youtube.com/watch?v=EK8nzKzdnIM
 Asthma
• Monitoring
– Monitor vital signs & O2 sat.
– Watch potassium with frequent Ventolin. Replace in IV as
needed. (Ventolin lowers potassium.)
• Medications
– Ventolin
– Atrovent – with first ventolin
– Oral Prednisone or IV Dexamethasone
– Supplemental O2 to keep sats > 90%
– Oxygen
– Ventolin
• Beta-agonist works by relaxing the muscles surrounding the
airways.
– Atrovent (Ipratropium Bromide)
• Anticholinergic, typically used in conjunction with Ventolin in
known asthmatic or history of previous wheeze.
 Asthma
• Tests/Procedures
–Testing for asthma doesn’t happen during acute
episodes.
–Diagnosis based on careful history and examination.
• Reassessment/Disposition
–Reassess as needed.
–Puffer & spacer teaching
–Discharge teaching
• Triggers, medication use and prevention
 Tuberculosis
• Every day, up to 200 children lose their lives to
tuberculosis – a preventable and curable
disease.
• Over half a million children fall ill with TB each
year and struggle with treatment that is not
child-friendly.
• TB in children is often missed or overlooked
due to non-specific symptoms and difficulties in
diagnosis.

(WHO, 2013)
 Tuberculosis
• Cause:
– Inhalation of droplets containing Tubercle Bacillus
• Most cases occur in young children < 5 years.
• Most disease occurs within 2 years after exposure.
– The majority within 1 year.
• BCG vaccinations as a newborn can decrease clinical
forms of all TB cases.
• Congenital TB is rare but possible (acquired I utero or
at delivery)
• Signs and symptoms:
– Fever
– Increased respirations
– In-drawing
– Chronic cough

TB is an infectious disease that is transmitted from person to

person by droplet transmission through coughing & sneezing.
 Tuberculosis
• Monitoring
– Highly contagious: Isolation required
– Hospitalize if in respiratory distress – may require oxygen therapy
• Medications
– Anti-TB drugs: 6-8 month course
– Initial ‘intensive’ phase – 2-3 months
• Three or more anti-TB drugs are therefore given to kill the TB bacteria rapidly.
– Continuation phase – 3-4 months
– Fewer drugs are required.
– If the patient does not take the full course of treatment some of the TB bacteria will not be killed
and the child will not be cured.
• Tests/Procedures
– Sputum collection – most specific, cost-effective and reliable
– Triad of: Known contact, positive TB skin test and abnormal CXR
• Reassessment/Disposition
– Close follow-up for during and after treatment.
– Test close household contacts.
– Register all children taking anti-TB medications with TB register.
 Tuberculosis
TB

Photo Credit: https://www.flickr.com/photos/pulmonary_pathology/7471756830

Types of Cough

https://youtu.be/nbCbOis-mwo
 Pneumonia: Refresher
Pneumonia: REVIEW

• Inflammation of the parenchyma of the lungs

• Infection of the lung tissue.
• Caused by bacteria, viruses, fungi or parasites.
• Is responsible for more deaths of children
under the age of 15 than AIDS and malaria
combined.
• Killed an estimated 922,000 children in 2015.
• This infection is completely preventable but
also potentially fatal if the correct antibiotics
are not administered.
(WHO, 2014)
 Pneumonia

• “In children under 5 years of age, who have

cough and/or difficult breathing, with or
without fever, pneumonia is diagnosed by the
presence of either fast breathing or lower
chest wall in-drawing where their chest moves
in or retracts during inhalation.”

(WHO, 2015)
 Case Study
• John is 18 months old. He is brought to the
OPD of a district hospital with his father.
• His father states, “John has been coughing for
2 days and he is having trouble breathing.”
• His temperature is 39.4⁰ Rectal, pulse 140,
respiratory rate 62 and he is lethargic
• You place him on an oximetry and his oxygen
saturations are 89%.
–What is the first action in the assessment phase?
 Rapid
Assessment
(ABCs)

Non- Urgent
Emergency Signs Priority Signs
Signs

Airway, breathing, circulation, Aged < 2 mon, febrile, trauma,

coma/convulsing, severe severe pallor, poisoning, severe
dehydration pain, resp distress, restless,
irritable or lethargic, severe
malnutrition, severe burns,
oedema of both feet
(WHO, 2013)

How would you assess John?

 Case Study: John
• You have assessed John and have found priority
signs, lethargy and respiratory distress.
• You determine he needs prompt assessment to
determine what further treatment is needed.
• You move him to the front of the queue and
continue with your assessment.
– What questions might you ask John’s father?
– How would you proceed in the assessment phase?
 First Intervention
• What would be your first intervention in a
child in respiratory distress?
Face mask – minimum
flow of O2 in a face mask
should be
greater than 6L/min due
to rebreathing of CO2 if
the flow is not enough.
 Pneumonia
• History of:
– Fever
– Chest pain
– Cough is productive, increased at night, recurrent
– Cough is persistent and may last three to four weeks
– Worse with activity

• Signs and Symptoms:

– Cough
– Chest pain
– Abnormal lung sounds (Grunting and crackles, rales)
esp. with severe pneumonia
– Retractions (intercostal, sub/supra-sternal)
– Dyspnoea/respiratory distress
– Shortness of breath/
Inability to complete sentences
Inflammation of the parenchyma of the lungs
caused by bacteria, viruses or chemical irritants
 Physical Exam
asthma

• Wheezing
• Crackles in the lung
• Muscle retractions
• Often can be normal

http://www.health-alliance.com/contentarchive/july99/images/asthma.jpg
 Case Study: John
• You ask the father to lift John’s shirt and you
count 61 breaths per minute.
• You note moderate chest in-drawing with no
audible stridor.
• Temperature is 39.4⁰C.
–What findings would cause concern?
–What further investigations would you
recommend? And why?
 The 3 signs of lower
respiratory infections Does John display
are…? the symptoms of
LRI?
Investigations: How Do We Diagnose?

• Pulse oximetry
• Labs
- Full blood count(focused more on
WBC differentials)
- Blood cultures
- ABGs (hypoxaemia)
• Malaria screen
• Chest X-ray (CXR)
 Case Study: John
• John was diagnosed with severe pneumonia
and admitted to the paediatric unit.
–What could you teach the family about this
condition?
–What management strategies would be
appropriate?
 Pneumonia
• Treatment/Medications
– Antibiotic therapy
– Analgesic/antipyretics
– Expectorants during the day

• Supportive care
– Supplemental O2 to keep sats > 90%
– Continue breastfeeding for infants
– Good nutrition (light nourishing, vitamin rich)

• Reassessment/Disposition
– Reassess as needed (focus resp. assessment).
– Discharge teaching
• Medication use/adherence, prevention, nutrition
 Case Study: John
• You have been assigned to take care of John
on the ward.
–What specific nursing interventions would you
provide?
 Nursing Priorities/Interventions:
Severe Pneumonia
• Give oxygen if sats < 90%.
• Manage airway as appropriate.
–Positioning and Supporting
–Suctioning
• Give recommended antibiotic.
• Treat high fever if present.

(WHO, 2013)
 Nursing Priorities/Interventions:
Pneumonia
• Provide adequate & appropriate fluid intake to meet
fluid requirements.
• Ensure adequate & appropriate intake to meet
nutritional requirement.
• Assess for other illnesses or conditions.
• Discharge teaching.

As a group, let’s discuss nursing interventions that

we could do to accomplish these priorities.
 Children with a Cough/Difficulty
Breathing….

Presenting with Presenting with Presenting with

wheeze stridor chronic cough
• Bronchiolitis • Viral croup • Pertussis
• Asthma • Diphtheria • Tuberculosis
• Cold • Epiglottitis • Foreign body
• Anaphylaxis aspiration

(WHO, 2013)
 Prevention Strategies - Childhood
Respiratory Disorders
• Vaccines
– Epiglottitis − Hib
– Diphtheria
– Pertussis
– Pneumonia – Hib, Pneumococcal
(s. pneumoniae)
• Environmental Factors
– Indoor Air Pollution
– Handwashing
• Adequate Nutrition
 Suctioning
Indications
• Patient unable to clear
secretions or obstructions
from the respiratory tract to
maintain a patent airway.
• Clearing airways helps with
feeding issues.
Suctioning
• Oral; Nasopharyngeal;
Nasotracheal or
Endotracheal
 Suction: Guidelines

Neonate 60-80mmhg Nasopharyngeal:

Child 80-100mmhg Measure from tip of
Older Child/Adult 100- nose to tip of ear and
120mmhg insert 2cm further

Oropharyngeal:
Measure from centre
of teeth to angle of jaw
and insert 2cm further

(Moore 2003; Trigg & Mohammed, 2010; ALSG, 2011)

 Equipment

• Negative pressure
source
• Suction canister
• Connective tubing
• Suction catheter
• Water soluble lubricant
• PPE
 Nasopharyngeal Suctioning
• Suspected Epiglottitis
• Occluded nasal passages
• Nasal bleeding
• Acute head, facial or
CONTRAINDICATIONS neck injury
• Bleeding disorder
• Laryngo-spasm
• Irritable airway
• Tracheal surgery

(ARCC, 2004)
 Take Home Messages
• Acute disease of the respiratory tract is the most
common cause of illness in infancy and childhood.
• Respiratory disease may present as a primary clinical
problem or as a secondary complication.
• Altered level of consciousness in an infant or child
with respiratory disease is often an ominous sign of
deterioration.
• In paediatrics, respiratory distress can
quickly lead to failure and arrest.
• Continuous assessment and monitoring
of child is key!
THANK YOU