UPPER AND LOWER
RAMYA DEEPTHI PULI
VIJAY MARIE COLLEGE OF NURSING
• Almost all of the pediatric codes are due to
respiratory distress in origin
• 80% of pediatric cardiopulmonary arrest
are primarily due to respiratory distress
• Majority of cardiopulmonary arrest occurs
at less than 1 year of age.
Normal pediatric airway anatomy
• Larynx composed of hyoid bone and a series of cartilages
• Single: thyroid, cricoids, epiglottis
• Paired: arytenoids, corniculates, and cuneiform
• Acute upper airway obstruction from
any cause can be a life-threatening
• Complete obstruction will result in
respiratory failure followed by
cardiac arrest in a matter of minutes.
• This situation requires an immediate,
• Upper airway includes
• Larynx (supraglottis, subglottis)
• Trachea (extrathoracic)
• Respiratory distress is one of the
most common chief complaints for
which children seek medical care.
• It accounts for nearly 10 percent of
pediatric emergency department
visits and 20 percent of
• Respiratory distress in children,
particularly neonates and infants,
must be promptly recognized and
aggressively treated because they
may decompensate quickly.
• Factors that contribute to rapid respiratory
compromise in children include-
increased metabolic demands,
decreased respiratory reserves, and
inadequate compensatory mechanisms as
compared to adults.
COMMON FACTORS INCLUDE-
swallowed or inhaled foreign objects
LOCATION OF OBSRTUCTION
Noise during INSPIRATION Noise during EXPIRATION
Difficulty breathing OUT
Distal to Thoracic Inlet
Trachea, bronchi, peripheral
Difficulty breathing IN
Proximal to Thoracic Inlet
Nose, pharynx, larynx
POSITION OF OBSRTUCTION
Snoring Stridor Wheeze
+ + -
Causes of upper airway obstruction
• Common cause of UAO in outpatient practice is CROUP.
• The term croup refers to “ a clinical syndrome characterized by
barking cough, inspiratory stridor and hoarseness of voice.
• Most cases of croup are of viral etiology and 65% of viral croup
is caused by three types of parainfluenza virus
• Since the viral infection is seen on larynx, trachea and bronchi
the viral croup is immediately referred as acute laryngo-
• Usually the term croup referres to viral croup.
• Extrathoracic foreign body obstruction
• Bacterial tracheitis
• Retropharyngeal abscess
• Epiglottitis (bacterial croup)
Assessment of upper airway obstruction
• UAO is a life threatening medical emergency because of
underlying progressive hypoxemia
• Clinical examination is the most important aspect that helps in
both the diagnosis and in the assessment of severity of
• Investigations add little in the initial workup
• As viral croup is the commonest cause of UAO, attempts to
identify other causes is also very important to confirm the
• Children with croup presents with viral prodrome along with
croupy cough, cough inspiratory stridor, hoarseness and
• Viral croup occurs between ages 3months and 5years
• Croup of bacterial cause occurs in older children 3-7 years.
• As the obstruction increases, stridor becomes continuous
associated with worsening of cough, nasal flaring, supra-
sternal, intra-sternal and inter-coastal retractions.
• Children with progressive stridor, severe retractions, hypoxia,
cyanosis, depressed sensorium needs hospitalization.
• Application of croup score may be useful in the management of
• Barking cough
• Respiratory distress
• Inspiratory stridor
• Elevated temperature
• Rapid pulse
• In severe cases, manifestations may progress
to shock, cyanosis, impaired consciousness
• In addition to complete medical history and
physical examination, diagnostic
procedures for croup may include-
• Neck and chest X-ray
• Blood tests, cultures done to rule out
• Pulse oxymetry to find out oxygen
0 1 2
Stridor None Inspiratory Inspiratory
Air entry Normal Decreased Minimal
Retractions None Suprasternal
Color Normal Cyanosis in
1. Monitor and facilitate respiration-
• Monitor respirations for rate and depth
• Observe for signs of respiratory distress
• Keep the child in humid atmosphere to liquefy secretions
• Provide steam inhalation
• Nebulize the child with epinephrine and corticosteroids. Epinephrine
is a short acting bronchodilator which helps in relieving respiratory
congestion and tissue edema. Corticosteroids nebulization has anti
inflammatory action in reducing inflammation
• Cool mist therapy may be provided as it tends to reduce mucosal
• Provide oxygen inhalation for respiratory distress
• Encourage the child to cough and breathe deeply
• Chest physiotherapy and suctioning can be done as advised by
ii. Administer prescribed medications
• In case of bacterial croup, administer antibiotics as prescribed
• Corticosteriods (50-75mg/kg ) can be given for reducing edema
and spasms of croup
iii. Maintain hydration and nutritional requirements
• Assess the hydration status of child
• If the child is unable to take oral feeds and is in shock,
intravenous fluids are given to prevent dehydration
• Clear and high calorie liquids are given orally, as tolerated by
• Maintain strict input and output chart
iv. Promote rest
If the child is apprehensive and crying, his
oxygen demand will increase, so, to
avoid this and conserve child’s energy
following measure are to be taken-
• Provide rest to child in fowlers position,
as this position facilitates better
• Familiar toys should be provided to the
• Mild sedation may be given if the child
is very restless to promote rest and
• Provide quite and restful environment to
v. Support and educate parents
• Keep the parents informed about the condition, progress and
• Allow parents to be with the child
• Reassure parents and involve them in child’s care.
SWALLOWED OR INHALED FOREIGN
• Anyone can swallow a foreign object.
• However, infants and toddlers are more likely to do so
than adults because of their natural curiosity and
tendency to put things into their mouths.
• In many cases, the swallowed object will be processed
by the digestive tract and exit body naturally.
• In other cases, though, the object may get stuck or
cause injuries on the way down.
• If this happens, healthcare provider should be
consulted immediately for treatment—surgery may be
• Toddlers and infants often explore items by
putting them in their nose and mouth.
• A child’s risk of swallowing something
potentially dangerous increases when he or
she is left with little to no supervision.
• Also occurs when children are in reach of
Identification of foreign body
• Foreign body can lodge either In nose or in airway leading to
partial or complete obstruction
• Nasal obstruction-
Signs and symptoms
• Usually, the symptoms of a swallowed foreign
object are hard to miss.
• They often appear immediately, since the item
is blocking the airway.
• The most common symptoms include:
• Physical examination
• If patient was not able to breath properly,
bronchoscopy is used to have detailed
view of airway.
• If coughing effectively, just encourage the child to cough, and
• If coughing is, or is becoming, ineffective, shout for help and
assess the child's conscious level.
• If the child is conscious, give up to five back blows, followed by
five chest thrusts to infants or five abdominal thrusts to children
(repeat the sequence until the obstruction is relieved or the
patient becomes unconscious).
• Establishing a secure and patent airway is
the most important goal in the
resuscitation of a patient with acute UAO.
• Quick history and clinical examination can
help in determining the site of obstruction.
• In the outpatient setting the most common
cause of UAO is obstruction of the larynx
with a foreign body
Guidance for management – foreign body
note : none of these
should be applied if
patient is able to speak or
Finger sweep / grasp
should be done only if
object is visible and will
• Heimlich maneuver is recommended for relief of the airway
obstruction in adults and children one to eight years of age
• Most important management is
medical management which
• Endotracheal intubation (transnasally
• Helium–oxygen mixture
• Surgical intervention which forms the most
important part of treatment in severe
• Fiberoptic intubation
• Diptheria is one of the acute infectious disease
of childhood characterized by local
inflammation of epithelial surface, formation of
membrane and severe toxemia.
• Agent: diptheria is caused by
• Source of infection: secretions and
discharges from an infected person
• Mode of infection: contact with droplets
of infected secretions
• Portal of entry: respiratory tract,
conjuctiva or open wound
• Preschoolers are at higher risk
• Sites affected were- nasal mucosa,
tonsils, pharynx, trachea, conjunctiva and
• Signs and symptoms depends on the site
• It initially resembles cold, may be unilateral or
bilateral, more often unilateral.
• There may be mild fever, nasal discharge
• Careful inspection may reveal a white membrane
on nasal septum
• The affected nostril gets obstructed and leads to
difficulty in breathing
Tonsillar and Pharyngeal Diphtheria
• It is most common clinical variety
• Initially anorexia, malaise, low grade fever, sore throat and
difficulty in swallowing occur
• With in 1-2 days, a white membrane appears on tonsils and
covers pharyngeal walls or progress down into larynx and
• Cervical lymph nodes are enlarged giving an appearance of
• In severe cases there will be respiratory obstruction, circulatory
• It is usually due to extension
of membrane from tonsils and
Common symptoms are-
• Noisy difficulty breathing
• Barking cough
• Hoarseness of voice
• Progressive stridor
• If obstruction is not relieved,
child may develop suffocation
and heart failure
• Based on clinical examination
• Confirmed with isolation of bacteria- Albert’s
• Other lab investigations- WBC count, raised
proteins and cells in CSF
• Diptheria is a serious illness which needs
• The first step is to give antitoxin
• This is followed by antibiotics like
• With the use of antibiotics and vaccines,
diphtheria is not only treatable, but
preventable as well.
• DPT vaccine at 6, 10, 14 weeks for infants
and at 18 months booster dose is given
• Laryngitis is when the voice box or vocal
cords become inflamed from overuse,
irritation, or infection.
• There are two main types of laryngitis: chronic
(long-term) and acute (short-term).
• The inflammation that causes laryngitis can be
tied to a variety of conditions. These include
viral infections, environmental factors, and in
rare cases, bacterial infections.
Causes of acute laryngitis include:
• viral infections
• straining vocal cords by yelling/talking more than normal
• bacterial infections (rare)
Causes of chronic laryngitis include:
• frequent exposure to harmful chemicals or allergens
• acid reflux
• frequent sinus infections
• smoking or being around smokers
• overusing of voice
• low-grade yeast infections caused by frequent use of an
The most common symptoms of laryngitis
• weakened voice
• loss of voice
• hoarse, dry throat
• constant tickling or minor irritation of throat
• dry cough
Laryngoscope is used to visualize the
larynx for diagnosis
Following were the findings for
• lesions on the voice box
• widespread swelling—a sign of
environmental factors behind
• vocal cord swelling only—a sign of
overuse of vocal cords
• If it of viral cause, symptoms will disappear
• If it of bacterial cause treatment of choice is antibiotics
Home remedies for management are-
• drinking lots of fluids
• gargling with salt water
• resting voice
• avoiding screaming or talking loud for long periods of time
• avoiding decongestants (medicines to help clear stuffy noses
by drying out nasal passages), which can dry throat
• sucking on lozenges to keep throat lubricated
• refraining from whispering, which can strain the voice
• Lower airway obstruction is mainly caused
by increased resistance in
the bronchioles (usually from a decreased
radius of the bronchioles) that reduces the
amount of air inhaled in each breath and
the oxygen that reaches the pulmonary
• It is different from airway restriction (which
prevents air from diffusing into the
pulmonary arteries because of some kind
of blockage in the lungs). Diseases that
cause lower airway obstruction are
termed obstructive lung diseases.
(COLD) OR CHRONIC OBSTRUCTIVE
PULMONARY DISEASE (COPD)
• Chronic obstructive lung disease (COPD)
describes a group of lung conditions
(diseases) that make it difficult to empty
the air out of the lungs.
• This difficulty can lead to shortness of
breath (also called breathlessness) or the
feeling of being tired.
• COPD is a word that can be used to
describe a person with chronic bronchitis,
emphysema or a combination of these.
• COPD is a different condition from asthma,
but it can be difficult to distinguish between
COPD and chronic asthma.
• Passive smoking
• Exposure to chemical, air pollution
• Inhalation of smoke
• Hereditary factors
Symptoms of COPD include:
• Constant coughing
• Shortness of breath while doing activities
• Excess sputum production
• Feeling like -can't breathe
• spirometry can detect COPD before
symptoms become severe.
• It is a simple, non-invasive breathing test
that measures the amount of air a person
can blow out of the lungs (volume) and
how fast he or she can blow it out (flow).
• The spirometry reading can help doctor
determine the best course of treatment.
• Bronchodilators to relax the muscles
around airways, to help open them and
make it easier to breathe.
• Inhaled steroids to prevent the airways
from getting inflamed.
• Pulmonary Rehabilitation to help learn
to exercise and manage disease with
physical activity and counseling.
• Oxygen therapy to help with shortness
• Many children with asthma develop symptoms
before age 5.
• There are a number of conditions that can
cause asthma-like symptoms in young
• But if child's symptoms are caused by asthma,
early diagnosis is important.
• Asthma treatment in children improves day-to-
day breathing, reduces asthma flare-ups and
helps reduce other problems caused by
WHAT IS ASTHMA
• Asthma is a condition of chronic swelling of the airways.
• These airways are sensitive to stimulation by a number of
things, such as infection, cold air, exercise, pollens, etc.
• The swelling may produce an obstruction of the airways,
similar to COPD.
• Some people with COPD also have asthma.
• Asthma is a reversible, episodic,
obstructive airway disease caused by
hyperactivity of the bronchial tree to a
variety of stimuli.
• It is the leading cause for school absents
in children under 17 yrs of age
• Onset usually occurs during first five years
• Boys are affected twice as often as girls
• Intrinsic asthma: refers to triggering factors
• Extrinsic asthma: also called as allergic
Some children have few day-to-day symptoms, but have severe
asthma attacks now and then. Other children have persistent
mild symptoms or symptoms that get worse with activity or
other triggers such as cigarette smoke or seasonal allergies.
• If child is an infant, manifestations such as slow feeding or
shortness of breath during feeding were observed.
• If child is a toddler or older, a decreased desire to run and
play due to breathlessness, fatigued easily and cough when
• For many children under age 5, asthma attacks are triggered
or worsened by colds and other respiratory infections. child's
colds last longer than they do in other children, or that signs
and symptoms include frequent coughing that may get worse at
For some children, severe asthma attacks can
be life-threatening and require emergency
room treatment. Signs and symptoms of an
asthma emergency in children under 5 years
• Gasping for air
• Breathing in so hard that the abdomen is
sucked under the ribs
• Trouble speaking because of restricted
• Diagnosing asthma can be tricky in young
• Wheezing, coughing and other asthma-like
symptoms can occur with conditions other
than asthma, such as viral infections.
• For this reason, it may not be possible to
make a definite diagnosis of asthma until
child is older.
• For older children and adults, doctors can
use breathing tests (lung function tests)
such as spirometry or peak flow
• As child gets older, these tests may be
used to help pinpoint on asthma diagnosis
and track how well treatment's working.
• Generally, children under age 5 aren't able
to do these tests.
• doctor may be able to check for
inflammation in child's airways with a test
that measures levels of nitric oxide gas in
• In general, higher levels of nitric oxide
mean child's lungs aren't working as well
as they should be, and asthma isn't under
• The goal of treatment for childhood
asthma are prevention of acute episodes,
maximum control of symptoms and
maintenance of normal growth and
• Medication and adjunct therapies, such as
chest physical therapy, exercise and
counselling are incorporated into the
treatment plan, which is individualized and
based on physiologic and developmental
• Medications are used in the preventive
management of asthma as well as in the
treatment of acute episodes.
• Drug therapy is employed to –
1. Promote bronchodilation
2. Reduce inflammation
3. Remove secretions
Medications may be necessary only when
the child experiences an attack or on a
continuous basis for control in more
severely affected children.
• Theophilline, aminophilline and its
derivatives are effective bronchodilators
frequently used in the management of
• Certain adrenergics such as epinephrine,
isoproteneraol are inactivated in GI hence
they should be administered only through IV
• Corticosteroids helps in relaxing bronchial
smooth muscles and reduces inflammatory
response such as mucosal edema. But these
should be administered to children who fails
to respond for other modalities of treatment
due to their associated side effects.
• Antibiotics are indicated for those with
• Antihistamines are not advised due to their
sedative and drying effects.
• Administration of humidifies oxygen through
nasal cannula to treat hypoxia
• The nursing care of children with asthma
involves comprehensive knowledge of disease
process, medical treatment modalities and
• Skillful assessment and innovative approaches
to assist the child towards optimal respiratory
functioning, growth and social development are
essential elements of care planning.
1. Providing emotional support and
• Child who is experiencing an acute attack
will be frightened, fatigued and
• The child should be addressed calmly
• External stimuli should be reduced to as
much as possible
• For elder children’s all procedure planned
and performing should be explained well
in age appropriate language
• The child in respiratory distress is better
able to breathe in sitting position.
• The child's bed should be raised and back
supported with pillows.
• If the child is more comfortable leaning
forward, a table to lean or a pillow to hug
should be kept available.
3. Evaluating respiratory status
• Nursing assessment of respirations should
be ongoing and documented.
• Frequent assessment for presence of
inspirational and expiration breath
use of accessory muscles for respiration,
the intensity or absence of wheezing
should be checked.
4. Administering Oxygen therapy
• Oxygen therapy - humidified
• Younger children are usually advised to keep
in mist tent
• Bed lines and dressing may required to be
changed frequently, as the cool mist may gets
saturated quickly and chills the child
• Older children are kept on nasal cannula
5. Monitoring intravenous medication
• When intravenous medication therapy is
required, the child must be closely monitored
• A bolus of Theophilline is frequently given on
• The apical pulse, respiratory rate and blood
pressures are taken and recorded every
5mins during the 20 minute bolus.
• Continuous Theophilline therapy is then
delivered by an infusion pump for safety.
• Vital signs needs to be monitored every 2nd
hourly and signs of toxicity needs to be
Supporting family members
• Parents and other family members needs
to be allowed in promoting child’s care.
• Parents should be allowed to verbalize
their feelings and supported with positive
re-inforcement for their care giver abilities.