Lower respiratory tract infection: BRONCHITIS, BRONCHIOLITIS, PNEUMONIA IN CHILDREN, ASTHMA IN CHILDREN: INTRODUCTIO, DEFINITION, CAUSES, PATHOPHYSIOLOGY, MANAGEMENT, NURSING DIAGNOSIS.

1. LOWER
RESPIRATORY
TRACT INFECTION

3. BRONCHITIS DEFINITION
It is defined as inflammation of one or more bronchi that is
characterized by dry cough ( which is worst at night ) and
wheezing.

4. Incidence and etiology
Especially in children less than 4 years of age usually associated
with previous URI.
Acute bronchitis may be bacterial or viral in origin.
Viral infection: adenovirus, RSV, Rhinovirus
Bacterial infection: mycoplasma pneumoniae
Chemical agents/ allergens: dust, allergens, strong fumes etc.

5. Clinical features
• Runny nose
• Malaise
• Chills
• Fever
• Back and muscle pain
• Sore throat
• Wheezing
• Shortness of breath
• Fatigue
• Coughing

6. Diagnostic evaluation
• History and physical examination
• X ray
• Sputum culture

7. Management
• Antibiotics: in case of the bacterial infection and to prevent
secondary infection.
• Cough expectorant : An expectorant to loosen and thin mucus
so it can be more readily discharged.
• Antipyretics medicines: if the child is suffering from the fever
• Steam inhalation
• Nebulization can be done with normal saline or
bronchodilators.
• Broncodilators: these will open the bronchial tubes and clear
out mucus. E.g.: salbutamol, salmeterol
• Mucolytics: these will thin and loosen the mucus in the airway.
E.g. : Guaifenesin
• Anti-inflammatory medicines

8. BRONCHIOLITI
S

9. INTRODUCTION
Bronchiolitis is lower respiratory tract infection caused by viral
infection mainly and is seasonal, peaking in winters.
The major cause of the bornchiolitis is RSV ( respiratory
synticial virus)

10. Definition
• Bronchiolitis is a serious illness characterized by inflammation
of bronchioles, causing sever dyspnea.
• Common under infant under age of 6 months.
• Common in winter and early spring.
Viral: RSV, adenovirus , influenza virus.
Bacteria: influenzae, pneumococcus and streptococcus
hemolyticus
Incidence and etiology

11. Pathophysiology
Hypoxemia
Normal exchange of gases is impaired
Atelectasis can occur when obstruction is complete
Bronchioles constrict during expiration, causing hyperinflation of lungs
Edema, mucus and cellular debris obstruct bronchioles
Upper respiratory infection usually by RSV

12. Clinical manifestations
• Dyspnea
• Nasal flaring
• Cyanosis
• Intercoastal, subcoastal. supracoastal retractions
• Diminished breath sounds
• Crackles sound
• Wheezing

13. • History and physical examination.
• Chest x ray: shows areas of collapse.
• Pulse oxymetry should be recorded on all patients.
• Cultures may be performed if sepsis suspected
• Blood gases may be useful if advanced respiratory
support is being considered.
Clinical manifestations

14. MANAGEMENT
• Children with less severe symptoms: antipyretics, adequate
hydration.
• Hospitalization is warranted for children on severe distress:
oxygen therapy, critical monitoring of vital signs and blood gas
level and ventilatory support be necessary.

15. Management
Supportive Management
• Oxygenation: aim to keep oxygen saturation > 92%. •
humidified head box oxygen should be used if physically
possible.
• Apnoea Monitoring
• Feeding: intravenous fluids should be reserved for severe
illness with severe respiratory distress or when nasogastric
feeds are not tolerated.
• Nebulised Hypertonic Saline: 4ml of 3% sodium chloride &
2.5mg salbutamol eight hourly via nebuliser can be given.
• Bronchodilators: salbutamol, ipratropium should be
administered to dilate the bronchioles.
• Inhaled / Oral Corticosteroids can be administered to relieve

16. Nursing diagnosis
Ineffective airway clearance related to Increased mucus and nasal
discharge
Interventions:
• Assess airway for patency.
• Assess breath sounds by auscultation.
• Monitor the vital signs: SP02, temperature, respiratory rate, pulse
rate.
• Elevate head of bed : semi fowlers position.
• Encourage fluid intake at frequent intervals over 24-h time periods.
• Assist to perform deep breathing and coughing exercises in child.
• Nebulization should be done as prescribed by the dr.
• Administer oxygen as prescribed.
• Administer medication as prescribed by the dr. : antipyretic,
bronchodilaters, antibiotics

17. Cont….
Ineffective breathing pattern related to Increased mucus and
nasal discharge
Impaired gas exchange related to Hypoxemia.
Disturbed sleep pattern related to difficulty in breathing.
Knowledge deficit related to treatment and prognosis about
the diseases.

18. PNEUMONIA IN
CHILDREN

19. Definition
An inflammation of the
lung parenchyma (the
respiratory bronchioles
and the alveoli) is known
as Pneumonia”.
Pneumonia is mainly
caused by microorganisms
which enter the lower
respiratory system and
cause infection. The
microorganism includes
bacteria, mycobacteria,
mycoplasma, fungi,
parasites, and viruses.

20. CLASSIFICATION
According to the causative organisms
• Viral pneumonia :- Rhinovirus, coronaviruses, influenza virus,
respiratory sncytial virus(RSV), adenovirus and parainfluenza.
• Bacterial pneumonia: it may be caused by pneumococcus,
streptococcus, staphylococcus etc.
• Fungal pneumonia :- Fungal pneumonia caused by
histoplasmosis , blastomycosis, candidiasis.
• Parasitic pneumonia :- Parasitic pneumonia (caused by
protozoa, nematodes, platyhelminthes); common organism is
Pneumocystis (carinii).

21. Cont…
• According to the areas of the lung involved/affected
• Lobar pneumonia
• Multilobar pneumonia
• Bronchial pneumonia
• Interstitial pneumonia

22. Cont…
• Miscellaneous types:
• Aspiration pneumonia: it is caused by aspiration of amniotic
fluid, food etc.
• Loffler’s pneumonia: it is a kind disease in which eosinophils
accumulates in lungs in response to parasitic infection.
• Hypersensitivity pneumonitis: it is an inflammation of alveoli
within the lungs caused by hypersensitivity to inhaled drugs.
• Hypostatic pneumonia: it results from collection of fluid in
dorsal region of lungs and occurs in bed ridden patient.

23. Pathophysiology
Causing difficulty in breathing, tachypnea, retractions
Consolidation occur
Pus or fluid is filled in air sac
Destruction of parenchymal tissue
Inflammation of air sac or mucous membrane of small bronchioles or interstial tissue
Agent destroy mucous membrane and causes interstial lesions.
Due to etiological conditions , infection, bacteria enters the respiratory tract and travels down.

24. CLINICALMANIFESTATION
Late symptoms:
Convulsions
Drowsiness
Chest indrawing
Wheezing
Hoarsness of voice
Cyanosis
Pleural pain: referred to
shoulder and abdomen.
• Fever with chills
• Cough with thick sputum
• Tachypnea
• Anorexia
• Nasal flaring
• Malaise
• Irritability
• Running nose
• Grunting

25. Diagnostic evaluation
1. History of the child
2. Chest x-ray: patchy consolidation can be seen
3. Culture of sputum: shows causative organisms.
4. Blood test: increased WBC
5. Bronchoscopy
6. Pleural fluid culture
7. Pulse oximetry
8. CT-scan

26. Management
Mild cases: some children with no retractions are treated at
home with:
1. Antipyretics
2. Bed rest
3. Adequate diet and fluid intake
4. Propped up position
In severe cases: hospitalization is required:
1. Initiation of antibiotics
2. Comfortable position
3. Oxygen inhalation
4. Adequate diet and fluid intake

27. Management
1. Pneumonococcal pneumonia Penicillin
2. Pneumonia by klebsiella and haemophilus Cephalosporin,
amoxicillin and
clavulanic acid
3. Mycoplasm pneumonia Erythromycin,
clarithromycin,
azithromycin
4. Anti fungal therapy Amphotericin
Flucanozole
sulphonamides

28. Supportive care
• Antipyretics (paracetamol 10- 15mg/kg/dose every 4-6hrs.
• Oxygen administration (oxygen hood, mask, nasal prongs)
• Hydration: Provide adequate fluid to meet the increased needs
of the body.
• Chest physiotherapy
• Nutrition:
1. Give high caloric and liquid diet.
2. And if the client is having breathing difficulty do not give
any feed as there are chances of aspiration is more.

29. Nursing care
• Assessment of a child and determine the causative organism.
• Control of fever : antipyretics and tepid sponging.
• Maintain patent airway
• Provision of high humidified oxygen.
• Positioning : semi fowlers position
• Monitor respiratory status and vital signs.
• Administration of antibiotics as prescribed by the dr.
• Promotion of rest
• Provision of appropriate and adequate fluids and nutrition
• Support and education to parents
• Prevention of complication.

30. Nursing diagnosis
• Ineffective airway clearance related to inflammation and
accumulations of secretions as evidenced by cough with sputum
productions.
• Impaired gas exchange related to alveolar capillary membrane
changes as evidenced by tachycardia and restlessness.
• Hyperthermia related to inflammatory process as evidenced by
increased body temperature.
• Risk for fluid volume deficit related to inadequate oral intake,
fever, as evidenced by poor skin turgor.
• Imbalanced nutrition less than body requirement related to
disease condition as evidenced by refusal of food by child.

31. Cont….
• disturbed Sleeping pattern related to hyperthermia and cough as
verbalized by mother’s concern for rest and sleep.
• Knowledge deficient about the conditions, prognosis, and
treatment of pneumonia as evidenced by less knowledge about
pneumonia management.

32. ASTHMA IN
CHILDREN

33. Definition
• Asthma is defined as a reversible, characteristized by an increased
responsiveness of the airways to various stimuli, manifest by wide
spread narrowing of the airways causing paroxysmal dyspnea, cough
and wheezing.
• Basically, Any of these stimuli can trigger a hyperactive allergic
response which produces:
1. Inflammation of the respiratory tract
2. Bronchoconstriction, and
3. Hypersecretion of mucus
• Asthma is a chronic inflammatory disorder of the airways
characterized by recurring symptoms, airway obstruction, and
bronchial hyperresponsiveness (National Asthma Education and

34. Etiology
Extrinsic asthma Intrinsic asthma
Also called as allergic asthma: in this
the symptoms are induced by the
hyper-immune response to the
inhalation of a specific allergen like
pollen, dust, smoke, powder
Non allergic asthma refers to same
manifestations of airway obstruction
but in response to an unidentified or
non specific factor in the environment.
Can be triggered by:
1. Exercise
2. Aspirin
3. Change in temperature
4. Viral respiratory infection
5. Emotional stress
6. Excitement

35. Pathophysiology

37. Clinical manifestation
• Wheezing
• Dyspnea
• Cough
• Retractions
• Nasal flaring
• Stridor
• Tachypnea
• Restlessnesss
• Abdominal pain
• Fatigue due to shortness of breath
• Cyanosis

38. Diagnostic evaluations
History taking
• Family history
• Passive cigarettes, smoking
• Exposure to triggering factors
• Socio-economic status
• Stressful condition
Physical examination
Sputum culture
Chest x-ray: shows air trapping
Blood examination shows eosinophilia
Pulmonary function test: Pulmonary function tests (PFTs) are
noninvasive tests that show how well the lungs are working.
The tests measure lung volume, capacity, rates of flow, and gas exchange.
RAST test or radioallergosorbent test

39. Management

40. Medical management
• Short acting bronchodilators: causes
relaxation of bronchiol smooth muscle.
E.g.: albuterol,terbutaline
• Anticholinergic: ipratropium bromide
• Mast cell inhibitors: cromolyn
sodium: an NSAIDS prevents asthma
by blocking of mast cell mediators.
• Corticosteroids: prednisolone
decreases airway inflammation.
• Leukotriene blockers: zileuton
diminish the mediator action of
leukotrienes.
• Antibiotics
• Oxygen therapy: oxygen can be
administered through oxygen masks
and cannula.

41. Cont…
• Magnesium sulphate: IV administration of drug have shown
bronchodilating effect.
• Heliox: a mixture of helium and oxygen can be given in case of
breathing difficulty.
• Methylxanthines: such as theophylline: it works by relaxing
the muscles around the airway.

42. Nursing management
• Nursing assessment: history and physical examination.
Ineffective airway clearance related to bronchospasm and
mucosal edema.
• Monitor respiratory rate, effort, color, heart rate.
• Administer humidified oxygen at ordered flow rate.
• Nebulization with normal saline or bronchodilaters.
• Positioning: upright position
• Keep NPO if respiratory distress is there.
• Maintain IV line.
• Administer medication as prescribed.

43. Nursing diagnosis
• Ineffective Airway Clearance related to bronchoconstriction,
increased mucus production, ineffective cough, possible
bronchopulmonary infection.
• Ineffective Breathing Pattern related to chronic airflow
limitation.
• Impaired Gas Exchange related to chronic pulmonary
obstruction abnormalities due to destruction of alveolar
capillary membrane.
• Risk for Infection related to compromised pulmonary function,
retained secretions, and compromised defense mechanism.

44. • Imbalanced Nutrition: Less Than Body Requirements related to
increased work of breathing, air swallowing, drug effects with
resultant wasting of respiratory and skeletal muscles.
• Activity Intolerance related to compromised pulmonary
function, resulting in shortness of breath and fatigue.
• Disturbed Sleeping Pattern related to hypoxemia and
hypercapnia.