Pediatric Respiratory: RSV/Bronchiolitis, Croup, Epiglottitis, Asthma (Pediatrics)

Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current references.

1. Overview

Children’s airways are small, so swelling or mucus causes big resistance. Upper airway problems (croup, epiglottitis) cause (high-pitched sound on inspiration). Lower airway problems (bronchiolitis, asthma) cause wheezing, crackles, and prolonged expiration.

Respiratory distress → failure progression: tachypnea, retractions, nasal flaring → grunting, head bobbing, tripod position → fatigue, slowing RR, decreased breath sounds (“silent chest”), lethargy, cyanosis = impending respiratory arrest.

2. Comparison Table

Feature	(often RSV)	(laryngotracheobronchitis)		Asthma
Age	< 2 yr (peak 2–6 mo)	6 mo – 3 yr	Classic 2–7 yr (now rare with Hib vaccine; can occur in any age)	Any; often school-age
Cause	Viral (RSV most common) — inflammation + mucus in bronchioles	Viral (parainfluenza) — subglottic swelling	Bacterial (historically H. influenzae type b)	Chronic airway inflammation, bronchospasm, triggers
Onset	Cold symptoms for 2–3 days → cough, wheeze, distress (peaks days 3–5)	Gradual cold → barky “seal” cough at night, hoarseness, inspiratory stridor	Sudden: high fever, toxic appearance	Episodic; triggers
Key signs	Copious nasal secretions, wheeze/crackles, tachypnea, retractions, poor feeding, apnea in young infants	Barky cough, stridor (at rest = more severe), low-grade fever	4 Ds: Drooling, Dysphagia, Dysphonia, Distress; tripod, muffled voice, no cough	Wheeze (expiratory), cough (often at night), chest tightness, prolonged expiration
Priority	Nasal suctioning, oxygen, hydration	Calm child, humidified air, steroids, racemic epinephrine	Airway emergency — don’t examine the throat	Bronchodilator, steroids, O₂

3. Bronchiolitis / RSV

Diagnosis is clinical (AAP guideline). Viral testing, chest X-ray, and routine labs are not usually needed
Nursing: nasal suction (bulb or nasal aspirator) before feeds and as needed — infants are nose breathers; humidified oxygen if SpO₂ persistently below target (often < 90%); hydration (small frequent feeds; IV or NG fluids if unable to feed); elevate head of bed; cluster care; monitor for apnea (especially < 2 mo, preterm)
Not recommended routinely: albuterol, epinephrine, steroids, antibiotics, chest physiotherapy
High-flow nasal cannula or CPAP for worsening distress
Contact + droplet precautions per facility (RSV spreads on hands and surfaces; survives hours) — hand hygiene; same nurse not assigned to immunocompromised patients
Prevention: hand washing, avoid smoke exposure, breastfeeding; per CDC, protect infants with either a maternal RSV vaccine during pregnancy or an RSV monoclonal antibody (nirsevimab or clesrovimab) for the infant — most infants don’t need both. Check current CDC guidance

4. Croup

Westley croup score rates severity (stridor, retractions, air entry, cyanosis, LOC)
Keep the child calm — crying worsens obstruction. Parent holds the child; avoid unnecessary procedures
Dexamethasone (single oral/IM/IV dose) reduces swelling for mild to severe croup
Racemic (nebulized) epinephrine for moderate–severe (stridor at rest): rapid relief, but observe ~2–4 hours for rebound symptoms
Cool mist or night air may soothe, but evidence is weak; humidified oxygen if hypoxic
Home teaching: when to return — stridor at rest, retractions, drooling, cyanosis, can’t drink, lethargy

5. Epiglottitis — Airway Emergency

Do NOT inspect the throat with a tongue depressor or take a throat culture — it can trigger complete laryngospasm/obstruction
Keep the child upright in a position of comfort (often on parent’s lap, tripod); don’t force them to lie down
Keep calm; avoid painful procedures (IV, lab draws) until the airway is secured
Have intubation and tracheostomy equipment at the bedside; the airway is secured by an experienced team (often in the OR)
IV antibiotics (e.g., third-generation cephalosporin) after the airway is secure; steroids may be used
Prevention: Hib vaccine. Droplet precautions until 24 h of antibiotics

6. Pediatric Asthma

Pathophysiology: chronic airway inflammation + bronchoconstriction + mucus/edema → reversible airflow obstruction. Triggers: viral infections, allergens (dust mites, pets, mold, pollen, cockroaches), smoke, cold air, exercise, stress, pollution.

Assessment: wheeze, cough, tachypnea, retractions, prolonged expiration, accessory muscle use, ability to speak (sentences → phrases → words), peak expiratory flow (compare with personal best; ≥ ~5 yr), SpO₂.

Zone (asthma action plan)	Peak flow (% personal best)	Action
Green	80–100%	Daily controller as prescribed
Yellow	50–79%	Use quick-relief inhaler; follow plan; call provider if not improving
Red	< 50%	Quick-relief now; seek emergency care

Medications:

Class	Examples	Nursing points
SABA (rescue)	Albuterol	Tachycardia, tremor, jitteriness, hypokalemia. Increased use = poor control
Inhaled corticosteroids (controller)	Fluticasone, budesonide	Rinse mouth after (thrush); use spacer; growth effects minimal at usual doses — monitor
ICS-formoterol	Budesonide-formoterol	Some plans use one inhaler for both control and relief (SMART) in children ≥ ~4 yr per guidelines
Leukotriene modifier	Montelukast	FDA boxed warning: neuropsychiatric effects (mood changes, suicidal thoughts, nightmares) — teach families
Systemic corticosteroids	Prednisolone, dexamethasone	Short course for exacerbations; ↑ glucose, mood changes
Anticholinergic	Ipratropium	Added to SABA in the ED for moderate–severe exacerbation
Magnesium sulfate IV	—	Severe exacerbation not responding
Biologics	Omalizumab, dupilumab, etc.	Severe persistent asthma; watch for anaphylaxis

Inhaler with spacer/valved holding chamber (with mask for young children) is as effective as a nebulizer for most exacerbations.

Status asthmaticus (emergency): severe distress not responding to rescue meds. “Silent chest” (little air movement) is ominous — the child is too tight to wheeze. Upright position, oxygen, continuous/back-to-back SABA + ipratropium, systemic steroids, IV magnesium, prepare for possible ventilation; rising or “normal” CO₂ in a breathless child signals fatigue.

7. Diagnostics (ranges vary)

SpO₂, work of breathing scores, RR trends
Chest X-ray only if complications suspected; “steeple sign” on neck X-ray = croup; “thumb sign” lateral neck = epiglottitis (don’t delay airway care for imaging)
Viral panels as needed for cohorting; blood gases in severe distress
Spirometry/peak flow for asthma in older children

8. Education

How to use nasal suction and saline drops; hydration signs (wet diapers)
Return precautions: retractions, grunting, flaring, pauses in breathing, blue color, not drinking, fewer wet diapers, lethargy
Asthma: action plan, trigger avoidance, correct inhaler/spacer technique, controller daily even when well, school plan, influenza and other recommended vaccines, smoke-free home and car
Avoid OTC cough/cold medicines in young children (FDA advises against in < 2 yr; manufacturers label not for < 4 yr)

9. Memory Aids

Bronchiolitis = “Suck, Sat, Sip” — suction, oxygen if needed, hydration
Croup = “Bark like a seal at night”; Epiglottitis = “4 Ds, no tongue blade”
Stridor = upper; wheeze = lower
“Silent chest is a scary chest”
Asthma zones like a traffic light: Green go, Yellow caution, Red stop and get help
Steroid inhaler? “Rinse and spit.”

10. NCLEX-Style Practice Questions

1. A 4-year-old has a sudden fever of 39.8 °C, drooling, a muffled voice, and sits leaning forward. Which action should the nurse avoid?

A. Keeping the child on the parent’s lap
B. Using a tongue depressor to look at the throat
C. Having emergency airway equipment ready
D. Notifying the provider immediately

Answer: B. These are classic signs of epiglottitis. Examining the throat can trigger total airway obstruction. Keep the child calm and upright and prepare for airway management.

2. A 3-month-old with RSV bronchiolitis has thick nasal secretions, RR 64, and is feeding poorly. What is the best first nursing action?

A. Give albuterol by nebulizer
B. Suction the nose with saline before feeding
C. Hold all feeds and start antibiotics
D. Perform chest physiotherapy

Answer: B. Infants are nose breathers; nasal suction improves breathing and feeding. Albuterol, antibiotics, and chest physiotherapy are not routinely recommended for bronchiolitis.

3. A child received racemic epinephrine for croup and now has no stridor at rest. The parent asks to go home. What is the best response?

A. “Yes, the treatment has cured the croup.”
B. “We need to observe for a few hours because symptoms can come back.”
C. “Your child will need to be admitted for a week.”
D. “Your child should start antibiotics at home.”

Answer: B. Racemic epinephrine works quickly but wears off in about 2 hours, so a rebound can occur. Observation (commonly 2–4 h) is needed. Croup is viral; antibiotics (D) don’t help.

4. A 9-year-old in an asthma exacerbation was wheezing loudly. Now the wheezing has stopped, breath sounds are faint, and the child is drowsy. What does this indicate?

A. Improvement — the bronchodilator worked
B. Impending respiratory failure
C. The child is falling asleep from relief
D. A normal response to steroids

Answer: B. A “silent chest” with drowsiness means very little air is moving and the child is tiring. This is an emergency — call for help and escalate care.

5. Which teaching points are correct for a child prescribed fluticasone and albuterol inhalers? Select all that apply.

A. Rinse the mouth after using fluticasone
B. Use albuterol for quick relief of symptoms
C. Stop fluticasone once symptoms go away
D. Use a spacer to improve medication delivery
E. Report needing albuterol more often than usual

Answer: A, B, D, E. Fluticasone is a controller taken daily even when well (C is wrong); rinsing prevents thrush. Increasing rescue-inhaler use signals poor control.

References

Centers for Disease Control and Prevention. (2026). RSV in infants and young children. https://www.cdc.gov/rsv/infants-young-children/index.html

Erickson, E. N., Bhakta, R. T., Tristram, D., & Mendez, M. D. (2025). Pediatric bronchiolitis. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519506/

Kadam, S. J., Daley, S. F., & Carr, B. (2025). Croup. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK431070/

Lizzo, J. M., Goldin, J., & Cortes, S. (2024). Pediatric asthma. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK551631/

Ralston, S. L., Lieberthal, A. S., Meissner, H. C., Alverson, B. K., Baley, J. E., Gadomski, A. M., Johnson, D. W., Light, M. J., Maraqa, N. F., Mendonca, E. A., Phelan, K. J., Zorc, J. J., Stanko-Lopp, D., Brown, M. A., Nathanson, I., Rosenblum, E., Sayles, S., III, & Hernandez-Cancio, S. (2014). Clinical practice guideline: The diagnosis, management, and prevention of bronchiolitis. Pediatrics, 134(5), e1474–e1502. https://doi.org/10.1542/peds.2014-2742

Sutton, A. E., & Waseem, M. (2024). Epiglottitis. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430960/