Pediatric Respiratory Disorders: Bronchitis & Bronchiolitis

Pediatric Respiratory Disorders

Bronchitis & Bronchiolitis

Comprehensive Nursing Education Notes

Introduction

Lower respiratory tract infections are common in childhood and can cause significant morbidity, especially in infants and young children. This guide focuses on two important respiratory conditions: Bronchitis and Bronchiolitis.

While these conditions have similar names and some overlapping symptoms, they affect different parts of the respiratory tract, have distinct pathophysiology, occur in different age groups, and require different nursing approaches.

Key Distinction:

Bronchitis primarily affects the larger airways (bronchi), while Bronchiolitis affects the smaller airways (bronchioles).

Respiratory System Review

Anatomy of the Pediatric Respiratory System

The pediatric respiratory system differs from adults in several important ways:

Smaller airways – More easily obstructed by inflammation or mucus
Immature immune system – More susceptible to infections
Higher metabolic rate – Increased oxygen requirements
Compliant chest wall – More likely to show retractions during respiratory distress
Underdeveloped respiratory muscles – Fatigue more easily during respiratory effort

Key Structures Affected in These Conditions

Structure	Function	In Bronchitis	In Bronchiolitis
Bronchi	Main air passages from trachea to lungs	Primary site of inflammation	May be affected
Bronchioles	Smaller airways, 1mm diameter or less	Minimally affected	Primary site of inflammation
Epithelial Cells	Line airways; contain cilia	Damaged, increased mucus	Necrosis, sloughing
Goblet Cells	Produce mucus	Hyperplasia	Less prominent

Pediatric Bronchitis

Pathophysiology

Bronchitis is characterized by inflammation of the bronchi, the main passageways that carry air to the lungs. In children, this condition leads to:

Inflammation of the bronchial mucosa
Increased mucus production
Epithelial cell damage and ciliary dysfunction
Airway hyperresponsiveness

Initial Infection: Pathogen (usually viral) enters respiratory tract

Inflammatory Response: Immune system activation, neutrophil infiltration

Goblet Cell Hyperplasia: Increased mucus production

Ciliary Dysfunction: Impaired mucus clearance

Cough Reflex Stimulation: Attempt to clear airways

Etiology

Acute Bronchitis: (90-95% cases)

Viral infections: Rhinovirus, RSV, influenza, parainfluenza
Bacterial infections: Less common, may include Mycoplasma pneumoniae, Bordetella pertussis

Chronic Bronchitis: (Less common in children)

Recurrent infections
Environmental irritants (secondhand smoke, pollution)
May be associated with asthma or cystic fibrosis

Clinical Presentation

Cardinal Signs & Symptoms:

Persistent cough (productive or non-productive)
Low-grade fever (usually < 38.5°C)
Chest discomfort or soreness
Fatigue and malaise
Possible sputum production (clear, white, yellow, or green)

Physical Examination Findings:

Crackles or coarse breath sounds on auscultation
Prolonged expiratory phase
Generally normal respiratory rate (may be increased if fever present)
Normal oxygen saturation in most cases

Diagnostic Evaluation

Bronchitis is primarily a clinical diagnosis. Limited testing is needed in most cases.

Common Assessments:

Thorough history and physical examination
Vital signs assessment
Respiratory assessment (rate, effort, auscultation)

Further Testing (If Indicated):

Chest X-ray – Only if pneumonia suspected
Pulse oximetry – If respiratory distress present
Sputum culture – Rarely needed, considered if bacterial infection suspected
Viral testing – Usually not necessary

Management

Important Note:

Antibiotics are generally NOT indicated for bronchitis in children, as most cases are viral in origin.

Supportive Management:

Adequate hydration (oral fluids)
Rest
Antipyretics for fever (acetaminophen or ibuprofen)
Humidity/cool mist to help loosen secretions
Avoidance of smoke exposure

Symptom Management:

Honey for cough in children >1 year (NOT for infants <1 year)
Over-the-counter cough medications not recommended for children <4 years
For older children, cough suppressants only at night if sleep is disturbed

When to Consider Antibiotics:

Suspected Mycoplasma or Bordetella infection
High fever persisting >3 days
Purulent sputum with signs of bacterial infection
Failure to improve after 7-10 days

Nursing Interventions

Assessment:

Monitor respiratory status (rate, effort, oxygen saturation)
Assess hydration status
Monitor temperature and fever pattern
Evaluate cough (frequency, character, productivity)
Assess for signs of respiratory distress

Interventions:

Encourage fluids to maintain hydration
Position for optimal breathing (elevated head of bed)
Administer medications as prescribed
Provide cool mist humidifier
Educate on proper handwashing

Parent Education:

Expected course of illness (1-2 weeks)
Home care instructions
When to seek medical attention
Prevention of spread to other family members
Importance of avoiding smoke exposure

Mnemonic: “BRONCHITIS”

Remember key aspects of pediatric bronchitis assessment and management:

B – Breathing pattern assessment

R – Rest is essential

O – Oxygen saturation monitoring

N – No antibiotics (usually unnecessary)

C – Cough assessment and management

H – Hydration maintenance

I – Inflammation of bronchi

T – Temperature monitoring

I – Irritants avoidance (smoke)

S – Supportive care focus

Prevention

Proper hand hygiene
Avoidance of known sick contacts
Annual influenza vaccination
Avoid exposure to tobacco smoke and air pollutants
Proper nutrition and hydration to support immune function
Prompt treatment of upper respiratory infections

Pediatric Bronchiolitis

Pathophysiology

Bronchiolitis involves inflammation of the bronchioles, the smallest airways in the respiratory tract. The disease process includes:

Viral infection of epithelial cells in the bronchioles
Necrosis and sloughing of infected epithelial cells
Edema and infiltration of inflammatory cells
Increased mucus production and cellular debris
Airway obstruction, air trapping, and atelectasis

Viral Entry: Typically RSV infects upper respiratory epithelium

Spread to Lower Airways: Virus infects bronchiolar epithelium

Epithelial Cell Damage: Cell necrosis and sloughing

Inflammatory Response: Edema, lymphocyte infiltration

Airway Obstruction: Mucus, cellular debris, edema → air trapping

Etiology

Primary Causative Agents:

Respiratory Syncytial Virus (RSV) – Responsible for 50-80% of cases
Human Metapneumovirus
Parainfluenza viruses
Influenza viruses
Adenovirus
Rhinovirus

Epidemiology:

Peak incidence: November to April in Northern Hemisphere
Most common in infants 2-6 months of age
Nearly all children infected with RSV by age 2
Highly contagious – spread through respiratory droplets

Clinical Presentation

Initial Phase (Days 1-2):

Rhinorrhea, nasal congestion
Low-grade fever
Decreased appetite
Mild cough

Progressive Phase (Days 3-5):

Increased respiratory effort
Persistent cough
Tachypnea
Wheezing and/or crackles
Retractions (subcostal, intercostal, suprasternal)
Nasal flaring
Irritability, poor feeding
Possible apneic episodes (especially in young infants)

Physical Examination Findings:

Tachypnea (elevated respiratory rate for age)
Wheezing (often diffuse, bilateral)
Crackles (fine, inspiratory)
Prolonged expiratory phase
Retractions
Hyperinflation
Possible hypoxemia (SpO₂ <95%)

Diagnostic Evaluation

Important Note:

Bronchiolitis is primarily a clinical diagnosis. Routine laboratory or radiographic studies are not recommended for diagnosis.

Core Assessments:

Thorough history and physical examination
Vital signs (respiratory rate, heart rate, temperature)
Oxygen saturation via pulse oximetry
Hydration status assessment
Work of breathing assessment

Additional Testing (When Indicated):

Viral testing (RSV, influenza) – May be useful for cohorting
Chest X-ray – Only if severe disease, atypical presentation, or concern for complication
Blood work – Not routinely indicated
Blood gas – For severe respiratory distress

Evidence-Based Management

Evidence-Based Practice:

According to AAP guidelines, routine use of bronchodilators, corticosteroids, or antibiotics is NOT recommended for bronchiolitis.

Supportive Care (Primary Treatment):

Nasal suctioning to clear secretions
Adequate hydration (oral or IV if needed)
Supplemental oxygen for hypoxemia (SpO₂ <90-92%)
Frequent, small feedings if tolerated
Fever management (acetaminophen or ibuprofen)
Minimal handling/clustering care

Advanced Support (Severe Cases):

High-flow nasal cannula (HFNC) oxygen therapy
Continuous positive airway pressure (CPAP)
Mechanical ventilation (rarely needed)
ICU admission for severe respiratory distress or apnea

Medications (Limited Role):

Bronchodilators – Not routinely recommended, may try as trial if strong bronchospasm
Corticosteroids – Not recommended
Antibiotics – Only for confirmed bacterial coinfection
Hypertonic saline – May be beneficial for hospitalized infants
Ribavirin – Very limited use, only for severe immunocompromised cases

Nursing Interventions

Assessment:

Continuous respiratory assessment using bronchiolitis severity scale
Monitoring of vital signs and oxygen saturation
Assessment of hydration status (intake/output, weight, fontanelle)
Monitor for signs of increasing distress or fatigue
Assessment of feeding tolerance

Interventions:

Nasal suctioning before feeds and as needed
Elevate head of bed 30-45 degrees
Administer supplemental oxygen as needed
Ensure proper positioning for optimal breathing
Support hydration (IV or enteral as appropriate)
Cluster care to minimize oxygen consumption
Implement isolation precautions

Parent Education:

Disease process and expected course (7-14 days)
Proper nasal suctioning technique
Signs of respiratory distress requiring medical attention
Feeding strategies for infants with respiratory distress
Importance of hand hygiene and isolation measures
Home oxygen therapy instructions (if applicable)

Bronchiolitis Severity Assessment Scale

Use this tool to assess severity and guide management decisions:

Parameter	Mild (0)	Moderate (1)	Severe (2)
Respiratory Rate	Normal	Increased	Significantly increased
Retractions	None or minimal	Intercostal	Intercostal + subcostal + suprasternal
Air Entry	Normal	Decreased	Significantly decreased
Wheezing	None or end-expiratory	Entire expiration	Inspiration and expiration
Oxygen Saturation	≥95% on room air	90-94% on room air	<90% on room air
Feeding	Normal	Decreased	Not feeding

Mild: Score 0-3

Consider outpatient management

Moderate: Score 4-8

Consider hospitalization

Severe: Score 9-12

Hospitalize, consider PICU

Mnemonic: “WHEEZES”

Key factors to assess and manage in bronchiolitis:

W – Work of breathing (retractions, nasal flaring)

H – Hydration status assessment

E – Eating/feeding ability

E – Exhalation (prolonged expiratory phase)

Z – Zero unnecessary medications

E – Effort of breathing assessment

S – Suctioning of nasal passages

Prevention

General Preventive Measures:

Strict hand hygiene
Avoid contact with sick individuals
Breastfeeding (provides protective antibodies)
Avoid secondhand smoke exposure
Proper respiratory hygiene/cough etiquette
Cleaning and disinfecting surfaces

Specific RSV Prophylaxis – Palivizumab:

Monthly intramuscular injections during RSV season for high-risk infants:

Premature infants born ≤29 weeks gestation and <12 months of age
Infants with chronic lung disease of prematurity requiring medical therapy
Infants with hemodynamically significant congenital heart disease
Infants with severe immunodeficiency
Children <2 years with neuromuscular disorders affecting respiratory function

Comparison: Bronchitis vs. Bronchiolitis

Feature	Bronchitis	Bronchiolitis
Affected Airways	Larger airways (bronchi)	Smaller airways (bronchioles)
Age Group	All ages, less common in young infants	Primarily infants <12 months (peak 2-6 months)
Primary Etiology	Various viruses (rhinovirus, influenza), occasionally bacterial	RSV (50-80%), other respiratory viruses
Cardinal Symptoms	Persistent cough, possibly productive	Wheezing, increased work of breathing
Physical Exam Findings	Coarse breath sounds, occasional crackles	Wheezing, crackles, retractions, nasal flaring
Typical Duration	7-10 days	7-14 days (peak symptoms days 3-5)
Oxygen Requirement	Rarely needed	Common in moderate to severe cases
Hospitalization Rate	Low	High (1-3% of all infants)
Seasonal Pattern	Year-round, peaks winter	Strong winter/spring seasonality
Primary Management	Supportive care, rarely requires hospitalization	Supportive care, may require respiratory support

Key Nursing Considerations

Assess for age-appropriate respiratory rate and work of breathing
Vital signs monitoring should include respiratory rate, heart rate, temperature, and oxygen saturation
Younger patients (especially infants <3 months) with bronchiolitis are at higher risk for apnea and severe disease
Bronchiolitis typically requires closer monitoring than bronchitis
Dehydration is a common complication in both conditions, especially in young infants
Use appropriate isolation precautions to prevent spread
Family education is essential for both home management and prevention of future episodes

Red Flags Requiring Immediate Attention

Respiratory rate >60 breaths/minute
Severe retractions or grunting
Cyanosis or oxygen saturation <90%
Lethargy or altered mental status
Apnea episodes
Inability to feed or dehydration
Deteriorating condition despite appropriate therapy
High fever (>39°C) in infants <3 months

Respiratory Infections: Mind Map

Bronchitis Process Flow

Causative Agents

Viral pathogens (90-95%)
Bacterial infections (occasionally)
Environmental irritants

Pathophysiology

Irritation of bronchial epithelium
Inflammation of larger airways
Increased mucus production
Ciliary dysfunction

Clinical Manifestations

Persistent cough (productive or non-productive)
Low-grade fever
Chest discomfort
Fatigue
Coarse breath sounds

Management Approach

Supportive care (hydration, rest)
Symptom management
Avoid unnecessary antibiotics
Monitor for improvement (7-10 days)
Parent education for home care

Bronchiolitis Process Flow

Causative Agents

RSV (50-80% of cases)
Human metapneumovirus
Parainfluenza, Influenza
Rhinovirus, Adenovirus

Pathophysiology

Viral infection of bronchiolar epithelium
Epithelial necrosis and sloughing
Inflammatory cell infiltration
Edema of bronchiolar wall
Mucus plugging and debris
Air trapping and atelectasis

Clinical Manifestations

Rhinorrhea → cough → respiratory distress
Wheezing and crackles
Tachypnea and retractions
Nasal flaring
Feeding difficulties
Hypoxemia
Possible apnea (in young infants)

Management Approach

Supportive care
Nasal suctioning
Oxygen supplementation if needed
Careful fluid management
Monitoring respiratory status
Possible hospitalization for severe cases
Respiratory support (HFNC, CPAP if indicated)

Evidence-Based Practice Guidelines

Bronchitis Guidelines

Key recommendations from the American Academy of Family Physicians (AAFP) and other societies:

Diagnosis: Primarily clinical based on history and physical examination
Antibiotics: Generally not recommended for uncomplicated acute bronchitis
Imaging: Chest X-rays not routinely recommended unless pneumonia suspected
Bronchodilators: Not routinely recommended unless wheezing or underlying reactive airway disease present
Cough management: Consider honey for children >1 year of age; avoid cough medications in children <4 years
Parent education: Emphasize expected duration of cough (up to 3 weeks)

Bronchiolitis Guidelines

Key recommendations from the American Academy of Pediatrics (AAP) Clinical Practice Guidelines:

Diagnosis: Clinical diagnosis based on history and physical examination
Testing: Routine viral testing not recommended
Chest X-ray: Not routinely recommended
Bronchodilators: Not recommended for routine use
Corticosteroids: Not recommended
Antibiotics: Not recommended unless bacterial infection confirmed
Hypertonic saline: May be beneficial for hospitalized patients
Suctioning: Nasal suctioning as needed for comfort

Nursing Care Recommendations

Evidence-based nursing interventions for both conditions:

Assessment

Use validated assessment tools appropriate for condition and age
Monitor vital signs, including respiratory rate and oxygen saturation
Assess work of breathing using standardized criteria
Regular hydration status evaluation
Document symptom progression

Interventions

Maintain adequate hydration
Position for optimal breathing
Cluster care to minimize energy expenditure
Nasal suctioning as needed
Maintain appropriate infection control practices
Implement oxygen therapy as indicated

Case Studies for Clinical Application

Case Study: Bronchitis

Patient: 7-year-old male presenting with 4-day history of cough, low-grade fever, and mild chest discomfort. Previously healthy with no significant past medical history.

Assessment Findings:

Temperature: 38.1°C
Respiratory rate: 26 breaths/minute
Heart rate: 98 beats/minute
Oxygen saturation: 97% on room air
Productive cough with clear sputum
Coarse breath sounds on auscultation
No retractions or nasal flaring

Nursing Diagnosis:

Ineffective airway clearance related to increased mucus production
Risk for dehydration related to fever and decreased oral intake
Acute pain (chest discomfort) related to persistent coughing

Nursing Interventions:

Administer antipyretics for fever as ordered
Encourage increased fluid intake
Educate on deep breathing exercises
Provide honey (1-2 tsp) before bedtime for cough (appropriate for age >1 year)
Educate family on expected course of illness
Instruct on importance of hand hygiene

Expected Outcomes:

Improved airway clearance within 3-5 days
Maintained adequate hydration
Reduced frequency of cough within 7 days
Complete resolution of symptoms within 10-14 days
Family demonstrates understanding of home care instructions

Case Study: Bronchiolitis

Patient: 4-month-old female presenting with 2-day history of rhinorrhea, cough, and increased work of breathing. Born at term with no significant past medical history.

Assessment Findings:

Temperature: 38.3°C
Respiratory rate: 58 breaths/minute
Heart rate: 162 beats/minute
Oxygen saturation: 92% on room air
Moderate subcostal and intercostal retractions
Diffuse wheezing on auscultation
Nasal flaring
Decreased feeding (taking only half of normal volume)

Nursing Diagnosis:

Ineffective breathing pattern related to airway inflammation and obstruction
Risk for dehydration related to increased respiratory rate and decreased oral intake
Impaired gas exchange related to airway narrowing and mucus obstruction
Risk for infection transmission related to contagious respiratory virus

Nursing Interventions:

Administer supplemental oxygen to maintain SpO₂ >92%
Perform nasal suctioning before feeds and as needed
Position with head of bed elevated 30°
Monitor vital signs and oxygen saturation every 2-4 hours
Administer small, frequent feedings
Maintain fluid balance with IV fluids if necessary
Implement contact/droplet precautions
Monitor for signs of respiratory fatigue or deterioration

Expected Outcomes:

Maintained oxygen saturation >92%
Decreased work of breathing within 48-72 hours
Improved feeding within 3-5 days
Adequate hydration maintained throughout illness
No spread of infection to other patients
Family demonstrates understanding of home care plan at discharge

Self-Assessment Questions

Test Your Knowledge

1. Which of the following is the most common causative agent of bronchiolitis in infants?

a) Rhinovirus

b) Respiratory Syncytial Virus (RSV)

c) Influenza virus

d) Mycoplasma pneumoniae

Hover for answer: b) Respiratory Syncytial Virus (RSV) causes 50-80% of bronchiolitis cases in infants.

2. Which of the following is NOT typically indicated in the treatment of pediatric bronchitis?

a) Rest

b) Adequate hydration

c) Routine antibiotics

d) Antipyretics for fever

Hover for answer: c) Routine antibiotics are NOT typically indicated as most cases of bronchitis are viral in origin.

3. A 3-month-old infant with bronchiolitis has which of the following clinical findings that would indicate severe disease requiring hospitalization?

a) Respiratory rate of 35 breaths/minute

b) Oxygen saturation of 97% on room air

c) Mild intercostal retractions

d) Oxygen saturation of 89% on room air

Hover for answer: d) Oxygen saturation of 89% on room air indicates significant hypoxemia requiring hospitalization and supplemental oxygen.

4. Which anatomical structure is primarily affected in bronchitis?

a) Bronchioles

b) Alveoli

c) Bronchi

d) Trachea

Hover for answer: c) Bronchi (the larger airways) are primarily affected in bronchitis.

5. Which nursing intervention is NOT appropriate for an infant with bronchiolitis?

a) Nasal suctioning before feeds

b) Honey for cough suppression

c) Elevation of the head of bed

d) Small, frequent feedings

Hover for answer: b) Honey is contraindicated in infants under 12 months of age due to risk of infant botulism.

6. Which of the following is a key distinguishing feature between bronchitis and bronchiolitis?

a) Presence of wheezing

b) Age of affected patients

c) Viral etiology

d) Need for antipyretics

Hover for answer: b) Age is a key distinguishing feature. Bronchiolitis primarily affects infants <12 months, while bronchitis can affect children of all ages.

References

American Academy of Pediatrics. (2014). Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics, 134(5), e1474-e1502.
American Academy of Family Physicians. (2016). Diagnosis and Treatment of Acute Bronchitis. American Family Physician, 94(7), 560-565.
Ralston, S. L., Lieberthal, A. S., Meissner, H. C., et al. (2014). Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics, 134(5), e1474-e1502.
The Royal Children’s Hospital Melbourne. (2022). Clinical Practice Guidelines: Bronchiolitis. Retrieved from https://www.rch.org.au/clinicalguide/guideline_index/Bronchiolitis/
Cincinnati Children’s Hospital Medical Center. (2022). Evidence-based clinical practice guideline for medical management of bronchiolitis in infants less than 1 year of age presenting with a first time episode.
Friedman, J. N., Rieder, M. J., & Walton, J. M. (2014). Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age. Paediatrics & Child Health, 19(9), 485-491.
Kinkade, S., & Long, N. A. (2016). Acute Bronchitis. American Family Physician, 94(7), 560-565.
Meissner, H. C. (2016). Viral Bronchiolitis in Children. The New England Journal of Medicine, 374(1), 62-72.
Smith, D. K., Seales, S., & Budzik, C. (2017). Respiratory Syncytial Virus Bronchiolitis in Children. American Family Physician, 95(2), 94-99.
Zorc, J. J., & Hall, C. B. (2010). Bronchiolitis: Recent Evidence on Diagnosis and Management. Pediatrics, 125(2), 342-349.