NCLEX-RN® Pediatric Respiratory Disorders: Croup, Epiglottitis, RSV, Asthma, and CF
Pediatric respiratory content for the NCLEX-RN®: differentiating croup from epiglottitis, RSV precautions, pediatric asthma management, and cystic fibrosis nursing priorities.
The big picture
Pediatric respiratory conditions are among the most tested disorders in the Physiological Integrity section for pediatric content on the NCLEX-RN®. Children are especially vulnerable to respiratory problems because of their small airway diameters — even 1 mm of mucosal swelling can reduce airflow by 75% in an infant. The nurse's priority is always recognizing distress early and acting before complete obstruction occurs.
Respiratory assessment in children — knowing distress
Signs of respiratory distress in children (escalation triggers)
| Sign | Clinical significance |
|---|---|
| Nasal flaring | Increased work of breathing — early sign |
| Grunting | Glottic closure to maintain PEEP — serious distress in infants |
| Retractions (intercostal, subcostal, supraclavicular, sternal) | Accessory muscle use — moderate to severe distress |
| Tachypnea (RR above normal for age) | Most sensitive early indicator |
| Tripod position | Child leans forward on hands — maximizes airway patency |
| Stridor | Audible inspiratory noise — upper airway obstruction |
| Head bobbing (infants) | Sternocleidomastoid use — severe distress in infants |
| SpO₂ < 92% | Hypoxia — requires immediate oxygen |
| Cyanosis | Late and critical sign — immediate intervention |
NCLEX® rule: In pediatric respiratory distress, act before cyanosis develops. Cyanosis is a late, serious sign. Tachypnea + retractions = distress → O₂ + provider notification now.
Croup (laryngotracheobronchitis)
What it is: Viral inflammation of the larynx, trachea, and bronchi. Most common cause of upper airway obstruction in children 6 months–3 years. Peak in fall and winter.
Cause: Parainfluenza virus (most common), RSV, influenza.
Presentation:
- Barky "seal" cough — the hallmark
- Inspiratory stridor
- Hoarseness
- Preceded by 1–2 days of URI symptoms
- Low-grade to moderate fever
- Child appears ill but not toxic; not drooling
Croup management
| Severity | Treatment |
|---|---|
| Mild (barky cough, no stridor at rest, no retractions) | Cool mist humidifier; take outside into cold night air; reassure |
| Moderate (stridor at rest, mild retractions) | Oral or IM dexamethasone; supplemental O₂ if needed |
| Severe (significant retractions, O₂ sat dropping, agitation) | Racemic epinephrine nebulized + dexamethasone; observe 3–4 hours minimum for rebound — rebound stridor can occur after racemic epinephrine wears off |
Key nursing teaching: Teach caregivers that cool, humid air often relieves symptoms. Running a hot shower (steam from bathroom) or going outside into cool night air can break a croup attack. Return to the ER if stridor is present at rest, child is not improving, or O₂ drops.
After racemic epinephrine: The effect wears off in 2 hours. Child must be observed in the ED for 2–4 hours to ensure stridor does not rebound before discharge.
Epiglottitis
What it is: Bacterial infection causing rapid, life-threatening swelling of the epiglottis. Rare since the Hib vaccine but still occurs in unvaccinated children and adults.
Cause: Haemophilus influenzae type B (most common before vaccine); now also Streptococcus and others.
Presentation:
- Sudden, rapid onset — distinguishes it from croup
- High fever (rapid rise)
- Drooling (unable to swallow)
- Muffled "hot potato" voice
- Tripod position (leaning forward, jaw thrust, hands on knees)
- Toxic-appearing child — severely ill, anxious, quiet
- Stridor (may be present)
What NOT to do — critical NCLEX® content
Do NOT:
- Examine the throat with a tongue blade or anything else — this can trigger complete obstruction
- Attempt IV access, blood draws, or any painful procedure while the child is unsedated
- Lay the child flat
- Separate the child from parents
- Leave the child alone
Do:
- Keep the child calm, in position of comfort, with parent present
- Oxygen via blow-by if tolerated (do not force a mask that distresses the child)
- Call provider immediately — this is an airway emergency
- Have emergency airway equipment at the bedside (laryngoscope, ETT, bag-valve-mask)
- Prepare for intubation in the OR by ENT and anesthesia
Respiratory syncytial virus (RSV)
What it is: The most common cause of bronchiolitis in infants and lower respiratory tract infections in children under 2 years. Peak season: November–March.
Bronchiolitis: Viral inflammation of the small bronchioles causing air trapping, hyperinflation, and wheezing.
Assessment findings
- Begins as URI (nasal congestion, mild fever, cough)
- Progresses to: wheezing, expiratory crackles, tachypnea, retractions
- Infants may develop apnea (especially premature infants < 44 weeks post-conceptual age)
- Prolonged expiratory phase
- Poor feeding — respiratory effort prevents coordinated suck-swallow
RSV management (mostly supportive)
| Intervention | Purpose |
|---|---|
| Nasal suctioning (bulb or low suction) | Infants are obligate nasal breathers — clear the nose before feeding and sleep |
| Small frequent feedings or NG tube if cannot coordinate | Maintains nutrition without exhausting infant |
| Supplemental O₂ | For SpO₂ < 92–94% |
| IV or NG fluids if not tolerating oral | Hydration |
| Positioning | Head of bed elevated (30–45°); infant seat |
No proven benefit: Bronchodilators (albuterol) are not routinely recommended for RSV bronchiolitis — evidence does not support routine use. Antibiotics are ineffective (viral cause).
RSV prevention — major 2023–2024 updates (high-yield)
Nirsevimab (Beyfortus) — now first-line for most infants: A single-dose RSV monoclonal antibody approved in 2023. Recommended by CDC/ACIP for all infants entering their first RSV season (not just high-risk). Has largely replaced palivizumab for most infants due to its convenience (one dose vs. monthly) and broader indication.
Maternal RSV vaccine (Abrysvo): FDA-approved August 2023. Given to pregnant people at 32–36 weeks gestation to transfer RSV antibodies to the fetus. Provides passive protection to newborns through the first RSV season.
Palivizumab (Synagis) — RSV prophylaxis (high-risk infants only)
Monthly IM injection during RSV season — now reserved for specific high-risk groups where nirsevimab is unavailable or insufficient:
- Premature infants < 29 weeks gestational age (current guidance; the old < 35-week threshold is outdated)
- Infants with chronic lung disease of prematurity or haemodynamically significant congenital heart disease
It reduces severity but does not prevent RSV entirely. It is not a vaccine — it provides passive immunity.
Asthma in children
Asthma is the most common chronic disease of childhood. The same pathophysiology as adult asthma (bronchospasm + inflammation) applies.
Pediatric-specific NCLEX® points
Triggers in children: Respiratory infections (most common trigger in children vs. allergens in adults), exercise, cold air, emotional stress, smoke, pet dander.
Step therapy: NAEPP guidelines recommend stepping up or down based on control:
- Step 1 (mild intermittent): SABA PRN only
- Step 2 (mild persistent): Low-dose ICS daily + SABA PRN
- Step 3–5: Adding LABAs, higher-dose ICS, or biologics
Spacer use — critical teaching for NCLEX®
Children < 5 years cannot coordinate breathing with an inhaler. Spacers (valved holding chambers) are required for all children using MDIs. Spacers allow the medication to be inhaled slowly without timing a single breath with the puff.
Teach:
- Shake inhaler and insert into spacer
- Child puts mouth around spacer mouthpiece (seal with lips)
- Press the inhaler once
- Breathe in slowly and deeply over 3–5 seconds; hold 10 seconds
- Wait 60 seconds between puffs
Peak flow meter monitoring
Children ≥ 5 years can use a peak flow meter to objectively assess airway obstruction:
- Green zone (≥ 80% personal best): Controlled; routine medications
- Yellow zone (50–79%): Caution; add rescue medications; follow action plan
- Red zone (< 50%): Medical alert; emergency treatment needed
Cystic fibrosis (CF)
What it is: Autosomal recessive genetic disorder caused by a defective CFTR gene. Leads to thick, viscous mucus in the lungs, pancreas, and other organs.
Genetic facts for NCLEX®:
- Autosomal recessive — requires two copies of the defective gene
- If both parents are carriers: 25% chance child has CF, 50% chance carrier, 25% unaffected
- Most common life-limiting genetic disease in Caucasian populations
Clinical manifestations
| System | Manifestation |
|---|---|
| Respiratory | Persistent productive cough; recurrent pneumonias; bronchiectasis; chronic Pseudomonas colonization |
| Pancreatic | Exocrine insufficiency → malabsorption → steatorrhea (bulky, foul, fatty stools); weight loss |
| Sweat glands | Elevated chloride in sweat (> 60 mEq/L) — diagnostic |
| Reproductive | Males: infertility (absent vas deferens); females: reduced fertility |
| GI | Meconium ileus in newborns (first sign in 10–15% of cases); constipation; rectal prolapse |
Sweat chloride test — the diagnostic gold standard
- Normal: < 40 mEq/L
- Borderline: 40–59 mEq/L
- CF diagnosis: ≥ 60 mEq/L
CF nursing management
| Priority | Intervention |
|---|---|
| Airway clearance | Chest physiotherapy (CPT) — percussion and postural drainage; 2–4× daily; before meals (to reduce emesis) |
| Mucus-thinning medications | Dornase alfa (DNase) nebulized; hypertonic saline nebulized |
| Bronchodilators | Before CPT to open airways |
| Pancreatic enzymes | Take with every meal and snack — prevents malabsorption; do not crush enteric-coated capsules |
| High-calorie, high-protein diet | CF patients require 110–200% of normal caloric needs due to malabsorption and increased work of breathing |
| Vitamins | Fat-soluble vitamins (A, D, E, K) in water-soluble form (malabsorption blocks fat-soluble forms) |
| Infection management | Pseudomonas aeruginosa is the most common and most serious pulmonary pathogen in CF |
Lung transplant is the only cure for end-stage CF lung disease. The CFTR modulator drugs are transforming outcomes — elexacaftor/tezacaftor/ivacaftor (Trikafta) was approved for ages 2 and up (April 2023), making it available to most CF patients with at least one F508del mutation from early childhood. Ivacaftor (Kalydeco) addresses other specific mutations.
NCLEX® clinical judgment focus
Pediatric respiratory questions prioritize the airway — every time.
| Situation | First action |
|---|---|
| Child with croup at home, worsening stridor | Bring outside into cool air; if SpO₂ drops or stridor is present at rest → ED |
| Suspected epiglottitis | Do NOT examine throat; keep calm; call provider; prepare for emergency airway |
| Infant with RSV, SpO₂ dropping | Apply supplemental O₂; suction nasal passages; elevate HOB; notify provider |
| Asthmatic child in yellow zone | Administer SABA; reassess; if no improvement or drops to red zone → call 911 or notify provider |
| CF child refusing CPT because it's time-consuming | Educate on importance; explore scheduling; involve child in self-management as age-appropriate |
FAQ
How do you tell croup from epiglottitis on NCLEX®?
Croup has a gradual onset, low-grade fever, barky cough, and responds to cool mist and steroids — the child looks ill but not toxic. Epiglottitis has sudden onset, high fever, drooling, tripod position, and the child appears severely toxic. The most important nursing action in epiglottitis: do NOT examine the throat.
Why are bronchodilators not routinely used for RSV bronchiolitis?
Multiple controlled trials have shown that bronchodilators like albuterol do not improve outcomes (oxygen saturation, length of stay, symptom resolution) in most infants with RSV bronchiolitis. The mechanism is inflammation and mucus plugging — not true bronchospasm — so bronchodilators have limited effect.
What is the most important teaching for a child with cystic fibrosis?
Airway clearance — chest physiotherapy 2–4 times daily, every day, for life. Consistent mucus clearance reduces infection frequency and slows pulmonary decline. Pancreatic enzyme replacement with every meal and snack is equally critical to prevent malnutrition.
Why is palivizumab not a vaccine, and what has replaced it?
Palivizumab is a monoclonal antibody that provides passive immunity against RSV — it doesn't stimulate the immune system to produce its own antibodies. It is given monthly during RSV season (not once for lifetime protection). Vaccines produce active immunity; passive immunity from palivizumab lasts only as long as the antibodies persist (about a month).
2023–2024 update: For most infants, palivizumab has been replaced by nirsevimab (Beyfortus) — a single-dose RSV monoclonal antibody recommended for all infants entering their first RSV season. Mothers can also receive the Abrysvo RSV vaccine at 32–36 weeks gestation to transfer antibodies to the newborn.
What is the sweat chloride test used for?
It is the diagnostic gold standard for cystic fibrosis. Pilocarpine is applied to the skin by iontophoresis to stimulate sweating, the sweat is collected, and chloride is measured. A level ≥ 60 mEq/L is diagnostic of CF. All positive newborn screens for CF are confirmed by a sweat chloride test.
Key takeaways
- Croup: Barky cough, gradual onset, not toxic. Cool mist + dexamethasone + racemic epi. Observe 3–4 hours minimum after epi.
- Epiglottitis: Sudden, drooling, tripod, toxic. NEVER examine throat. Keep calm. Emergency airway.
- RSV/Bronchiolitis: Supportive care. Suction nares. O₂ if SpO₂ < 92%. No routine bronchodilators. Prevention: nirsevimab (Beyfortus) for all infants (first-line 2023+); maternal Abrysvo vaccine at 32–36 weeks gestation.
- Asthma: SABA rescue first. Spacer required for children. Peak flow monitoring. Step therapy.
- Cystic fibrosis: Autosomal recessive. Sweat Cl⁻ ≥ 60 = diagnostic. CPT before meals. Pancreatic enzymes with every meal/snack. High-calorie diet.
Sources: NCSBN NCLEX-RN® 2023 Test Plan; CDC Respiratory Syncytial Virus (RSV) Resources; WHO Integrated Management of Childhood Illness.
See also:
- NCLEX-RN® Pediatrics: Growth, Development & Safety
- NCLEX-RN® Respiratory Disorders
- Pediatric Cardiac and Neuro Disorders
- NCLEX-RN® Pharmacology Guide
- NCLEX-RN® Patient Safety Guide
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