11.3 Lifespan Respiratory Care

The official FNP-BC Test Content Outline scores eight age groups — infant through frail elderly — against every body system. Respiratory items will not all be 55-year-old smokers. This section is how the same airway looks different at each end of the waiting room.

Infants: bronchiolitis, croup, and foreign body

Bronchiolitis (usually RSV or another virus in the first year or two of life) is a lower-airway infection with cough, tachypnea, and crackles or wheeze after a viral prodrome. Treatment is supportive: frequent feeding or fluids, nasal suction, and oxygen if the infant is hypoxic. Do not routinely give albuterol, systemic corticosteroids, or antibiotics. Those three are the exam’s favorite wrong answers. Skip routine chest radiographs and viral panels unless the result will change cohorting or you suspect something else (heart failure, foreign body, bacterial pneumonia). Watch work of breathing, hydration, and pulse oximetry. A well-hydrated infant saturating well in room air with only mild effort goes home with suction teaching and clear return precautions. Poor feeding, apnea, hypoxia, marked retractions, or a very young or former-preterm infant is an emergency-department or admission decision. Prevention (maternal RSV vaccination, infant nirsevimab or other current seasonal products) is a Planning item — it is not a treatment for the infant already wheezing in your office.

Croup (laryngotracheobronchitis) is a viral, barking cough and hoarse cry, often worse at night, in a toddler who looks better than the noise suggests. First-line medication is a single dose of dexamethasone. Mild croup can go home after the steroid. Stridor at rest, marked retractions, or hypoxia needs racemic epinephrine, observation, and a higher level of care. Position of comfort and cool air help; do not force an oral exam that agitates a child whose airway is already tight. Separate croup from epiglottitis (toxic, drooling, tripod, little cough — do not throat-exam, call emergency airway help) and from bacterial tracheitis. Immunization history matters, but a fully immunized child can still have viral croup.

Foreign body is the sudden story: a witnessed choke, an abrupt cough while eating a nut or a small toy, then unilateral wheeze or a persistently “asthmatic” toddler who never had eczema. Do not perform a blind finger sweep. Complete obstruction is basic life support (back blows and chest thrusts in infants; abdominal thrusts in older children). Partial obstruction with a suggestive history needs urgent specialty bronchoscopy, not a five-day albuterol trial. Recurrent pneumonia in the same lobe is a delayed foreign-body clue.

School-age children: action plans and sports

Once the child is in school, the diagnosis is often asthma and the Implementation skill is the written asthma action plan. Green zone: usual controller (Track 1 as-needed ICS-formoterol, or daily ICS / ICS-LABA on Track 2) and normal activity. Yellow: increased reliever, early contact, and the rule for starting a steroid burst if your local/NAEPP-style plan uses one. Red: severe work of breathing, words-per-breath falling apart, peak flow in the red if you use peak flow — emergency care. Put the plan in the parent’s phone and at the school. A 504 or school-medication form that lets the child carry the reliever is part of the prescription, not paperwork you defer to August.

Sports are allowed and expected when asthma is controlled. Uncontrolled exercise symptoms mean the controller is wrong, the device is unused, or the warm-up reliever plan is missing — not that the child should quit the team. GINA prefers that the reliever itself be anti-inflammatory (ICS-formoterol) rather than a SABA-only sports inhaler that never touches inflammation. If Track 2 is in use, a pre-exercise SABA can be appropriate on top of daily ICS, not instead of it. Recheck seasonal allergic triggers, locker-room irritants, and swimming-pool chlorine as you would any other trigger. Peak-flow personal bests help some athletes; they are optional monitoring, not a sports physical requirement.

Pregnancy: keep the ICS

Pregnant patients with asthma should continue inhaled corticosteroid. Budesonide has the longest observational record, but the bigger error is stopping a working ICS because someone labeled it “a steroid.” Poorly controlled asthma is riskier for mother and fetus than ICS — hypoxia, preterm birth, and growth restriction track with exacerbations, not with standard inhaled doses. Keep a reliever available. Treat exacerbations with oxygen, bronchodilators, and a short systemic steroid course when indicated; do not withhold a burst out of fetal fear while the parent desaturates. Influenza and COVID vaccination in pregnancy protect the airway as well as the season. Montelukast is not required in every pregnancy and still carries the neuropsychiatric warning. This is not the ACE-inhibitor chapter; the respiratory rule to memorize is do not stop the ICS.

Older and frail adults: aspiration, vaccines, COPD plus frailty

Aspiration is the older-adult pneumonia you prevent before you prescribe. Stroke, Parkinson disease, dementia, heavy sedation, and poor dentition all raise risk. Sit upright for meals, refer to swallow evaluation when there is coughing with liquids or a wet voice, and do not call every nursing-home fever “viral bronchitis.” Acid suppression and antipsychotics can worsen swallow or sedation; review them when pneumonias repeat.

Vaccines are primary prevention for the aging lung. Follow current ACIP for influenza every season, COVID per current adult schedule, RSV products indicated for older adults, and pneumococcal vaccination (PCV20 or PCV21, or PCV15 followed by PPSV23, depending on the product available and prior doses). Do not invent a 2026 product name the outline does not require — do invent the habit of checking the record at every Medicare Welcome and every COPD visit. Tdap still matters for the grandparent who will hold a newborn (pertussis returns in Section 11.1).

COPD plus frailty changes the device more than the GOLD letter. A patient who cannot generate a fast, deep inhalation will fail a DPI. Arthritis may block a particular inhaler click. Cognitive impairment means a once-daily LAMA the caregiver can supervise beats a four-step MART the patient cannot sequence. Pulmonary rehabilitation, nutrition, and fall-safe oxygen tubing matter as much as the next escalation. Recheck the indication for ICS if there is recurrent pneumonia and low eosinophils. Home oxygen still needs documented chronic severe hypoxemia and specialty confirmation — frailty is not itself an oxygen criterion.

Smoking and vaping at every age

Ask about combustible tobacco and e-cigarettes at every age, including adolescents. Vaping is not a harm-free sports accessory; it delivers nicotine, can inflame airways, and has been linked to severe acute lung injury (EVALI) when products are adulterated. For adults, offer a real cessation plan: brief advice plus pharmacotherapy when appropriate (combination NRT, varenicline, or bupropion, chosen against contraindications) and a follow-up date. For adolescents, start with behavioral counseling and school/parent partnership; do not wait until age 21 to open the topic, and do not assume an ICS-formoterol prescription “covers” ongoing vaping. Document the ask. Relapse is expected; repeating the ask is the intervention.

Age-group traps: albuterol “trials” for every wheezing infant; sending croup home without dexamethasone because “it is just a virus”; stopping budesonide at the positive pregnancy test; giving a frail adult a DPI they cannot inhale; and skipping the vaping history in a 16-year-old with a new cough. Match the airway to the age group, then use the same GINA and GOLD rules you already learned.