Nasal flaring is the abnormal widening of the nostrils, usually during inspiration, which signals increased work of breathing. It is a clinical indicator of respiratory distress and may range from mild dysfunction to life-threatening conditions requiring immediate intervention. It is particularly important in infants and young children, who cannot verbalize breathing difficulty.

Pathophysiology

Nasal flaring occurs due to activation of the alae nasi muscles, which attempt to reduce airway resistance and increase airflow during respiratory compromise. It typically accompanies tachypnea, accessory muscle use, intercostal retractions, and cyanosis. The underlying mechanisms can involve:

1. Obstructive processes: Upper or lower airway obstruction increases inspiratory effort.

2. Restrictive or parenchymal lung disease: Reduced lung compliance (e.g., ARDS, pulmonary edema) increases work of breathing.

3. Hypoxemia and hypercapnia: Chemoreceptor-mediated respiratory drive increases, causing exaggerated nostril dilation.

4. Cardiopulmonary compromise: Conditions such as pulmonary embolus or congenital heart disease elevate respiratory effort.

Emergency interventions

• Rapidly assess respiratory status: Observe for cyanosis, absent breath sounds, diaphoresis, and tachycardia.

• Relieve airway obstruction: Perform back blows or abdominal thrusts in case of complete obstruction; if unsuccessful, prepare for emergency intubation or tracheostomy.

• Supplemental oxygen: Administer via nasal cannula or face mask.

• Mechanical ventilation: Consider for severe respiratory distress.

• Monitoring and access: Insert IV line, monitor cardiac status, and obtain baseline vitals.

• Diagnostic evaluation: Obtain chest X-ray, arterial blood gas (ABG), and electrolytes.

History and Physical Examination

• Obtain history of respiratory, cardiac, and allergic conditions.

• Ask about recent infections, trauma, or exposures.

• Record smoking history and drug use.

• Examine for tachypnea, intercostal retractions, cyanosis, accessory muscle use, and breath sounds.

• Assess for associated symptoms such as wheezing, stridor, cough, frothy sputum, hemoptysis, or altered LOC.

Medical causes

Other causes

• Diagnostic maneuvers: Forced inspiration during pulmonary function tests.

• Therapeutic interventions: Deep breathing exercises, respiratory therapy.

Special considerations

• Place patient in high Fowler’s position to ease breathing.

• Use modified Trendelenburg or side-lying if aspiration risk exists.

• Suction secretions frequently; provide humidified oxygen.

• Encourage hydration, coughing, and deep breathing.

• Avoid sedatives or opioids that depress respirations.

• Continuously monitor vital signs and oxygen saturation every 30 minutes or as needed.

• Prepare for diagnostic tests: chest X-ray, pulmonary arteriography, lung scan, sputum culture, ABG, CBC, ECG.

Patient counseling

• Explain procedures and treatment rationale.

• Demonstrate inhaler use if prescribed.

• Educate about smoking cessation.

• Emphasize early recognition and treatment of respiratory distress.

Pediatric pointers

• Nasal flaring is a critical sign of respiratory distress in infants and young children.

• Common pediatric causes: airway obstruction, hyaline membrane disease, croup, acute epiglottitis.

• Use of croup tent may improve oxygenation and humidification.

• Closely monitor infants with prematurity or underlying cardiopulmonary disease.