Pediatric Respiratory Care

Croup, epiglottitis, bronchiolitis, asthma, and pediatric airway emergencies.

intermediate75 min estimated3 lessons

Croup vs. Epiglottitis: Critical Distinctions

Croup (laryngotracheobronchitis) and epiglottitis are both upper airway obstructions but differ critically in presentation, management, and urgency.

Croup: caused by parainfluenza virus, affects children 6 months–3 years. Classic 'seal bark' cough, stridor worse at night, low-grade fever. AP neck X-ray shows 'steeple sign' (subglottic narrowing). Treatment: cool humidified air (debated), nebulized racemic epinephrine for moderate-severe, dexamethasone 0.6 mg/kg PO/IM (single dose).

Epiglottitis: caused by H. influenzae type B (now rare due to Hib vaccine), also S. pyogenes, S. aureus. Rapid onset, high fever, drooling, tripod positioning, muffled 'hot potato' voice. Lateral neck X-ray: 'thumbprint sign' (swollen epiglottis). EMERGENCY — do not examine throat; secure airway in OR.

Croup: parainfluenza, bark cough, steeple sign, dexamethasone + racemic epi
Epiglottitis: H. influenzae, tripod, drooling, thumbprint sign — airway emergency
Never examine throat in suspected epiglottitis — can precipitate complete obstruction
Racemic epinephrine: monitor for rebound after 2–3 hours (admit if given)
Heliox (70:30) reduces turbulent flow in upper airway obstruction — can bridge to definitive treatment

Clinical tip

In croup, the child can be calm and playful between attacks. In epiglottitis, the child is anxious, sitting upright, drooling, and looks toxic — very different pictures.

Bronchiolitis and Pediatric Asthma

Bronchiolitis is an acute lower respiratory tract infection, primarily from RSV, affecting infants <2 years. Features: viral prodrome, tachypnea, wheezing, fine crackles, hyperinflation on CXR. Treatment is supportive: hydration, superficial nasal suctioning for comfort (avoid routine deep suctioning), and supplemental O2 if SpO2 stays below 90%. Albuterol, epinephrine, systemic corticosteroids and chest physiotherapy are NOT recommended (AAP 2014 clinical practice guideline). Nebulized hypertonic saline should not be given in the emergency department; it may be used for hospitalized infants expected to stay longer than 72 hours.

Pediatric asthma is reversible bronchospasm. Assess severity: mild (talking, SpO2 >95%), moderate (sentences, SpO2 91–95%, accessory muscles), severe (words only, SpO2 <91%, tripoding), life-threatening (silent chest, cyanosis, altered mental status).

Treatment escalation: albuterol MDI/neb → ipratropium → systemic steroids → IV magnesium → heliox → BiPAP/intubation.

Bronchiolitis: RSV most common, infants <2 years — supportive care only
No bronchodilators or steroids for bronchiolitis (AAP 2014 guidelines)
Hypertonic saline: not in the ED; may be used if a hospital stay >72 hr is expected (AAP 2014)
Supplemental O2 in bronchiolitis only if SpO2 is persistently <90% (AAP 2014)
Silent chest in asthma = severe obstruction, not improvement — emergency
IV magnesium sulfate 50–75 mg/kg for refractory pediatric asthma

Clinical tip

A 'silent chest' in an asthmatic child means airflow is so severely reduced that no wheeze can be generated. This is a pre-arrest finding requiring immediate escalation.

Pediatric Airway Anatomy and Differences

Pediatric airways differ from adults in ways that profoundly affect respiratory care:

1. Narrowest point: subglottis in children (cricoid ring); glottis in adults — why uncuffed ET tubes were traditionally used in <8 years 2. Large tongue relative to airway size — occludes airway more easily 3. More compliant chest wall — retractions are more visible but also mean less respiratory reserve 4. Higher metabolic rate → faster oxygen desaturation during apnea 5. Obligate nasal breathers until ~3–4 months — nasal congestion impairs feeding and breathing 6. Larynx more anterior and cephalad — Miller blade (straight) preferred for infant intubation

ET tube sizing: uncuffed (age/4 + 4); cuffed (age/4 + 3.5). Depth (cm): age/2 + 12 cm at lip.

Pediatric narrowest airway: subglottis (cricoid ring) — not glottis as in adults
Uncuffed ET tube: size = age/4 + 4; cuffed: age/4 + 3.5
ET tube depth at lip: age/2 + 12 cm
Miller (straight) blade preferred for infant laryngoscopy
Infants <3–4 months: obligate nasal breathers

Clinical tip

For pediatric intubation, always have a tube 0.5 size smaller available. If the chosen tube won't pass through the cricoid without significant resistance, downsize.

Clinical cases

Child with Stridor and Drooling

A 4-year-old presents with sudden-onset high fever (39.5°C), stridor, drooling, difficulty swallowing, and sitting forward in the tripod position. He appears toxic and anxious.

What is the suspected diagnosis and what is the immediate management priority?

Suspected epiglottitis. Do NOT examine the throat. Call anesthesia and ENT immediately. Prepare for emergency airway in the OR with surgical backup.

Classic epiglottitis: high fever, drooling, tripod positioning, sudden onset. The child is at risk for complete airway obstruction from any stimulation. Do not perform throat exam, do not obtain AP neck X-ray if patient is unstable — take directly to OR for controlled intubation by most experienced provider with surgical airway backup.

Know this for NBRC

Croup vs epiglottitis: presentation, X-ray findings, management
Bronchiolitis: supportive care only, no bronchodilators
Racemic epinephrine for croup: rebound monitoring required
Pediatric ET tube sizing formulas
Silent chest = critical asthma emergency

Key facts

Croup: parainfluenza, 6 mo–3 yr, steeple sign, dexamethasone 0.6 mg/kg x1
Epiglottitis: H. influenzae, thumbprint sign, do NOT examine throat, OR airway
Bronchiolitis: RSV, <2 yr, supportive care — no bronchodilators, no steroids
Racemic epinephrine for croup: observe 2–3 hr for rebound before discharge
Silent chest in asthma = critical emergency, not improvement
Uncuffed ET tube size: age/4 + 4; Cuffed: age/4 + 3.5
Pediatric asthma life-threatening: silent chest, altered mental status, cyanosis
Heliox 70:30 (He:O2) reduces turbulent upper airway flow in croup/epiglottitis

NBRC pearls

NBRC distinguishes croup from epiglottitis — know signs, X-ray findings, management
Bronchiolitis = supportive only; any bronchodilator answer is wrong for bronchiolitis
Steeple sign = croup; Thumbprint sign = epiglottitis
Racemic epinephrine for croup is temporary — must observe for rebound

Memory tricks

Croup: 'BARK' — Barky cough, Afebrile or low-grade, Racemic epi, Kids (6mo–3yr)
Epiglottitis: 'DEBT' — Drooling, Epiglottis swollen, Bacterial, Tripod
ET tube uncuffed: '4 plus 4' = (age/4) + 4

Common mistakes

Giving albuterol or steroids for bronchiolitis (not recommended per AAP)
Examining the throat in suspected epiglottitis (can cause complete obstruction)
Interpreting silent chest as improvement in asthma (it's a pre-arrest finding)
Using Macintosh blade for infant intubation (Miller preferred for anterior airway)

Pediatric Respiratory Care

Croup vs. Epiglottitis: Critical Distinctions

Bronchiolitis and Pediatric Asthma

Pediatric Airway Anatomy and Differences

Clinical cases

NBRC pearls

Memory tricks

Common mistakes

Related topics

Pediatric Respiratory Care

Croup vs. Epiglottitis: Critical Distinctions

Bronchiolitis and Pediatric Asthma

Pediatric Airway Anatomy and Differences

Clinical cases

NBRC pearls

Memory tricks

Common mistakes

Related topics

Lessons

Croup vs. Epiglottitis: Critical Distinctions

Bronchiolitis and Pediatric Asthma

Pediatric Airway Anatomy and Differences

Clinical cases

NBRC pearls

Memory tricks

Common mistakes

Related topics

Lessons

Croup vs. Epiglottitis: Critical Distinctions

Bronchiolitis and Pediatric Asthma

Pediatric Airway Anatomy and Differences

Clinical cases

NBRC pearls

Memory tricks

Common mistakes

Related topics