Croup, epiglottitis, bronchiolitis, asthma, and pediatric airway emergencies.
75 min estimated
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.
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 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: nasal suctioning, hydration, supplemental O2. Bronchodilators and steroids are NOT recommended (AAP guidelines).
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.
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 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.
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.
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.
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