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Difficulty: MediumPediatric Respiratory Disorders

A 22-year-old girl is brought to the emergency department by her parents because of noisy breathing and a harsh cough. Her symptoms began two days ago with a runny nose, mild congestion, and a low-grade fever. Last night, she developed a loud, "barking" cough and her voice became hoarse. Over the past 22 hours, her parents noticed a high-pitched noise when she breathes in, even when she is sitting quietly in her mother's lap. Her temperature is 38.2∘C38.2^{\circ}\text{C} (100.8∘F100.8^{\circ}\text{F}), pulse is 142/min142/\text{min}, and respirations are 42/min42/\text{min}. Pulse oximetry is 96%96\% on room air. The patient is up-to-date on all childhood immunizations. On physical examination, the child is alert but appears anxious. There is noticeable inspiratory stridor at rest, accompanied by suprasternal and intercostal retractions. She is not drooling, and her oropharynx is clear without erythema or exudate. Auscultation of the lungs reveals transmitted upper airway sounds but no wheezing or crackles. Which of the following is the most appropriate next step in management?

  1. A
    Administration of nebulized albuterol and oral dexamethasone
  2. B
    Administration of nebulized hypertonic saline and nasal suctioning
  3. Administration of nebulized racemic epinephrine and oral dexamethasoneAnswer
  4. D
    Discharge home with instructions for cool mist humidification
  5. E
    Intramuscular administration of ceftriaxone and otolaryngology consultation

Answer

The most appropriate next step in management is the administration of nebulized racemic epinephrine and oral dexamethasone.
The patient's presentation of a mild viral prodrome followed by a barking cough, hoarseness, and inspiratory stridor is classic for croup (laryngotracheobronchitis), most commonly caused by parainfluenza virus. The presence of stridor at rest and suprasternal retractions indicates moderate-to-severe disease. The most appropriate next step in management for moderate-to-severe croup is the administration of corticosteroids (such as oral or intramuscular dexamethasone) to reduce laryngeal edema, combined with nebulized racemic epinephrine. Epinephrine causes rapid mucosal vasoconstriction, temporarily relieving the severe upper airway obstruction while the corticosteroids take effect.

Step-by-Step Solution

1
Diagnose the patient based on the clinical presentation.
The patient has croup (laryngotracheobronchitis) based on the viral prodrome, barking cough, hoarseness, and inspiratory stridor.
Identifying the specific respiratory syndrome allows for targeted treatment and rules out other causes of stridor like epiglottitis or foreign body aspiration.
2
Assess the severity of the respiratory distress.
The patient has moderate-to-severe croup, evidenced by the presence of inspiratory stridor at rest and suprasternal retractions.
Severity classification dictates whether conservative outpatient management or active pharmacologic intervention in the emergency department is necessary.
3
Select the appropriate pharmacologic interventions for the determined severity.
The patient requires both a corticosteroid (dexamethasone) and nebulized racemic epinephrine.
Corticosteroids reduce overall airway inflammation, while nebulized epinephrine provides rapid, temporary mucosal vasoconstriction to immediately relieve severe subglottic edema.

Key Concept

The management of moderate-to-severe croup (characterized by stridor at rest) requires the administration of both corticosteroids (to decrease airway inflammation) and nebulized racemic epinephrine (for rapid reduction of subglottic edema).
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Topics

Pediatric Respiratory Disorders

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