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Adult and Pediatric Respiratory Emergency. Christopher Martella, DO FACOEP. Adult and Pediatric Respiratory Emergency. Discuss the differential diagnosis of Adult and Pediatric Respiratory Emergencies Pathophysicology Epidemiology History Physical findings Treatments.

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adult and pediatric respiratory emergency

Adult and Pediatric Respiratory Emergency

Christopher Martella, DO FACOEP

adult and pediatric respiratory emergency2
Adult and Pediatric Respiratory Emergency
  • Discuss the differential diagnosis of Adult and Pediatric Respiratory Emergencies
  • Pathophysicology
  • Epidemiology
  • History
  • Physical findings
  • Treatments
adult and pediatric respiratory emergencies
Adult and Pediatric Respiratory Emergencies
  • DDX in Adults
  • HEENTAngiodema Anaphylaxis Pharyngeal infections Deep neck infections Foreign body Neck trauma

Chest wall Rib fractures Flail chest

Pulmonary COPD exacerbation Asthma exacerbation Pulmonary embolism Pneumothorax Pulmonary infection ARDS Pulmonary contusion or other lung injury Hemorrhage

Cardiac ACS ADHF Flash pulmonary edema High output failure Cardiomyopathy Arrhythmia Valvular dysfunction Cardiac tamponade Neurological Stroke Neuromuscular disease

  • Toxic/metabolic Organophosphate poisoning Salicylatepoisioning CO poisoning Toxic ingestion Diabetic ketoacidosis Sepsis Anemia Acute chest syndrome Miscellaneous Hyperventilation Anxiety Pneumomediastinum Lung tumor Pleural effusion Intra-abdominal process Ascites Pregnancy Massive obesity
adult and pediatric respiratory emergencies4
Adult and Pediatric Respiratory Emergencies
  • DDX in children
    • Respiratory tract Infection Epiglottitis Retropharyngeal abscess Peritonsillar abscess Croup Tracheitis Bronchiolitis Pneumonia Asthma Anaphylaxis Foreign body Upper airway Lower airway Esophageal
    • Biologic or chemical weapons
    • Chest wall/thoracic Chest wall deformity (eg, thoracic dystrophy, flail chest) Air leak (eg, tension pneumothorax) Mass lesion (eg, pulmonary sequestration, malignancy)
    • Cardiovascular Heart failure Cyanotic heart disease Pericarditis Cardiac tamponade Myocarditis
    • Nervous system Depressed ventilation (from ingestion, injury, or infection) Hypotonia (poor pharyngeal tone, ineffective respiratory effort) Loss of airway protective reflexes (aspiration)
    • Gastrointestinal Splinting from abdominal pain Abdominal distention Aspiration as the result of gastroesophageal reflux
    • Metabolic/endocrine Acidosis (eg, diabetic ketoacidosis, severe dehydration, sepsis) Hyperthyroidism Hypothyroidism
    • Hematologic Decreased oxygen carrying capacity (eg, severe anemia, methemoglobinemia)
    • Trauma Blunt or penetrating (eg, pneumothorax, pulmonary contusion) Inhalational injury (eg, airway burn, smoke inhalation)


  • Time of onset
  • Current medications
  • Recent use of beta 2 agonists
  • Risk factors for severe disease is ED visits, hospitalizations, ICU admits intubations, repeated courses of oral glucocorticoids, hx of intubation and food allergy

Physical findings

Use of accessory muscles

Brief fragmented speech

Inability to lie supine



Cyanosis, depressed mental status, inability to maintain respiratory effort

Pulmonary Index in pediatrics patients

I to E ratio

Pulus paradoxus


Clinical finding

Hypoxia -nearly all asthma patients have hypoxia as a result of V/Q mismatch. Beta 2 agonist may worsen this mismatch by causing pulmonary vasodilation in areas of the lung that are poorly ventilated

Marked hypoxia PO2<60 SaO2<90

Infrequent but potential cause of complications and death. Recommendations for continuous Pulse ox monitoring for patients with PEFR <40 % of baseline

Hypercapnia (ABG)

Asthma patients are usually tachynic therefore normal or high PaCO2 could be an ominous sign

Chest x-ray rarely helpful unless patient with fever suspected PTX

Labs not helpful


Treatment for Adult patient

  • Oxygen to maintain SaO2 >92%
  • Inhaled beta agonist Albuterol 2.5-5.0 mg neb x 3 q 20 minutes then 1-4 hours as needed or MDI w/ spacer 4 puffs q 10 min or 8 puffs q 20 min for up to 4 hours then 1-4 hours as needed
  • Critically ill patients continuous neb 10-15 mg over one hour
  • IV hydration NSS bolus to replace insensible losses

Nebs vs MDI essentially no difference and MDI maybe better


Ipratopium 500mcg neb q 20 minutes for three doses, then as needed or 8 puffs via MDI q 20 min then as needed for up to 3 hours.

Usually reserved for severe obstruction failing to improve despite beta agonists


Systemic glucocorticoids

Speeds rate of recovery with patients with persistent wheezing despite intensive bronchodilator therapy likely secondary to airway flow obstruction due to airway inflammation and intraluminal mucous plugging

Current guidelines encourage early systemic glucocorticoids for all patients who have a moderate (PEFR of < 70%) or severe exacerbation ( PEFR<40%)


Systemic glucocorticoids

Optimal dose unknown

Corticosteroids: give methylprednisolone 60-125 mg IV or prednisone 40-60 mg po; alternatives include: dexamethasone 6-10 mg IV or hydrocortisone 150-200 mg IV; steroids may be given IM or orally if IV access is unavailable

PO absorbed rapidly with similar bioavailability to IV

IV dosing can be used for vomiting or severely ill patients

IM as effective as PO

Duration rough guide 10-14 days for severe attacks

Tapering is not necessary

  • Magnesium
  • IV MGSO4 has a bronchodilator activity possibly due to inhibition of calcium influx into airway smooth muscle cells
  • Routine use does not seem to confer significant benefit beyond beta agonists and systemic glucocorticoids, MgSO4 is suggested for patients who have life-threatening exacerbations
  • Dose 2 gm over 20 minutes
  • Nonstandard therapies
    • Helium-oxygen
    • Leukotriene receptor antagonist
    • BiPAP
    • Terbutaline 0.25 mg SC q 20 minx 3 doses
    • Epinephrine 0.2-0.5 ml 1 :1000 SC

Ineffective therapies


Inhaled glucocorticoids

Empiric antibiotics


Treatment in Peds

Similar approach to adults

Levalbureol vs Racemic albuterol


Parental beta 2-agonist Epinephrine and Terbutaline

  • Parental beta 2-agonist Epinephrine and Terbutaline

May be superior to inhaled beta 2-agonists for children with severe exacerbations and poor inspiratory flow or anxious young children who are uncooperative with or have suboptimal response to initial aerosolized therapy.

The intramuscular route may provide for more rapid drug absorption, although direct comparisons are lacking. In this setting, terbutaline may be expected to produce fewer adverse effects than epinephrine.


Heart failure (HF) is a common clinical syndrome representing the end-stage of a number of different cardiac diseases. It can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. There are two mechanisms by which reduced cardiac output and HF occur:

Systolic dysfunction

Diastolic dysfunction.


The New York Heart Association's classification:

Class I describes a patient who is not limited with normal physical activity by symptoms.

Class II occurs when ordinary physical activity results in fatigue, dyspnea, or other symptoms.

Class III is characterized by a marked limitation in normal physical activity.

Class IV is defined by symptoms at rest or with any physical activity.

  • Frequency
    • United States
      • More than 3 million people have congestive heart failure (CHF), and more than 400,000 new patients present yearly. The prevalence rate of CHF is 1-2%.
  • Mortality/Morbidity
    • Approximately 30-40% of patients with congestive heart failure (CHF) are hospitalized every year.
    • CHF is the leading diagnosis-related group (DRG) among hospitalized patients older than 65 years.
    • 5-year mortality rate after diagnosis was reported in 1971 as 60% in men and 45% in women. In 1991, data from the Framingham heart study showed the 5-year mortality rate for CHF essentially remaining unchanged, with a median survival of 3.2 years for males and 5.4 years for females.
    • The most common cause of death is progressive heart failure, but sudden death may account for up to 45% of all deaths. Patients with coexisting insulin-dependent diabetes mellitus have a significantly increased mortality rate.
  • Race
    • Blacks are 1.5 times more likely to die of CHF than whites are. Nevertheless, black patients appear to have similar or lower in-hospital mortality rates than white patients.
  • Sex
    • Prevalence is greater in males than in females in patients aged 40-75 years.
    • No sex predilection is noted among patients older than 75 years.
  • Age
    • Prevalence of CHF increases with increasing age and affects about 10% of the population older than 75 years.
  • Causes
    • The most common cause of heart failure is coronary artery disease,
    • Other disease processes include
      • hypertension,
      • valvular heart disease
      • congenital heart disease
      • myocarditis and infectious endocarditis.
  • CHF is often precipitated by cardiac ischemia or dysrhythmias, cardiac or extracardiac infection, pulmonary embolus, physical or environmental stresses, changes or noncompliance with medical therapy, dietary indiscretion, or iatrogenic volume overload.
  • One also must consider systemic processes such as pregnancy and hyperthyroidism as precipitants of CHF.
  • History
  • Anxiety
  • Dyspnea at rest
  • Dyspnea upon exertion: This has been found to be the most sensitive symptom reported, yet the specificity for dyspnea is less than 60%.
  • Orthopnea and paroxysmal nocturnal dyspnea the sensitivity for orthopnea and PND is only 20-30% but specificity 74-80%.
  • Cough: Cough that produces pink, frothy sputum is highly suggestive of congestive heart failure (CHF).
  • Edema
  • Nonspecific symptoms
    • Weakness
    • Lightheadedness
    • Abdominal pain
    • Malaise
    • Wheezing
    • Nausea
  • Physical Findings for the vet with Acute decompensated heart failure (ADHF)
    • Displaced Apical Pulse most sensitive and specific of all physical findings of Systolic HF. Apical impulse laterally displaced past midclavicular line
    • Peripheral edema, jugular venous distention, and tachycardia are highly predictive of congestive heart failure (CHF). specificity of physical examination reported at 90%
    • Tachypnea, using accessory muscles of respiration, has been observed.
    • Hypertension may be present.
    • Pulsus alternans (alternating weak and strong pulse indicative of depressed left ventricle [LV] function) may be observed.
    • The skin may be diaphoretic or cold, gray, and cyanotic.
    • Jugular venous distention (JVD) is frequently present.
    • Wheezing or rales may be heard on lung auscultation.
    • Cardiac auscultation may reveal aortic or mitral valvular abnormalities (S3 or S4).
    • Lower extremity edema may also be noted, especially in the subacute process.

Work up

Labs Chem 7, CBC, Cardiac enzymes, BNP

ABG levels may be of benefit in evaluation of hypoxemia, ventilation/perfusion (V/Q) mismatch, hypercapnia, and acidosis.

ECG nonspecific tool but may be useful in diagnosing concomitant cardiac ischemia, prior myocardial infarction (MI), cardiac dysrhythmias, chronic hypertension, and other causes of left ventricular hypertrophy

ECHO Emergency transthoracic echocardiography may help identify regional wall motion abnormalities as well as globally depressed or myopathic left ventricular function.

ECHO may help reveal cardiac tamponade, pericardial constriction, and pulmonary embolus.

ECHO is also useful in revealing valvular heart disease, such as mitral or aortic stenosis or regurgitation.


Work up

CXR Chest radiography is the most useful tool diagnostic tool. A recent study showed that 1 out 5 patients admitted to the hospital with CHF lacked signs of congestion on chest radiograph.

  • Cardiomegaly may be observed with a cardiothoracic ratio greater than 50%. Pleural effusions may be present bilaterally or if they are unilateral more commonly observed on the right.
  • Early CHF may manifest as cephalization of pulmonary vessels, generally reflecting a pulmonary capillary wedge pressure (PCWP) of 12-18 mm Hg. As the interstitial fluid accumulates, more advanced CHF may be demonstrated by Kerley B lines (PCWP is 18-25 mm Hg).
  • Pulmonary edema is observed as perihilar infiltrates often in the classic butterfly pattern, reflecting a PCWP of more than 25 mm Hg.
  • Several limitations to chest radiography are observed when attempting to diagnose CHF. Classic radiographic progression is often not found, and as much as a 12-hour radiographic lag from onset of symptoms may occur. In addition, radiographic findings frequently persist for several days despite clinical recovery.
  • Treatment depends on
    • Acuity of presentation
    • Volume status
    • Systemic perfusion
  • As always in Every ER lecture ABC’s
    • Noninvasive positive pressure Ventilation
    • Endotracheal intubation

Treatment Acute Decompensated Heart Failure

HOSPITALIZATION — Hospital admission is recommended for patients with ADHF with the following clinical conditions:

  • Hypotension
  • Worsening renal function
  • Altered mentation
  • Dyspnea at rest
  • Also consider hospitalization for:

Worsened congestion, even if without dyspnea; typically reflected by a weight gain of ≥5kg

Signs and symptoms of pulmonary or systemic congestion, even in the absence of weight gain

Major electrolyte disturbance

Associated comorbid conditions such as pneumonia, pulmonary embolus, diabetic ketoacidosis, or symptoms suggestive of TIA or stroke

Repeated ICD firings

Previously undiagnosed HF with signs and symptoms of systemic or pulmonary congestion

High BNP levels

Poor compliance or ability to manage symptoms as an outpatient

  • Acute Pulmonary edema with normal or elevated BP
    • Sublingual NTG 0.4 mg q minute until reduction of BP or improvement of symptoms. IV NTG gtt can be used with rapid titration to 200ug/min or higher
    • IV Nitroprusside or Nesirtidemay can be used as an alternative
    • Diuretics IV Furosemide (40mg ) or bumetanide(1-3 mg) Ethacrynic acid (50mg) for sulfa allergy
    • Morphine 2-5 mg IV venodialtor
    • Contraindication to Vasodilators Right Ventricular MI, AS, Hypertrophic Cadiomyopathy
      • Goal of therapy in HCM with Pulmonary edema is to decreasing outflow gradient by slowing the hear in the ICU
  • Decompensated HF
    • Stable vitals, adequate oxygenation with symptoms i.e. SOB, DOE, JVD orthopnea and S3
    • Usually do well with Diuresis, O2 and BP control

Beta-blockers, particularly carvedilol, have been shown to improve symptoms in patients with moderate-to-severe heart failure. However, the role of beta-blockers in the acute setting is currently unclear; limit use until hemodynamic studies indicate that further deterioration is not possible. 

Digoxin has no place in the treatment of acute HF

Potassium sparring diuretics such as Spironolactone are generally reserved for class III or IV HF, aggressive use could result in hypokalemia

Nitroprusside Cardiac steal syndrome

Angiotensin-Coverting Enzyme Inhibitor

  • Drugs to aviod
    • Calcium channel blockers may result pulm edema and cardigenic shock secondary to negative inotropic effects
    • NSAIDS inhibits effects of ACEI and diuretics
    • Antiarrhythmics HFf patients are sensitive to pro-arrhythic and cardiodepressent effects
  • Pediatric
    • Most common cause is Congenital Heart Disease and dx in first 4 weeks of life
    • Masquerades or co-exists with pneumonia or sepsis
    • Symptoms poor feeding, weak cry, grunting and nasal flaring, diaphoresis, lethargy, poor weight gain, Murmur
chf peds

DDX of CHF based upon age

Age Spectrum

1 min anemia, acidosis, hypoxia, hypoglycemia,

1 hour hypocalcemia, sepsis

1 day PDA

1 week hypoplastic L verntricle

2 weeks Coarctation

1 month VSD

3 months SVT

1 year Myocarditis, Cardiomyopathy, severe anemia

10 year Rheumatic fever

pulmonary embolus
Pulmonary Embolus

DEFINITIONS — PE refers to obstruction of the pulmonary artery or one of its branches by material (eg, thrombus, tumor, air, or fat) that originated elsewhere in the body


Acute or Chronic

Submassive or Massive which is defined as causes hypotension, defined as a systolic blood pressure <90 mmHg or a drop in systolic blood pressure of ≥40 mmHg from baseline for a period >15 minutes

NATURAL HISTORY — Untreated PE is associated with a mortality rate of approximately 30 percent. Recurrent embolism is the most common cause of death.

pulmonary embolus45
Pulmonary Embolus


RV dysfunction — RV dysfunction due to PE predicts increased PE-related mortality

Brain natriuretic peptides (BNP)  — An elevated BNP or N-terminal pro-brain natriuretic peptide (NT-proBNP) predicts RV dysfunction and mortality, according to three meta-analyses

RV thrombus have a higher 14-day mortality

pulmonary embolus46
Pulmonary Embolus

PATHOPHYSIOLOGY — Most PE arise from thrombi in the deep venous system of the lower extremities. However, they may also originate in the right heart or the pelvic, renal, or upper extremity veins.

It is estimated that 50 to 80 percent of iliac, femoral, and popliteal vein thrombi

Fortunately, most calf vein thrombi resolve spontaneously and only 20 to 30 percent extend into the proximal veins if untreated

pulmonary embolus47
Pulmonary Embolus


Dyspnea most common symptoms were at rest or with exertion (73 percent),

Pleuritic pain (44 percent)

cough (34 percent)

>2-pillow orthopnea (28 percent)

Calf or thigh pain (44 percent)

Calf or thigh swelling (41 percent)

Wheezing (21 percent)

Tachypnea (54 percent)

Tachycardia (24 percent),

Rales (18 percent),

Recreased breath sounds (17 percent),

Accentuated pulmonic component of the second heart sound (15 percent)

pulmonary embolus48
Pulmonary Embolus
  • Laboratory — Routine laboratory findings are nonspecific. They include leukocytosis, an increased ESR, and an elevated serum LDH or AST (SGOT) with a normal serum bilirubin.
  • Arterial blood gas (ABG) measurements and pulse oximetry have a limited role in diagnosing PE
    • The typical arterial blood gas findings are not always seen
      • Hypoxemia can be minimal or absent. A PaO2 between 85 and 105 mmHg exists in approximately 18 percent of patients with PE.
      • Up to 6 percent may have a normal alveolar-arterial gradient for oxygen.

Troponins, BNP, ECG, CXR


Lower Extremity Ultrasound

pulmonary embolus49
Pulmonary Embolus
  • D-dimer — D-dimer is a degradation product of cross-linked fibrin. It can be detected in serum using a variety of different assays:
    • Enzyme-linked immunosorbent assay (ELISA) (results in >8 hrs)
    • Quantitative rapid ELISA (results in 30 min)
    • Semi-quantitative rapid ELISA (results in 10 min)
    • Qualitative rapid ELISA (results in 10 min)
    • Quantitative latex agglutination assay (results in 10 to 15 min)
    • Semi-quantitative latex agglutination assay (results in 5 min)
    • Erythrocyte agglutination assay (SimpliRED) (results in 2 min)

Angiography — Pulmonary angiography is the definitive diagnostic technique or "gold standard" in the diagnosis of acute PE. It is performed by injecting contrast into a pulmonary artery branch after percutaneous catheterization, usually via the femoral vein. A filling defect or abrupt cutoff of a small vessel is indicative of an embolus. A negative pulmonary angiogram excludes clinically relevant PE.

Spiral CT  98 percent of patients with PE were detected by CT-PA

The frequency of negative CT-PA among patients without PE was more consistent, around 90 percent

pulmonary embolus50
Pulmonary Embolus
  • Wells criteria
    • PE is unlikely (score ≤4) or likely (score >4). The modified Wells Criteria include the following :
      • Clinical symptoms of DVT (3 points)
      • Other diagnoses less likely than PE (3 points)
      • Heart rate >100 (1.5 points)
      • Immobilization ≥3 days or surgery in previous four weeks (1.5 points)
      • Previous DVT/PE (1.5 points)
      • Hemoptysis (1 point)
      • Malignancy (1 point)
pulmonary embolus51
Pulmonary Embolus
  • Common questions asked by clinicians when a patient presents with PE include:
    • Which anticoagulant should I administer? How much? How long?
    • Should I administer thrombolytic therapy?
    • Should an inferior vena caval filter be placed?
    • Is embolectomy indicated?
    • Can I withhold therapy and follow the patient instead?
pulmonary embolus52
Pulmonary embolus
  • Risk of death from PE untreated is 30%
  • Risk of bleeding complication is 3 %
  • Options
    • SC Low Molecular weight Heparin
    • IV Unfractionated Heparin
    • SC Unfractionated Heparin
    • SC Fondaparinux
pulmonary embolus53
Pulmonary Embolus
  • Warfarin
    • Highly effective for preventing recurrent PE
    • Can be intiated on same day of Hepatin and should not be started prior to heparin because of three fold increase in incidence of recurrent PE/DVT
    • Should be overlapped with Heparin for a minimum of 5 days until INR reaches 2-3 for at least 24 hours
pulmonary embolus54
Pulmonary Embolus

Duration of Therapy

  • First Episode
    • Reversible Risk factor i.e. immobilization, surgery and trauma Warfarin for 3 months
    • Unprovoked
      • Studies have shown benefit for . Then 3 month therapy in patient with PE or DVT and other studies have shown no benefit
      • 2008 ACCP antithrombotic and Thrombolytic therapy quidelines recommended 3 months of therapy because the study that recommeded 3 months of therapy was speciffically for PE
pulmonary embolus55
Pulmonary embolus
  • Reccurrent PE
  • Indefinate Warfarin therapy for patinets with 2 or more episodes of PE or PE
pulmonary embolus56
Pulmonary Embolus
    • Improves important physiologic parameters, such as RV function and pulmonary perfusion.
    • However, no clinical trial has been large enough to conclusively demonstrate a mortality benefit.
    • Thrombolytic therapy is associated with an increased risk of major hemorrhage.
    • Persistent hypotension due to PE (ie, massive PE) is the most widely accepted indication for thrombolytic therapy.
    • Some clinicians believe that thrombolysis should be considered on a case-by-case basis in certain other clinical circumstances, such as severe hypoxemia, large perfusion defects, right ventricular dysfunction, free-floating right atrial or ventricular embolus, and patent foramen ovale
pulmonary embolus57
Pulmonary Embolus
  • IVC FILTERS — Inferior vena caval (IVC) filters provide a screen in the inferior vena cava, allowing blood to pass through while preventing large emboli from traveling from the pelvis or lower extremities to the lung.
  • Indications — 
    • Absolute contraindication to anticoagulation (eg, active bleeding)
    • Recurrent PE despite adequate anticoagulant therapy
    • Complication of anticoagulation (eg, severe bleeding)
    • Hemodynamic or respiratory compromise that is severe enough that another PE may be lethal
pulmonary embolus58
Pulmonary Embolus
  • EMBOLECTOMY — Embolectomy (ie, removal of the emboli) can be performed using catheters or surgically. It should be considered when a patient's presentation is severe enough to warrant thrombolysis (eg, persistent hypotension due to PE), but this approach either fails or is contraindicated.
  • WITHHOLDING THERAPY — The diagnosis of PE almost invariably leads to treatment with anticoagulants or IVC filter placement. However, one retrospective analysis that used data from two prospective studies suggested that patients with PE who are hemodynamically stable, have adequate cardiopulmonary reserve, and have a contraindication to anticoagulation, can be safely observed without treatment if serial lower extremity venous ultrasounds are negative over 14 days. Although intriguing, the data are clearly insufficient to recommend this approach.
  • Croup (laryngotracheitis) is a respiratory illness characterized by inspiratory stridor, barking cough, and hoarseness.
    • It typically occurs in children six months to three years of age
    • Caused by parainfluenza virus.
    • Corticosteroids and nebulized epinephrine have become the cornerstones of therapy
  • Westley croup score 
    • Level of consciousness: Normal, including sleep = 0; disoriented = 5
    • Cyanosis: None = 0; with agitation = 4; at rest = 5
    • Stridor: None = 0; with agitation = 1; at rest = 2
    • Air entry: Normal = 0; decreased = 1; markedly decreased = 2
    • Retractions: None = 0; mild = 1; moderate = 2; severe = 3
      • Mild croup is defined by a Westley croup score of ≤2.
      • Moderate croup is defined by a Westley croup score of 3 to 7.
      • Severe croup is defined by a Westley croup score of ≥8.
  • MILD CROUP — Children with mild symptoms, defined by a Westley croup score of ≤2, should be treated symptomatically with humidity, fever reduction, and oral fluids. Many such children can be managed by phone, provided that none of the criteria for further evaluation described above are present.
    • Randomized controlled trials have demonstrated that treatment with a single dose of oral dexamethasone (0.15 to 0.6 mg/kg, maximum dose 10 mg) may reduce the need for reevaluation, shorten the course, improve duration of the child's sleep, and reduce parental stress
  • MODERATE TO SEVERE CROUP —  Westley croup score 3 to 7, stridor and retractions at rest without agitation should be evaluated in the emergency department or office
  • Supportive care for children with moderate/severe croup includes administration of humidified air or humidified oxygen
  • The child with severe croup must be approached cautiously, as any increase in anxiety may worsen airway obstruction.
  • Nebulized epinephrine should be added as quickly as possible
    • Racemic epinephrine is administered as 0.05 mL/kg per dose (maximum of 0.5 mL) of a 2.25 percent solution diluted to 3 mL total volume with normal saline. It is given via nebulizer over 15 minutes.
    • - L-epinephrine is administered as 0.5 mL/kg per dose (maximum of 5 mL) of a 1:1000 dilution. It is given via nebulizer over 15 minutes.
  • Dexamethasone (0.6 mg/kg, maximum of 10 mg), by the least invasive route possible: has a foul taste. The intravenous preparation is more concentrated (4 mg per mL) and can be given orally mixed with syrup. A single dose of nebulized budesonide is another option
  • Observation
  • Hospitalization
  • Indications — Children with moderate/severe croup whose condition worsens or fails to improve as expected after treatment with nebulized epinephrine and corticosteroids should be admitted to the hospital for repeated doses of nebulized epinephrine, observation, and supportive care. Poor response to nebulized epinephrine in conjunction with high fever and toxic appearance should prompt consideration of bacterial tracheitis Additional factors that influence the decision regarding admission include :
    • Need for supplemental oxygen
    • Moderate retractions and tachypnea, indicating increased work of breathing, which may lead to respiratory fatigue and failure
    • Degree of response to initial therapies
    • "Toxicity" or clinical picture suggesting serious secondary bacterial infection
    • Poor oral intake and degree of dehydration
    • Young age, particularly younger than six months
    • Ability of the family to comprehend the instructions regarding recognition of features that indicate the need to return for care
    • Ability of the family to return for care (eg, distance from home to care site, weather/travel conditions)
    • Recurrent visits to the ED within 24 hours
  • Epiglottitis is inflammation of the epiglottis and adjacent supraglottic structures. Without treatment, epiglottitis can progress to life-threatening airway obstruction.
  • Infectious epiglottitis is a cellulitis of the epiglottis, aryepiglottic folds, and other adjacent tissues
    • Children — Haemophilus influenzae type b (Hib) is the most common infectious cause of epiglottitis in children. Although the incidence of Hib epiglottitis declined after Hib was added to the routine infant immunization schedule in the United States and other developed countries, Hib epiglottitis still occurs, even in immunized children
    • Adults — In adults, epiglottitis has been associated with a broad range of bacteria, viruses, combined viral-bacterial infections, fungi, and noninfectious causes
  • Incidence — The epidemiology of epiglottitis changed after the addition of the Hib conjugate vaccine to the routine infant immunization schedule in the United States and other developed countries . Important changes included:
    • A decrease in the average annual incidence of epiglottitis in children.
    • An increase in the median age of epiglottitis in children (from approximately 36 months to 70 to 139 months) .
    • An increase in the average annual incidence of epiglottitis in adults.
    • The annual incidence of epiglottitis among children immunized against Hib ranges from 0.6 to 0.78 cases per 100,000. The annual incidence of epiglottitis in adults appears to be increasing, from <1 case per 100,000 in 1986 to two to three per 100,000 in the early to mid-2000s .
  • The reason for the increased incidence of epiglottitis in adults is not clear. Possible explanations include an increase in cases of non-Hib epiglottitis and increased diagnosis of milder cases secondary to greater physician awareness and increased availability of flexible nasopharyngoscopy
  • Clinical features
    • The clinical features of epiglottitis differ with age, severity, and etiology. Young children classically present with respiratory distress, anxiety, and the characteristic "tripod" or "sniffing" posture
    • However, the presentation may be subtle . Older children, adolescents, and adults may present with a severe sore throat but relatively normal oropharyngeal examination.
    • Children — Abrupt onset and rapid progression (within hours) of dysphagia, drooling, and distress ("the three D's") are hallmarks of epiglottitis in children
  • Symptoms:
  • Children
    • Difficulty breathing (80 percent)
    • Stridor (80 percent)
    • Muffled or hoarse voice (79 percent)
    • Pharyngitis (73 percent)
    • Fever (57 percent)
    • Sore throat (50 percent)
    • Tenderness of anterior neck (38 percent)
    • Cough (30 percent)
    • Difficulty swallowing (26 percent)
    • Change in voice (20 percent)
  • Symptoms
  • Adults
    • Sore throat or odynophagia (90 to 100 percent)
    • Fever ≥37.5ºC (26 to 90 percent)
    • Muffled voice (50 to 80 percent)
    • Drooling (15 to 65 percent)
    • Stridor or respiratory compromise (approximately 33 percent)
    • Hoarseness (20 to 40 percent)
  • Examination
    • Examining children — Examination of a child in whom epiglottitis is a consideration should occur in a setting where the airway can be secured immediately if necessary (eg, the operating room, emergency department, or intensive care unit).
    • Examination efforts should be individualized according to the severity of illness of the child. There are rare reports of cardiorespiratory arrest during attempts to visualize the epiglottis. These arrests have been attributed to functional airway obstruction (resulting from increased respiratory effort secondary to increased anxiety) and/or aggravation of airway obstruction caused by supine positioning.
  • Examination
    • Examination of the oral cavity and oropharynx in patients with epiglottitis is normal in the majority of patients.
    • Pooled secretions may be noted.
    • The laryngotracheal complex may be tender to palpation, particularly in the region of the hyoid bone
    • Laboratory features — Laboratory studies should not be performed in patients with suspected epiglottitis until the airway is secured. Laboratory evaluation should include complete blood count with differential, blood culture, and epiglottal culture (in intubated patients).
  • Radiographic features — 
    • Soft-tissue lateral neck radiographs can confirm the diagnosis of epiglottitis but are not necessary in many cases. Radiographs are most helpful in the evaluation of children in whom epiglottitis is a possibility but other conditions are more likely
    • Radiographic features of epiglottitis include:
      • An enlarged epiglottis protruding from the anterior wall of the hypopharynx (the "thumb sign". In adults with epiglottitis, the width of the epiglottis is usually >8 mm.
      • Loss of the vallecular air space, a finding that may be underappreciated.
      • Thickened aryepiglottic folds. In adults with epiglottitis, the width of the aryepiglottic folds is usually >7 mm.
      • Distended hypopharynx (nonspecific).
      • Straightening or reversal of the normal cervical lordosis (nonspecific)
  • DIAGNOSIS — Diagnosis of epiglottitis is made by visualization of the epiglottis or demonstration of epiglottal swelling on lateral neck radiographs. Cultures of the blood and/or surface of the epiglottis identify the microbial pathogen.