Pediatric Upper Airway Obstruction: Croup, Epiglottitis & Tracheitis
Comprehensive emergency evaluation and protocolized management of acute infectious pediatric upper airway obstruction: viral laryngotracheobronchitis (Croup/parainfluenza), acute bacterial epiglottitis (Haemophilus influenzae type b, Streptococcus), bacterial tracheitis, and peritonsillar/retropharyngeal abscesses; differentiating inspiratory stridor from expiratory wheezing, the Westley Croup Score, nebulized racemic epinephrine vs. standard L-epinephrine dosing, oral/IM Dexamethasone, post-epinephrine rebound observation periods, and the 'tripod/sniffing position' difficult airway.
Resuscitation Quick Actions • First 2 Minutes
Dexamethasone Dose
0.6 mg/kg PO/IM/IV once (max 16 mg); effective within 1–2 hours with an elimination half-life of 36–72 hours
Nebulized Epinephrine
Racemic Epinephrine 2.25% (0.5 mL in 3 mL NSS) OR Standard 1:1,000 L-Epinephrine (5 mL nebulized); rapid alpha-1 mucosal vasoconstriction
Post-Epinephrine Rebound
Observe all patients receiving nebulized epinephrine for a minimum of 2 to 4 hours in the ED to ensure stridor does not recur as vasoconstriction wanes
Epiglottitis Tripod Sign
Child sitting upright, leaning forward, chin tilted up ('sniffing'), mouth open, drooling, high fever; DO NOT agitate with tongue blades or IV attempts
Bacterial Tracheitis Suspect
Failure to respond to nebulized epinephrine + high fever + toxic appearance + copious thick 'pseudomembranous' tracheal pus = Tracheitis
Operating Room Intubation
In severe epiglottitis or tracheitis, intubation should occur in the Operating Room with pediatric ENT and surgical airway equipment ready
Bottom-Line Clinical Pearl
Pediatric upper airway obstruction presents with acute inspiratory stridor, barking cough, and retractions. Croup (parainfluenza) is the most common cause (ages 6 mo–3 yr); steeple sign on AP neck X-ray reflects subglottic tracheal narrowing. All croup patients benefit from Dexamethasone 0.6 mg/kg (oral or IM, max 16 mg). Moderate-to-severe stridor at rest requires Nebulized Epinephrine (0.5 mL of 2.25% racemic epinephrine or 5 mL of standard 1:1,000 L-epinephrine). Observe for at least 2–4 hours post-epinephrine for rebound stridor. If a croup patient deteriorates with high fever, toxic appearance, and copious purulent tracheal secretions unresponsive to epinephrine, suspect Bacterial Tracheitis (Staphylococcus aureus) and prepare for emergent endotracheal intubation in the operating room.
The pediatric airway is narrowest at the cricoid ring (subglottic space), unlike the adult airway which is narrowest at the vocal cords. By Poiseuille's law, airflow resistance is inversely proportional to the radius to the fourth power ($R \propto 1/r^4$). In an infant with a 4 mm subglottic tracheal diameter, just 1 mm of circumferential mucosal edema reduces the cross-sectional airway area by 75% and increases airway resistance 16-fold.
| Condition & Peak Age | Microbiology & Onset | Hallmark Clinical Features | Radiographic Signs & Emergency Actions |
|---|---|---|---|
| Croup (Laryngotracheitis) (6 months to 3 years) | Parainfluenza virus (types 1 & 3); gradual onset following viral URI | Inspiratory stridor, barking 'seal-like' cough, hoarseness, low-grade fever; child usually non-toxic | 'Steeple Sign' on AP soft-tissue neck X-ray (subglottic tracheal tapering). Administer oral Dexamethasone 0.6 mg/kg + Nebulized Epinephrine. |
| Acute Epiglottitis (2 to 7 years, or unvaccinated) | Haemophilus influenzae type b (Hib), Streptococcus pyogenes, Staphylococcus aureus; rapid hyperacute onset | High fever, toxic appearance, absence of barking cough, the '4 Ds': Drooling, Dysphagia, Dysphonia, Distressed inspiratory stridor; classic tripod positioning | 'Thumbprint Sign' on lateral neck X-ray (thickened, rounded epiglottis). DO NOT agitate the child. Transfer immediately to OR for controlled intubation. |
| Bacterial Tracheitis (1 to 8 years) | Staphylococcus aureus (including MRSA), Streptococcus pneumoniae; secondary bacterial superinfection following viral croup | High fever, worsening toxicity, subglottic edema, failure to respond to nebulized epinephrine, copious thick purulent secretions | Subglottic narrowing with ragged, irregular tracheal mucosal borders. Prepare for urgent intubation and tracheal toilet with vancomycin + cefepime. |
| Clinical Parameter | 0 Points | 1 Point | 2 Points | 3 Points |
|---|---|---|---|---|
| Inspiratory Stridor | None | With agitation/crying | At rest | — |
| Chest Retractions | None | Mild (intercostal) | Moderate (substernal) | Severe (supraclavicular) |
| Air Entry (Auscultation) | Normal | Decreased | Markedly decreased | — |
| Cyanosis | None | — | — | With agitation (4 pts)/At rest (5 pts) |
| Level of Consciousness | Normal alert | — | — | Disoriented/Depressed (5 pts) |
Scoring Tiers & Protocolized Management: Mild ($\le 2$ pts): Single dose Dexamethasone 0.6 mg/kg PO; safe for discharge with return precautions. Moderate ($3\text{ to }5$ pts): Dexamethasone 0.6 mg/kg PO/IM + Nebulized Racemic Epinephrine; observe for 2–4 hours. Severe ($\ge 6$ pts): Immediate Nebulized Epinephrine + IV/IM Dexamethasone + humidified blow-by oxygen; prepare for hospital admission or ICU transfer.
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