Clinical scenario 3: Harry

Harry, a two year old boy, presents with a barking cough and stridor at rest. He had been well up until this evening, apart from a mild runny nose and slight cough. On examination he has moderate respiratory distress with intercostal and subcostal recessions and tug. His RR is 35, HR 140 and saturations 94% in room air. He has a clear chest and inspiratory stridor at rest. He has been previously well and his immunisations are up to date.

The following five questions refer to Harry's clinical scenario.

Question 15

Which one of the following features would be most concerning in a child with stridor?
Loud stridor
Presence of fever to 38.5ºC
Biphasic stridor
Wheeze
History of allergy
Check answer

Explanation

The combination of biphasic (inspiratory and expiratory) stridor increases the likelihood of an underlying fixed tracheal obstruction (e.g. acquired subglottic stenosis). This will need urgent assessment by an ENT or paediatric specialist.

Question 16

Which one of the following is the most likely diagnosis?
Bacterial tracheitis
Anaphylaxis
Croup
Epiglottitis
Laryngeal foreign body
Check answer

Explanation

Croup is the most common cause of this type of presentation. Epiglottitis is extremely rare post-Hib vaccination and usually presents with a toxic child with quiet breathing and drooling.

Question 17

Which of the following would you include in your initial management of this child?
Oxygen via mask, nebulised salbutamol and oral dexamethasone
Oxygen via mask, nebulised adrenaline and oral dexamethasone
IM adrenaline, oral dexamethasone, and nebulised salbutamol
Oxygen via mask and oral dexamethasone
Nebulised salbutamol and oral dexamethasone
Check answer

Explanation

Oxygen is the immediate treatment of choice for children with severe viral croup who have considerable upper airway obstruction, prior to the administration of pharmacological treatment in the hospital setting. A child with persisting inspiratory stridor at rest and marked chest wall retractions has severe croup. He should receive immediate treatment with nebulised adrenaline (1:1000 concentrations at a dose of 0.5 ml/kg. Max 5ml). A dose of oral corticosteroid (dexamethasone 0.15 to 0.6 mg/kg/dose) or prednisone 1-2mg/kg/dose) should be administered. The child should be reassessed regularly.

For more information, please see the NSW Health croup guidelines

Harry's clinical scenario continued

You give Harry oxygen via a face mask, then nebulised adrenaline, as well as a dose of dexamethasone as per the NSW health guidelines. He has minimal response and has a further dose of nebulised adrenaline.

When you review him again, you note he is febrile to 39ºC. He appears flushed and unwell. He prefers to lie flat. His respiratory rate is now 45 with a HR 160. His stridor is now soft and biphasic.

Question 18

Which one of the following is the most likely diagnosis?
Bacterial tracheitis
Retropharyngeal foreign body
Croup
Epiglottitis
Diphtheria
Check answer

Explanation

Bacterial tracheitis is not common, while croup is. However, if a child is not responding to treatment of croup as expected and appears toxic, you should consider a broader differential than simple croup.

Question 19

Which one of the following is the most likely organism?
Parainfluenza
Staphylococcus aureus
Haemophilus influenza B
Group A streptococcus (Strep pyogenes)
Corynebacterium diphtheriae
Check answer

Explanation

Bacterial tracheitis almost always occurs in the setting of prior airway mucosal damage, as occurs with antecedent viral infection. Staphylococcus aureus is the most common bacterial isolate. Other commonly isolated bacteria include streptococcus pneumoniae, group A streptococcus (streptococcus pyogenes), alpha-hemolytic streptococci, and moraxella catarrhalis. The most frequently reported clinical features include fever, stridor, cough and a preference to lie flat. Drooling is uncommon, but may be present.

Children with peritonsillar, retropharyngeal cellulitis/abscess or other painful infections of the oropharynx may present with drooling, change in voice quality and neck extension. Two-to-four years is the peak age of presentation. It is often a poly-microbial infection. The predominant bacterial species are Group A streptococcus, staph aureus and respiratory anaerobes. The cornerstones of treatment for bacterial tracheitis are maintenance of the airway, fluid resuscitation and administration of appropriate antimicrobial agents. Broad coverage for these pathogens generally requires an antistaphylococcal agent (eg, vancomycin or clindamycin) plus a third-generation cephalosporin (eg,cefotaxime or ceftriaxone). Some children require emergent or urgent evaluation of the airway via endoscopy. They should generally be admitted to a paediatric intensive care unit, even if endotracheal intubation is not required due to risk of disease progression.

With epiglottitis, sudden onset of high fever (between 38.8º and 40.0ºC), severe sore throat, odynophagia and drooling is common. Children usually appear "toxic", are anxious, restless and irritable. Their speech is muffled and may lack hoarseness, cough and stridor until late in the disease process. Haemophilus influenzae type b (Hib) is the most common infectious cause of epiglottitis in children. Thus, the incidence has dramatically reduced with routine immunisation, although cases still occur.

The clinical presentation of diphtheria can be similar to that of bacterial tracheitis, with sore throat, malaise and low-grade fever. A diphtheritic membrane may be present. Diphtheria is exceedingly rare in countries with high rates of immunization for diphtheria, tetanus, and pertussis.

Loading stats...