A 2-year-old boy is brought to the emergency department due to difficulty breathing that started 6 hours earlier. The patient has had rhinorrhea, nasal congestion, and a dry cough that sounds "like a barking dog" for the past day. Temperature is 37.7 C (99.9 F), blood pressure is 92/64 mm Hg, pulse is 122/min, and respirations are 30/min. Pulse oximetry is 99% on room air. The patient has inspiratory stridor when crying. He is diagnosed with croup, administered oral dexamethasone, and observed in the emergency department. On reassessment 30 minutes later, oxygen saturation is 96% on room air and respirations are 40/min. The patient has inspiratory stridor at rest and subcostal and intercostal retractions. Which of the following is the best next step in management of this patient?

Question

A 2-year-old boy is brought to the emergency department due to difficulty breathing that started 6 hours earlier.  The patient has had rhinorrhea, nasal congestion, and a dry cough that sounds "like a barking dog" for the past day.  Temperature is 37.7 C (99.9 F), blood pressure is 92/64 mm Hg, pulse is 122/min, and respirations are 30/min.  Pulse oximetry is 99% on room air.  The patient has inspiratory stridor when crying.  He is diagnosed with croup, administered oral dexamethasone, and observed in the emergency department.  On reassessment 30 minutes later, oxygen saturation is 96% on room air and respirations are 40/min.  The patient has inspiratory stridor at rest and subcostal and intercostal retractions.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d1fe_17b3_bc81_935517d387f0_MD0003_00 Croup is a viral illness that causes laryngeal and tracheal inflammation, leading to subglottic edema and narrowing. The classic presentation includes a barky, seal-like cough with inspiratory stridor. Mild cases (no stridor at rest) are treated with a single dose of corticosteroids (eg, dexamethasone) to decrease airway edema. Stridor at rest (severe croup), such as in this patient, can develop in those with progressive airway swelling and obstruction; these patients are treated with nebulized epinephrine in addition to corticosteroids. Nebulized epinephrine constricts mucosal arterioles in the upper airway and alters capillary hydrostatic pressure, leading to decreased airway edema and reduced secretions. After administration, patients are observed for 4 hours because symptoms can recur. Patients needing multiple doses of nebulized epinephrine typically require hospital admission. Intubation with mechanical ventilation is reserved for those who have failed treatment with corticosteroids and nebulized epinephrine and/or have signs of impending respiratory failure (eg, altered mental status, poor respiratory effort) (Choice B). (Choice A) Steeple sign on chest x-ray confirms croup if the diagnosis is uncertain. However, this patient has classic croup, and imaging would delay intervention for his respiratory distress. Steeple sign (Choice C) Nebulized albuterol is the first-line treatment for asthma exacerbations because its beta-agonist effect (bronchodilation) relieves lower airway bronchospasm. Albuterol does not reduce subglottic edema or play a role in the treatment of croup. (Choice E) Although supplemental oxygen should improve hypoxemia (oxygen saturation <92%), this patient is not hypoxemic and oxygen would not correct the underlying subglottic edema. Educational objective: Croup, a viral infection that causes subglottic edema and narrowing, presents with a barky cough and inspiratory stridor. Patients with stridor at rest are treated with corticosteroids and nebulized epinephrine. References: Croup. (http://www.ncbi.nlm.nih.gov/pubmed/25263284) Viral croup: diagnosis and a treatment algorithm. (http://www.ncbi.nlm.nih.gov/pubmed/24596395)

A 2-Year-Old Boy Is Brought to the Emergency Department Due