Paediatric Respiratory Conditions: Croup, Epiglottitis, RSV Bronchiolitis, Asthma

Paediatric Respiratory Conditions: Croup, Epiglottitis, RSV Bronchiolitis, Asthma

A high-density, practical guide for clinicians, nurses, and students

What Is This?

This guide covers four critical paediatric respiratory conditions: croup, epiglottitis, RSV bronchiolitis, and asthma. You’ll learn to recognise, assess, and manage these conditions in real-world clinical settings—whether in emergency departments, primary care, or inpatient wards.

Why it matters today: - Croup and epiglottitis are life-threatening upper airway emergencies requiring rapid intervention. - RSV bronchiolitis is the leading cause of infant hospitalisation in winter. - Asthma is the most common chronic childhood disease, with acute exacerbations causing preventable morbidity. Mastering these conditions saves lives, reduces hospital stays, and improves long-term outcomes.

Why It Matters

Real-World Impact

Industry relevance: - Emergency medicine: Fast, accurate diagnosis prevents intubation and ICU transfers. - Primary care: Early recognition reduces hospital admissions. - Public health: RSV and asthma management reduces healthcare costs and improves quality of life.

Core Concepts

1. Pathophysiology: Why These Conditions Differ

2. Clinical Red Flags (When to Worry)

3. Key Investigations

4. Management Principles

How It Works: Clinical Approach

Step-by-Step Assessment

1. ABCDE Approach (Always Start Here)
2. Airway: Listen for stridor (croup/epiglottitis) or wheeze (asthma/RSV).
3. Breathing: Count respiratory rate (tachypnoea = distress).
4. Circulation: Check pulse (tachycardia = hypoxia/dehydration).
5. Disability: Assess alertness (lethargy = severe hypoxia).

6. Exposure: Look for retractions, cyanosis, rash.

7. Differentiate Upper vs. Lower Airway

8. Upper airway (croup/epiglottitis): Stridor, hoarse voice, barking cough.

9. Lower airway (RSV/asthma): Wheeze, prolonged expiration, crackles.

10. Severity Grading

11. Croup: Westley Score (mild/moderate/severe).
12. Asthma: PRAM Score (Paediatric Respiratory Assessment Measure).

13. RSV: Bronchiolitis Severity Score (mild/moderate/severe).

14. Decide: Home vs. Hospital

15. Home: Mild croup (no stridor at rest), mild asthma (no hypoxia).
16. Hospital: Severe croup (stridor at rest), epiglottitis, RSV with SpO? <90%, asthma with silent chest.

Hands-On: Managing an Acute Case

Prerequisites

• Knowledge: Basic paediatric airway anatomy, ABCDE approach.
• Equipment:
• Pulse oximeter, nebuliser, oxygen, suction, IV access.
• Medications: Dexamethasone, adrenaline, salbutamol, prednisolone.

Step-by-Step: Child with Croup (Moderate-Severe)

1. Assess:
2. 18-month-old with barking cough, stridor at rest, retractions.

3. SpO? 92% on room air, RR 40, HR 150.

4. Intervene: ```plaintext

5. Give dexamethasone 0.6 mg/kg PO (or IM if vomiting).
6. Administer nebulised adrenaline (1:1000, 5 mL) via face mask.
7. Apply oxygen (1–2 L/min via nasal cannula) if SpO? <92%.

8. Monitor closely for worsening stridor or lethargy. ```

9. Expected Outcome:

10. Stridor improves within 30 minutes of adrenaline.
11. Child discharged home after 2–4 hours of observation if stable.

Step-by-Step: Infant with RSV Bronchiolitis

1. Assess:

2. 6-month-old with wheeze, crackles, poor feeding, SpO? 88%.

3. Intervene: ```plaintext

4. Apply oxygen (via nasal cannula) to maintain SpO? >90%.
5. Perform nasal suctioning (bulb syringe or wall suction).
6. Start NG feeds if unable to feed orally.

7. Consider HFNC if severe (e.g., RR >70, apnoea). ```

8. Expected Outcome:

9. Oxygen weaned over 24–48 hours.
10. Discharged when feeding well, SpO? >90% on room air.

Common Pitfalls & Mistakes

Best Practices

1. Communication with Parents

• Croup: "This is a viral infection causing a barking cough. Steroids will reduce swelling in the airway."
• Epiglottitis: "This is an emergency. We need to secure the airway first, then give antibiotics."
• RSV: "This virus causes mucus buildup. Suctioning and oxygen will help your baby breathe easier."
• Asthma: "This is a long-term condition. We’ll adjust medications to prevent flare-ups."

2. Discharge Criteria

3. Prevention Strategies

• Croup/RSV: Hand hygiene, avoid sick contacts, palivizumab (for high-risk infants).
• Epiglottitis: Hib vaccine (dramatically reduced cases).
• Asthma: Inhaled corticosteroids (ICS), asthma action plan, trigger avoidance.

Tools & Frameworks

Clinical Scores

Equipment

Real-World Use Cases

1. Emergency Department: Child with Stridor

• Scenario: 2-year-old presents at 2 AM with barking cough, stridor, retractions.
• Action:
• Dexamethasone 0.6 mg/kg PO (or IM if vomiting).
• Nebulised adrenaline if stridor at rest.
• Observe for 2–4 hours-discharge if improved.
• Outcome: Avoids intubation, reduces ED crowding.

2. Paediatric Ward: Infant with RSV

• Scenario: 4-month-old with wheeze, poor feeding, SpO? 88%.
• Action:
• Oxygen via nasal cannula (target SpO? >90%).
• Nasal suctioning before feeds.
• NG feeds if unable to feed orally.
• HFNC if severe (RR >70, apnoea).
• Outcome: Prevents respiratory failure, shortens hospital stay.

3. Primary Care: Asthma Exacerbation

• Scenario: 7-year-old with wheeze, cough, PEF 50% predicted.
• Action:
• Salbutamol 4–6 puffs via spacer (repeat every 20 mins).
• Prednisolone 1–2 mg/kg PO (max 60 mg).
• Refer to ED if no improvement in 1 hour.
• Outcome: Prevents hospital admission, improves lung function.

Check Your Understanding (MCQs)

Question 1

A 2-year-old presents with a barking cough, stridor at rest, and retractions. What is the most appropriate first-line treatment?

A. Oral amoxicillin B. Nebulised salbutamol C. Oral dexamethasone D. IV ceftriaxone

Correct Answer: C. Oral dexamethasone Explanation: This child has moderate-severe croup, where dexamethasone (0.6 mg/kg) is first-line to reduce airway oedema. Why the Distractors Are Tempting: - A (Amoxicillin): Croup is viral (parainfluenza), so antibiotics are not indicated. - B (Salbutamol): Used for asthma, not croup (wheeze vs. stridor). - D (Ceftriaxone): Used for epiglottitis, not croup.

Question 2

A 6-month-old with wheeze, crackles, and SpO? 88% is diagnosed with RSV bronchiolitis. Which intervention is most likely to improve oxygenation?

A. Nebulised salbutamol B. Nasal suctioning C. Oral prednisolone D. IV fluids

Correct Answer: B. Nasal suctioning Explanation: RSV causes mucus plugging in small airways. Suctioning clears secretions and improves oxygenation. Why the Distractors Are Tempting: - A (Salbutamol): Ineffective in RSV (no bronchospasm). - C (Prednisolone): Steroids do not help in RSV bronchiolitis. - D (IV fluids): Helps dehydration but does not improve oxygenation.

Question 3

A 4-year-old with asthma presents with silent chest, SpO? 89%, and inability to speak. What is the next best step?

A. Oral prednisolone B. Nebulised salbutam