A 2-Year-Old Child With Cough and Respiratory Distress: Family Medicine and Community Health

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CASE
Family Medicine and Community Health
CASE STUDY
A 2-year-old child with cough and respiratory distress

John Murtagh
Case history other respiratory viruses (influenza, adenovi- CORRESPONDING AUTHOR:

A 2-year-old girl was brought to the hospital rus, and respiratory syncytial virus) can cause John Murtagh
for evaluation of a harsh cough and difficulty an identical illness. Emeritus Professor, Department
breathing. She developed a cold with a runny Although uncommon, croup is a life- of General Practice, Monash Uni-
versity, Victoria 3165, Australia
nose 3 days ago and has been feeling ill. Her threatening illness. Other serious conditions
E-mail: john.murtagh@monash.
mother said she was awake most of the previous to consider are influenza (SARS or avian edu
night with a barking cough and noisy breathing. influenza), pneumonia, epiglottitis, and inha-
The physical examination revealed an oth- lation of a foreign body. Funding: This research received
erwise healthy child with persistent inspiratory In the current case, croup was classified as no specific grant from any fund-
ing agency in the public, com-
stridor and lower rib retractions at rest. Her vital grade 2, which requires careful observation
mercial, or not-for-profit sectors.
signs included a pulse of 130/min, a respiratory and anti-inflammatory treatment.
rate of 40/min, a BP of 90/60 mmHg, and an Received 24 March 2014;
axillary temperature of 37.3°C. Auscultation Grading system for croup Accepted 9 May 2014
revealed an inspiratory stridor transmitted CROUP SCORE
through the lung fields. There was no cyanosis Grade 1 – Stridor at rest without chest retrac-
and no other abnormal physical signs. tions and no distress
Grade 2 – Stridor at rest with sternal and chest
Questions to ask wall retractions
–– What is the most likely diagnosis? Grade 3 – Marked respiratory distress, as indi-
–– What serious life-threatening conditions cated by irritability, pallor, cyanosis, tachycar-
must be considered in this patient? dia, and exhaustion, with impending airway
–– Can the patient be treated at home with obstruction.
simple methods, such as exposure to
steam or other forms of humidified air? Management
–– Should antibiotics be prescribed? The patient had grade 2 croup (n.b., grade 2 or
–– Should the child be hospitalized 3 croup require close observation). With grade
for safety reasons and specialized 2 croup, the serious symptoms may resolve in
treatment? approximately 3 days, but during that time
airway obstruction is a potential problem. As
Discussion a general rule, children with stridor at rest or
The provisional diagnosis for this presentation other signs of respiratory distress require hos-
is laryngotracheal bronchitis (croup), which pitalization or at least close observation in a
is usually caused by parainfluenza virus, but medical facility.
Family Medicine and Community Health 2014;2(2):37–3837

www.fmch-journal.org DOI 10.15212/FMCH.2014.0133
© 2014 Family Medicine and Community Health
STUDY
CASE
Murtagh
The main indications for special observation and care are demonstrated any significant benefit. However, we do know
as follows: that children with mild croup benefit from being taken out-
• Respiratory distress or stridor at rest doors, especially if the atmosphere is humid, the air is moist, or
• Uncertainty of diagnosis if there is a steamy atmosphere in the home. Parents should not
• Social reasons be discouraged from trying this treatment approach, but must
In the current case, first-line treatment was corticosteroids. be warned of the dangers of burns from steam in the home.
Oral, intravenous, intramuscular, and nebulized corticos-
teroids are all effective options. Oral corticosteroids (pred- Nebulized adrenaline
nisolone [1 mg/kg] or dexamethasone [0.3 mg/kg]) can be Nebulized adrenaline should be used for grade 3 croup, or
administered as a once daily dose for 1 or 2 days. Nebulized grade 2 croup not responding to corticosteroids. The dose
budesonide should be considered for children who have vom- of nebulized adrenaline is 5 mL of 1:1000 adrenaline in the
ited after taking oral steroids. Some children are upset by the nebulizer (run with oxygen at 8 L a minute). This dose can be
nebulization process. repeated if there is an unsatisfactory response after 10–15 min.
Antibiotics and anti-tusssives are not recommended for The fluid from the ampoules of adrenaline is simply emptied
croup. into the nebulizer. Some authorities regard nebulized adrena-
line as first-line therapy
Steam and humidified air
Traditional humidified air or ‘mist’ therapy, such as in a mist Conflict of interest
tent, is no longer recommended as controlled studies have not The author declares no conflict of interest.
38 Family Medicine and Community Health 2014;2(2):37–38

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