What is the initial step in managing a 2-year-old patient with a persistent cough, cold and flu symptoms, barking cough, and respiratory distress, presenting with tachycardia (elevated heart rate)?

Management of a 2-Year-Old with Barking Cough and Respiratory Distress

The initial step in managing this 2-year-old child with barking cough and respiratory distress should be administration of oral dexamethasone (0.15-0.60 mg/kg) as a single dose. 1

Clinical Assessment and Diagnosis

This child presents with classic symptoms of croup:

• Persistent cough progressing to a barking cough
• Respiratory distress (difficulty catching breath)
• 3-day history of cold and flu symptoms
• Tachycardia
• Similar symptoms in brother that resolved spontaneously

These findings strongly suggest viral croup (laryngotracheobronchitis), which is the most common cause of acute airway obstruction in young children 2. The barking cough is particularly characteristic of croup, resulting from subglottic edema and inflammation.

Management Algorithm

Step 1: Assess Severity

• Mild croup: Barking cough, no audible stridor at rest, minimal respiratory distress
• Moderate croup: Barking cough, audible stridor at rest, mild to moderate respiratory distress
• Severe croup: Prominent stridor, significant respiratory distress, agitation or lethargy

This child appears to have moderate croup based on the barking cough and respiratory distress.

Step 2: Initial Treatment

• Administer dexamethasone 0.15-0.60 mg/kg orally as a single dose 1
• This is recommended for all severities of croup to reduce symptoms, return visits, and length of hospitalization

Step 3: For Moderate to Severe Symptoms

• If the child has significant respiratory distress, administer nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 mL) 1
• Monitor oxygen saturation - provide supplemental oxygen if saturation is <92% 3, 1

Step 4: Observation and Disposition Decision

• Monitor the child for at least 2-3 hours after nebulized epinephrine administration (if given) to watch for rebound symptoms 1
• Consider hospital admission if any of the following are present:
  • Oxygen saturation <92% or cyanosis
  • Persistent significant respiratory distress after treatment
  • Stridor at rest that persists after treatment
  • Need for more than one dose of nebulized epinephrine
  • Inability to tolerate oral fluids
  • Toxic appearance 1

Important Considerations

Supportive Care

• Maintain a calm environment to avoid agitating the child
• Position the child comfortably (often upright position is preferred)
• Ensure adequate hydration 1

Monitoring

• Closely monitor respiratory rate, work of breathing, and oxygen saturation
• Watch for signs of deterioration including increased work of breathing, lethargy, or cyanosis 3

Cautions

• Avoid routine imaging unless there is suspicion of an alternative diagnosis or failure to respond to standard therapy 1
• The effect of nebulized epinephrine is short-lived (1-2 hours), and patients should be observed for rebound symptoms 1, 4
• Rare but serious complications of racemic epinephrine can occur, including myocardial effects 4

Differential Diagnosis Considerations

• Epiglottitis: Distinguished from croup by sudden onset, dysphagia, drooling, and absence of viral prodrome
• Foreign body aspiration: Distinguished by absence of fever and viral prodrome, sudden onset
• Bacterial tracheitis: More toxic appearance, higher fever
• Recurrent croup: If this is not the first episode, consider underlying structural or inflammatory airway abnormalities 2

Most children with croup can be managed as outpatients with appropriate treatment and follow-up instructions, as the condition typically resolves within 2 days 1.