What is the most appropriate treatment approach for a patient with severe laryngotracheitis, agitation, pan-retractions, biphasic stridor, and hypoxia despite receiving dexamethasone and inhaled racemic epinephrine?

Rapid Sequence Intubation is the Most Appropriate Treatment

This child requires immediate rapid sequence intubation (RSI) to secure the airway and prevent imminent respiratory arrest. Despite maximal medical therapy with dexamethasone and multiple doses of racemic epinephrine, she demonstrates severe respiratory failure with persistent hypoxia (SpO2 82% on high-flow oxygen), pan-retractions, biphasic stridor, and agitation—all indicating impending complete airway obstruction 1, 2.

Why RSI is Indicated Now

This patient has failed medical management and meets criteria for immediate airway intervention:

• Severe hypoxemia unresponsive to oxygen therapy (SpO2 82% on 10 L/min) indicates critical respiratory failure requiring definitive airway control 1
• Pan-retractions with biphasic stridor signify severe upper airway obstruction with exhaustion of respiratory muscles 1
• Agitation is a sign of hypoxia and impending respiratory arrest, not simply anxiety 1
• Failure of three doses of racemic epinephrine demonstrates that medical therapy has been maximized without success 2, 3

RSI Technique for Pediatric Severe Croup

Pre-intubation Preparation

• Position the child semi-upright (head and torso inclined) to optimize oxygenation and reduce work of breathing 4
• Preoxygenate with high-flow oxygen via well-fitting mask for 3-5 minutes, though this may be limited by the child's agitation 4
• Have vasopressors immediately available (epinephrine infusion ready) as hemodynamic instability is common during pediatric RSI 1
• Prepare for difficult airway: Have a videolaryngoscope ready as first-line device, with smaller endotracheal tubes available (consider using a tube 0.5-1.0 size smaller than predicted due to airway edema) 4

Medication Selection

• Ketamine 1-2 mg/kg IV is the induction agent of choice, as it maintains cardiovascular stability and preserves airway reflexes better than other agents in critically ill children 4
• Rocuronium 1.2 mg/kg IV for neuromuscular blockade, ensuring full paralysis before laryngoscopy to prevent coughing and further airway trauma 4
• Administer sedative-hypnotic before neuromuscular blockade to prevent awareness 4

Intubation Approach

• Use videolaryngoscopy as first-line technique to maximize first-pass success and allow the operator to maintain distance from the airway 4
• Limit attempts: Maximum of 3 attempts before transitioning to rescue techniques 4
• Have a bougie immediately available to facilitate tube passage through the edematous, narrowed airway 4

Why Other Options Are Inappropriate

Calming Measures Alone

Attempting calming measures at this stage is dangerous and inappropriate. The agitation is a manifestation of severe hypoxia, not anxiety 1. Delaying definitive airway management will result in respiratory arrest.

Noninvasive Positive-Pressure Ventilation (NIPPV)

NIPPV is contraindicated in this scenario because:

• The child is agitated and hypoxic, making mask tolerance impossible 4
• Severe upper airway obstruction from laryngeal edema prevents effective positive pressure ventilation 4
• Risk of gastric distention and aspiration is high with NIPPV in an agitated child with airway obstruction 4

Needle Cricothyrotomy

While needle cricothyrotomy is a rescue technique for "can't intubate, can't ventilate" situations, it should not be the first-line approach 4. RSI should be attempted first by an experienced operator. Needle cricothyrotomy has significant limitations:

• Inadequate for effective ventilation in patients with high airway resistance or poor lung compliance 4
• High complication rates in pediatric patients
• Should only be performed after failed intubation and failed rescue oxygenation with supraglottic airway devices 4

Critical Pitfalls to Avoid

• Do not delay intubation waiting for the child to "calm down"—agitation indicates severe hypoxia requiring immediate intervention 1
• Do not attempt awake intubation—this is inappropriate in a hypoxic, agitated child and will worsen airway obstruction 4
• Do not use excessive positive pressure ventilation immediately post-intubation, as this can cause hemodynamic collapse 1
• Ensure full neuromuscular blockade before attempting laryngoscopy to prevent coughing and laryngospasm 4

Post-Intubation Management

• Perform recruitment maneuvers (inspiratory pressure 30-40 cm H2O for 25-30 seconds) to improve oxygenation after intubation 4
• Continue dexamethasone to reduce airway edema and shorten duration of intubation 2, 3, 5
• Anticipate need for smaller endotracheal tube due to subglottic edema 6