What is the best course of treatment for a pediatric patient presenting with a dry barking cough and high-grade fever, suspected of having a severe respiratory infection such as croup, pneumonia, or epiglottitis?

Pediatric Dry Barking Cough with High-Grade Fever

A pediatric patient presenting with a dry barking cough and high-grade fever most likely has croup and should receive a single dose of oral dexamethasone (0.15 to 0.60 mg/kg) immediately, regardless of severity, along with supportive care including antipyretics and hydration. 1

Immediate Clinical Assessment

Determine severity by evaluating for signs of respiratory distress:

• Assess respiratory rate and work of breathing (look for intercostal retractions, nasal flaring, grunting) 2
• Check for stridor at rest versus only with agitation 1
• Evaluate oxygen saturation—hypoxemia (SpO2 <92%) indicates severe disease requiring immediate escalation 2
• Assess for signs of impending respiratory failure: cyanosis, altered consciousness, severe retractions, or inability to maintain adequate ventilation 2

Rule out life-threatening alternative diagnoses immediately:

• Epiglottitis: toxic appearance, drooling, tripod positioning, muffled voice, high fever—do NOT examine the throat if suspected; secure airway emergently 3, 4
• Bacterial tracheitis: high fever, toxic appearance, purulent secretions, failure to respond to croup treatment 3
• Foreign body aspiration: sudden onset without viral prodrome, unilateral findings, history of choking 1

Definitive Treatment Algorithm

All Patients with Croup (Mild, Moderate, or Severe)

Administer dexamethasone 0.15 to 0.60 mg/kg orally as a single dose immediately 1

• This is recommended for ALL patients with croup, including those with mild disease 1
• Oral route is as effective as intramuscular and preferred for patient comfort 5
• Most symptoms resolve within 48 hours with this intervention 1, 5

Moderate to Severe Croup (Stridor at Rest, Respiratory Distress)

Add nebulized epinephrine (racemic epinephrine or L-epinephrine) 1, 4

• Indicated for patients with moderate to severe respiratory distress 1
• Provides rapid but temporary relief (effects last 2 hours) 4
• Critical pitfall: Patients receiving nebulized epinephrine must be observed for at least 3-4 hours after administration due to potential rebound airway obstruction 1

Impending Respiratory Failure

Prepare for immediate airway management:

• Oxygen therapy to maintain SpO2 >92% 2
• Consider heliox (helium-oxygen mixture) as a temporizing measure while preparing for intubation 5
• Secure definitive airway if signs of respiratory failure progress despite maximal medical therapy 2, 4
• Less than 3% of hospitalized croup patients require intubation 1

Supportive Care Measures

Provide antipyretics for fever control and comfort:

• Use acetaminophen or ibuprofen to reduce fever and improve patient comfort 2
• Do NOT use aspirin in children under 16 years 2

Maintain adequate hydration:

• Encourage oral fluids if child can tolerate 2
• If unable to maintain oral intake, consider IV fluids at 80% basal levels with electrolyte monitoring 2

Minimize patient agitation:

• Keep child calm and comfortable—agitation worsens airway obstruction 2
• Allow parent to hold child in position of comfort 1

What NOT to Do

Do NOT prescribe antibiotics 2

• Croup is viral (most commonly parainfluenza virus types 1-3) and does not respond to antibiotics 1, 5
• Antibiotics are only indicated if bacterial tracheitis or secondary bacterial pneumonia is suspected 3

Do NOT use humidification therapy 1

• Despite historical use, humidification has not been proven beneficial in randomized trials 1, 5

Do NOT use over-the-counter cough medications 6, 7

• These have no proven efficacy and carry risk of adverse effects in children 6, 7

Do NOT perform chest physiotherapy 2

• Not beneficial and should not be performed 2

Disposition and Follow-Up

Admission Criteria (Only 1-8% of croup patients require hospitalization) 1

Admit if any of the following are present:

• Persistent stridor at rest after dexamethasone and epinephrine 1
• Hypoxemia requiring supplemental oxygen 2
• Inability to maintain oral hydration 2
• Altered mental status or severe lethargy 2
• Age less than 6 months 1
• Uncertain diagnosis or concern for alternative etiology 1

Outpatient Management (Majority of Cases)

Discharge home if:

• No stridor at rest after treatment 1
• Normal oxygen saturation on room air 2
• Able to tolerate oral fluids 2
• Reliable caregivers with clear return precautions 2

Provide clear return precautions:

• Return immediately for worsening respiratory distress, inability to speak or swallow, drooling, cyanosis, or altered consciousness 2
• Expect cough to resolve within 2 days in most cases 6, 1
• If fever or symptoms persist beyond 48 hours, re-evaluate for complications including bacterial tracheitis or pneumonia 2

Special Considerations

Recurrent croup (≥2 episodes per year):

• Consider underlying structural airway abnormality (subglottic stenosis, laryngomalacia) or inflammatory condition 8
• Refer to pediatric otolaryngology for direct laryngoscopy and bronchoscopy 8

Age-specific nuances:

• Infants under 6 months may present with mixed clinical picture resembling both croup and epiglottitis with more severe obstruction 4
• Classic croup presentation is most common in children 6 months to 3 years of age 1, 5