WIDI - P6) Barking cough and inspiratory stridor in a child

P6) Barking cough and inspiratory stridor in a child

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a pediatric patient with stridor.
Review the DDx considerations in a pediatric patient with stridor.
Identify the spectrum of imaging findings in appropriate modalities for evaluating a pediatric patient with stridor.

History

A 2-year old male presents to the ED due to worsening cough, fevers, nasal congestion, and nasal discharge over the last 48 hours. He attends daycare where other children have recently been ill from a viral respiratory infection. His vaccinations are up to date.

Physical Exam

BP: 110/60, HR 150, RR 50, Temp 101.5F, O2 saturation 95%. Pulmonary: Barking cough. High-pitched breathing on the inspiratory phase. Breathing is comfortable. ENT: Moist mucous membranes. Skin: Capillary refill <2 seconds.

Labs

Rapid strep test: negative. Influenza swab: negative. Rapid RSV antigen test: pending.

Provisional Diagnosis

Select the Dx you believe is most appropriate

Influenza

Common cold

Pneumonia

Croup

Epiglottitis

The patient most likely has croup considering the new onset barking cough, inspiratory stridor, low-grade fever, and rhinorrhea with congestion.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

The patient requires urgent management. Unmanaged croup can lead to airway obstruction.

First Imaging Study

What is the first imaging study you will order?

Neck X-ray

Chest X-ray

CT Chest

While the diagnosis can be made without imaging, a soft tissue X-ray of the extended neck can help confirm the diagnosis.

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Xray Case

The epiglottis is normal.

Yes

There is no evidence of inflammation of the epiglottis such as a “thumb” sign.

The subglottis is normal.

Yes

There is subglottic edema with a “steeple sign” on the frontal view.

View Report

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View the full study if you'd like to take a look yourself.

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Second Imaging Study

What is the next imaging study you will order?

Chest CT

Chest X-ray

None

No further imaging is needed as the diagnosis is confirmed with radiography.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Croup

Croup with severe dehydration

Croup with respiratory distress

The patient is not exhibiting signs of dehydration (moist mucous membranes) or respiratory distress (no use of accessory muscles with retractions or grunting).

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

The patient requires urgent management as unmanaged croup can lead to airway obstruction.

Assessment and Plan

Please provide your assessment and plan for this patient

This patient is a 2-year-old male presenting with croup. He should be administered dexamethasone, an antipyretic, humidified mist, and be reassessed shortly.

Lessons Learned:
- Croup is a respiratory viral illness that can lead to severe dehydration or respiratory failure.
- The diagnosis can be made without imaging. If a neck X-ray is obtained, it may demonstrate subglottic narrowing with a “steeple sign.”
- Treatment is based on severity of symptoms. Generally, dexamethasone, antipyretics, and humidified mist are provided in mild cases. More severe cases may require racemic epinephrine and hospitalization.

Socioeconomic Factors: Approximately 15% of all lower respiratory disease in children is caused by croup, but little is known about its risk factors or recurrence rate.

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