Pediatric Respiratory Emergencies Overview
Respiratory emergencies are the leading cause of cardiac arrest in pediatric patients. Children are anatomically and physiologically different from adults in ways that make them more susceptible to airway obstruction. Their airways are narrower, their tongues are proportionally larger, their tracheal rings are softer, and they rely more heavily on their diaphragm for breathing. These differences mean that even minor airway swelling can cause significant respiratory distress in a child.
Two upper airway conditions that EMTs must distinguish are croup (laryngotracheobronchitis) and epiglottitis. While both cause stridor and respiratory distress, their management differs significantly. Misidentifying one for the other can lead to inappropriate interventions that worsen the patient's condition.
Croup (Laryngotracheobronchitis)
Croup is a viral infection that causes inflammation of the larynx, trachea, and bronchi. It most commonly affects children between 6 months and 3 years of age and typically occurs in the fall and winter months. The parainfluenza virus is the most common cause, though influenza, RSV, and adenovirus can also be responsible.
The hallmark presentation of croup includes a "barking" or "seal-like" cough, inspiratory stridor, hoarseness, and a low-grade fever. Symptoms typically develop gradually over 1 to 2 days and are often worse at night. The child may have had upper respiratory symptoms (runny nose, mild cough) before developing the characteristic barking cough. Most cases are mild and self-limiting.
Croup Management
Prehospital management of croup focuses on keeping the child calm and comfortable. Crying and agitation increase oxygen demand and can worsen airway obstruction. Allow the child to remain in a position of comfort, usually sitting up in the parent's lap. Administer humidified oxygen if available and if the child tolerates it. Avoid invasive procedures or anything that might upset the child. Cool night air can sometimes improve symptoms, which is why parents often notice improvement during the ambulance ride to the hospital.
Epiglottitis
Epiglottitis is a bacterial infection (most commonly Haemophilus influenzae type B) that causes severe inflammation of the epiglottis and surrounding structures. While the Hib vaccine has dramatically reduced the incidence in children, epiglottitis still occurs and can be rapidly fatal. It tends to affect children ages 2 to 7 years, though it can occur at any age, including in adults.
Epiglottitis presents with an abrupt onset of high fever (often over 104 degrees F), severe sore throat, drooling (due to inability to swallow), muffled or "hot potato" voice, and the "tripod" or "sniffing" position (sitting upright, leaning forward with the chin thrust out and mouth open). The child appears toxic, meaning they look seriously ill, and stridor may be present.
Epiglottitis Management: Critical Differences
The management of epiglottitis differs dramatically from croup. Do not attempt to visualize the airway, do not place anything in the patient's mouth, and do not lay the child down. Any of these actions can cause complete airway obstruction. Keep the child calm and in their position of comfort. Provide blow-by oxygen without agitating the child. This is a true emergency requiring rapid transport to a facility capable of surgical airway intervention. Notify the receiving hospital early so they can prepare an operating room and airway specialists.