Paediatric respiratory distress — croup with moderate to severe obstruction

(a) Severity scoring — the Westley croup score (4 marks).

The named tool is the Westley croup score (maximum 17 points), with mild defined as 2 or below. Stridor at rest with marked recession and reduced air entry scores well above mild — moderate to severe croup mandating nebulised epinephrine in addition to the corticosteroid.^[2]

(b) Immediate pharmacological management, observation and disposition (8 marks).

• Keep the child calm on the carer's lap, upright; give oxygen by the least upsetting method; do NOT upset the child with cannulation as a first manoeuvre.
• Dexamethasone as a single dose — proven effective at all severities including mild: 0.6 mg/kg oral cut return to 7.3 vs 15.3 percent, and 0.15 mg/kg is equally effective in moderate to severe disease.^[2]
• Nebulised epinephrine — for moderate to severe croup with stridor at rest. Transient 30-minute relief, racemic and L-forms equivalent. Estimate the weight first.^[4]
• Observe 2 to 4 hours after epinephrine plus steroid: 5 percent return, 2 percent admitted, no adverse outcomes; epinephrine always accompanies the steroid, never alone.^[14]
• Discharge the settled child with stridor resolved to exertion-only and a reliable carer; admit stridor persisting at rest, poor intake, or concern.

(c) Features shifting the diagnosis away from viral croup (3 marks) — the toxic-child mimics.

• A febrile, toxic child with reduced interaction unresponsive to nebulised epinephrine — bacterial tracheitis: MSSA commonest, 69 percent PICU, 43 percent intubated.^[14][17]
• A toxic stridulous child with airway compromise — epiglottitis in the differential; all such entities require early recognition of obstruction.^[9]
• A clear choking history with variable stridor — inhaled foreign body; low bronchoscopy threshold.

Any of these mandates senior airway involvement, a controlled airway, and no agitation.^[9][14]