EM · Paediatric respiratory distress
Paediatric respiratory distress — croup, bronchiolitis and acute asthma
Also known as Croup · Laryngotracheobronchitis · Bronchiolitis · Paediatric asthma · Stridor in children · Wheeze in children
Paediatric respiratory distress — the three exam pillars of croup (upper-airway swelling, inspiratory stridor, barking cough, dexamethasone for all severities with nebulised epinephrine for moderate to severe and 2-4 h observation), bronchiolitis (clinical diagnosis, supportive care with bronchodilators and steroids lacking efficacy, high-flow rescue), and acute asthma (SABA plus anticholinergic lowering admission, early steroid, IV magnesium for refractory with scant evidence), distinguished from the can't-miss mimics of foreign body (low bronchoscopy threshold, rigid gold standard), tracheitis (febrile toxic non-responder, MSSA, 43% intubated) and pertussis/pneumonia/laryngomalacia.
Checked against its sources on 13 Oct 2026
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Related topics
- The sick child and paediatric resuscitation
- Upper airway obstruction in the emergency department
- Acute severe asthma
- Respiratory failure (type 1 and type 2)
- Paediatric sepsis and septic shock (the septic child in the emergency department)
- Non-invasive ventilation in the emergency department (CPAP and BiPAP)
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Target exams
Red flags
- Children with severe croup are at risk for intubation — dexamethasone for all severities, nebulised epinephrine for moderate to severe, observe 2 to 4 hours
- The febrile toxic stridulous child unresponsive to nebulised epinephrine is bacterial tracheitis — close airway monitoring plus broad-spectrum IV antibiotics; 43 percent need intubation
- Bronchiolitis is supportive only — bronchodilators and corticosteroids lack efficacy; high-flow rescue answers 61 percent of standard-therapy failures
- Suspected foreign-body aspiration needs prompt intervention with a low bronchoscopy threshold — rigid techniques remain the gold standard
- Pertussis kills neonates and young infants — the cougher with apnoea is tested rapidly; pneumonia at 2-59 months takes amoxicillin first-line
Meet the patient
It is 3am. A two-year-old is carried in on his father's lap, barking like a seal with every cough — an inspiratory stridor audible from the doorway, recessing hard, but alert and only low-grade fever. Across the bay, a four-month-old in mid-winter is wheezing and coughing, has taken half her feeds, and her mother whispers that she "forgot to breathe" twice on the way in.[1]
The toddler has croup — the commonest stridor of childhood; the infant has bronchiolitis — the commonest wheeze of infancy. The single question that orders everything you do next is the one this whole topic turns on: is the obstruction above or below the glottis — stridor or wheeze? Hold that question, then add a second: how hard is the child working, and is it getting better or worse?[1]
References25ShowHide
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- [3]Russell KF, Liang Y, O'Gorman K, et al. Glucocorticoids for croup Cochrane Database Syst Rev, 2011.PMID 21249651
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- [17]Casazza G, Graham ME, Nelson D, et al. Pediatric Bacterial Tracheitis-A Variable Entity: Case Series with Literature Review. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, 2019.PMID 30348058
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- [24]Ciarallo L, Sauer AH, Shannon MW Intravenous magnesium therapy for moderate to severe pediatric asthma: results of a randomized, placebo-controlled trial. The Journal of pediatrics, 1996.PMID 8969721
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