Indian J Pediatr

DOI 10.1007/s12098-014-1559-4

REVIEW ARTICLE

Guest Editor: Bhim S. Pandhi

Acute Respiratory Distress in Children: Croup and Acute Asthma

B. S. Sharma & Dhananjay S. Shekhawat & Prity Sharma &
Chetan Meena & Hari Mohan

Received: 24 March 2014 / Accepted: 12 August 2014

# Dr. K C Chaudhuri Foundation 2014

Abstract Acute respiratory distress is one of the most com-
mon reason for emergency visits in children under 5 y of age.
An accurate understanding of the epidemiology of these dis-
eases, identification of risk factors and etiology is critical for
successful treatment and prevention of related mortality. The
cause of acute respiratory distress varies in etiology, and hence
is amenable to different treatment modalities. Depending on
the predominant symptoms and signs, a child presenting to the
clinician can be divided into six groups, viz., stridor; cough,
fever and difficulty in breathing or fast breathing; wheezing;
mediastinal shift with severe respiratory distress; slow or
irregular breathing in absence of any pulmonary sign; and
respiratory distress with cardiac findings. A detailed history
followed by a thorough clinical examination and laboratory
evaluation assisted by imaging modalities if indicated, helps
to establish the exact cause of respiratory distress in the child.
Early recognition and prompt institution of appropriate man-
agement or referral can significantly improve the outcome of
this illness. This article offers clinicians a brief update on the
general management guidelines of respiratory distress in pe-
diatric patients. Specific treatment depends on the exact cause,
however croup and acute severe asthma have been discussed
in this article.
Keywords Acute respiratory distress in children . Croup
syndrome . Acute severe asthma
Acute Respiratory Distress in Children
Any child with respiratory distress has a potential to progress
to respiratory failure. It includes:
1. Altered breathing pattern (fast, slow, feeble or
absent)
2. Forced breathing pattern or obstructed breathing
3. Chest wall in drawing
Signs of respiratory failure include respiratory distress and
cyanosis along with central nervous system (CNS) and /or
cardiovascular signs of hypoxemia.
CNS signs of hypoxemia: Restlessness, obtunded sensori-
um, somnolence, seizures and coma.
Cardiovascular signs of hypoxemia: Marked tachycardia,
bradycardia, hypotension and cardiac arrest.
Causes of Respiratory Distress in Children
& Central nervous system disturbances (altered central reg-
ulation of respiration)
& Neuromuscular problems (paralysis or weakness of respi-
ratory muscles)
& Interference with air entry
○ Obstruction in the upper airways

▪ Acute laryngitis
▪ Laryngotracheitis
B. S. Sharma (*) : D. S. Shekhawat : C. Meena : H. Mohan
Department of Pediatric Medicine, S.M.S. Medical College, Jaipur, ▪ Diphtheria
Rajasthan 302004, India ▪ Foreign body aspiration
e-mail: drbssharma@gmail.com ○ Obstruction of the lower airways
P. Sharma
Department of Pediatric Medicine, Fortis Escorts Hospital, Jaipur, ▪ Bronchiolitis
Rajasthan, India ▪ Bronchial asthma

○ Compression of lungs
▪ Large pleural effusion
▪ Pneumothorax
& Interference with alveolar gas exchange
○ Failure of alveolar ventilation
▪ Pneumonia
& Cardiovascular problems
& Decreased tissue oxygen supply/ Increased oxygen
demand
○ Congestive heart failure (CHF)
○ Sepsis
○ Severe anemia
Diagnostic Evaluation
A. History
& Acute, recurrent or chronic and nature of progression
& Associated symptoms: cough, fever, rash, chest pain
& Preceding events: foreign body inhalation, trauma,
accident, exposure to chemical or environmental
irritants
& Family history: exposure to infections, tuberculosis,
atopy
B. Physical examination
& Assess stability of airways and ventilation
i. Respiratory rate, rhythm, depth and work of
breathing
ii. Color, level of activity and playfulness
iii. Chest movements and indrawing of chest wall
iv. Abnormal sounds, stridor, wheezing and grunting
(audible)
& Tracheal position
& Auscultation: air entry, type of breath sounds, adven-
titious sounds (rhonchi, crepts etc.)
& Assessment of other symptoms
C. Diagnostic workup
& Routine blood investigations: CBC, septic profile,
blood culture
& Imaging studies (X-ray, USG, as indicated)
Indian J Pediatr
Differential Diagnosis
Depending on the predominant symptoms and signs, a child
presenting to the clinician can be divided into following 6
groups:
1. Stridor
a. Acute laryngotracheitis (Viral croup): Usually a youn-
ger child presenting with a viral prodrome of fever,
cough, coryza, suddenly develops a barking cough
and respiratory distress with stridor. Diagnosis in most
cases can be established on clinical grounds and rou-
tine X-ray of neck is not recommended.
b. Bacterial tracheitis: It should be suspected when a
clinical picture similar to that of viral croup is com-
plicated by high grade fever, toxicity and copious
purulent tracheal secretions.
c. Foreign body in the larynx or trachea: An acute epi-
sode of coughing, choking or gagging followed by
stridor in infants and toddlers while eating nuts or
playing with small objects is typical. However in 1/
3rd patients below 3 y of age, such a history may not
be available. Unequal breath sounds on clinical ex-
amination combined with asymmetrical lung aeration
on chest X-ray usually establishes the diagnosis. In
absence of these findings with a strong suspicion of
foreign body, a CT chest is recommended. Diagnostic
bronchoscopy may be indicated in exceptional cases.
d. Diphtheria: Gradual onset with mild sore throat and
moderate fever is usually present. A grayish membrane
forms over the tonsils which may extend to affect the
larynx. The patient presents with harsh cough, hoarse
voice, stridor, neck swelling and increased difficulty in
breathing. The child may be severely toxic and death
may occur due to laryngeal obstruction and an emer-
gency tracheostomy is required in certain cases.
e. Acute epiglottitis: It is a rare cause of stridor in India.
Usually occurs in children between 2 and 7 y of age
and very rarely below 2 y of age. Characteristically,
there is high grade fever of sudden onset, rapidly
progressing rattling or snoring, stridor, toxic appear-
ance, muffled voice, difficulty in swallowing. The
child assumes a characteristic airway protective pos-
ture, i.e., sitting and leaning forward with protrusion
of jaw and open mouth with drooling of saliva. X-ray
lateral view of neck may be helpful. It shows a grossly
distended hypopharynx, swollen epiglottis and
aryepiglottic folds, and a normal subglottic airway.
f. Retro-pharyngeal abscess: High-grade fever, sore
throat, inspiratory stridor and difficulty in swallowing.
Neck is generally hyper-extended, so as to achieve
maximum airway. Lateral X-ray of the neck is
Indian J Pediatr
diagnostic. It shows airway narrowing, and widening
of retro-pharyngeal space.
g. Acute severe tonsillitis superimposed on tonsillar and
adenoid hypertrophy is an important cause of severe
upper airway obstruction.
2. Cough, fever and difficulty in breathing or fast breathing
a. Pneumonia: Cough, fever and difficulty in breathing
in the absence of signs of airway obstruction are
suggestive of pneumonia. Presence of grunting, chest
wall indrawing, and inability to feed normally are
signs of severe disease.
3. Wheezing
a. Bronchiolitis: Should be considered in any child less
than 2 y of age with first episode of wheezing and
respiratory distress. There is usually a history of co-
ryza 2–3 d preceding the onset of irritating cough,
wheezing and respiratory distress. The chest may
appear barrel shaped. Auscultation reveals reduced
air entry, bilateral fine crepitations and sibilant
rhonchi.
b. Acute asthma is one of the most common causes of
wheezing in children. Family history of allergy, his-
tory of severe attacks in past, intractable cough, expi-
ratory wheeze and multiple adventitious sounds on
auscultation are characteristic. Attacks are frequently
precipitated by exposure to allergens, infections, ex-
ercise, and sometimes by emotional disturbance.
c. Bronchitis and pneumonia may be associated with
wheezing and can be confused with the first attack
of asthma. This is secondary to airway edema and
mucus production. A clinical picture consistent with
infection and a chest X-ray are helpful for its differ-
entiation from asthma.
d. Foreign body aspiration: There is usually a sudden
onset with cough, choking and onset of stridor and
wheezing. Stridor may occur initially but once the
foreign body slips below carina, stridor disappears
and wheezing predominates.
4. Mediastinal shift
a. Pleural effusion / Empyema
b. Atelectasis
c. Pneumothorax
These conditions can be diagnosed on the basis of
a meticulous clinical examination, chest X-ray, and
pleural tap / bronchoscopy, if needed.
5. Bradypnea and/or irregular breathing
In the absence of history or physical findings sugges-
tive of primary respiratory illness, bradypnea and/or ir-
regular breathing is most likely to be due to depression of
central nervous system.
6. Associated finding of congestive cardiac failure
The presence of significant auscultatory findings on
examination of heart in association of congestive cardiac
failure indicates underlying heart disease. In children with
congenital heart defects with a left to right shunt, there is
an increased incidence of recurrent respiratory tract infec-
tions. In these patients, the respiratory distress might arise
either from CHF or a respiratory infection. Chest X-ray,
echocardiography and ECG may be helpful in establish-
ing the exact diagnosis.
General Management
1. General supportive measures
a. Positioning of the child: Allow the child to assume a
position of maximum comfort and allay the anxiety.
b. Minimize handling in procedures: If the diagnosis is
established, there is no urgency to agitate the child for
blood sampling.
c. Ensure adequacy of circulation, maintenance of tem-
perature and hydration.
2. Oxygen should be administered when the child is
cyanosed or have stridor, wheeze, tachypnea with inter-
costal retractions. Humidified oxygen is administered to
prevent the drying up of epithelium of the respiratory
passages and ciliary dysfunction. Oxygen should be ad-
ministered without agitating the child.
3. Children with severe respiratory distress, cyanosis (due to
respiratory cause) and impending respiratory failure
should be referred immediately after initial stabilization
to a higher center for further treatment.
4. Specific management depends on the etiology. The de-
tailed discussion of each condition is beyond the scope of
this article; however the authors will discuss here the man-
agement of croup and acute asthma.
Croup Syndrome
Croup syndrome is most common cause of stridor in children,
and primarily affects children between 3 mo and 5 y of age,
with the peak in the 2nd year of life. The term “croup syn-
drome” refers to a group of diseases that vary in anatomic
involvement and etiologic agents and includes:
& Laryngotracheitis
& Spasmodic croup
& Bacterial tracheitis
& Laryngotracheobronchitis
& Laryngotracheobronchopneumonitis

MILD
(without stridor or significant
chest wall indrawing at rest)
Give oral dexamethasone 0.6 mg/kg
Educate parents
− Anticipated course of illness
− Signs of respiratory distress
− When to seek medical
assessment
Give oral dexamethasone 0.6 mg/kg
May discharge home without
further observation
Sustained improvement as
evidenced by no longer
having:
− Chest wall indrawing
− Stridor at rest
Educate parents (as for mild
croup)
Discharge home
Persistent mild symptoms
No recurrences of:
− Chest wall indrawing
− Stridor at rest
Provide education (as for mild
croup)
Discharge Home
Fig. 1 Treatment algorithm of croup
MODERATE
(stridor and chest wall indrawing
at rest without agitation)
Minimize intervention
Place child on parent’s lap
Provide position of comfort
Nebulize with epinephrine
No or minimal improvement
Nebulize with epinephrine
Good response to nebulized
epinephrine
Observe for 2 h
Recurrence of severe respiratory
distress:
Repeat nebulized epinephrine
If good response continue to
observe
Indian J Pediatr
SEVERE
(stridor at rest and indrawing of
the sternum associated with
agitation or lethargy)
Minimize intervention (as for
moderate croup)
Provide ‘blow-by’ oxygen
(optional unless cyanosis is
present)
Nebulize epinephrine
− Racemic epinephrine 2.25%
(0.5 ml in 2.5 ml saline)
or
− L-epinephrine 1:1000 (5 ml)
Give oral dexamethasone (0.6
mg/kg): may repeat once
− If vomiting / too distressed to
take oral medication, consider
administering budesonide (2
mg) nebulized with
epinephrine
Poor response to nebulized
epinephrine
Repeat nebulized epinephrine
Poor response to nebulized
epinephrine
Shift to pediatric ICU for
further management
Indian J Pediatr

Acute viral infection is the most common cause of croup, & Children with pre-existing upper airway narrowing such
but bacterial and atypical agents have also been identified as sub-glottic stenosis and those having Down’s syndrome
[1, 2]. are at higher risk of severe croup.

Clinical Features A. Supportive Care

Initial prodromal phase lasting 12–48 h is associated with
rhinorrhea, pharyngitis, low-grade fever, with or without
cough, following which there is gradual development of the
triad of barking cough, hoarseness, and inspiratory stridor.
Fever may or may not be present.
Child may develop more severe obstruction with inspira-
tory stridor at rest, increased heart rate, respiratory rate, nasal
flaring, chest wall retractions, progressive hypoxia and cya-
nosis. Symptoms may worsen at night, with agitation and on
crying. Mild illness lasts for 3–7 d, but in the severe form it
can last upto 2 wk.
Spasmodic croup tends to occur at evening or night in
young children between 3 mo and 3 y of age. The child
awakens with a characteristic barking cough, stridor and
respiratory distress and is usually afebrile. Symptoms
usually subside within several hours. Less severe attacks
without severe respiratory distress may occur for the next
two or three successive nights. Spasmodic croup repre-
sents an allergic reaction to viral antigens rather than a
direct infection.
Diagnosis
The diagnosis of croup is made on clinical grounds. Radiog-
raphy is not routinely indicated.
Management of Croup (Fig. 1)
& Assess severity of airway obstruction and NOT the stridor.
Worsening obstruction may lead to soft stridor.
& Repeated clinical assessment is the key.
& Child should be calm and comfortable. Agitation may
worsen airway obstruction.
& Do not examine the throat with a tongue depressor.
B. Oxygen
‘Blow-by’ (administration of oxygen through a plastic
hose with the end opening held near the child’s nose and
mouth) oxygenation is often the most beneficial way of
administering oxygen and should be reserved for children
having moderate to severe croup. Current evidence does
not support the role of humidified air in management of
croup [3].
C. Pharmacological Management
1. Adrenaline [4, 5]
• Mechanism of action: Constriction of capillary
arterioles resulting in consequent decrease in la-
ryngeal mucosal edema.
• Duration of action: ≤ 2 h
• Efficacy: Racemic and L-epinephrine are equally
efficacious (Racemic form not available in India)
• Indications: Moderate to severe stridor at rest, the
possible need for intubation, respiratory distress, and
hypoxia.
L-epinephrine
♦ Dose: 0.5 ml/kg/dose of 1:1,000 L-
epinephrine in 2.5 ml of normal saline
via nebulizer
♦ Frequency: Repeat every 2 hourly if
needed. Where possible, nebulisation
should be driven by oxygen
♦ Maximum dose: 5 ml

Table 1 Pulmonary score index

Score Respiratory rate Wheezing present* Accessory muscles usage

<6y >6 y

0 < 30 <20 None No apparent activity

1 31–45 21–35 Terminal expiration with stethoscope Questionable increase
2 46–60 36–50 Entire expiration with stethoscope Increase apparent
3 >60 >50 During inspiration and expiration without stethoscope Maximal activity
Add Score 0–3 Mild *If wheezing is absent (due to minimal air flow), score >3
4–6 Moderate
>6 Severe
 Indian J Pediatr

& As its activity diminishes, symptoms of croup can reappear Dexamethasone: Most commonly used
& Use cautiously in patients with congenital heart disease ♦ Dose: 0.15 to 0.6 mg/kg orally (preferred),
such as Tetralogy of Fallot, or ventricular outlet IV, IM
obstruction. ♦ Frequency: Once
♦ Duration of action: 24 to 72 h
Nebulized Budesonide
2. Corticosteroids: [6–12] ♦ Efficacy equals to dexamethasone. Consider
Corticosteroids decrease edema of the laryngeal in children with emesis or severe respiratory
mucosa via their anti-inflammatory action. distress.

MILD (PS 0-3) MODERATE (PS 4-6) SEVERE (PS > 6)/Red flag signs
SA β2 agonist Oxygen Oxygen + I.V. fluids
MDI + spacer ± mask 4-6 SA β2 agonist neb q20 mins x 3 May switch to IV steroid
puffs q20 min x 3 or Continue SA β2 agonist neb q1h/
SA β2 agonist MDI + spacer ± 2 continuous
puffs q2-3 mins till 6 puffs x 3 Start Ipratropium neb q30 mins x 3 and
or then q6 h for 24 h
Sustained Not sustained
If inhalation therapy is not Observe over 1-2 h
4-6 h for 4-6 h or
available:
risk factors,
− Adrenaline 0.01 ml/kg sc q20
start first dose
min x 3 If no response on above therapy:
rescue steroid
− Or Terbutaline 0.01 ml/kg s.c. IV magnesium sulfate 25-50 mg/kg + 50
1 mg/kg/d
one dose ml NS infusion over 30 mins stat (max 2g)
Commence /continue rescue IV aminophylline 5 mg/kg bolus followed
steroid by IV infusion 0.8-1 mg/kg/h
Observe hourly for 3-4 h Terbutaline infusion if no response: 2-10
SA β2 agonist neb q1 hour p.r.n. mcg/kg loading dose followed by infusion
of 0.1-0.4 mcg/kg/min

Sustained 4-6 h
Reduce SA β2 agonist q4-6 h No response/ill sustained response
Continue intensified ward plan
Blood gas studies
Possible intubation and mechanical
DISCHARGE CRITERIA ventilation with Ketamine and
Pulmonary score < 3 Midazolam/Fentanyl IV infusion
Comfortable Paralysis with Vecuronium, if required
Slept well at night
Feeding well

DISCHARGE PLAN Response sustained 4-6 h

Continue treatment with inhaled SA β2 agonist MDI + spacer Follow the principle ‘Last in-First out’
± mask q4-6 h till symptoms
Continue course of rescue steroid for 3-7 d (tapering not
necessary)
Review adherence, trigger elimination, preventer drug use
Review/initiate long term strategy
Plan follow up visit within 7-14 d

Fig. 2 Management of acute severe asthma. PS Pulmonary score; SA Short acting; MDI Metered dose inhaler; NS Normal saline
Indian J Pediatr

Prednisolone & Arterial blood gases: rate of rise of PaCO2 >5 mm Hg/h,
♦ Dose: 1 mg/kg and prescribe a second dose PaCO2 >40 mm Hg, PaO2 <60 mm Hg, metabolic acidosis
for the next evening. (−Base excess >7–10)
In patients with severe distress or near respiratory & SpO2 on room air <92%
failure, the simultaneous administration of
budesonide and epinephrine is logical and may be
Conclusions
more effective than epinephrine alone.
3. Antibiotics
List of various causes of acute respiratory distress as illustrated
Antibiotics are not indicated in viral croup.
in the article will guide us in arriving to a precise diagnosis. A
Antibiotics are reserved for patients who have
thorough history, good clinical examination and judicious use of
evidence of laryngotracheobronchitis or
laboratory investigations and imaging can pinpoint the cause of
laryngotracheobronchopneumonitis, which have a
respiratory distress in majority of situations. In addition to the
bacterial disease component.
general principles of ABC, the treatment directed towards spe-
4. Analgesics and anti-pyretics
cific cause can be rewarding in most of the situations. Applying
Acetaminophen, may be given if the child has a fever.
the protocols of management of acute asthma and croup men-
DO NOT GIVE ASPIRIN
tioned in the article can make the approach simple for the
5. Antitussive and decongestants not indicated.
treating physician in the ER.
D. Endotracheal intubation may be required only for a
brief period until laryngeal edema resolves for pa-
tients who have severe croup that does not respond Contributions BSS: Conceptualised the article and scrutinised and
to the previously cited therapies. finalised the contents; DS: Collected the material from different sources
and helped in writing the manuscript; PS: Searched the different refer-
ences and finally shaped the manuscript; CM: Helped in typing the
manuscript; HM: Helped in collection and compilation of data. BSS will
Criteria for Discharge act as guarantor for this paper.

& No stridor at rest Conflict of Interest None.

& Normal pulse oximetry
& Normal color Source of Funding None.
& Normal level of consciousness
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