An 18-month-old boy presents with 2 days of runny nose and cough. Tonight he awoke with fever and difficulty breathing. Mother reports child has improved a little since leaving home. Temperature is 39.5°C, heart rate 180, respiratory rate 42, and room air oxygen saturations 95%. The child is awake, flushed, and breathing labored. He has inspiratory stridor and suprasternal retractions. Your initial management should be:
Albuterol sulfate nebulized treatment
CBC and blood culture
Minimize patient agitation
Racemic epinephrine nebulized treatment
Soft-tissue neck radiograph
Croup is the most common cause for stridor in children older than 6 months. Most common pathogen is the parainfluenza virus but others such as RSV and human bocavirus can be infectious etiologies. Initial management of stridor at rest causing distress is racemic epinephrine nebulization. This can aide in airway edema reduction from its vasoconstrictor effects. Albuterol nebulization is not indicated and may worsen situation by vasodilatation of vascular beta-receptors. Laboratory studies are unnecessary as these are viral process with clinical diagnosis. Soft-tissue radiography is not indicated for initial management but may be useful if patient has atypical response to routine croup treatments. Minimizing agitation may be of some benefit but will not reduce respiratory distress significantly in children with moderate-to-severe croup.