Epiglottitis and croup
Stem
A 4-year-old boy, 17 kg, who has never been vaccinated, is brought to the emergency department with six hours of fever to 39.8 °C and a sore throat. He is sitting forward on his mother's lap, drooling, with a muffled voice and soft inspiratory stridor. He has no cough. SpO2 is 94% on room air. The emergency physician wants to place an IV and get a lateral neck radiograph.
Question
What is your working diagnosis, and how will you manage his airway?
Ideal answer
HeadlineEpiglottitis until proven otherwise. He stays on his mother's lap; no IV, throat examination or radiology; I call the most experienced anesthesiologist available and ENT.
- The picture fits: sudden high fever, drooling, tripod or sniffing posture and stridor without a barking cough, unvaccinated.1 Upset, he can obstruct completely, so blow-by oxygen only if tolerated.2
- To the OR together, mother with him, ENT scrubbed, for rigid bronchoscopy or tracheostomy.3
- Sevoflurane in 100% oxygen, sitting up, breathing spontaneously, adding CPAP as he loses tone; an assistant places the IV once deep.
- Gentle laryngoscopy, oral tube smaller than his age predicts, as the swollen airway bleeds easily; expecting a cherry-red epiglottis, bubbles marking the glottis.
- Cultures and IV antibiotics once the airway is secure,3 then PICU, intubated, sedated, usually two to three days, until a cuff leak, no fever and he can swallow.3
Breaking down the answer
- Diagnose from the bedside, not from imaging — a lateral neck film is only for a stable, cooperative child; agitation, IV placement and an oral examination can precipitate complete obstruction.2
- Contrast it with croup — croup is viral laryngotracheitis in children 6 months to 3 years, with a barking cough, hoarseness and stridor over a day or two; epiglottitis is sudden, toxic, drooling and coughless.3 1
- Secure, do not observe — routine intubation in epiglottitis carries lower mortality than medical management without an artificial airway.3
- Induction choice is judgment, not dogma — there is no consensus for inhalational over IV induction; inhalational keeps him breathing, and complete obstruction stops further uptake so he lightens.3
- Why ENT is scrubbed — the swollen epiglottis can make laryngoscopy impossible, so a surgical airway is planned before induction, not improvised after.3
- Vaccination changed the bug, not the urgency — Haemophilus influenzae type b remains the classic cause; cases persist from other organisms and vaccine failure.3
Follow-up question
Halfway through the inhalational induction he obstructs completely; the chest moves but the bag does not, SpO2 falls to 70%, and his heart rate drops to 70. What do you do?
Follow-up answer
HeadlineComplete supraglottic obstruction with hypoxic bradycardia, and I say it aloud: "He is obstructed, we intubate now."
I apply firm CPAP with jaw thrust while my colleague gives atropine and has epinephrine ready. I do not wait to deepen him further; I laryngoscope immediately with a small tube and stylet, aiming at the bubbles or the swollen cleft between the arytenoids. If I cannot pass a tube within one attempt, ENT passes the rigid bronchoscope to ventilate through it, and if that fails, performs a surgical airway.3 Once a tube is in, I confirm end-tidal CO2, recheck heart rate and saturation, and secure it firmly for transport.
Pitfalls that cost points
- Lying him supine or separating him from his parent before induction.
- Giving paralysis before confirming the airway can be maintained.
- Treating epiglottitis as croup with racemic epinephrine and discharge.
Rapid-fire
Q: What steroid dose do most croup trials use? A: Oral dexamethasone 0.6 mg/kg as a single dose, about 10 mg for this child.1
Q: How much nebulized epinephrine for severe croup? A: Racemic epinephrine 0.5 mL or 5 mL of 1:1000 L-epinephrine, regardless of age or weight.1
Q: How long do you observe after nebulized epinephrine? A: Two to four hours; discharge is safe if croup symptoms do not recur.1
Q: Is post-extubation stridor dosed and observed the same way? A: No: croup guidance gives a fixed 0.5 mL and discharges after 2–4 symptom-free hours;1 after extubation I give 0.05 mL/kg (max 0.5 mL) and observe at least 4 hours.4
Q: What is bacterial tracheitis? A: An exudative tracheal infection, usually Staphylococcus aureus, with a toxic child who responds poorly to nebulized epinephrine and usually needs intubation.3 1
Q: Where is the narrowest part of a child's airway? A: The subglottis, which is why croup's subglottic edema obstructs so quickly.2
Numbers to know
| Item | Value |
|---|---|
| Croup age range | 6 months–3 years3 |
| Dexamethasone for croup | 0.6 mg/kg once1 |
| Nebulized epinephrine onset | 10–30 min1 |
| Nebulized epinephrine effect | At least 1 h, gone by 2 h1 |
| Observation after epinephrine | 2–4 h for croup in the ED;1 ≥4 h after extubation4 |
| Intubation for epiglottitis | Usually 2–3 days3 |
Links
- Pediatric airway anatomy and equipment, Foreign body aspiration in a child, laryngospasm, The child with an upper respiratory infection, Tracheostomy, laser surgery and jet ventilation
- Canadian Paediatric Society croup practice point (updated 2026)
Sources
- 1.Acute management of croup in the emergency department (Practice point) · Canadian Paediatric Society, 2026 · cps.caPosted 2017, updated March 2026; includes a differential-diagnosis table contrasting croup and epiglottitis.
- 2.Epiglottitis · NYSORA · nysora.com
- 3.Paediatric airway infections · BJA Education, 2017 · ebi.ac.ukDavies and Jenkins, BJA Educ 2017;17:341-5; full text via Europe PMC (PMC7104950).
- 4.Postextubation Stridor · OpenAnesthesia (IARS) · openanesthesia.orgRacemic epinephrine 0.05 mL/kg (max 0.5 mL) of 2.25% diluted to 3 mL; effect about 1 h, gone by 2 h; observe at least 4 h after the nebulizer.
Facts on this page were checked against these sources on Oct 15, 2026. Guidelines change; confirm doses against current institutional protocols.