🧸 Pediatrics · Lesson 2 of 5 · 7 min
Croup, Epiglottitis and the Tongue Blade You Never Use
🐕 A barking cough at 2 a.m. is croup, and a dose of dexamethasone treats it. A silent, drooling, terrified child sitting forward is epiglottitis, and the tongue blade a well-meaning nurse reaches for can close the airway for good.
💡 Key idea
Croup barks and gets a steroid, plus nebulized epinephrine for stridor at rest. Epiglottitis drools, sits forward and gets an airway team, never a tongue blade. RSV gets suction and contact precautions. CF gets enzymes with every bite.
🧠 Why it matters
CROUP (laryngotracheobronchitis): viral, with a barking cough, inspiratory stridor, hoarseness and low-grade fever, worse at night; treat with a corticosteroid (oral dexamethasone) and, for stridor at rest, nebulized racemic epinephrine, keeping the child calm with the parent; cool mist or cool night air may comfort the child but does not treat croup. EPIGLOTTITIS: bacterial (classically Haemophilus influenzae type b, now rare with vaccination), with sudden high fever, the four Ds (drooling, dysphagia, dysphonia, distress), a tripod position and no cough; DO NOT examine the throat, use a tongue blade or lay the child flat; keep the child calm, upright and with the parent, and prepare for emergency intubation with the airway team present. BRONCHIOLITIS (usually RSV): wheezing, tachypnea, nasal flaring and retractions in infants; supportive care with nasal suctioning before feeds, hydration, oxygen as needed, and contact precautions. PERTUSSIS: paroxysmal coughing with an inspiratory whoop, droplet precautions, macrolide antibiotics. CYSTIC FIBROSIS: thick secretions, salty skin, steatorrhea and failure to thrive; chest physiotherapy, pancreatic enzymes with every meal and snack, high-calorie high-protein diet with fat-soluble vitamins, and added salt in hot weather. FOREIGN BODY: sudden coughing or stridor in a toddler; if the child cannot cough, cry or speak, give repeated cycles of 5 back blows and 5 chest thrusts under age 1, or 5 back blows and 5 abdominal thrusts for older children.
🏥 In the real world
🚫 A 4-year-old arrives febrile, drooling, leaning forward, refusing to swallow. A student nurse picks up a penlight and tongue depressor to look at the throat. The charge nurse stops her, keeps the child in the mother's lap, and calls anesthesia. Visualizing the epiglottis outside the operating room can trigger complete obstruction. The exam's correct answer is the one that does nothing to the throat.
📌 Takeaways
- Croup: barking cough, stridor at night; dexamethasone, plus racemic epinephrine for stridor at rest
- Epiglottitis: drooling, tripod, no cough: no throat exam, prepare for intubation
- RSV: suction before feeds, contact precautions; CF: enzymes with every meal
📖 Terms in this lesson
Croup: A viral airway infection in young children with a barking cough and stridor, treated with dexamethasone and, for stridor at rest, nebulized epinephrine.
Epiglottitis: A bacterial swelling of the epiglottis with drooling and a tripod position; never examine the throat.
✅ Test yourself
A child with suspected epiglottitis is drooling and sitting upright leaning forward. Which action by a nurse requires immediate intervention?
- Inspecting the throat with a tongue blade
- Calling for the airway team to come to the bedside
- Allowing the child to remain upright
- Keeping the child upright in the parent's lap
Answer: A · Inspecting the throat with a tongue blade
Throat examination can precipitate complete airway obstruction; the airway is secured by skilled staff in a controlled setting.
Which intervention is appropriate for a toddler with croup and mild stridor at home?
- Keep the child calm and upright
- Encourage vigorous play to loosen secretions
- Give over-the-counter cough suppressants
- Place the child flat on the back
Answer: A · Keep the child calm and upright
Calm and upright eases breathing and lowers oxygen demand, and the provider usually prescribes one dose of oral dexamethasone; stridor at rest needs urgent care. Cool mist may comfort but does not treat croup. Cough suppressants are not recommended for young children, lying flat worsens breathing, and vigorous play raises oxygen demand.
A child with cystic fibrosis is about to eat lunch. What should the nurse ensure?
- The child receives pancreatic enzymes with the meal
- The meal is low in fat and calories
- The child avoids salt
- Chest physiotherapy is done immediately after eating
Answer: A · The child receives pancreatic enzymes with the meal
Enzymes with every meal and snack allow fat and protein absorption; CF diets are high in calories, fat and salt, and chest physiotherapy is done before meals.
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