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PE25.1-6 | Respiratory System — PBL Case

CLINICAL SETTING

It is 11:30 PM at a 200-bed district general hospital in rural Maharashtra. The paediatric emergency ward has two on-duty interns and a senior resident on call from home. The monsoon season has brought an influx of respiratory infections. Three children have arrived within the same hour, each with stridor and respiratory distress.

Trigger 1: Three Children, Three Presentations

Three families have arrived simultaneously in the emergency department: **Child A — Arjun, 18 months:** Mother reports 2 days of runny nose, then suddenly at bedtime, Arjun developed a barky, seal-like cough with noisy breathing that frightens the whole family. He is crying and clinging to his mother, which seems to make the stridor worse. Temperature 38.2°C, RR 44/min, SpO2 96%, mild subcostal retractions. He calms slightly when held upright. **Child B — Priya, 5 years:** Father states Priya had one day of sore throat and high fever (40°C), and over the last 2 hours has been drooling, sitting rigid in a forward-leaning position, refusing to speak, and appears very unwell. She looks toxic. No cough. The father tried to look in her throat at home but she pushed his hand away. **Child C — Kiran, 9 months:** Kiran was eating peanuts (given by an older sibling) when he suddenly choked, turned blue, and cried loudly. The cyanosis has resolved but he now has persistent wheeze and decreased air entry on the right. CXR shows right lung hyperinflation.

DISCUSSION POINTS

  • What is your FIRST priority action for each child — and how do you decide the triage order?
  • What single examination finding or feature in each child's history immediately narrows your diagnosis?
  • For Child B (Priya): a junior intern reaches for a tongue depressor to examine the throat. What should you do and why?
  • For Child C (Kiran): what is the anatomical reason the right lung is more commonly affected in foreign body aspiration?
Click to reveal Trigger 2: Investigations and Emerging Information (discuss previous trigger first!)

Trigger 2: Investigations and Emerging Information

The senior resident has triaged: - **Priya (Child B)** is taken immediately to the procedure room with ENT alerted. The lateral neck X-ray shows a thumbprint sign. Blood culture is drawn. - **Arjun (Child A)** has an AP neck X-ray showing the steeple sign. His Westley Croup Score is calculated at 4 (stridor at rest + mild retractions + normal air entry). - **Kiran (Child C)** — his mother mentions this is the third episode of 'wheeze' in 3 months, always right-sided. Additional history emerges: Arjun's mother asks, 'Can I give him steam at home? My mother-in-law said that works.' The father of a 4th child (Ramu, 4 years) approaches and says his son has been coughing for 4 days with fever and fast breathing. Ramu's RR is 46/min, no chest indrawing, no danger signs. The intern asks if Ramu has pneumonia.

DISCUSSION POINTS

  • Using the Westley Croup Score, what is the severity category for Arjun and what specific treatments do you prescribe (drug, dose, route)?
  • How do you respond to the mother's question about steam therapy? What is the evidence?
  • For Ramu (4 years, RR 46/min, no chest indrawing): apply IMNCI classification. Does he have 'pneumonia', and what treatment is indicated?
  • For Kiran's recurring right-sided wheeze: what does 'three episodes in 3 months, always right-sided' suggest, and what is the diagnostic and therapeutic next step?
Click to reveal Trigger 3: Management Decisions and Complications (discuss previous trigger first!)

Trigger 3: Management Decisions and Complications

One hour later: - **Priya** is in the operating theatre. Anaesthesia has intubated her (tube 0.5 mm smaller than predicted). IV ceftriaxone has been started. The ENT surgeon notes the epiglottis is swollen and cherry-red. - **Arjun** received oral dexamethasone (0.3 mg/kg) and one dose of nebulised adrenaline. His Westley score is now 2 (mild improvement). The family asks if he can go home. - **Kiran** is being prepared for rigid bronchoscopy. The consultant asks the intern to counsel the family on what to expect. - **A new infant arrives — Farida, 5 months:** fever for 3 days, runny nose, RR 62/min, subcostal intercostal retractions, SpO2 88%. Diffuse bilateral crackles and wheeze. NPA sent; the ward nurse asks if she should start salbutamol nebulisation.

DISCUSSION POINTS

  • For Arjun: what are the criteria for safe discharge after croup treated with adrenaline? Why must you observe for at least 4 hours post-adrenaline?
  • For Priya: Hib vaccine is part of India's National Immunization Schedule. What is the current schedule, and why can vaccinated children still develop Hib disease?
  • For Farida (5 months): classify her diagnosis. Should the nurse give salbutamol? What does evidence say about bronchodilators in bronchiolitis? What are the indications for hospitalisation?
  • For Kiran's family counselling on rigid bronchoscopy: what do you explain about the procedure, success rate, and risks?
Click to reveal Trigger 4: Prevention and Population Health (discuss previous trigger first!)

Trigger 4: Prevention and Population Health

It is now 4 AM. All four children are stabilised. The resident sits down with the intern to debrief. She says: 'Tonight we saw four different conditions — croup, epiglottitis, foreign body aspiration, and bronchiolitis. All caused stridor or respiratory distress. Three of these four conditions are largely preventable.' The next morning, the District Health Officer visits the ward. He asks the medical team to prepare a brief talk for the district ASHA workers on prevention of childhood respiratory emergencies. Separately, Arjun's mother returns and says, 'My older child had ear pain last week. The PHC doctor said to wait and see. Is that right?'

DISCUSSION POINTS

  • Which of the four conditions seen tonight are vaccine-preventable? Name the specific vaccines, antigens, and NIS schedules.
  • What public health messages for ASHA workers would you include about: (a) foreign body aspiration prevention for toddlers, (b) danger signs in a child with respiratory distress that require immediate referral?
  • Regarding Arjun's mother's question about ear pain and the 'wait and see' approach: what are the indications for immediate antibiotics vs. watchful waiting in AOM? What antibiotic, dose, and duration is prescribed when antibiotics are needed?
  • Looking back at all four cases: create a one-table differential diagnosis of 'child with stridor' comparing croup vs. epiglottitis vs. foreign body aspiration vs. laryngomalacia across five clinical parameters.

Group Task Assignments

Group 1: Collaborative Task

Group 2: Collaborative Task

Group 3: Collaborative Task

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [PE25.1] What are the causative organisms of AOM in order of frequency, and what is the evidence basis for high-dose amoxicillin (80–90 mg/kg/day) versus standard dose?
  2. [PE25.2] Why is examining the throat in suspected epiglottitis dangerous? What is the physiological mechanism of complete airway obstruction that can be precipitated by this examination?
  3. [PE25.3] What is the Westley Croup Score, how is it calculated, and how does the severity category determine the treatment choice (dexamethasone alone vs. dexamethasone + nebulised adrenaline vs. intubation)?
  4. [PE25.4] What is laryngomalacia, and what anatomical features of the supraglottis cause the characteristic inspiratory stridor that worsens with supine positioning and feeding?
  5. [PE25.5] Why does foreign body aspiration more commonly cause right-sided pathology, and what are the age-specific BLS manoeuvres for choking infants (<1 year) versus children (>1 year)?
  6. [PE25.6] What is the evidence for and against bronchodilators and corticosteroids in RSV bronchiolitis, and what are the current WHO/IAP criteria for hospitalisation in infants with bronchiolitis?