A young child in respiratory distress

A 21 month old girl presented to the emergency department after her mother saw her chewing on a crayon. The child had some initial choking, coughing, and wheeze witnessed at home, and then settled with no immediate signs of respiratory distress. In the emergency department she was not in distress, observations were all stable, and chest examination clear. As she was well, a clinical decision was made to observe her in the emergency department. She underwent no investigations, and after four hours of uneventful observation, she was discharged home with her parents who were given general advice on re-presenting if the breathing worsened.

The child re-presented 24 hours later after her parents found her to have progressively noisy breathing, increased work of breathing, and a generally disturbed night. In the emergency department she was distressed and tachypnoeic; her oxygen saturations dropped to 88% despite attempts at …