You are called at 0125 hrs to a home address to a 2 year old male patient; Ryan, who is short of breath. When you arrive you find some very anxious parents who tell you that Ryan is extremely unwell, and they want you to rush Ryan to hospital without delay.

Upon calming the parents they give you the following information. History:

Ryan became unwell 2 week ago with some mild coughing and a runny nose. He was taken to the GP who diagnosed Ryan with an URTI and prescribed some Paracetamol and 2 teaspoons of honey 30 minutes before bedtime.

Over the last 24 hours the coughing has increased in ferocity to what his parents describe as episodic coughing “fits”. They say that on occasions it has been so bad that he has vomited after the “fit” and turned a blue colour. They also describe a “weird” high pitched sound when he breathes in during each episode.

PMHx
Pre-term birth at 29 weeks; had spent 5 weeks in the neonate intensive care unit.

Tonight Ryan has had a severe coughing episode and vomited. Paracetamol and was last administered at 2330 hrs but do not appear to have relieved Ryan.

Physical examination:
General appearance: Ryan appears to have a good colour and is not visibly having trouble breathing. He is tired and lethargic and will answer questions when prompted by his parents.

Observations:
GCS: 15 but appears tired and lethargic
HR: 120
BP: 90/45 – but struggles as you inflate the cuff. Skin: pink, warm and dry
Cap refill: <2 sec
ECG: sinus tachycardia
RR: 32;
SpO2: 99%
Chest sounds: Lower basal fine crackles