Emergent Management of Pediatric Epiglottitis

Updated: Nov 22, 2014
  • Author: Robert Allan Felter, MD, FAAP, CPE, FACPE; Chief Editor: Kirsten A Bechtel, MD  more...
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Overview

Overview

Epiglottitis, or supraglottitis, is an inflammation of the epiglottis and/or the supraglottic tissues surrounding the epiglottis. This includes the aryepiglottic folds, arytenoid soft tissue, and, occasionally, the uvula.

Epiglottitis is usually an infectious process of bacterial etiology, but it can be caused by caustic ingestion, thermal injury, or direct trauma. Historically caused by Haemophilus influenzae type B, it was also a disease of children aged 2-7 years. With the introduction of the HiB vaccine in the 1980s, not only has the incidence of the disease lessened, but also the age prevalence and the bacteriology have changed. A recent study stated that the average age is 45 years. While the overall frequency in patients younger than 18 years has decreased, of the reported cases, there has been a significant increase in cases in children younger than 1 year. [1] In addition, a review of pediatric upper airway infections suggests that bacterial tracheitis is more prevalent now than epiglottitis or croup. [2]

The changes in age distribution have changed the clinical presentation. The classic triad of dysphagia, drooling, and distress can still be seen in the younger patients. Patients younger than 1 year may have an unclear course of fever and respiratory distress. The distinction between croup, laryngotracheitis, and epiglottitis is more difficult in younger children. A recent study is consistent with accepted knowledge that patients with epiglottitis do not cough and children with croup do not drool. [3] Older children and adults may have more subtle signs of respiratory difficulties, i.e. inability to lay flat, voice changes, and dysphagia out of proportion to clinical findings. The classical signs of ‘‘tripod position’’ are drooling, stridor, dyspnea, tachypnea and a child sitting forward assuming the sniffing position in order to maximize the airway. These classical signs may not be seen in older children, adults, or early in the disease process. [4, 5, 6] There mayalso be pain with movement of the larynx. In comparison to retropharyngeal abscess presentation, another differential for upper airway obstruction in children, epiglottitis usually has a more acute-onset presentation. [7]

Other than type B H influenzae, Streptococcus pneumoniae and the Streptococcus species are the most common bacterial causes. [8] Nontypeable Haemophilus influenzae have also been reported as causes of epiglottitis. [9]

Children with viral infections can also present with epiglottitis secondary to subsequent superinfection with bacteria, including Epstein-Barr, varicella-zoster, parainfluenza, and herpes simplex viruses. [9]

Epiglottitis can occur in fully immunized children, thus it should not be removed from the differential of children presenting with typical symptoms (see image below). [10]

Postintubation image in a child with acute epiglot Postintubation image in a child with acute epiglottitis. Note the cherry red epiglottis. This image was taken in 2008; the child was completely immunized and grew Haemophilus influenzae (Hib) from surface culture.

As untreated epiglottitis can rapidly lead to upper airway obstruction and death, it must be considered in children presenting with upper airway compromise and fever in younger children and sore throat out of proportion to physical findings in older children.

As with many other aspects of the pediatric airway, the epiglottis is significantly different in the child from in the adult. In the infant, the epiglottis is located more anteriorly and superiorly than in the adult, and it is at a greater angle with the trachea. It is also more omega shaped and floppy than the more rigid, U-shaped epiglottis in the adult. All of these anatomical differences contribute to the rapid progression of upper airway obstruction in cases of epiglottitis.

In addition to infectious causes, numerous other causes of the epiglottic inflammation exist such as that from thermal inhalational injury or thermal ingestion, [7, 11] trauma to the upper airway, such as foreign bodies, and chemical irritation. [12] Other etiologies include absence of immunization, an immunocompromised state, and smoking. [13] All of these diverse causes share the most serious complication of airway occlusion caused by the tissue edema; when untreated, this can lead to respiratory failure and death. In the young child, this can take place in hours. As the disease becomes more rare, its existence and its quick progression may be forgotten; therefore, it is crucial for clinicians to promptly recognize and appropriately treat epiglottitis. [14, 15] See the image below.

Comparison of a normal pediatric airway (bottom) a Comparison of a normal pediatric airway (bottom) and airway from a child who died from epiglottitis (top).

If epiglottitis is suspected, an otolaryngologist or general surgeon, as well as an anesthesiologist, should be consulted immediately. While in the emergency department (ED), the child should be kept as calm as possible. Laryngoscopy in the ED is discouraged. Ideally, the child should be taken to the operating room to secure the airway; no diagnostic tests are required before proceeding to the operating room. In addition, because the child should be admitted to an intensive care unit, the intensivist must be consulted.

Other causes of upper airway obstruction can mimic epiglottitis, such as bacterial tracheitis, croup, retropharyngeal abscess, and even Guillain-Barré syndrome with bilateral vocal cord paralysis and neurological compromise. It is important to manage and protect the airway in all situations involved. [16]

See also the following:

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Prehospital Care

If the child has adequate oxygenation, urgent transport to the nearest appropriate facility is required. Everything should be done to keep the child calm, often in the arms of a parent. The conscious and stable child should be allowed to assume a position of comfort. Obtaining vital signs or any other diagnostic procedures are secondary to assuring an adequate airway. Oxygen may be administered if it does not disturb the child.

If the child has a respiratory arrest, first attempt ventilation with a bag-valve mask. Long, slow ventilations are best. Orotracheal intubation should be attempted if emergency service personnel are unable to ventilate the child. Needle cricothyroidotomy is used only if the airway is unable to be secured.

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Initial ED Management

In order to correctly manage acute epiglottitis, one must first consider it as a potential diagnosis. In addition to the decreased frequency, the demographic changes lead to a less than "typical" presentation. If the diagnosis is possible, the child should have respiratory and cardiac monitoring placed, and he or she should be kept in plain view of medical staff at all times. Furthermore, the child's condition must be constantly evaluated in order to determine need for emergency airway management. Minor procedures, such as intravenous access, may precipitate respiratory distress and can be performed more safely after intubation.

Precautions

Any manipulation of the upper airway with direct or fiberoptic laryngoscopy may precipitate laryngospasm; thus, visualization of the epiglottis should not be performed unless staff members capable of securing an airway are present, although in reality, no cases of laryngospasm due to such visualization have ever been reported in the literature.

Lateral neck radiographs [17] are useful when evaluating a child with symptoms suggestive of epiglottitis, but these should not delay taking the patient to the operating room for definitive management. If radiographs are ordered, the child should be in constant attendance by the medical staff with available airway equipment.

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Laryngoscopy

Laryngoscopy is the best way to confirm the diagnosis of epiglottitis, but this should not be done outside the operating room or where an immediate airway can be obtained. Simply depressing the child's tongue with a tongue blade may help in visualizing the epiglottitis in some situations. Some concern exists regarding the safety of such procedures, which can provoke anxiety and increased respiratory effort or laryngospasm during examination, leading to airway obstruction.

A study performed in Germany recommended laryngoscopy to aid in the diagnosis in patients with atypical presentations or with crouplike coughs. [18] It also showed that fiberoptic endoscopy is especially useful in cooperative older children with moderate respiratory distress.

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Emergent Ventilation

If respiratory arrest occurs, the patient should be ventilated using a bag-valve mask device, and intubation should be performed. Nonblind, fiberoptic-assisted nasotracheal intubation under controlled conditions is preferred. In a patient with respiratory distress, "rescue" airway equipment should be prepared before rapid sequence intubation. Anesthesia and ear, nose, and throat (ENT) or general surgery specialists should be notified of the airway risk, and a collective decision should be made regarding intervention.

Orotracheal intubation or needle cricothyroidotomy (also known as percutaneous transtracheal ventilation or translaryngeal ventilation) may be necessary in emergent situations. Pediatric epiglottitis is one of the few instances in which the emergency physician may need to rapidly perform needle cricothyrotomy. See Percutaneous Transtracheal Ventilation in Pediatric Epiglottitis. Needle cricothyrotomy is a temporizing method used to treat cases of severe epiglottitis when the patient cannot be intubated before a formal tracheostomy. This procedure involves inserting a needle through the cricothyroid membrane which lies inferior to the thyroid cartilage and superior to the cricoid cartilage. The cricothyroid arteries typically course through the superior portion of the membrane.

Tracheostomy should be reserved for patients in which endotracheal intubation is unsuccessful due to severe laryngeal edema.

Oxygen wall ports: pressure-controlled versus volume-controlled

Most physicians are not aware that normal, volume-controlled, oxygen wall ports are incapable of delivering the pressure needed to adequately oxygenate an adult through a 14-gauge catheter (50 psi). In some trauma centers, needle jet setups are specifically preinstalled to address this concern, with a pressure-controlled port (instead of the volume-controlled port). For children, a setting of 1 psi/kg is recommended, although literature data are lacking.

Transtracheal jet insufflation does little for ventilation; however, it may salvage enough time in cases of complete inspiratory airway occlusion to perform tracheostomy or begin extracorporeal bypass maneuvers.

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Antibiotic Therapy

Antibiotic therapy is necessary but should be initiated after securing the airway. Empiric antimicrobial therapy must cover all likely pathogens in the context of the clinical setting.

Before culture results, use antibiotic agents that will cover the most likely organisms. The cause of infection is currently more likely to be Staphylococcus aureus (especially following trauma to the epiglottitis) or group A streptococci [19, 20, 21] as opposed to Haemophilus influenzae type B (Hib) because of widespread vaccine use against this organism, [5, 2] and antibiotic therapy should be directed as such. With the presence of white patches, Candida albicans should be suspected. [22] Sedation for comfort is also required.

In general, antibiotic treatment should continue for 7-10 days.

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PICU Admission

The child should be admitted to the pediatric intensive care unit (PICU) and, if intubated, should be sedated and/or paralyzed.

No controlled studies exist on the use of intravenous steroids for reduction of airway structure edema due to pediatric epiglottitis. Nonetheless, some clinicians routinely use them in cases with adults.

Laryngoscopy should be repeated 24-48 hours after treatment to evaluate the degree of inflammation, [23] and a decision should be made when to consider extubation. Criteria for extubation include air leaks around the endotracheal tube or decreased edema and erythema of the epiglottis.

After observation of 24-48 hours postextubation, the patient can be discharged on oral antibiotics.

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Transfer

If the hospital is unable to care for critically ill children, transfer should be arranged to the nearest appropriate facility, which, ideally, would be a hospital with a pediatric intensive care unit (PICU).

The airway should always be secured. Only then should an intravenous line be placed. In addition, the child should be sedated and given antibiotics before the transfer.

Transport of patients with epiglottitis may be a concern, especially for patients who are maintaining an airway in the emergency department but who could lose airway protection during transport. A survey done at the 1990 Pediatric Critical Care Transport Leadership Conference showed that 49% of physicians recommend intubation before interhospital transfer. The other 49% made decisions on a patient-to-patient basis. Therefore, the physician should use clinical judgment in making this decision.

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