Emergent Management of Pediatric Epiglottitis 

Epiglottitis, also termed supraglottitis, is an inflammation of the epiglottis and/or the supraglottic tissues surrounding the epiglottis, including the aryepiglottic folds, arytenoid soft tissue, and, occasionally, the uvula. A child complaining of a severe sore throat but with minimal findings on examination should be considered to have epiglottitis.^[1]

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.

Numerous causes of the epiglottic inflammation exist, but the common problem is airway occlusion caused by the tissue swelling and, when untreated, 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.^{[2, 3]} See the image below.

If epiglottitis is suspected, an otolaryngologist or general surgeon should be consulted immediately as well as an anesthesiologist. 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.

See also the following:

• Epiglottitis
• Pediatric Epiglottitis
• Rapid Sequence Intubation

Immediately secure the child's airway, and transport the child with suspected epiglottitis to the nearest appropriate facility (emergency department approved for pediatrics [EDAP] or pediatric critical care center [PCCC]).

Obtaining vital signs or any other diagnostic procedures are secondary to securing the 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.

The conscious and stable child should be allowed to assume a position of comfort. The parent should be allowed to hold the child.

The first emergency department (ED) priority for a patient with epiglottitis is securing and providing respiratory support before a definitive airway is obtained. Initially, humidified oxygen can be given by a nasal cannula or a nonrebreather mask, as required.

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 periodically evaluated in order to determine need for intubation. Minor procedures, such as intravenous access, may cause respiratory distress and can be performed more safely after intubation.

Precautions

Direct 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.

Despite evidence of increased morbidity and mortality in patients treated without intubation, reports of children managed on an observation basis have been reported. Patients managed successfully with observation were generally older and able to tolerate their secretions. This approach should be used with caution.

Laryngoscopy is the best way to confirm the diagnosis of epiglottitis, but it is not advised to attempt any procedures without securing the airway. 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 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. It also showed that fiberoptic endoscopy is especially useful in cooperative older children with moderate respiratory distress.

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) 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.

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^{[4, 5, 6]} as opposed to Haemophilus influenzae type B (Hib) because of widespread vaccine use against this organism,^{[7, 8]} and antibiotic therapy should be directed as such. With the presence of white patches, Candida albicans should be suspected.^[9] Sedation for comfort is also required.

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

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,^[10] 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.

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.