Pediatric Epiglottitis Treatment & Management

Treatment in patients with epiglottitis is directed toward relieving the airway obstruction and eradicating the infectious agent. Optimally, initial treatment is provided by a pediatric anesthesiologist and either a pediatric surgeon or a pediatric otolaryngologist. Once the airway is controlled, a pediatric intensivist is required for inpatient management.

Avoid procedures that might increase the child's anxiety until after the child's airway is secured. Procedures such as venipuncture and intravenous access, although appropriate in most cases involving children with acute epiglottitis, may heighten anxiety and precipitate airway compromise.

Do not underestimate the potential for sudden deterioration. As soon as epiglottitis is suspected, initiating and mobilizing a medical and surgical team capable of securing the airway is imperative.

Never place a child in a supine position (other than during the endotracheal intubation procedure), because immediate respiratory arrest in this position has been reported.

See also Epiglottitis and Emergent Management of Pediatric Epiglottitis.

When a child has respiratory arrest, the first step is to administer bag-valve-mask ventilation with 100% oxygen. All of these children can be oxygenated and ventilated with good bag-valve-mask technique. Once the child is oxygenated and ventilated, the airway can be secured with an endotracheal tube, cricothyrotomy, or tracheostomy. These treatments should prevent cerebral anoxia, arrest, and death, the most feared complications.

Once an airway is established, admit the child with epiglottitis to an intensive care unit (ICU), where the patient should be sedated and/or paralyzed to prevent inadvertent extubation.

Medical treatment begins by evaluating airway, breathing, and circulation. Supplemental oxygen administration, a nonthreatening initial step, is easily accomplished with blow-by oxygen administered by a parent.

Place the equipment needed for emergent airway management at the bedside, and keep the patient in view at all times.

As discussed in Managing Respiratory Arrest, if acute respiratory arrest occurs, ventilate the child with 100% supplemental oxygen, using a bag-valve-mask device, and arrange for intubation. When a child has a respiratory arrest and appropriate surgical personnel are unavailable, the attending physician may attempt intubation.

Alternative methods to gain immediate control of the airway, such as needle cricothyrotomy, are considered temporary until a more permanent procedure (eg, tracheostomy) can be performed.

Once supplemental oxygen is provided, the next crucial step is to mobilize a team to establish an appropriate airway via endotracheal intubation. Mortality rates for children who receive endotracheal intubation are less than 1%. Children who do not receive intubation have mortality rates as high as 10%.

At a minimum, the team should include an anesthesiologist and a surgeon capable of establishing a pediatric surgical airway (ie, tracheostomy). Ideal team members would be a pediatric anesthesiologist and a pediatric surgeon or pediatric otolaryngologist.

The best setting for an endotracheal intubation is in an operating room with the patient under general anesthesia.

Endotracheal intubation procedure details are as follows:

• Move the patient to the operating room and prepare the equipment needed for a tracheostomy and bronchoscopy.
• Place the precordial stethoscope and electrocardiograph and pulse oximetry leads; then, with the patient in a sitting position, induce anesthesia using a mask with oxygen and halothane.
• Once the child is anesthetized, place the patient in a supine position and insert an intravenous line.
• Perform a laryngoscopy while the patient is under deep halothane anesthesia, inserting an orotracheal tube 0.5-1.0 mm smaller than predicted for the child.

When the endotracheal tube is in place, an otolaryngologist should examine the supraglottic structures using direct laryngoscopy and obtain appropriate surface cultures of the epiglottis. A secured nasotracheal tube usually replaces the orotracheal tube.

Tracheostomy

If endotracheal intubation is unsuccessful, perform a tracheostomy with percutaneous translaryngeal ventilation used as a temporizing measure (see Percutaneous Transtracheal Ventilation).

Racemic epinephrine administration plays little role in the management of infectious or thermal epiglottitis and is not indicated.

Appropriate antibiotics include ceftriaxone, cefotaxime, and cefuroxime (for nonmeningitic infections) (see Medications). As in all invasive Haemophilus influenzae type b (Hib) infections, contacts should receive rifampin chemoprophylaxis. For epiglottitis due to other organisms, antibiotics should be tailored to the cause of the infection.

Corticosteroid administration, although advocated in the past based on anecdotal reports, remains controversial. These agents have no proven efficacy for treating epiglottitis.

Although epiglottitis has declined with the use of the Haemophilus influenzae type b (Hib) conjugate vaccine, epiglottitis can still occur, albeit rarely, in a child who is adequately vaccinated.

All close contacts (including daycare center staff and children) who are exposed to a child with epiglottitis should receive a 4-day prophylactic course of treatment with rifampin at 20 mg/kg (not to exceed 600 mg/d).

Children older than 2 years with epiglottitis do not need vaccination, because the disease provides immune protection.

Patients recovering from epiglottitis may be extubated when repeated direct laryngoscopy at 24- to 48-hour intervals indicates reduced size and inflammation of the epiglottis. Criteria for extubation include decreased erythema and edema of the epiglottis and air leaks around the endotracheal tube.

The intravenous catheter may be removed when the patient can tolerate oral fluids and antibiotics. The total duration of antibiotic treatment is 7-10 days.

After further observation for 24-36 hours, patients who are afebrile and doing well may be discharged.