Extra Topic 2.4 -- Epiglottitis

Question 1

What do you think is the cause of respiratory distress in this child?

(You are called to the emergency room to assist with a 2-year-old girl that presents with fever, drooling, stridor, and substernal retractions.**)

Answer 1

One of the most serious potential causes of a clinical presentation consisting of fever, drooling, stridor, and respiratory distress in a child between the ages of 2 and 7 is acute epiglottitis.

However, I would also consider several other potential causes of similar symptomatology, such as laryngotracheobronchitis (LTB), foreign body aspiration, severe tonsillitis, pharyngitis, and pharyngeal abscess.

(NOTE: per UBP Online Course, have this differential in mind to determine what’s what.)

In order to narrow my differential, I would perform a careful history and examination, focusing on –

• the onset of her symptoms (epiglottitis is associated with a sudden onset, while the onset of LTB is usually more insidious);
• the occurrence of coughing, choking, or cyanosis while eating (suggestive of foreign body aspiration – peanuts, jellybeans, popcorn, and hotdogs are the most commonly associated foods);
• previous vaccination against Haemophilus influenzae type B (the most common cause of epiglottitis); and
• the nature of her stridor, with inspiratory stridor being associated with supraglottic obstruction (epiglottis), expiratory stridor usually resulting form intrathoracic processes, and biphasic stridor occurring when both the larynx and subglottic structures are involved (LTB).

Radiographic examination, which may be helpful in making a more definitive diagnosis, should only be performed when the child is stable and when skilled personnel with the appropriate equipment are able to accompany the child to the radiographic facility.

This child with signs of severe respiratory distress (stridor, substernal retractions, and drooling), on the other hand, should be immediately transferred to the operating room under the supervision of both the anesthesiologist and the surgeon.

Question 2

Would you obtain airway radiographs to help with the diagnosis?

Wouldn’t your treatment vary depending on the diagnosis?

(You are called to the emergency room to assist with a 2-year-old girl that presents with fever, drooling, stridor, and substernal retractions.)

Answer 2

As I mentioned, given the risk of impending airway obstruction in this patient with stridor, drooling, and substernal retractions, I would NOT delay definitively securing the airway in order to obain airway radiographs.

If the patient were stable, airway radiographs may be helpful in making a diagnosis by identifying the thickening of the aryepiglottic folds and glottic swelling associated with epiglottitis (“thumbprint” sign);

the subglottic narrowing associated with LTB (“steeple” sign); or

the air trapping, pulmonary infiltrate, and/or atelectasis associated with foreign body aspiration (90% of foreign bodies are not radiopaque).

However, given this patient’s severe respiratory distress, my initial treatment would be the same regardless of the cause, namely, immediate transfer to the operating room for emergent airway management under general anesthesia (intubation, removal of foreign body, or surgical airway).

(If the patient child is stable enough to go down for radiographic exam, then Let the examiner know that you will accompany the patient with emergency airway equipment, etc.)

Question 3

You decide that the patient is not stable enough to perform a radiographic examination and are preparing to transfer the patient to the operating room when the mother tells you that her brother died from “anesthesia fever”.

Assuming that this is epiglottitis, what are you going to do?

(You are called to the emergency room to assist with a 2-year-old girl that presents with fever, drooling, stridor, and substernal retractions.)

Answer 3

Use 4 Critical Components in answering this question.

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I would administer 100% oxygen, maintain the child in the sitting position, and personally accompany the child to the operating room after obtaining the appropriate emergency drugs and airway equipment for the transfer.

Since excessive anxiety, agitation, or crying can exacerbate airway obstruction, and given my reluctance to administer any sedatives prior to securing the airway, I would ask the parent to provide comfort to the child during the transfer and induction.

Upon arrival in the operating room, I would maintain the child in the sitting position; apply standard ASA monitors along with a precordial stethoscope; and ensure the presence of emergency airway equipment, various sizes of endotracheal tubes, surgical airway equipment, a surgeon capable of obtaining a surgical airway, and appropriate support personnel.

Next, given the family history suggesting malignant hyperthermia, I would administer an intramuscular dose of ketamine (2-3 mg/kg) with the goals of providing sedation and maintaining spontaneous ventilation while securing intravenous access.

I would then deepen and maintain anesthesia with intravenous medications (avoiding inhalational agents and succinylcholine), perform gentle laryngoscopy, place a styletted endotracheal tube that is one half size smaller than normal (to facilitate passage and avoid additional damage to the edematous airway), allow the surgeon to examine the larynx to confirm the diagnosis (some sources then suggest changing the endotracheal tube to a nasotracheal tube, which is better tolerated), ensure that blood cultures were taken and appropriate antibiotic therapy was initiated, ensure adequate sedation, and transfer the patient to the ICU for observation and radiographic confirmation of proper ETT placement.

Question 4

When would you extubate this child?

(You are called to the emergency room to assist with a 2-year-old girl that presents with fever, drooling, stridor, and substernal retractions.)

Answer 4

I would only consider extubation once the child’s fever, neutrophilia, and epiglottic swelling had resolved (these patients usually remained intubated for 24-48 hours following the initiation of treatment).

The resolution of airway edema is suspected with the return of swallowing and when a significant leak around the nasotracheal tube is present (10-20 cm. H20 peak inflation pressure).

Prior to extubation, I would transfer the patient to the operating room, induce general anesthesia, and confirm the resolution of airway edema by visual inspection with a flexible fiberoptic bronchoscope.

I would then extubate the child and continue to monitor her for post-extubation edema.