Acute epiglottitis (supraglottitis) in the pediatric population is a potentially life threatening bacterial infection involving the supraglottic structures (lingular surface epiglottis, arytenoids, aryepiglottic folds). This infection is generally caused by Haemophilus influenzae type B (Hib) or Group A beta-hemolytic streptococci. Due to the advent of the Hib vaccine in the 1980’s, the presentation of epiglottitis in the pediatric population has drastically decreased, while the rare presentation of the adult has stayed consistent. The typical presentation of acute epiglottitis in a child is a 2-6 year old with severe sore throat, dysphagia, and a muffled voice without cough or rhinorrhea. In more severe cases, the patient may present in a sitting, or tripod, position in effort to alleviate upper airway obstruction as well as with inspiratory stridor. Epiglottitis is an airway emergency and can progress to severe upper airway obstruction and death within hours.
In a child presenting with acute epiglottitis, emergent airway management should be of primary concern. Once epiglottitis is suspected, further airway management should be coordinated between the pediatric anesthesiologist, otolaryngologist, and intensivist. A laryngoscope with blades, endotracheal tubes with stylets, and a bronchoscope and otolaryngologist should be available at all times during management. Equipment for fiberoptic bronchoscopy or emergent tracheostomy should be available if direct laryngoscopy is unsuccessful. No airway manipulation should be attempted until the patient is transported to the operating room with pulse-oximeter and oxygen mask.
After placement of standard monitors, a sevoflurane/oxygen inhalation induction should be performed in the sitting position with maintenance of spontaneous ventilation. Continuous positive pressure of 10-15 cmH20 should be applied to maintain patency of the upper airway with inspiration. Muscle relaxation is contraindicated due to risk of pharyngeal muscle relaxation and complete airway obstruction. Direct laryngoscopy may demonstrate a cherry red epiglottis and surrounding structures. If the inflammation makes it difficult to identify the glottic opening, manual chest compressions may create air bubbles at the glottis opening and assist in the visualization of the glottis. Use a cuffed endotracheal tube that is 1-2 sizes smaller than normally indicated based on age. After confirmation of bilateral breath sounds, CPAP should be maintained to decrease risk of pulmonary edema from relief of severe upper airway obstruction. Depending on the practitioner’s level of comfort, a nasotracheal intubation may be preferred for long-term airway
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