EPIGLOTTITIS

Janey had a 102.8°F fever, difficulty of breathing, and drooling. She also
always sits on a tripod position because this position makes her breathe
easier. Her parents brought her in for a check-up and was informed that their
child has epiglottitis.

Contents [hide]
 1 Description
 2 Pathophysiology
 3 Statistics and Incidences
 4 Causes
 5 Clinical Manifestations
 6 Assessment and Diagnostic Findings
 7 Medical Management
o 7.1 Pharmacologic Management
 8 Nursing Management
o 8.1 Nursing Assessment
o 8.2 Nursing Diagnosis
o 8.3 Nursing Care Planning and Goals
o 8.4 Nursing Interventions
o 8.5 Evaluation
o 8.6 Documentation Guidelines
 9 Practice Quiz: Epiglottitis
 10 See Also
 11 Further Reading

Description

Acute epiglottitis and associated upper airway obstruction has significant

morbidity and mortality and may cause respiratory arrest and death.
  Epiglottitis is acute inflammation of the epiglottitis.
 Epiglottitis, also termed supraglottitis or epiglottiditis, is an
inflammation of structures above the insertion of the glottis and is
most often caused by bacterial infection.
 Affected structures include the epiglottis, aryepiglottic folds,
arytenoid soft tissue, and, occasionally, the uvula.
 The epiglottis is the most common site of swelling.

Pathophysiology

Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae can

colonize the pharynges of otherwise healthy children through respiratory
transmission from intimate contact.

 The epiglottitis becomes inflamed and swollen with edema.

 Hib infection of the epiglottis leads to acute onset of inflammatory
edema, beginning on the lingual surface of the epiglottis where the
submucosa is loosely attached.
 Swelling significantly reduces the airway aperture.
 Edema rapidly progresses to involve the aryepiglottic folds, the
arytenoids, and the entire supraglottic larynx.
  The tightly bound epithelium on the vocal cords halts edema spread
at this level.
 Frank airway obstruction, aspiration of oropharyngeal secretions, or
distal mucous plugging can cause respiratory arrest.

Statistics and Incidences

The use of the Haemophilus influenzae type b (Hib) vaccine has reduced
incidence of epiglottitis in the United States, making this a rare condition in
children.

 Studies have shown an annual incidence rate of 0.63 cases per

100,000 persons, and studies of children of all ages with epiglottitis
report a seasonal variation in incidence.
 A retrospective case series of 107 patients admitted to a pediatric
hospital’s intensive care unit (ICU) from 1997 to 2006 concluded
that bacterial tracheitis is now 3 times more likely to be the cause of
pediatric respiratory failure compared with viral croup and
epiglottitis combined.
 The international incidence of epiglottitis widely varies, with a
significantly greater prevalence in countries without universal
immunization.
 Among countries with mandatory immunization, the reported
incidences are 0.9 cases per 100,000 persons in Sweden and 0.6
cases per 100,000 in the United Kingdom, for example.
 Most studies show no racial predominance for epiglottitis, although a
recent study showed higher incidence among black and Hispanic
individuals.
 There also appears to be a 60% male predominance, which has
remained true even with the changing epidemiology of epiglottitis.

Causes
Commonly caused by Haemophilus influenzae type B, epiglottitis most often
affects children 2 to 7 years.

 Haemophilus influenzae. Historically, Haemophilus influenzae

type b (Hib) was the predominant organism (>90%) in pediatric
epiglottitis cases.
 Viral agents. Although viruses normally do not cause epiglottitis, a
previous viral infection may allow bacterial superinfection to occur;
viral agents may include herpes simplex virus (HSV), parainfluenzae
virus, varicella-zoster virus (VZV), human immunodeficiency virus
(HIV), [3] and Epstein-Barr virus (EBV); varicella can cause a
primary or secondary infection often with group A beta-hemolytic
streptococci.
 Non-infectious causes. Noninfectious etiologies include thermal
injuries, trauma-causing blind finger sweeps to remove a foreign
body from the pharynx, angioneurotic edema, hemophagocytic
lymphohistiocytosis, and acute leukemia.

Clinical Manifestations

The child may have been well or may have had a mild upper respiratory
infection before the development of the symptoms.

 Fever. Fever is usually the first symptom, and temperatures often

reach 40°C.
 Dysphagia. Dysphagia or difficulty in swallowing is one of the
symptoms in the clinical triad.
 Drooling. Due to dysphagia, drooling occurs and is also one of the
symptoms in the clinical triad.
 Respiratory distress. The last of the three symptoms in the triad,
fever with associated respiratory distress or air hunger occurs in
most patients.
  Tripod position. The child is very anxious and prefers to breathe
by sitting up and leaning forward with the mouth open and the
tongue out.

Assessment and Diagnostic Findings

Securing an airway is the overriding priority; an expert in pediatric airway

management should always perform an endotracheal intubation on any child
with suspected epiglottitis before radiography or blood work is performed.

 Laryngoscopy. Laryngoscopy is the best way to confirm the

diagnosis, but it is not advised to attempt any procedures without
securing the airway.
 Blood and epiglottis cultures. Blood cultures and culture of the
epiglottis should be performed only after the airway is secured;
blood cultures may show Haemophilus influenzae type b (Hib)
between 12-15% and 90% of cases.
 Lateral neck radiography. Never obtain a lateral neck radiograph
before achieving definitive airway control; if radiography is required,
the safest procedure is to perform portable radiography at the
bedside.
 Percutaneous transtracheal ventilation. Also termed needle
cricothyrotomy or translaryngeal ventilation, percutaneous
transtracheal ventilation is a temporizing method used to treat
cases of severe epiglottitis when the patient cannot be intubated
before a formal tracheostomy.

Medical Management

Treatment in patients with epiglottitis is directed toward relieving the airway

obstruction and eradicating the infectious agent.
  Manage respiratory arrest. When a child has respiratory arrest,
the first step is to administer bag-valve-mask ventilation with 100%
oxygen; 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.
 Moist air administration. Moist air is necessary to help reduce the
inflammation of the epiglottitis.
 Pulse oximetry. Pulse oximetry is required to monitor oxygen
requirements.
 Endotracheal intubation. 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%.
 Tracheostomy. If endotracheal intubation is unsuccessful, perform
a tracheostomy with percutaneous translaryngeal ventilation used
as a temporizing measure.

Pharmacologic Management

Medications used for a child with epiglottitis are:

 Antibiotics. Appropriate antibiotics include ceftriaxone, cefotaxime,

and cefuroxime (for nonmeningitic infections); 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.
 Corticosteroids. Corticosteroid administration, although advocated
in the past based on anecdotal reports, remains controversial.

Nursing Management
Nursing management of a child with epiglottitis include:

Nursing Assessment

Assessing a child with epiglottitis should include:

 Respiratory assessment. Assess the child’s breathing, any history

of injury to the throat, breathing through the mouth, stridor, and
hypoxia.
 Cardiovascular assessment. Assess the child’s pulse; assess for
tachycardia and a thready pulse.
 Gastrointestinal assessment. Assess if there is an inability to
swallow.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnoses are:

 Ineffective breathing pattern related to upper airway edema.

 Anxiety related to respiratory distress.
 Hyperthermia related to inflammatory process.
 Deficient knowledge related to lack of knowledge on the disease
process.

Nursing Care Planning and Goals

Main Article: 5 Epiglottitis Nursing Care Plans

The major goals are:

 Patient and family will verbalize strategies to reduce anxiety.

 Patient and family will demonstrate an understanding of what has
been taught.
 Patient and family will Verbalize understanding of condition/disease
process and treatment.
 The patient’s temperature will be within normal range.
  The patient will maintain adequate ventilation and oxygenation.
 The patient will maintain a patent airway.

Nursing Interventions

The nursing interventions for a child with epiglottitis are:

 Anxiety control. The child and the family should display personal
actions to eliminate or reduce feelings of apprehension and tension
from an unidentifiable source.
 Learning facilitation. The nurse should promote the ability to
process and comprehend information, and encourage improvement
of the ability and willingness to receive information.
 Medications. Administer antibiotics as prescribed, such
as cefuroxime.
 Hydration. Regulate IV fluid accordingly, since the child could not
swallow.

Evaluation

Goals are met as evidenced by:

 Patient and family verbalized strategies to reduce anxiety.

 Patient and family demonstrated an understanding of what has been
taught.
 Patient and family verbalized understanding of condition/disease
process and treatment.
 The patient’s temperature is within normal range.
 The patient maintained adequate ventilation and oxygenation.
 The patient maintained a patent airway.

Documentation Guidelines

Documentation in a child with epiglottitis include:

 Breath sounds, presence and character of secretions, use of

accessory muscles for breathing.
 Plan of care.
 Teaching plan.
 Responses to interventions and actions performed.
 Attainment or progress towards desired outcomes.
 Modifications to the plan of care.