Twenty plus years ago the presentation of a child with upper respiratory tract infections (URTIs) was fraught with anxiety that the infection was a killer disease called Epiglottitis. inflammation of the Epiglottis, a small flap like piece of anatomy that sits like a trap door over the trachea.
As the Epiglottis becomes inflamed it loses its function as an airway protecting flap, and in children especially, becomes so engorged and top heavy, that is flops onto the trachea causing obstruction, and subsequent death.
The most common incidences are seen in adults or children who have not been immunised for Haemophylus influenzae type B (HIB). Although other throat infection causing bacteria eg Strep Pyogenes, Moraxella, and Staph Aureus, are causative, HIB remains the most common cause, and is not caught per se, because it is a resident normal flora in our respiratory tree.
Children with epiglottitis are sick. I mean critically unwell, so airway assessment and security is the highest priority.
Classically they are hyperpyrexic with temps over 39.5C.
They are reluctant to swallow their own saliva causing a characteristic drooling, and because of airway obstruction, they will often tripod their position.
They can rarely lay flat, they are reluctant to talk and if they do, have a muffled voice. They just look septic, often pale, listless, disinterested and frightened.
This illness is rapid in its onset; one case I nursed was a 4 year old boy who went from being a child picked up from daycare at 4pm to needing a surgical airway and helicopter retrieval inside 90 minutes. It is most common in adults, but in children (unimmunised), it represents a high priority emergency and a triage category of at least 2. HIB can also cause septicaemia, and pneumonia, so it is one serious disease.
Whilst the immediate management is always airway security, and the preparation for endotracheal intubation, and urgent surgical airway needs to be made, the initial focus is on a de-stressing environment for the child and their parents. Low lights, calm atmosphere, careful positioning, and no sudden surprises that startle or scare the family unit. The child's anxiety is heightened if 'Mum' is stressed, so calm, soothing quiet movements are paramount.
Unless all difficult airway equipment is primed and ready, with a specialist anaesthetist at the ready, don't attempt to assess the throat of the child. At any hint of distress the child may obstruct, making ETT impossible.
In adults it is a painful and miserable disease, but it is rarely fatal in this population. That said George Washington was reported to have died from epiglottitis.
Cephtriaxone is one of the common antibiotics of choice. Pre-empting it's use intravenously once airway is secured would be reasonable. In children, where IV cannula insertion is very distressing, the liberal application of 'Emla' or AngelGel would be a sensible early intervention.
Differential diagnosis:
Croup a milder viral inflammation of the Larynx and Trachea,
Peritonsilar abscess (Quinsy)
Remember these kids are often drooling and have a rapid onset of symptoms. Suspected Epiglottitis is an emergency.
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