Acute Epiglottitis PDF

2 - 4 sudden - - A three-year-old male known to be healthy arrived at the emergency department (ED) with a history of high grade - fever, vomiting, and progressive shortness of breath. - According to his mother, the patient did not have any...

2 - 4 sudden - - A three-year-old male known to be healthy arrived at the emergency department (ED) with a history of high grade - fever, vomiting, and progressive shortness of breath. - According to his mother, the patient did not have any suggestive event of choking or previous episodes of respiratory distress. The patient was febrile, low pitched inspiratory stridor and - hyperextension of the neck and an oral breathing pattern with drooling.. what is the most likely diagnosis? acute epiglotitis triaxone Cetipre a intubation. meropeine. In the past, Haemophilus influenzae type b was the most - commonly identified etiology of acute epiglottitis. Since the widespread use of the H. influenzae type b vaccine, invasive disease caused by H. influenzae type b in pediatric patients has been reduced by 99%. Therefore, other agents, such as Streptococcus pyogenes, Streptococcus pneumoniae, nontypeable H. influenzae, and Staphylococcus aureus, represent a larger portion of pediatric cases of epiglottitis in vaccinated children. The age was 2-4 yr of age, although cases were seen in the 1st yr of life and in patients as old as 7 yr of age. Acute Epiglottitis (Supraglottitis) This now rare, but still dramatic and potentially lethal, condition is characterized by 1-an acute rapidly progressive and potentially fulminating course of high fever, sore throat, dyspnea, and rapidly progressing respiratory obstruction. 2-The degree of respiratory distress at presentation is variable. The initial lack of 3 5 respiratory distress can deceive the unwary clinician; respiratory distress can also be the 1st manifestation. 3-Often, the otherwise healthy child suddenly develops a sore throat and fever. Within a matter of hours, the patient appears toxic, swallowing is difficult, and breathing is labored. 4-Drooling is usually present, and the neck is hyperextended in an attempt to maintain the airway. 5-The child may assume the tripod position, sitting upright and leaning forward with the chin up and mouth open while bracing on the arms. 6-Stridor is a late finding and suggests near-complete airway obstruction. Complete obstruction of the airway and death can ensue unless adequate treatment is provided. The barking cough typical of croup is rare. Usually no other family members are ill with acute respiratory symptoms. FOUR D in epiglottitis Dysphagia Dysphonia Drooling Dyspnea  Diagnosis 1-The diagnosis requires visualization under controlled circumstances of a large, cherry red, swollen epiglottis by laryngoscopy ,laryngoscopy should be performed expeditiously in a controlled environment such as an operating room or intensive care unit. 2-Anxiety-provoking interventions such as phlebotomy, intravenous line placement, placing the child supine, or direct inspection of the oral cavity should be avoided until the airway is secure. 3-If epiglottitis is thought to be possible but not certain in a patient with acute upper airway obstruction, the patient may undergo lateral radiographs of the upper airway - 1st. Classic radiographs of a child who has epiglottitis show the thumb sign.  Treatment 1-Epiglottitis is a medical emergency and warrants immediate treatment with an artificial airway placed under controlled conditions, either in an operating room or intensive care unit. Establishing an airway by endotracheal or nasotracheal intubation or, less often, by tracheostomy is indicated in patients with epiglottitis. The duration of intubation depends on the clinical course of the patient and the duration of epiglottic swelling, as determined by frequent examination using direct laryngoscopy or flexible fiberoptic laryngoscopy. In general, children with acute epiglottitis are intubated for 2-3 days, because the response to antibiotics is usually rapid. 2-Ceftriaxone, cefepime, or meropenem should be given parenterally, pending culture and susceptibility reports, because 10–40% of H. influenzae type b cases are resistant to ampicillin. 3-Epiglottitis resolves after a few days of antibiotics, and the patient may be extubated; antibiotics should be continued for at least 10 days. 1-The parainfluenza viruses (types 1, 2, and 3;) account for approximately 75% of cases; other viruses associated with croup include influenza A and B, adenovirus, respiratory syncytial virus, and measles. 2-Influenza A is associated with severe laryngotracheobronchitis. 3-Mycoplasma pneumoniae has rarely been isolated from children with croup and causes mild disease. 4-Most patients with croup are between the ages of 3 mo and 5 yr, with the peak in the 2nd yr of life. It occurs most commonly in the late fall and winter but can occur throughout the year  CLINICAL MANIFESTATIONS The term laryngotracheobronchitis refers to viral infection of the glottic and subglottic regions 1-Most patients have an upper respiratory tract infection with some combination of rhinorrhea, pharyngitis, mild cough, and low-grade fever for 1-3 days before the signs and symptoms of upper airway obstruction become apparent. 2-The child then develops the characteristic barking cough, hoarseness, and inspiratory stridor. The low-grade fever can persist, although temperatures may occasionally reach 39-40°C (102.2-104°F); some children are afebrile. 3- Symptoms are characteristically worse at night and often recur with decreasing intensity for several days and resolve completely within a week. 4-Agitation and crying greatly aggravate the symptoms and signs. The child may prefer to sit up in bed or be held upright. 5-Other family members might have mild respiratory illnesses with laryngitis. Es acute epiglotif is  Physical examination 1-reveal a hoarse voice, coryza, normal to moderately inflamed pharynx, and a slightly increased respiratory rate. 2-Rarely, the upper airway obstruction progresses and is accompanied by an increasing respiratory rate; nasal flaring; suprasternal, infrasternal, and intercostal retractions; and continuous stridor. 3-Croup is a disease of the upper airway, and alveolar gas exchange is usually normal. 4-Hypoxia and low oxygen saturation are seen only when complete airway obstruction is imminent. The child who is hypoxic, cyanotic, pale, or obtunded needs immediate airway management.  Diagnosis Croup is a clinical diagnosis and does not require a radiograph of the neck. Radiographs of the neck can show the typical subglottic narrowing, or steeple sign, of croup on the posteroanterior view. However, the steeple sign may be absent in patients with croup, may be present in patients without croup as a normal variant, and may rarely be present in patients with epiglottitis. TREATMENT 1- The mainstay of treatment for children with croup is airway management and treatment of hypoxia. Treatment of the respiratory distress should take priority over any testing. 2- Most children with either acute spasmodic croup or infectious croup can be managed safely at home. 3-Despite the observation that cold night air is beneficial, a Cochrane review has found no evidence supporting the use of cool mist in the emergency department for the treatment of croup. 4-Nebulized racemic epinephrine is the established treatment for moderate or severe croup. The mechanism of action is believed to decrease the laryngeal mucosal edema. Traditionally, racemic epinephrine, a 1 : 1 mixture of the D- and L- isomers of epinephrine, has been administered. A dose of 0.25-0.5 mL of 2.25% racemic epinephrine in 3 mL of normal saline can be used as often as every 20 min. Racemic epinephrine was initially chosen over the more active and more readily available -epinephrine to minimize anticipated cardiovascular side effects such as L tachycardia and hypertension. Current evidence does not favor racemic epinephrine over L-epinephrine (5 mL of 1 : 1,000 solution) in terms of efficacy or safety. The indications for the administration of nebulized epinephrine include >moderate to severe stridor at rest, >the possible need for intubation, >respiratory distress, and hypoxia. Children with croup should be hospitalized for any of the following: G.11 J > progressive stridor, , >severe stridor at rest, respiratory distress, >hypoxia, cyanosis, >depressed mental status, drowsy >poor oral intake, or the need for reliable observation 5-The effectiveness of oral corticosteroids in viral croup is well established. Corticosteroids decrease the edema in the laryngeal mucosa through their antiinflammatory action. Oral steroids are beneficial, even in mild croup, as measured by reduced hospitalization, shorter duration of hospitalization, and reduced need for subsequent interventions such as epinephrine administration. Most studies that demonstrated the efficacy of oral dexamethasone used a single dose of 0.6 mg/kg. - Intramuscular dexamethasone and nebulized budesonide have an * - equivalent - clinical effect; oral dosing of dexamethasone is as effective as - intramuscular administration. - Indication for discharge from ER Patients can be safely discharged home after a 2-3 hr period of observation provided they have > no stridor at rest; > have normal air entry, >normal pulse oximetry, > and normal level of consciousness; > and have received steroids. dis = COMPLICATIONS Complications occur in approximately 15% of patients with viral croup. The most common is >extension of the infectious process to involve other regions of the respiratory tract, such as the middle ear, the terminal bronchioles, or the pulmonary parenchyma. > Bacterial tracheitis may be a complication of viral croup rather than a distinct disease. >Pneumomediastinum and pneumothorax are the most common complications of tracheotomy. Bacterial tracheitis Bacterial tracheitis is an acute bacterial infection of the upper airway that is potentially life-threatening. >S. aureus is the most commonly isolated pathogen, with isolated reports of methicillin-resistant S. aureus. S. pneumoniae, S. pyogenes, Moraxella catarrhalis, nontypeable H. influenzae; anaerobic organisms have also been implicated. >The mean age is between 5 and 7 yr. There is a slight male predominance. >Bacterial tracheitis often-follows a viral respiratory infection (especially = laryngotracheitis), so it may be considered a bacterial complication of a viral disease, - rather than a primary bacterial illness. This life-threatening entity is more common than epiglottitis in vaccinated - populations  CLINICAL MANIFESTATIONS Typically the child has a brassy cough, apparently as part of a viral laryngotracheobronchitis. 1-High fever and toxicity with respiratory distress can occur immediately or after a few days of apparent improvement. Jisi 2-The patient can lie flat, does not drool, and does not have the dysphagia associated with epiglottitis. The usual treatment for croup (racemic epinephrine) is ineffective. = DIAGNOSIS The diagnosis is based on evidence of bacterial upper airway disease, which includes high fever, purulent airway secretions, and an absence of the classic findings of epiglottitis. X-rays are not needed but can show the classic findings 1`purulent material is noted below the cords during endotracheal intubation TREATMENT Appropriate antimicrobial therapy, which usually includes antistaphy-lococcal agents, should be instituted in any patient whose course suggests bacterial tracheitis. 1-Empiric therapy recommendations for bacterial tracheitis include vancomycin or clindamycin and a 3rd-generation cephalosporin (e.g., ceftriaxone or cefepime). 2-When bacterial tracheitis is diagnosed by direct laryngoscopy or is strongly suspected on clinical grounds, an artificial airway should be strongly considered. Supplemental oxygen is usually necessary. Intubation or tracheostomy may be necessary, but only 50–60% of patients require intubation for management; younger patients are more likely to need intubation. `