PANCE Blueprint Pulmonary (9%)

Patient will present as → a 4-year-old boy is brought to the emergency department by his parents with a sudden onset of high fever, difficulty breathing, and a muffled voice. The parents report that he was fine the previous day but developed symptoms rapidly over the past few hours. They also note that he is drooling and seems to prefer sitting upright, leaning forward. When asked, the parents report, "we don't believe in vaccinations." On examination, the child appears anxious, has a high fever of 39.5°C (103.1°F), and demonstrates significant respiratory distress with stridor. He is drooling and unable to swallow his saliva. His voice is hoarse. A lateral neck X-ray is cautiously performed, revealing a swollen epiglottis, classically described as a "thumbprint" sign, consistent with acute epiglottitis. Due to the risk of airway obstruction, immediate consultation with an otolaryngologist and anesthesiologist is sought for airway management. The child is prepared for potential intubation in a controlled setting. Blood cultures are drawn, and empiric intravenous antibiotics are initiated with coverage that includes Haemophilus influenzae type B.

The adult patient (now the most common) will present as → a 45-year-old man with one to two days of severe sore throat and painful swallowing out of proportion to a normal-appearing oropharynx. He has a muffled "hot potato" voice, fever, and tenderness over the anterior neck at the hyoid. He is vaccinated, and stridor and drooling are absent — their appearance would signal impending airway obstruction.

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Epiglottitis is a rapidly progressive bacterial infection of the epiglottis and supraglottic tissues that can cause sudden, complete airway obstruction — a medical emergency

• Hib is the classic cause in unvaccinated children and under-vaccinated regions (Hib vaccine at 2, 4, ± 6 months + booster at 12–15 months) — in the vaccine era, most cases are Streptococcus pneumoniae, group A strep, and Staph aureus (including MRSA), and epiglottitis is now more common in adults
• Key test clue: severe throat pain with minimal oropharyngeal findings + drooling/stridor = epiglottitis until proven otherwise
• Tripod or "sniffing" posture (sitting forward, neck extended to maximize the airway)
• vs. croup — epiglottitis is abrupt, high fever, toxic, drooling, no cough; croup has a barking cough, hoarseness, and the steeple sign

High suspicion or an unstable patient goes straight to the OR — laryngoscopy is the definitive diagnosis (edematous, "cherry-red" epiglottis) and secures the airway in the same controlled setting

• Stable patients only: lateral neck X-ray → classic thumbprint sign; never send an unstable patient to radiology, and avoid CT — lying flat can obstruct the airway
• Blood and epiglottic cultures after the airway is secured

Airway management, first and foremost — anticipate tracheal intubation in a controlled setting (OR, with ENT/anesthesia); if intubation is impossible, needle or surgical cricothyroidotomy

• ⚠️ Keep the child calm — no tongue-depressor throat exam, no IV sticks, no supine positioning until the airway is secure — agitation can precipitate complete obstruction
• Once the airway is stable: third-generation cephalosporin (ceftriaxone or cefotaxime) + an antistaphylococcal agent (vancomycin, per local MRSA prevalence); corticosteroids are often given to reduce swelling, though evidence is limited
• All patients are admitted (usually ICU) for airway monitoring — never outpatient
• Prevention — Hib immunization; rifampin prophylaxis for unvaccinated close contacts when Hib is the cause

Osmosis