PANCE Blueprint Pulmonary (10%)

Acute epiglottitis

Patient will present as → a 3-year-old boy who is brought to the ER with a sudden onset of fever (104.0 F), respiratory distress, and stridor. On examination, the boy appears acutely ill. He is sitting, leaning forward with his mouth open, he has a muffled voice and is drooling. When asked the parents report "we don't believe in vaccinations."

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Epiglottitis is supraglottic inflammation/obstruction of the airway due to infection with Haemophilus influenzae

  • Considered a medical emergency
  • Caused by Haemophilus influenzae Type B bacteria (Hib)
  • Kids without shots (in developed countries kids get Hib vaccine at 2, 4, 6, and 12-15 months)
  • Underserved areas or nations
  • Tripod or "sniffing dog" posture (neck extended)

Signs and symptoms of epiglottitis include inspiratory stridor, restlessness, cough, dyspnea, fever, and drooling

3 D’s of epiglottitis:

  1. Dysphagia
  2. Drooling
  3. Respiratory Distress

Diagnosis of epiglottitis, in a person who is stable and breathing comfortably, is done with a lateral neck X-ray which will classically show a thumbprint sign from swelling of the epiglottis

  • A CT scan would also show a narrow airway from tissue swelling, but lying flat for a CT can obstruct the airway
  • Definitive diagnosis is by laryngoscopy (in a controlled clinical setting like the OR)
    • The endoscopic appearance of edematous or "cherry red" epiglottis is indicative of epiglottitis
Thumbprint Sign

Thumbprint Sign

Airway management first and foremost

  • Individuals are often given extra oxygen, and in severe cases, may need tracheal intubation
    • If tracheal intubation isn’t possible, a needle or surgical cricothyroidotomy may be needed
  • Once the airway is stable, antibiotics ceftriaxone (Rocephin) to treat the infection, and intravenous steroids to decrease the swelling from the immune response
  • Immunization against H. influenza type b
  • May treat as an outpatient if there is no concern about the airway, otherwise, admit

osmosis Osmosis
Picmonic
Epiglottitis Assessment

IM_NUR_Epigoltitis_Assessment_V1.1_

Epiglottitis is supraglottic inflammation/obstruction of the airway due to infection with Haemophilus influenzae. The Hib vaccine is available to protect against Haemophilus influenzae type b and should be given to infants in three to four divided doses starting at the age of two months. Signs and symptoms of epiglottitis include inspiratory stridor, restlessness, cough, dyspnea, fever, and drooling. It is important to note that the throat should not be examined if epiglottitis is suspected, as this could cause spasm and complete closure of the airway. Assessment of the throat should only be done when immediate endotracheal intubation is possible. Epiglottitis requires emergency treatment.

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Epiglottitis Interventions

Epiglottitis is supraglottic inflammation/obstruction of the airway due to infection with Haemophilus influenzae. It is important to note that the throat should not be examined if epiglottitis is suspected, as this could cause spasm and complete closure of the airway. Assessment of the throat should only be done when immediate endotracheal intubation is possible. Epiglottitis requires emergency medical treatment.

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Haemophilus influenzae

IM_MED_HaemophilusInfluenzaeDisease_V1.2_ASSETS

Haemophilus influenzae is a gram-negative coccobacillus that can cause several diseases, including meningitis, pneumonia, otitis media, and epiglottitis. Most strains of H. influenzae live in their host without causing disease, and only cause problems when the host has reduced immune function or inflammation in the area. Naturally acquired disease can occur in infants and young children. Type b Haemophilus influenzae can cause pneumonia and bacterial meningitis. It can also cause otitis media and epiglottitis. In fact, this organism is the most common etiologic agent associated with epiglottitis, which has a thumbprint sign seen on X-ray. Ceftriaxone antibiotic is commonly used for treatment in severe cases.

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Question 1
A 4 year-old child presents with a rapid onset of high fever and extremely sore throat. Which of the following findings are suggestive of the diagnosis of epiglottitis?
A
Croupy cough and drooling
B
Thick gray, adherent exudate
Hint:
Thick gray adherent exudate is suggestive of diphtheria.
C
Beefy red uvula, palatal petechiae, white exudate
Hint:
Beefy red uvula, palatal petechiae, and white exudate are findings suggestive of streptococcal pharyngitis.
D
Inflammation and medial protrusion of one tonsil
Hint:
Inflammation with medial protrusion of the tonsil is suggestive of a peritonsillar abscess.
Question 1 Explanation: 
A croupy cough with drooling in a patient who appears very ill is consistent with epiglottitis. Examining the throat is contraindicated, unless the airway can be maintained.
Question 2
A 35 year-old patient presents with a sudden onset of fever, dysphonia, drooling, and difficulty drinking a few hours ago. Physical examination reveals a temperature of 102 degrees F. The patient appears ill and is sitting forward. Inspiratory retractions are noted and there is a soft stridor. Which of the following is the most likely diagnosis?
A
Angioedema
Hint:
Angioedema would present with swelling of the mouth and upper airway. Patient would not have fever or inspiratory retractions.
B
Foreign body aspiration
Hint:
Patients with foreign body aspiration are unlikely to appear acutely ill or be febrile.
C
Epiglottitis
D
Bacterial pharyngitis
Hint:
Bacterial pharyngitis is not associated with stridor or inspiratory retractions.
Question 2 Explanation: 
Epiglottitis is characterized by fever, dysphonia, drooling, and dysphagia. Patients often appear ill and sit up leaning forward in an attempt to breathe.
Question 3
A 23-month-old male presents to the office with his father who reports the patient has had an acute onset of severe pharyngitis, fever of 103.5 degrees F and what sounds like harsh, high-pitched breath sounds. His dad states the child has started drooling and seems to be worsening. The child is not presently crying but has muffled voice sounds. The child has not been immunized due to religious reasons. What is the most appropriate next step?
A
Administer ceftriaxone (Rocephin)
Hint:
See B for explanation.
B
Emergent transfer
C
Administer racemic epinephrine
Hint:
See B for explanation.
D
Obtain intravenous access
Hint:
See B for explanation.
Question 3 Explanation: 
Epiglottitis requires endotracheal intubation to maintain the airway but should be performed only in the operating room or emergency room with a competent physician prepared to place an endotracheal tube or less often to perform a tracheostomy.
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