How is nebulization of epinephrine (adrenaline) used in children with acute epiglottitis?

Nebulization of Epinephrine in Children with Acute Epiglottitis

Epinephrine nebulization is not effective for treating acute epiglottitis in children and should not be used as it does not relieve the obstruction caused by edematous aryepiglottic folds and hypopharyngeal structures. 1

Pathophysiology and Management of Acute Epiglottitis

Acute epiglottitis is a potentially life-threatening condition characterized by:

• Rapid infection and swelling of the epiglottis and aryepiglottic folds
• Progressive airway obstruction that can be fatal if not managed appropriately
• Typically caused by Haemophilus influenzae type B (though vaccination has reduced incidence)

Key Management Principles

1. Airway Management (Primary Intervention):

   • Endotracheal intubation is the mainstay of treatment for airway obstruction in epiglottitis 2
   • Nasotracheal intubation has been shown to be as safe as tracheotomy in controlling the upper airway 3
   • In severe cases, tracheotomy may be necessary if intubation fails

2. Medication Management:

   • Intravenous antibiotics are essential to treat the underlying infection 3, 2
   • The role of steroids remains controversial - one study found no significant effect on duration of intubation or infectious complications 3

3. Important Monitoring Considerations:

   • Patients typically require intubation for 18-24 hours (mean 18 ± 9.5 hours in one large study) 4
   • Criteria for extubation include resolution of fever (<37.5°C), passage of time (12-16 hours), and improvement in general appearance 4

Why Epinephrine Nebulization Is Not Effective

Unlike in laryngotracheobronchitis (croup) where nebulized epinephrine can be effective, research has shown that:

• Nebulized racemic epinephrine does not relieve the obstruction caused by edematous aryepiglottic folds and other hypopharyngeal structures in epiglottitis 1
• Approximately half of patients with epiglottitis required an artificial airway despite attempts with nebulized epinephrine treatment 1

Distinguishing Epiglottitis from Other Conditions

It's crucial to differentiate epiglottitis from:

• Viral laryngotracheobronchitis (croup) - where nebulized epinephrine may be beneficial
• Pseudo-membranous bacterial tracheitis - which is rare but requires different management 2

Complications to Monitor

• Pulmonary edema has been reported as a complication after intubation in children with epiglottitis 5
• Treatment for this complication includes oxygen therapy and positive end-expiratory pressure 5

Practical Management Algorithm

1. Suspect epiglottitis if child presents with:

   • Rapid onset of respiratory distress
   • Drooling
   • Dysphagia
   • Muffled voice
   • Sitting in tripod position

2. Do not attempt:

   • Throat examination without airway equipment ready
   • Nebulized epinephrine as primary treatment

3. Immediate actions:

   • Secure the airway through intubation or tracheotomy
   • Start intravenous antibiotics
   • Monitor in intensive care setting

4. Extubation when:

   • Fever resolves (<37.5°C)
   • 12-16 hours have passed
   • Child's general appearance improves

Remember that epiglottitis is a medical emergency requiring rapid intervention focused on securing the airway, not nebulized treatments that have been proven ineffective for this specific condition.