What is the appropriate management for a pediatric patient with epiglottitis?

Management of Pediatric Epiglottitis

Pediatric epiglottitis is a life-threatening emergency requiring immediate airway management via nasotracheal intubation performed by an experienced pediatric anesthesiologist in a controlled setting (operating room or ICU), combined with intravenous antibiotics targeting Haemophilus influenzae type b. 1, 2, 3

Immediate Airway Management

The priority is securing the airway before any other intervention, as the swollen epiglottis can cause sudden complete airway obstruction. 4

Critical Safety Principles

• Never attempt to visualize the epiglottis with a tongue depressor or swab the pharynx, as this can precipitate complete airway obstruction and is contraindicated 4
• Avoid any manipulation that disturbs the epiglottis until the airway is secured in a controlled environment 4
• Keep the child calm and in a position of comfort (typically sitting upright) during transport 1, 2
• Do not perform blood draws, IV placement, or any procedures that agitate the child until the airway is secured 1, 2

Definitive Airway Approach

Nasotracheal intubation under general anesthesia is the airway management method of choice, performed by an experienced pediatric anesthesiologist-intensivist in the operating room or pediatric ICU 1, 2, 3, 5

• Use intravenous anesthetic agents and muscle relaxants for intubation 1
• After intubation, patients should be paralyzed, sedated, and mechanically ventilated 1
• Nasotracheal intubation has superior outcomes compared to tracheostomy, with fewer complications and no scarring or tracheal stenosis 2, 5
• Tracheostomy should be reserved only for failed intubation attempts 2, 3

Personnel and Setting Requirements

• An experienced pediatric anesthesiologist-intensivist must perform the intubation 1
• Have an ENT surgeon immediately available for emergency tracheostomy if intubation fails 4
• The procedure must occur in a setting with full resuscitation equipment and capability 1, 2

Diagnostic Confirmation

Lateral neck radiograph is a quick, safe, and reliable method to confirm epiglottitis (showing the classic "thumb sign" of epiglottic swelling), but should only be obtained if it does not delay airway management 3

• Blood cultures should be obtained after the airway is secured, as they yield Haemophilus influenzae type b in 97% of cases 4, 3
• Direct visualization of the cherry-red, swollen epiglottis should only occur during controlled intubation in the operating room 2, 3

Antibiotic Therapy

Intravenous antibiotics must be started immediately after airway stabilization, targeting Haemophilus influenzae type b as the primary pathogen 1, 2, 6, 3, 5

Antibiotic Selection

• Broad-spectrum coverage including Streptococcus pneumoniae is mandatory 4
• Third-generation cephalosporins (ceftriaxone or cefotaxime) are first-line agents given the prevalence of beta-lactamase producing H. influenzae 3
• Alternative regimens include ampicillin-sulbactam or amoxicillin-clavulanate for susceptible organisms 3

Duration of Intubation and Extubation

Significant improvement in airway obstruction typically occurs 8-12 hours after initiating antibiotic therapy, allowing for earlier extubation than previously practiced 6

• Most patients can be safely extubated within 24-48 hours of intubation 6, 5
• Perform extubation in a controlled setting with ENT surgeon availability for emergency reintubation if needed 4
• Use a negative leak test (checking for air leak around the deflated endotracheal tube cuff) to assess readiness for extubation 4

Post-Extubation Management

• Monitor closely in the ICU or PACU for at least 2 hours after extubation 4
• Nebulized epinephrine may be used for post-extubation stridor, though its effect is rapid (30 minutes) but transient (2 hours) 4
• Dexamethasone administration before and after extubation may reduce stridor risk, though evidence is stronger in neonates than older children 4

Common Pitfalls to Avoid

• Do not delay airway management to obtain imaging or laboratory studies if clinical suspicion is high 1, 2
• Do not attempt awake fiberoptic examination in the emergency department, as this can precipitate complete obstruction 4, 2
• Do not use racemic epinephrine or IPPB as primary treatment, as these are ineffective for epiglottic obstruction (unlike croup) 6
• Avoid corticosteroids as routine therapy, as they provide no significant benefit in reducing intubation duration and are associated with gastrointestinal bleeding 5
• Do not transport the child supine or force them into a lying position, as this worsens airway obstruction 1, 2
• Recognize that referring physicians frequently misdiagnose epiglottitis (wrong diagnosis in 81% of cases in one series), causing dangerous delays in airway management 2

Prognosis

With appropriate airway management and antibiotics, survival approaches 100% in modern series 2, 3, 5

• Mortality occurs almost exclusively from delayed airway management or airway manipulation outside controlled settings 2, 3
• Long-term complications are rare with nasotracheal intubation compared to tracheostomy 2, 5