1. Epiglottitis

·         Etiology. This is a bacterial infection and inflammatory edema of the supraglottic laryngeal structures. Complete Airway obstruction can easily occur. This disease is always considered a pediatric emergency!

Hemophilus Influenza virus Type B-H. Flu is a very common organism that spreads in day care centers or public places. Children who attend daycare normally receive a vaccination against H. flu at 18 or 24 months.

·         Epidemiology-10-15% of all systemic H. Flu infections are Epiglottitis. The most common ages are between 2-8 years, the most common time is winter/spring, and males and females have equal incidence.

·         Clinical Manifestations

o        Acute Febrile Illness-temp >= 39°C, onset <= 24 hours

o        Mild to Moderate Respiratory distress

o        Hoarse-c/o sore throat

o        Drooling

o        Inspiratory Stridor

o        Moderate to Severe suprasternal and intercostal retractions

o        Hypoxemia may cause decreased mental status and agitation.

o        As the swelling of the epiglottis becomes worse, the child assumes a sitting position with the chin thrusting forward. This position maintains an open airway.

·         Dx

o        The clinical history should arouse suspicion.

o        Position the child on the parent's lap and do no anxiety producing procedures such as ABG's. Hold an O₂ mask near the child's face but not covering it.

o        CXR-the lateral neck will show the "thumb sign"-a swollen protuberant epiglottis-usually don't bother with as going straight to the OR. Never go to radiology alone-take the Doc.

·         Rx

o        In the OR, the ENT attending or the anesthesiologist will do a direct visualization of the epiglottis-either a Naso or oral ETT or Tracheostomy (preferred)

o        Transfer to ICU. Mechanical ventilation is rarely necessary, but humidified warm or cool O2 via ETT or Trach is usually adequate.

o        The duration of intubation/trach is usually between 12 hours and 5 days. What clinical sign would indicate to you the infection was passing? Extubation usually occurs within 36-48 hours. Before extubation, we get a everything (equipment and drugs) ready for reintubation.

o        How important is an airway? Research studies show up to a 25% mortality rate without an airway and <= 1% mortality rate with an airway.

o        Lab studies show that H, flu can normally be recovered from the blood or by swabbing the epiglottis, but IV ampicillin and/or chloramphenicol is given prophylactically pending C and S results.

2. Croup

·         Definition and Etiology-This is normally a subglottic inflammation of the lower airway. Children can also acquire Croup from a congenital narrowing of the airway or previous intubations. Viral Croup can be life threatening!

The organisms that normally cause croup are parainfluenza viruses (Type I and II), RSV (Respiratory Syncytial Virus), Adenoviruses.

·         Epidemiology-Age 8-30 months, more common in males than females, repeat episodes are common.

·         Clinical Manifestations

o        febrile, barking stridorous cough

o        URI symptoms for several days before the croupy cough.

o        Symptoms become worse at night when the child is asleep.

o        Runny nose is common; WBC's are normal or slightly elevated (compare to Epiglottis).

o        Mild to moderate respiratory distress with suprasternal retractions.

o        Lower airway edema results in V/Q abnormalities, thus hypoxia may be seen in ABG's. The child is tachycardic, cyanotic and anxious.

·         CXR-subglottic narrowing

·         Rx

o        The majority of children can be managed at home with cool humidified air via vaporizer (really a nebulizer) or the shower. Children normally improve dramatically when taken out in the night air-Why?

o        Only 10% of children with croup need to be hospitalized (i.e., only if mild to moderate respiratory distress is present).

o        Rx includes a croup tent with Air or O2, IV hydration, close observation. These kids will not normally tolerate an O2 mask. All laboratory procedures such as ABG's and physical exam should be postponed.

o        Frequent monitoring of VS is necessary to prevent hypoxemia. We feed the child normally or via IV's if PO intake is inadequate.

o        Corticosteriods may be given to decrease airway inflammation. and also Racemic Epinephrine (Vaponephrin or Micronephrin) 0.25 or 0.5 ml diluted in 2.5 ml NS as needed. How does this drug work? What are its dangers? Careful as there may be rebound effect several hours later?

o        <= 5% of children with croup require intubation, but for example, allergic croup may cause anaphylactic shock (insect bite, allergy to a specific food) and require a tube.