01Approach to the Critical Patient/attcp49

Immediate airway priorities

›Airway threat recognition

›Inspiratory stridor indicating critical airway narrowing

›Tripod or sniffing position in toxic-appearing child

›Drooling with inability to swallow secretions

›Muffled "hot potato" voice

›Impending arrest features

›Cyanosis or SpO2 < 92% on any supplemental oxygen

›Altered mental status or severe agitation

›Respiratory fatigue with paradoxical breathing

›If impending complete obstruction, immediate mobilization of most experienced airway provider

›Surgical team at bedside for emergency cricothyrotomy or tracheostomy

›Do NOT attempt bag-mask ventilation alone without surgical backup

›Airway management pathway

›Controlled intubation in operating room is gold standard

›Most experienced airway provider performs intubation

›Anesthesia and ENT/surgery present simultaneously

›Nasotracheal intubation preferred; ETT 0.5-1.0 sizes smaller than age-predicted

›Pre-OR stabilization

›Keep child calm in position of comfort, preferably on parent's lap

›Humidified blow-by oxygen if mask not tolerated

›Avoid all agitating procedures until airway is secured

›If OR unavailable and complete obstruction occurs

›Bag-mask ventilation as temporizing measure

›Emergency surgical airway as last resort

Monitoring and targets

›Continuous monitoring bundle

›Pulse oximetry with continuous waveform

02History/hx51

Presentation pattern

›Classic symptom triad

›Acute onset high fever, typically >39 degrees C

›Onset typically within hours not days

›Much faster progression than croup viral prodrome

›Dysphagia and drooling

›Drooling sensitivity 0.79, specificity 0.94 for epiglottitis versus croup

›Refusal to swallow saliva highly specific

›Voice change

›Muffled hot potato quality

›Not hoarse as in croup

›Differentiating symptom features

›Absence of barking cough

›Cough predicts croup not epiglottitis

›Sensitivity 1.00 specificity 0.98 for croup diagnosis

›Positional preference

›Insistence on upright or tripod position

›Refusal to lie supine

›Respiratory character

›Inspiratory stridor from supraglottic obstruction

›No URI prodrome typical of croup

Risk factors and exposure history

›Immunization status

›Hib vaccination series completion status

›Single most important risk factor in children

›Under-immunized children at highest risk

›Vaccine failure possible

›Documented cases even after complete series

03Physical Exam/exam47

General and vital signs

›Toxic appearance assessment

›Anxious and distressed but conscious

›Disproportionate apprehension relative to apparent distress level

›Toxic appearance differentiates from croup

›Positional findings

›Tripod position: leaning forward, hands on knees

›Sniffing position: neck extended, chin forward

›Refusal to lie supine or recline

›Vital sign pattern

›High fever typically >39 degrees C

›Tachycardia proportional to fever and distress

›Respiratory rate elevation

›Tachypnea with increased work of breathing

›Oxygen saturation

›Hypoxia is a late and ominous sign

›Normal SpO2 does not exclude critical airway compromise

Airway and respiratory exam

›Stridor characteristics

›Inspiratory stridor from supraglottic narrowing

›High-pitched inspiratory phase

›Worsens with agitation

›Absence of expiratory component

›Differentiates from tracheal or subglottic pathology

›Oropharyngeal findings

›Drooling present

›Pooled secretions at lips

›Refusal to swallow

04Differential Diagnosis/ddx35

Life-threatening mimics

›Bacterial tracheitis

›ICD-10 J04.10

›Toxic child initially resembling croup but worsening despite treatment

›Thick purulent tracheal secretions

›Staphylococcus aureus most common organism

›Retropharyngeal abscess

›ICD-10 J39.0

›Neck stiffness and dysphagia with unilateral cervical adenopathy

›Lateral neck radiograph shows prevertebral widening

›Drooling can be present

›Foreign body aspiration

›ICD-10 T17.308A

›Sudden onset without fever, history of choking event

›No toxic appearance

›Unilateral wheeze or air trapping possible

›Angioedema

›ICD-10 T78.3XXA

›Rapid onset, no fever, possible urticaria

›Allergen exposure history

›ACE inhibitor use as trigger

Infectious supraglottic and adjacent mimics

›Croup (laryngotracheobronchitis)

›ICD-10 J05.0

›Barking cough, gradual onset with viral prodrome over days

›Responds to corticosteroids and nebulized epinephrine

›Drooling absent, cough prominent

›Peritonsillar abscess

05Laboratory Tests/lt36

Core infectious labs

›Complete blood count with differential

›Leukocytosis with left shift expected

›WBC >15 x 10^9/L with bandemia correlates with bacteremia

›Severe leukocytosis supports bacterial rather than viral etiology

›Neutrophilia prominent in H. influenzae and Streptococcal disease

›C-reactive protein

›Elevated CRP associated with aggressive disease course

›Trend value more than single measurement

›High CRP may predict need for intubation

›Blood glucose

›Hyperglycemia associated with more severe disease

›Stress hyperglycemia in septic-appearing child

›Blood cultures

›Obtain after airway is secured, not before

›Historically positive for Hib in up to 96% of pre-vaccine era cases

›Post-vaccine era often negative or mixed flora

›Two sets from separate sites before antibiotics when feasible and airway safe

Additional diagnostic labs

›Throat and epiglottic cultures

›Obtain at time of direct laryngoscopy or intubation

›Swab of epiglottic surface for organism identification

›Guides antibiotic narrowing after organism identified

›Inflammatory markers for severity trending

›Procalcitonin for bacterial infection support

›Not a rule-out test for epiglottitis

›Electrolytes and renal function

›Dehydration from poor oral intake

06Diagnostic Tests/dt50

Scoring Systems

›No validated pediatric epiglottitis severity scoring tool

›Clinical gestalt and symptom complex guides urgency

›Drooling plus stridor plus tripod position: high specificity combination

›Any one of these in toxic child should prompt OR mobilization

›Severity stratification based on features predicting airway intervention

›Stridor present: high risk

›Hypoxia present: very high risk, impending arrest

›Dyspnea with retractions: intubation likely required

›Drooling with inability to swallow: confirms supraglottic compromise

MRI

›MRI not indicated in acute epiglottitis

›Duration of scan incompatible with unstable airway monitoring

›No role in acute management

›Cannot safely monitor airway in MRI suite

›Post-treatment imaging role

›MRI of neck if abscess or deep space infection suspected

›Only after airway secured and child stabilized

CT

›CT neck

›Generally unnecessary for diagnosis of classic epiglottitis

›Not required when clinical presentation is classic

›Lateral neck radiograph is preferred imaging modality

›Indications in selected stable patients

›Suspected deep neck space infection or retropharyngeal abscess

›Atypical presentation or failure to respond to antibiotics

›CT findings when obtained

›Enlarged, enhancing epiglottis

07Disposition/dispo32

Admission and level of care

›All confirmed or suspected cases require hospital admission

›PICU or ICU admission for all intubated patients

›75.9% of patients in one series required ICU-level care

›Airway compromise requiring intubation occurred in 27.6% in post-vaccine cohorts

›High-dependency unit acceptable only for stable, non-intubated patients with close monitoring

›Continuous cardiorespiratory monitoring mandatory

›Immediate escalation pathway confirmed before admission

›Transfer criteria

›Facility lacking pediatric anesthesia, ENT, or surgical capability

›Arrange emergent transfer with physician skilled in airway management accompanying patient

›Do not transfer unstable child without secured airway

›Transfer vehicle must have full pediatric airway kit

Intubation and extubation planning

›Intubation duration targets

›Mean intubation duration approximately 18 hours

›90% of children extubated within 24 hours with appropriate treatment

›Extubation criteria

›Resolution of fever below 37.5 degrees C

›Clinical improvement in supraglottic swelling assessed by laryngoscopy

›Passage of 12-16 hours after intubation minimum

›Pre-extubation direct laryngoscopy not required routinely if clinical criteria met

Discharge criteria

›Minimum criteria before discharge

›Afebrile for at least 24 hours

›Tolerating oral intake without dysphagia

›No stridor at rest

›Antibiotic transition to oral therapy completed and tolerated

08Treatment/t63

Initial stabilization

›Minimize disturbance protocol

›Position of comfort maintained throughout

›Parent holds child on lap in upright position

›Tripod or sniffing position not corrected

›Supplemental oxygen delivery

›Blow-by technique if face mask not tolerated

›High-flow humidified oxygen at 10-15 L/min blow-by

›Defer all IV access and laboratory draws until airway secured

›Exception only if intraosseous access needed for emergency resuscitation

Airway management

›Controlled intubation in operating room

›Team composition

›Most experienced pediatric airway provider as intubator

›Anesthesiologist and ENT/surgeon simultaneously present

›Surgical backup immediately available for emergency tracheostomy

›Technique

›Nasotracheal intubation preferred

›ETT 0.5-1.0 size smaller than age-predicted formula

›Video laryngoscopy or direct laryngoscopy with backup equipment at hand

›Induction agents for inhalational induction preferred in children

›Sevoflurane inhalational induction maintains spontaneous respirations

›Allows assessment of airway anatomy before paralytic administration

›Post-intubation management

›Confirm ETT position with capnography and chest radiograph

›Sedation and analgesia protocol

›Prevents self-extubation during healing phase

›Opioid plus benzodiazepine or dexmedetomidine infusion

09Special Populations/sp47

Pregnancy

›Epiglottitis in pregnancy

›Rare but reported in adult pregnant patients

›Physiologic upper airway mucosal edema of pregnancy increases severity risk

›Airway management technically more difficult due to mucosal engorgement

›Antibiotic considerations in pregnancy

›Cephalosporins (ceftriaxone) generally safe in pregnancy

›Metronidazole safe after first trimester if anaerobic coverage needed

›Fetal monitoring

›Continuous electronic fetal monitoring during any airway intervention

›Maternal hypoxia has direct fetal consequences

›Anesthetic considerations

›Aspiration risk higher in pregnancy due to delayed gastric emptying

›RSI with cricoid pressure if general anesthesia required after first trimester

Geriatric

›Epiglottitis in older adults

›Post-vaccine era epiglottitis has shifted to adult predominance

›Adults more likely to present with sore throat as chief complaint

›Drooling and tripod position less common in adults

›Atypical presentations more common

›May present without classic triad of fever, drooling, stridor

›Longer symptom duration before airway compromise

›Higher rates of underlying immunocompromise

›Diabetes mellitus increases risk and severity

›Malignancy and immunosuppressive therapy risk factors

›Airway management considerations

›Awake fiberoptic intubation may be preferred over inhalational induction

›More airway reserve than pediatric patients but higher comorbidity burden

10Background/b70

Epidemiology

›Incidence and vaccination impact

›99% reduction in pediatric epiglottitis in children under 5 years since Hib conjugate vaccine introduction

›Pre-vaccine incidence approximately 6-10 per 100,000 children per year

›Post-vaccine incidence now rare, exact rates difficult to determine

›Current causative organism distribution

›Haemophilus influenzae type b still isolated in incompletely immunized

›S. pneumoniae and Group A Streptococcus now most common bacterial pathogens

›Viral etiologies including influenza A and EBV increasingly recognized

›Demographics

›Historical peak age 2-6 years with mean approximately 3.5 years

›Post-vaccine era cases predominantly in adults and adolescents

›Male sex associated with more aggressive clinical course

›Highest risk populations

›Under-immunized or unimmunized children

›Indigenous communities with higher Hib disease burden

›Immunocompromised patients at any age

›Outcomes data

›Misdiagnosis rate 37% in one large series

›All fatal respiratory obstructions occurred within 12 hours of presentation

›75.9% of confirmed cases required ICU-level care in post-vaccine cohort

›Mean intubation duration approximately 18 hours; 90% extubated within 24 hours

Pathophysiology

›Infectious mechanism

›Bacterial or viral invasion of epiglottic mucosa

›Rapid inflammatory edema of epiglottis and aryepiglottic folds

›Supraglottic structures affected: epiglottis, arytenoids, aryepiglottic folds, uvula

›Hib mechanism

›Bacteremic seeding of epiglottic tissue

›Blood cultures positive in up to 96% of pre-vaccine era cases

›Post-vaccine era bacteremia rates much lower

›Anatomical vulnerability in children

›Smaller absolute airway diameter amplifies edema effect

›Poiseuille's law: resistance proportional to radius to the fourth power

›Small absolute reduction in radius causes exponential increase in resistance

›Soft, compliant supraglottic structures more easily deformed by edema

›Epiglottis omega-shaped in infants, more vulnerable to collapse

›Obstruction progression

›Edema causes loss of airway patency in supine position

›Gravity worsens posterior displacement of swollen epiglottis

›Upright position partially maintains airway by anterior displacement

›Complete obstruction can occur suddenly

›Any agitation, crying, or foreign object in mouth can precipitate acute closure

›Obstruction may occur within minutes of apparent stability

Therapeutic Considerations

›Airway management philosophy

›Early controlled intubation preferred over expectant management in children

›Historical pediatric literature supports elective intubation of all confirmed cases

›Risk of sudden complete obstruction too high for observation alone

›Inhalational induction advantages in children

›Maintains spontaneous respiration during induction

›Avoids paralysis before airway visualized and secured

›Preferred technique by most pediatric anesthesiologists

›Antibiotic evidence

›Two-dose ceftriaxone protocol shown effective in prospective trial

›100 mg/kg on day 1 followed by 50 mg/kg on day 2

›Safe and effective alternative to prolonged courses

›Duration guidance

›Typical total course 7-10 days

›Oral step-down appropriate when clinically improved and tolerating oral intake

›Antibiotic narrowing guided by cultures when available

›Corticosteroid and epinephrine role

›Dexamethasone evidence extrapolated from croup studies

›Theoretical benefit in reducing supraglottic edema

›No high-quality randomized controlled trial data specific to epiglottitis

›Racemic epinephrine temporizing only

›Not a substitute for definitive airway management

›Rebound edema may occur 30-60 minutes after administration

›Contact prophylaxis

›Rifampicin prophylaxis for household contacts of confirmed Hib cases

›Eradicates nasopharyngeal Hib carriage in contacts

›Reduces secondary attack rate in household

›Not indicated if causative organism is not Hib

11Patient Discharge Instructions/pdi26

copy discharge instructions

›Discharge instructions for Pediatric Epiglottitis

›Your child was treated for epiglottitis, a serious infection of the structure above the voice box

›This infection has responded to antibiotics and airway treatment

›Most children recover fully within 48-72 hours of appropriate treatment

›Medications to complete at home

›Take all antibiotic doses as prescribed even if your child feels better

›Do not stop antibiotics early without calling the doctor

›Activity and diet

›Offer soft foods and plenty of fluids

›Your child may have mild throat discomfort when swallowing for a few days

›Immunizations

›Your child needs Hib vaccination even after this illness

›Having the infection does not always protect against future disease

›Speak with your family doctor about completing the immunization schedule

›Follow-up appointments required

›Ear, nose, and throat specialist within 1-2 weeks

›Family doctor or pediatrician within 1 week of leaving the hospital

›Return to emergency immediately if

›Any noisy breathing, high-pitched sound when breathing in, or difficulty breathing

›This is the most urgent warning sign

›Drooling or inability to swallow

›Fever returning after your child was improving

›Change in voice quality becoming muffled or very quiet

›Child refuses to drink fluids for more than 4-6 hours

›Child appears very anxious, restless, or cannot get comfortable in any position

›Blue color around the lips or fingertips at any time

12References/r23

Guidelines and key sources

›Primary references

›Eskander A, de Almeida JR, Irish JC. Acute Upper Airway Obstruction. New England Journal of Medicine. 2019

›Comprehensive review of supraglottic and airway obstruction management

›Tibballs J, Watson T. Symptoms and Signs Differentiating Croup and Epiglottitis. Journal of Paediatrics and Child Health. 2011

›Drooling sensitivity 0.79 specificity 0.94; cough sensitivity and specificity data

›Baird SM et al. Review of Epiglottitis in the Post Haemophilus Influenzae Type-B Vaccine Era. ANZ Journal of Surgery. 2018

›ICU admission rates, intubation rates, thumbprint sign imaging performance

›Sawyer SM et al. Successful Treatment of Epiglottitis With Two Doses of Ceftriaxone. Archives of Disease in Childhood. 1994

›Two-dose ceftriaxone protocol evidence and extubation criteria

›Kim KH et al. Accuracy of Objective Parameters in Acute Epiglottitis Diagnosis: A Case-Control Study. Medicine. 2018

›Lateral neck radiograph epiglottis width sensitivity 96.2% specificity 98.2%

›Vaccination and epidemiology

›Briere EC et al. Prevention and Control of Haemophilus Influenzae Type B Disease: ACIP Recommendations. MMWR. 2014

›Hib prophylaxis guidance, chemoprophylaxis indications, immunization schedule

›Soeters HM et al. Current Epidemiology and Trends in Invasive Haemophilus Influenzae Disease. Clinical Infectious Diseases. 2018

›Post-vaccine era epidemiology and organism distribution data

›Marques JG et al. Haemophilus Influenzae Type B Vaccine Failure in Portugal. Pediatric Infectious Disease Journal. 2023

›Vaccine failure rates and mechanism

›Point-of-care imaging

›Hung TY et al. Bedside Ultrasonography as a Safe and Effective Tool to Diagnose Acute Epiglottitis. American Journal of Emergency Medicine. 2011

›Alphabet P sign description and technique

›Darras KE et al. Imaging Acute Airway Obstruction in Infants and Children. Radiographics. 2015

›Lateral neck radiograph technique and safety considerations

Evidence & Review

Evidence & Review