Chapter 23 Epiglottitis
PATHOPHYSIOLOGY
Epiglottitis is an acute bacterial infection of the epiglottis and the surrounding areas (the aryepiglottic folds and the supraglottic area) that causes airway obstruction. The infection is caused by Haemophilus influenzae type B or, on rare occasions, by staphylococci, streptococci, pneumococci, or Candida albicans. The use of H. influenzae type B vaccine in infants has resulted in a dramatic reduction in the incidence of epiglottitis. Onset is sudden, and infection progresses rapidly, causing acute respiratory difficulty. This condition requires emergency airway stabilization and medical measures, since a complete airway obstruction may occur due to swelling of the epiglottis. If left untreated, the outcome can be fatal.
CLINICAL MANIFESTATIONS
1. Respiratory difficulty, which can progress to severe respiratory distress in a matter of minutes or hours (dyspnea)
2. Dysphagia, constant drooling
4. Edematous, cherry-red epiglottis
6. Breathing in upright position with head extended forward (classic “tripod” position)
LABORATORY AND DIAGNOSTIC TESTS
1. Oxygen saturation—decrease in the amount of oxygen
2. Arterial blood gas values—decreased pH, decreased partial pressure of oxygen (Po2), increased partial pressure of carbon dioxide (Pco2)
3. Lateral neck radiographic study—to confirm diagnosis. The epiglottis will be swollen, and the hypopharynx will be dilated. This is known as the “thumb” sign.
4. Throat and blood cultures—to rule out other bacterial infections
5. Direct laryngoscopy—to confirm diagnosis; performed in operating room to prevent complications
MEDICAL MANAGEMENT
Children suspected of having epiglottitis should be examined where personnel and equipment are available for an emergency tracheal intubation or tracheostomy. Visual examination of the throat is contraindicated until this requirement is met. Keep child as calm and comfortable as possible. Lateral neck radiographic studies may help confirm the diagnosis but should be performed in the least distressing manner possible, usually with the child being held in the parent’s lap. Endotracheal intubation or tracheostomy is performed in the operating room along with blood draws for laboratory testing, collection of throat culture specimen, and placement of intravenous lines. The child is observed in the intensive care area until swelling of the epiglottis decreases, usually by the third day. Antibiotics are given for a total of 7 to 10 days following extubation. The child is extubated when the epiglottis appears normal and the child is able to breathe around the tube (usually 48 to 72 hours after antibiotic treatment is started).
NURSING ASSESSMENT
Caution: Do not examine the throat if epiglottitis is suspected because of the risk of reflex laryngospasm, which will result in complete airway obstruction.
NURSING INTERVENTIONS
1. Monitor respiratory status (including vital signs).
2. Observe and report signs of increased respiratory distress or changes in respiratory status.
3. Maintain position of comfort and security for child, to facilitate breathing (usually upright in parent’s lap). Never leave child unattended.
4. Prepare child preoperatively for airway insertion (endotracheal tube or tracheostomy) if condition allows.
5. Assist and support physician during emergency procedure.
6. Maintain patency of airway and ventilator function.
7. Provide tracheostomy care (if tracheostomy is performed).
8. Monitor action and side effects of prescribed medications.
9. Assess hydration status: monitor input and output and specific gravity.
10. Provide for child’s developmental needs during hospitalization.
11. Provide consistent nursing care to promote trust and alleviate anxiety.
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