Epiglottitis Nursing Care Planning and Management

Treat acute epiglottitis as a true airway emergency. The epiglottis is a small cartilage at the base of the tongue that covers the windpipe during swallowing; when it swells, the airway can close in minutes. Do not examine the throat, do not lay the child flat, and do not agitate them. Keep the child upright, keep the parent close, and get someone skilled in pediatric airway management to the bedside before anyone touches a tongue depressor. Upper airway obstruction here carries real mortality and can progress to respiratory arrest and death.

What is Epiglottitis?

Epiglottitis (also called supraglottitis) is acute inflammation of the structures above the glottis, most often from bacterial infection. Swelling can involve the epiglottis, aryepiglottic folds, arytenoid soft tissue, and occasionally the uvula. The epiglottis itself is the most common site of swelling.

Pathophysiology

Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae colonizes the pharynx of otherwise healthy children through respiratory spread from close contact. Hib infection triggers acute inflammatory edema, starting on the lingual surface of the epiglottis where the submucosa is loosely attached, so swelling builds fast and chokes down the airway aperture. Edema spreads to the aryepiglottic folds, the arytenoids, and the entire supraglottic larynx, halting at the vocal cords where the epithelium is tightly bound. Frank airway obstruction, aspiration of oropharyngeal secretions, or distal mucous plugging can drive respiratory arrest.

Statistics and Incidences

Hib vaccine has made epiglottitis rare in children in the United States. Annual incidence runs about 0.63 cases per 100,000 persons, with seasonal variation across childhood. A retrospective series of 107 patients admitted to a pediatric ICU from 1997 to 2006 found bacterial tracheitis is now 3 times more likely to cause pediatric respiratory failure than viral croup and epiglottitis combined. International rates vary widely and are far higher where universal immunization is absent; among countries with mandatory immunization, reported incidence is 0.9 cases per 100,000 in Sweden and 0.6 cases per 100,000 in the United Kingdom. Most studies show no racial predominance, though one recent study showed higher incidence among black and Hispanic individuals. There is a roughly 60% male predominance, which has held even as the epidemiology shifted.

Causes

Epiglottitis most often hits children 2 to 7 years old. Historically Hib was the predominant organism, over 90% of pediatric cases. Viruses do not usually cause it, but a prior viral infection can open the door to bacterial superinfection; viral agents include herpes simplex virus, parainfluenza virus, varicella-zoster virus, HIV, and Epstein-Barr virus, and varicella can drive primary or secondary infection often with group A beta-hemolytic streptococci. Noninfectious causes include thermal injury, trauma from blind finger sweeps to clear a pharyngeal foreign body, angioneurotic edema, hemophagocytic lymphohistiocytosis, and acute leukemia.

Clinical Manifestations

The child may have been well or had a mild upper respiratory infection before symptoms hit. Know the classic triad and the posture:

• Fever, usually the first symptom, often reaching 40°C.
• Dysphagia, difficulty swallowing.
• Drooling, because the child cannot swallow secretions.
• Respiratory distress or air hunger, present in most patients.
• Tripod position: the anxious child sits up, leans forward, mouth open and tongue out, to keep the airway open.

Assessment and Diagnostic Findings

Securing the airway is the overriding priority. An expert in pediatric airway management performs endotracheal intubation on any child with suspected epiglottitis before radiography or blood work. Everything below waits until the airway is safe.

• Laryngoscopy is the best way to confirm the diagnosis, but never attempt it before the airway is secured.
• Blood and epiglottis cultures are drawn only after the airway is secured; blood cultures may show Hib between 12-15% and 90% of cases.
• Lateral neck radiography is never obtained before definitive airway control; if imaging is needed, portable bedside radiography is safest.
• Percutaneous transtracheal ventilation (needle cricothyrotomy, or translaryngeal ventilation) is a temporizing method for severe cases when the patient cannot be intubated before a formal tracheostomy.

Medical Management

Management is directed at relieving airway obstruction and eradicating the infection.

• Respiratory arrest. First step is bag-valve-mask ventilation with 100% oxygen; once oxygenated and ventilated, secure the airway with an endotracheal tube, cricothyrotomy, or tracheostomy. This prevents cerebral anoxia, arrest, and death.
• Moist air helps reduce inflammation.
• Pulse oximetry monitors oxygen requirements.
• Endotracheal intubation. After supplemental oxygen, mobilize a team to establish a definitive airway; mortality for children who receive intubation is less than 1%, while those who do not run mortality as high as 10%.
• Tracheostomy. If intubation fails, perform a tracheostomy, with percutaneous translaryngeal ventilation as a temporizing measure.

Pharmacologic Management

• Antibiotics. Ceftriaxone, cefotaxime, and cefuroxime (for nonmeningitic infections); as in all invasive Hib infections, contacts receive rifampin chemoprophylaxis. For epiglottitis from other organisms, tailor antibiotics to the cause.
• Corticosteroids. Use remains controversial, based largely on anecdotal reports.

Nursing Management

Nursing Assessment

• Respiratory. Assess breathing, any throat injury history, mouth breathing, stridor, and hypoxia.
• Cardiovascular. Assess pulse for tachycardia and a thready quality.
• Gastrointestinal. Assess for inability to swallow.

Nursing Diagnosis

• Ineffective breathing pattern related to upper airway edema.
• Anxiety related to respiratory distress.
• Hyperthermia related to an inflammatory process.
• Deficient knowledge related to the disease process.

Nursing Care Planning and Goals

• Patient and family verbalize strategies to reduce anxiety.
• Patient and family demonstrate understanding of teaching.
• Patient and family verbalize understanding of the condition and treatment.
• Temperature stays within normal range.
• The patient maintains adequate ventilation and oxygenation.
• The patient maintains a patent airway.

Nursing Interventions

• Anxiety control. Keep the child and family calm; agitation tightens the airway and raises oxygen demand.
• Learning facilitation. Help the family take in and act on information.
• Medications. Give antibiotics as prescribed, such as cefuroxime.
• Hydration. Regulate IV fluids, since the child cannot swallow.

Evaluation

Goals are met when the patient and family verbalize anxiety-reduction strategies, demonstrate understanding of teaching, and verbalize understanding of the condition and treatment, and when temperature is normal and the child maintains adequate ventilation, oxygenation, and a patent airway.

Documentation Guidelines

• Breath sounds, presence and character of secretions, use of accessory muscles.
• Plan of care and teaching plan.
• Responses to interventions and actions performed.
• Attainment of or progress toward desired outcomes.
• Modifications to the plan of care.