Upper airway obstruction — the paediatric epiglottitis

Diagnosis. Acute epiglottitis until proven otherwise. In children the inflammation is localised to the epiglottis with a classic acute presentation, and children present more often with acute respiratory distress and fever (adults more often with subacute severe dysphagia). Epiglottitis has become rare in developed countries with universal Haemophilus influenzae vaccination, but it can be rapidly fatal if not promptly recognised and appropriately managed.^[1][5][3]

Distinguish from croup. Croup is the commonest cause of stridor in children and usually self-limited; it is a clinical diagnosis in a febrile child with barking cough and stridor preceded by an upper respiratory infection.^[3][2]

Management.

1. Treat this as a true airway emergency: in epiglottitis and bacterial tracheitis, IV antibiotics are the mainstay, but the prime concern is the airway, which frequently needs endotracheal intubation.^[2]
2. Bring the team: maintaining an open and stable airway often needs emergency physician, paediatrician, otorhinolaryngologist and paediatric pulmonologist together; emergency measures often precede any investigation.^[2]
3. In children, emergent tracheal intubation under general anaesthesia in the operating theatre is standard.^[1]
4. When airway collapse is imminent, proceed directly to endoscopy for definitive diagnosis and airway protection.^[4]
5. Antibiotics alongside airway management, then intensive care for airway observation or ventilation.^[5]
6. Use waveform capnography — failure to use it contributed to 74 per cent of NAP4 deaths or persistent neurological injuries in ICU and the ED.^[6]

The cardinal rule. The airway plan — team, theatre, equipment — comes before investigations. Lateral neck radiographs may be falsely negative; visualisation of the epiglottis is the key to diagnosis.^[5][2]