Epiglottitis Case Study: Diagnosis and Treatment (2025)

Epiglottitis is a serious and potentially life-threatening condition caused by inflammation of the epiglottis, a small flap of tissue that covers the trachea’s opening during swallowing. When inflamed, the epiglottis can obstruct the airway, making it difficult to breathe.

While epiglottitis can occur in individuals of any age, it is most common in children between the ages of 2 and 6, requiring urgent medical attention.

This case study explores the diagnosis and treatment of a young child who presented with the classic signs and symptoms of epiglottitis, providing insight into the prompt interventions required for managing this critical condition.

Epiglottitis Clinical Scenario

You are called to the pediatric unit to assess a 4-year-old girl who is 41 inches tall and weighs 16 kg. Her parents report that she woke up with cold-like symptoms, and they noticed a low-pitched noise coming from her throat. Concerned by her difficulty breathing, they brought her to the ER. The patient has no significant medical history and is not on any medications. She is extremely anxious and becomes distressed, screaming when touched by healthcare providers.

Physical Examination Findings

HEENT

• Pupils reactive to light
• Nasal flaring present
• Low-pitched noise is audible from her upper airway, both with and without a stethoscope, indicating stridor
• No jugular venous distention
• Trachea is midline
• Complains of a sore throat
• Signs of drooling and dysphagia (difficulty swallowing), which are hallmark signs of epiglottitis

Chest Assessment

• Bilateral, equal chest expansion
• Mild substernal and intercostal retractions observed, with accessory muscle use during inspiration
• Auscultation reveals clear but diminished breath sounds throughout all lung fields
• Normal findings on percussion and palpation
• Abdomen soft and non-distended

Extremities

• No pedal edema
• Capillary refill time is 2 seconds, indicating adequate circulation
• No signs of digital clubbing or cyanosis in the fingertips

Vital Signs

• Respiratory rate: 36 breaths/min (tachypnea)
• Heart rate: 130 beats/min (tachycardia)
• SpO2: 89% (indicating hypoxemia)
• Temperature: 102.1 °F (febrile, suggesting infection)

Abnormal Laboratory Results

• White blood cell count: 14,000/µl (elevated, indicating infection)
• PCR test: Positive for Haemophilus influenzae type B, the most common bacterial cause of epiglottitis

Note: This clinical presentation, combined with lab results, strongly suggests epiglottitis. The patient exhibits classic signs such as drooling, dysphagia, stridor, and difficulty breathing. Immediate intervention is critical to prevent airway obstruction, a life-threatening complication of epiglottitis.

Diagnosis

Based on the clinical presentation, the patient is highly likely to have epiglottitis. Several key findings support this diagnosis:

• Low-pitched noise in the upper airway (stridor)
• Substernal and intercostal retractions
• Use of accessory muscles during breathing
• Hypoxemia (SpO2 of 89%)
• Tachycardia (heart rate of 130 beats/min)
• Tachypnea (respiratory rate of 36 breaths/min)

Additionally, diminished breath sounds throughout all lung fields point to decreased tidal volumes, likely due to upper airway obstruction caused by epiglottitis.

The presence of a bacterial infection is evident, as indicated by the patient’s fever, elevated white blood cell count, and a positive PCR test for Haemophilus influenzae type B.

What Causes a Low-Pitched Noise in the Upper Airway with Clear but Diminished Lung Sounds?

The low-pitched noise heard in the upper airway is known as inspiratory stridor, which is a hallmark of upper airway obstruction. This sound is typically audible both with and without a stethoscope.

When an upper airway obstruction is present, it’s important to auscultate both the throat and thoracic region to differentiate between sounds originating in the lungs versus the upper airway. In this case, the stridor clearly originates from the upper airway, not the lungs.

Failing to distinguish between upper and lower airway sounds could lead to a misdiagnosis and inappropriate treatment.

How to Differentiate Between Croup and Epiglottitis?

Although both croup and epiglottitis are upper airway infections, they differ in the location of the swelling and the severity of obstruction:

• Croup: Swelling occurs in the subglottic area, below the vocal cords.
• Epiglottitis: Swelling occurs in the supraglottic area, above the vocal cords.

Epiglottitis can cause rapid supraglottic swelling, potentially leading to complete airway obstruction. In contrast, croup tends to progress more gradually.

Because of its rapid onset and potential to fully block the airway, epiglottitis is considered a medical emergency that requires immediate intervention to prevent life-threatening complications.

Primary Differences Between Croup and Epiglottitis

• Onset: Epiglottitis has a sudden onset, with symptoms worsening rapidly, often within 2 to 4 hours. Croup has a gradual onset, typically developing over 2 to 3 days.
• Fever: Epiglottitis is often accompanied by a high fever. Croup usually has an absent or mild fever.
• Cough: Croup is characterized by a barking, hoarse cough. In epiglottitis, the cough, if present, is muffled and softer due to airway obstruction.
• Dysphagia (Difficulty Swallowing): Epiglottitis causes significant difficulty swallowing and drooling, hallmark symptoms of the condition. In croup, dysphagia and drooling are uncommon.
• Elevated White Blood Cells (WBC): Epiglottitis often presents with an elevated WBC count, indicating a bacterial infection. Croup typically does not show a marked increase in WBC, as it is usually viral.

What Diagnostic Test Can Confirm the Diagnosis of Croup and Epiglottitis?

A lateral neck radiograph (x-ray) is the diagnostic test used to confirm croup or epiglottitis. The x-ray reveals characteristic findings that differentiate the two conditions:

• Croup: Shows subglottic swelling, which appears as the classic “steeple sign”—a narrowing of the airway below the vocal cords.
• Epiglottitis: Shows supraglottic swelling, known as the “thumb sign”, where the swollen epiglottis appears enlarged, resembling the shape of a thumb.

Note: These radiographic findings help distinguish between croup’s subglottic narrowing and epiglottitis’s life-threatening supraglottic swelling, guiding the appropriate medical intervention.

Treatment

After confirming epiglottitis via a lateral neck x-ray, you initiated oxygen therapy using a nasal cannula at 1 L/min. However, the patient remains extremely irritable and screams whenever a healthcare provider approaches.

It is crucial to keep the patient calm because screaming and crying can exacerbate the airway obstruction caused by epiglottitis. Increased agitation leads to greater respiratory effort, which can cause the upper airway to swell more rapidly, potentially resulting in a complete obstruction—a life-threatening situation.

Despite oxygen therapy, the patient’s SpO2 continues to decrease, even after increasing the flow to 4 L/min. The patient is now breathing faster, and her inspiratory stridor has worsened. Additionally, her fingertips are turning blue, indicating cyanosis.

What Treatment Method Would You Recommend?

The next step in managing this patient is intubation. The signs of decreasing SpO2, worsening stridor, tachypnea, and cyanosis all suggest that the upper airway is becoming more severely obstructed.

To secure an airway before a complete obstruction occurs, an endotracheal tube (ET tube) should be inserted promptly.

Intubation for a Child with Epiglottitis

For a four-year-old child, a 4.5 mm cuffed endotracheal tube is appropriate, based on the formula:

Tube Size = (Patient’s Age / 4) + 3.5
Tube Size = 1 + 3.5
Tube Size = 4.5

The tube should be inserted to a depth of 13.5 cm, which can be determined by multiplying the internal diameter of the ET tube by three (4.5 x 3 = 13.5 cm).

After insertion, it’s important to confirm proper tube placement by:

• Auscultating breath sounds to ensure bilateral ventilation
• Using an end-tidal capnometer to verify exhaled CO2
• Observing for equal chest rise
• Ordering a chest x-ray to confirm that the tube is positioned between the T3 to T4 vertebrae on the radiograph

Initial Ventilator Settings for a Child with Epiglottitis

Once the airway is secured, the child should be placed on mechanical ventilation with the following initial settings:

• Respiratory rate: 25–30 breaths/min
• Tidal volume: 205–330 mL (4–8 mL/kg based on the child’s weight)
• Inspiratory time: 0.6–0.7 seconds
• PEEP: 5 cmH2O
• FiO2: 36% (matching the oxygen flow rate of 4 L/min used before intubation)

Note: These settings should be carefully adjusted based on the patient’s response, with the goal of maintaining adequate oxygenation and ventilation, which can be monitored through SpO2 and arterial blood gas (ABG) results.

Additional Treatment Methods

• Antibiotics: Administer antibiotics to target the bacterial infection, especially if Haemophilus influenzae type B (Hib) is the cause.
• Antipyretic drugs: Prescribe antipyretics to lower the patient’s fever and reduce discomfort.
• Weaning protocols: Once the swelling in the upper airway has subsided, initiate weaning protocols to gradually remove the patient from the ventilator.

Note: By following these steps, the patient can be stabilized, and the upper airway swelling can be managed until full recovery is achieved.

Final Thoughts

Epiglottitis is a life-threatening condition that can rapidly lead to complete upper airway obstruction, making timely recognition and intervention crucial.

Respiratory therapists play a critical role in quickly assessing and treating patients to prevent catastrophic airway compromise.

Understanding the differences between croup and epiglottitis is vital, as their symptoms can appear similar. However, epiglottitis can be confirmed with a lateral neck x-ray, which will reveal the characteristic thumb sign caused by supraglottic swelling.