Epiglottitis is a potentially life-threatening condition that results when the epiglottis, a small flap of tissue that covers the opening to the trachea, becomes inflamed.
The condition is most common in children between the ages of 2 and 6.
This case study will review the diagnosis and treatment of a child who presented with signs and symptoms of epiglottitis.
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Epiglottitis Clinical Scenario
While working in the pediatric unit of a hospital, you are called to assess a 4-year-old girl who is 41 inches tall and weighs 16 kg. The parents stated that the child woke up with a cold and they heard a low-pitched noise coming from her throat. They brought her to the ER after noticing she was struggling to breathe. The patient has no notable medical history and is not on any medications at home. She is extremely anxious and will scream when touched by healthcare providers.
On physical examination, the patient showed the following signs and symptoms:
- Her pupils are reactive to light.
- She shows signs of nasal flaring.
- A low-pitch noise is heard coming from her upper airway. It can be heard both with and without using a stethoscope.
- There is no jugular venous distention present.
- Her trachea is positioned in the midline.
- She has a sore throat.
- She is showing signs of drooling and dysphagia.
- She has bilateral, equal chest expansion.
- She is having mild substernal and intercostal retractions and is using her accessory muscles during each inspiration.
- Auscultation reveals clear and diminished breath sounds throughout all lung fields.
- Percussion and palpation findings are normal.
- Her abdomen is soft and non-distended.
- There are no signs of pedal edema.
- Her capillary refill time is two seconds.
- There are no signs of digital clubbing or cyanosis in the fingertips.
- Respiratory rate: 36 breaths/min
- Heart rate: 130 beats/min
- SpO2: 89%
- Temperature: 102.1 °F
Abnormal Laboratory Values
- White blood cell count: 14,000 μl
- PCR test: Positive results for Haemophilus influenza type B
What is the Diagnosis?
Based on the information given, the patient likely has epiglottitis. The key findings that point to this diagnosis are:
- Low-pitched noise in the upper airway
- Substernal and intercostal retractions
- Use of accessory muscles
Diminished breath sounds throughout all lung fields is another important finding. This is likely due to decreased tidal volumes resulting from the upper airway obstruction.
You may have also noticed the presence of a bacterial infection, as evidenced by signs of fever, increased WBC, and a positive PCR test.
What Causes a Low-Pitched Noise in the Upper Airway With Clear and Diminished Lung Sounds During Auscultation?
A low-pitched sound heard in the throat is known as inspiratory stridor, which is a sign of an upper airway obstruction. This finding is typically heard with or without a stethoscope.
When an upper airway obstruction is present, it’s important to listen to both the throat and thoracic region. This helps determine if the noise originated in the lungs or upper airway. In this case, the sound was clearly not coming from the lungs.
Only listening to a patient’s lungs and failing to differentiate between upper and lower airway sounds can lead to a misdiagnosis and inappropriate forms of treatment.
How to Differentiate Between Croup and Epiglottitis?
Croup and epiglottitis are both upper airway conditions that are brought on by infections. Therefore, it’s easy for medical professionals to mistake one for the other.
The primary difference between the two conditions is the region in which the swelling and obstruction take place:
- Croup: The swelling occurs in the subglottic area, which is below the vocal cords.
- Epiglottitis: The swelling occurs in the supraglottic area, which is above the vocal cords.
Important note: Epiglottitis can cause immediate supraglottic swelling, resulting in complete obstruction of the upper airway. Croup, on the other hand, progresses more gradually in comparison. Therefore, epiglottitis is considered to be an urgent, life-threatening condition that requires immediate medical intervention.
Primary Differences in Croup and Epiglottitis
- Onset: Epiglottitis has a sudden onset, and the symptoms can appear and worsen within two to four hours. Croup has a slower onset that appears over the course of two to three days.
- Fever: Epiglottitis often causes a fever, while croup does not.
- Cough: Croup causes hoarseness and a barking cough. In epiglottitis, the cough has more of a muffled sound.
- Dysphagia: Epiglottitis causes difficulty swallowing and drooling, but this is not common in patients with croup.
- Elevated WBC: Increased white blood cells are often noted in patients with epiglottitis but not in those with croup.
What Diagnostic Test Can Confirm the Diagnosis of Croup and Epiglottitis?
The test that can confirm the diagnosis of croup or epiglottitis is a laternal neck radiograph. This x-ray reveals key findings to differentiate the two conditions:
- Croup: Subglottic swelling that appears as a “steeple sign” on the x-ray
- Epiglottitis: Supraglottic swelling that appears as a “thumb sign” on the x-ray
Epiglottitis is characterized by a swollen epiglottis, which appears larger and looks like a “thumb” on the x-ray. Croup causes swelling and narrowing below the vocal cords, which causes the airway to look like a “steeple” on the x-ray.
After confirming epiglottitis with a lateral neck x-ray, you decided to administer oxygen therapy with a nasal cannula at 1 L/min. However, the patient is still extremely irritable and screams when any healthcare provider gets close. In this case, why is it important to keep the patient calm?
It’s important for the patient to remain calm because screaming and crying can further exacerbate the symptoms of epiglottitis. It can cause the upper airway obstruction to progress more rapidly, which could be fatal in the case of a complete obstruction.
After initiating oxygen therapy, the patient’s SpO2 decreased, even after increasing the flow up to 4 L/min. The patient is breathing faster, and her inspiratory stridor has also worsened. Her fingertips are now turning blue. What treatment method would you recommend?
The next step in treating this patient is intubation. The decreasing SpO2, worsening stridor, tachypnea, and cyanosis all indicate that her upper airway is becoming more obstructed.
Therefore, an endotracheal tube should be inserted to establish an airway before it becomes too swollen and completely obstructed.
Intubation for a Child with Epiglottitis
The patient is only four years old; therefore, a size 4.5 cuffed endotracheal tube would be appropriate. You can determine the appropriate ET tube size for pediatric patients by using the following formula:
Tube Size = (Patient’s Age / 4) + 3.5
Tube Size = 1 + 3.5
Tube Size = 4.5
The endotracheal tube should be inserted down to the 13.5 cm mark on the tube. This depth can be determined by multiplying the internal diameter of the ET tube by three.
After insertion, it’s important to listen to the patient’s breath sounds and use an end-tidal capnometer to help confirm the correct positioning of the tube.
Also, be sure to look for equal chest rise and order a chest x-ray to confirm the proper placement. The tube should be located between T3 to T4 on the radiograph.
Initial Ventilator Settings for a Child with Epiglottitis
The initial ventilator settings for a four-year-old child should be set as follows:
- Respiratory rate: 25–30 breaths/min
- Tidal volume: 205–330 mL (i.e., 4–8 mL/kg)
- Inspiratory time: 0.6–0.7 seconds
- PEEP: 5 cmH2O
- FiO2: 36% (i.e., the same as 4 L/min before intubation)
The ventilator settings should be adjusted and titrated according to the patient’s response. The goal is to maintain adequate oxygenation and ventilation parameters, which can be assessed by looking at the SpO2 and arterial blood gas (ABG) values.
Other Treatment Methods
- An antibiotic should be prescribed to treat the infection.
- An antipyretic drug should be administered to reduce her fever.
- Weaning protocols should be implemented to get the patient off the ventilator once the upper airway swelling has subsided.
Epiglottitis is a serious condition that can rapidly progress to a complete upper airway obstruction. Therefore, respiratory therapists must be able to quickly recognize, assess, and treat patients with this condition.
It’s important to recognize the difference between croup and epiglottitis.
Their findings appear similar, but the diagnosis can be confirmed with a lateral neck x-ray in epiglottitis.
Hopefully, this case study has given you a better understanding of epiglottitis and the respiratory therapy interventions that are used to treat it. Thanks for reading, and, as always, breathe easy, my friend.
John Landry, BS, RRT
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
- Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020.
- Clinical Manifestations and Assessment of Respiratory Disease. 8th ed., Mosby, 2019.
- Guerra, Amanda M., and Muhammad Waseem. “Epiglottitis.” National Library of Medicine, StatPearls Publishing, Jan. 2022.
- Abdallah, Claude. “Acute Epiglottitis: Trends, Diagnosis and Management.” National Library of Medicine, Saudi J Anaesth, Sept. 2012.
- Sizar O, Carr B. Croup. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.