URTObstruction - Diseases
Introduction Physical Examination Differential Diagnosis Specific Diseases Epiglottitis Clinical Diagnosis Airway management Supportive therapy Viral croup Foreign body aspiration Retropharyngeal abscess References Other Lectures		The airway can be secured by immediate endotracheal intubation. It is mandatory that each emergency department, along with the pediatric, ENT and anesthesia departments, develop a protocol for managing the child with epiglottitis. Decisions concerning intubation or transfer to a tertiary center must be made prior to the patient's arrival in the emergency room. It is totally unacceptable to "carefully" observe the patient in an intensive care setting for signs of deterioration. What will surely be observed is sudden and total airway obstruction; the objective of airway management is to prevent this from occurring. Most patients are treated with endotracheal intubation as soon as the diagnosis is made. This should be performed under controlled conditions in the sedated or anesthetized patient, whether in the ER, OR or PICU. Use an endotracheal tube that is one size smaller than ordinarily used for the patient's age to reduce the incidence of postintubation sequelae. Initial orotracheal intubation followed by nasotracheal intubation is preferred; however orotracheal intubation alone is also well tolerated. If an oral ETT is used, an oral airway must also be inserted to prevent the patient from biting down on the ETT. Except for the patient who comes in in respiratory arrest and does not begin spontaneous ventilations after resuscitation (hypoxic brain damage), mechanical ventilation is not necessary. The duration of intubation is 36 to 48 hours, after which time the patient can usually be extubated without revisualizing the epiglottis. This should be done during day shift hours when adequate personnel are available. Once an ETT is in place, a lateral neck Xray will not show the epiglottis. Occasionally, postextubation edema causes mild stridor which responds well to nebulized Vaponephrine (racemic epinephrine). The older teenager and adult very often can be managed expectantly, without mandatory intubation. This is due to the larger baseline size of the airway in these patients. Steroids have often been used in this age category, but no studies have demonstrated their efficacy. If the adult patient does need to be intubated, the duration of intubation is usually longer than in the child, mean of 3.5-4 days. Return to top of page