THE QUICK AND DIRTY GUIDE TO CROUP AND EPIGLOTTITIS
Laryngo-tracheobronchitis is a lot to spit out in a single mouth full, for a term that simply means "a respiratory infection" or the Croup. No matter what you like to call it, the common croup normally affects children between 1 and 3 years of age. Although it can affect any region of the respiratory tract, it normally presents to EMS providers with inspiratory stridor that is suggestive of an upper airway occlusion caused by swelling. A patient with croup that also is experiencing wheezes and is more than likely is suffering from an infection that has spread to the lower airway. A characteristic cough and various degrees of respiratory distress can be expected with these patients. Croup manifests as a common cold symptom, a low-grade fever, a barking cough, and hoarseness. Croup's upper respiratory infection may be mild, moderate, or severe. It tends to be worse at night and is most commonly identified by the classic “seal-bark cough”. Many of these children have recently had the flu and/or have experienced croup previously. Nasal flaring, intercostal retractions, and cyanosis are late signs of respiratory insufficiency. Children with severe croup are at risk of serious airway compromise from the narrowed diameter of the trachea.
EMS Croup Management
Good prehospital management of croup includes airway maintenance with the administration of humidified, or nebulized oxygen and rapid transport in the position of comfort to an appropriate medical facility. Symptoms may improve dramatically in patients with croup after the child is treated with O2 therapy.
If your patient is severely hypoxic, racemic Epinephrine may be indicated, check your local protocol and medical command for direction.
Epiglottitis although rare, is inflammation of the epiglottis. The epiglottis is located in the upper airway. It's that little flap that covers the trachea during swallowing. If this "flap" becomes inflamed, it swells and this swelling could cause a partial or even complete airway occlusion, thus compromising ventilation and if intubation is needed. The inflammation may involve other structures such as the arytenoid, false cords and the posterior tongue. Epiglottitis affects children 2-5 years of age; however, the median age has been steadily increasing over the past decade and may be seen in children of all ages. The associated inflammation common with epiglottitis presents acutely in these otherwise healthy children. Epiglottic inflammation occurs quickly and can be deadly if not recognized and dealt with rapidly. A serious fever above 104F (40C) often accompanies the illness and can be dangerous if the patient isn't treated promptly.
These children will often be found sitting on the edge of their chair; leaning forward and using accessory muscles in an attempt to help move air in and out of their lungs more effectively. Many children with epiglottitis will complain of a severe sore throat especially when they swallow. It is common to witness excessive salivation in children experiencing a sore throat and/or difficulty swallowing (dysphagia). A cough is usually not associated with epiglottitis, mainly due to the upper airway component of the illness. Epiglottitis is a true medical emergency that requires prompt, expert airway management!
These kids sound sick, look sick, and may get even sicker; be prepared!
As always, aggressive airway management, including intubation, may be indicated if the child appears to be experiencing impending respiratory failure.
- Severe hypoxia
- Decreasing respiratory effort
If the patient doesn't present with imminent signs and symptoms like the ones mentioned above, it is important to obtain a good medical history from parent (when possible):
- Does the patient have any known drug allergies?
- Has the child had an upper respiratory infection in the past?
- If they have; did the illness present like this episode?
- It is important to know: was the onset acute or gradual?
(Epiglottitis generally presents with an acute onset)
- Has the child been sick lately; perhaps with the flu or common cold?
- Is your patient up to date with pediatrics vaccinations?
(Most cases of epiglottitis are caused by hemophilus influenza for which there is a vaccine that is very effective)
- Has the child ever been intubated for any reason?
(This helps identify whether you will need to be aggressive)
Children with acute epiglottitis are in danger of full airway obstruction and respiratory arrest that comes on rapidly and may be caused by minor irritation of the throat. For this reason; gentle handling of a child suspected of having epiglottitis is essential. The following guidelines should be observed when dealing with the potentially fatal illness:
- DO NOT try to lay the patient flat or dictate their position of comfort
- DO NOT visualize the airway if the airway of the child is still adequately ventilating
- Advise the receiving facility of your suspicion of epiglottitis
- Administer 100% humidified oxygen by mask, if tolerated
- DO NOT attempt vascular access (the added stress can be detrimental to the airway)
- Have the proper advanced airway adjuncts ready and at hand
- Intercostal retractions with decreasing stridor is an ominous sign of impending respiratory failure
- Transport the child in a position of comfort with parent nearby
- Decreasing mental status means decreasing respiratory drive; TREAT AGGRESSIVELY!
- If respiratory arrest occurs before arrival at the ED, intubation should be attempted once, rapidly
- If respiratory arrest occurs then IV/IO access is appropriate after airway control is initiated
Epiglottitis Intubation Tips
The EMS professional should be prepared for a difficult intubation if epiglottitis is the culprit causing the occlusion because the vocal cords will more than likely be hidden by swollen tissues. The important thing in this situation is to depend on your skills and training to defeat a bad situation. Remember; adapt and overcome! You have what it takes to win the battle!
The following Tips may help you conquer a difficult airway:
- Choose an uncuffed ET tube that is 1-2 sizes smaller than the tube you would have normally used for this patient
- Locate the laryngeal opening to the larynx by looking for mucus "bubbles' in the cleft between the edematous folds and the swollen epiglottis
(chest compressions during glottic visualization may produce bubbles at the tracheal opening)
- Sometimes a patient may be ventilated effectively with a BVM and a tight facial seal. This method requires two skilled rescuers to deliver the ventilations
- If the patient can not be intubated; medical command may order a needle cricothyroidotomy
- Don't forget to check out 6 Pack for Success: Intubation Tips and Respiratory Emergencies from JEMS