Epiglottitis and bacterial tracheitis: SAQ

This preschool child shows the classic constellation of acute epiglottitis: a toxic, frightened child who sits forward drooling, speaks in a muffled voice, has a soft inspiratory stridor, and has no barking cough, all evolving over hours. The uncertain immunisation history raises rather than lowers the concern for Haemophilus influenzae type b. This is an airway emergency in which the overriding priorities are to avoid distressing the child and to secure a definitive airway under controlled conditions before any investigation. [1]

Question 1 (10 marks)

Describe your immediate approach to this child, including what you must and must not do before the airway is secured. [1]

The immediate priority is to do no harm. Keep the child calm and upright on her mother's lap, do not lie her flat, do not examine her throat with a tongue depressor, do not cannulate or take blood, and do not force an oxygen mask if she resists it, because any of these can precipitate complete airway obstruction. Offer oxygen only as tolerated, using a blow-by technique if a mask distresses her. [1]

Assess her observationally from a distance using the paediatric assessment triangle, noting her posture, drooling, muffled voice, stridor, work of breathing, colour, and conscious level, without touching her. Recognise that a softening of the stridor with drowsiness or bradycardia would signal imminent complete obstruction rather than improvement. [1]

Call simultaneously for the most senior anaesthetist available, an ear, nose and throat surgeon, and paediatric intensive care, and prepare to move the child to the operating theatre. The airway team, not the first responder, should instrument the airway, and all diagnostic activity is deferred until the airway is safe. [2]

Question 2 (10 marks)

Outline the definitive airway management and the empiric antibiotic treatment, and comment on how the changing epidemiology of epiglottitis affects your antibiotic choice. [1]

The definitive management is controlled airway control in theatre. The child is taken to the operating theatre and a gas induction is performed with her sitting up and maintaining spontaneous ventilation, with the surgeon scrubbed and ready to perform rigid bronchoscopy or an emergency tracheostomy if intubation fails. Once the airway is secured with an endotracheal tube, blood cultures are taken and intravenous antibiotics started, and she can usually be extubated within twenty-four to forty-eight hours once a leak develops and the swelling settles. [1]

Empiric antibiotics must cover Haemophilus influenzae, streptococci, and staphylococci, so a third-generation cephalosporin such as ceftriaxone 50 mg/kg (max 2 g) intravenously once daily is the standard first-line choice, with vancomycin or clindamycin added where meticillin-resistant Staphylococcus aureus is a concern, and therapy is narrowed once cultures return. [2]

The changing epidemiology matters because widespread Hib vaccination has near-eliminated classic Hib epiglottitis and shifted the disease toward older patients and non-Hib pathogens such as Streptococcus pyogenes, Streptococcus pneumoniae, and Staphylococcus aureus. This is why empiric cover targets streptococci and staphylococci as well as Haemophilus, rather than relying on the pre-vaccine assumption that Hib is the sole cause. The uncertain immunisation status here still keeps Hib firmly in the differential. [3]