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YOUR PATIENT

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A 4-year-old female presents to the emergency room with inspiratory stridor, excessive drooling, and substernal retractions and fever. She complains of a sore throat.

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PREOPERATIVE CONSIDERATIONS

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Epiglottitis begins with a high fever and a sore throat. Other symptoms may include abnormal breathing sounds (stridor), chills and shaking, cyanosis, drooling, dyspnea (the patient may need to sit upright and lean slightly forward in order to breathe), dysphagia, dysphonia, and voice changes (hoarseness). The etiology of epiglottitis is bacterial: Haemophilus influenzae type b (75% of cases), Group A β-hemolytic Streptococcus pneumoniae, Staphylococcus aureus, and Klebsiella pneumoniae.

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Examination of the upper airway should be limited to noting the respiratory rate, assessing the work of breathing, and observing the level of respiratory distress. No manipulation or examination of the mouth or pharynx should be performed unless it is in a controlled setting. The anesthesiologist must be certain that all necessary bronchoscopes, endotracheal tubes, and emergency tracheostomy equipment are available. A skilled otolaryngologist must be present and should accompany the child at all times once the diagnosis is suspected, should the need for a surgical airway arise.

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No blood work should be done, and no intravenous catheter should be placed. The child should be disturbed as little as possible. If parental separation would cause undue anxiety, the parents should be allowed into the operating room.

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Concerns regarding a full stomach are theoretically reasonable, as these children have not fasted. However, these children are often so sick, and swallowing is so painful, that food and fluid intake has probably decreased prior to presentation.

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ANESTHETIC MANAGEMENT

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  • Maintain the child in a sitting position and provide general inhalational anesthesia with 100% oxygen and sevoflurane. The ability to transfer gas to allow for oxygenation, removal of CO2, and the uptake of inhalation agents may be severely restricted by the size of the orifice at the glottic inlet. An inhalational induction with sevoflurane may be quite prolonged as a result of this restricted gas flow.

  • Spontaneous ventilation is maintained with gentle assisted respirations as needed until the patient is deep enough to allow for IV placement. Standard American Society of Anesthesiologists monitors are placed.

  • Opioids and muscle relaxants are avoided until the airway is established.

  • With the child deep and spontaneously ventilating, the otolaryngologist will perform a direct laryngoscopy and rigid bronchoscopy. Visuali-zation of the larynx is often difficult, and the epiglottis needs to be lifted very gently with a blade or a rigid bronchoscope. Because of airway swelling and secretions, an endotracheal tube one to two sizes smaller than would be appropriate for the age and size of the patient is placed.

  • If during the induction, any problem leading to a loss of spontaneous ventilation or airway obstruction arises, an emergent direct laryngoscopy or rigid bronchoscopy needs to be attempted.

  • The surgeon ...

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