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A previously healthy 4-year-old boy is en route to the children's hospital via helicopter. He was well until 8 hours ago when he began to complain of sore throat and pain on swallowing. His mother brought him to the local emergency department (ED). The emergency physician on duty met a sick, flushed, aphonic, and fearful boy who sat very still and reluctantly swallowed his saliva with visible effort and discomfort. He had no visible respiratory distress or stridor. He was able to lie down on request but preferred to sit. His temperature was 39.6°C, BP 142/75 mm Hg, and HR 145 bpm. Examination of the chest revealed no signs of distress, but coarse ronchi were audible on auscultation. The throat was not examined and the remainder of the general physical examination was negative. On direct questioning, the mother admitted that she did not believe in vaccinations and that their children had not received the hemophilus influenza B (HIB) vaccine. The ED physician suspected supraglottitis and called for an emergency transfer to the nearest children's hospital. While waiting for the helicopter to arrive, the physician started an IV, administered 0.6 mg·kg−1 of dexamethasone, 25 mg·kg−1 of ceftriaxone, and started oxygen 40% by face mask. During transport, the air medical crew administered epinephrine aerosols every 20 minutes. The transport was uneventful but it was noted that the boy was developing moderate indrawing and was insisting on sitting up. His pulse oximeter read 100% on oxygen 4.0 L·min−1 flow, by non-rebreathing face mask, throughout the flight. He arrived in the ED at the children's hospital after a 25-minute flight. On examination, the physical findings were as before but the boy had now adopted the classic tripod sniffing position. His breath sounds were muted, he was visibly drooling, and he maintained a posture of fearful rigidity. When made to speak, he had a muffled hot potato in the mouth voice. Chest examination revealed mild intercostal and sternal notch indrawing. Without supplementary oxygen his oxygen saturation by pulse oximeter dropped to 89%. After preliminary assessment, he was transferred immediately to the operating room for airway management. No lateral neck airway radiographs were taken.

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43.2.1 What Is Supraglottitis and What Is Its Pathophysiology? How Does Supraglottitis in a Child Usually Present?

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Supraglottitis is characterized by inflammation of the structures above the insertion point of the glottis. These include the epiglottis, aryepiglottic folds, arytenoid soft tissue, and the uvula. It is quite common for the terms supraglottitis and epiglottitis to be used interchangeably.1 While traditionally the term epiglottitis was more widely used, the more recently used term supraglottitis is perhaps anatomically more correct, and hence will be used throughout this narrative.

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Now a rarity, supraglottitis was once the most common pediatric airway emergency faced by anesthesia practitioners and ENT surgeons. Most cases were caused by infection with an invasive strain of HIB. While the widespread introduction of conjugated HIB ...

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