Page 713 - ACCCN's Critical Care Nursing

690 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

prevalence rate from 22.7 to 3.3 per 100,000 children in
TABLE 25.5 Clinical features of croup and epiglottitis 1998 and 2008, respectively. 101,102 Hib infection can
cause meningitis, septicaemia, septic arthritis and celluli-
Croup Epiglottitis tis as well as epiglottitis. The disease process and devel-
opment of major symptoms progress rapidly over a few
Aetiology Viral Bacterial
hours and an untreated child may become acutely
Age 6 months–3 years Infancy through obstructed. A child will make a full recovery without
adulthood sequelae if diagnosis and treatment are appropriate and
Onset Subacute (over days) Acute (over hours) timely. Supraglottitis has emerged in recent times as a
more accurate description of a similar range of symp-
Fever Mild (±38°C) Severe (>38.5°C)
toms as epiglottitis, and has been linked with the herpes
Cough Present (often barking or Absent virus and other organisms, requiring treatment with aci-
seal-like) clovir and vancomycin. 99
Drooling Absent Present
Activity Distressed Lethargic Clinical manifestations
Colour Pale/sick Toxic The child with epiglottitis presents looking unwell with
a fever, is unable to swallow secretions, drooling saliva
Obstruction +++ + and refusing to talk or swallow. The child may maintain
Stridor Inspiratory, high-pitched Expiratory snore an upright position, usually leaning with the head
extended, supporting a sitting position with the arms
Sore throat Uncommon Common
stretched out behind in what is known as the tripod posi-
Position Any Tripod; sitting up tion. Hypoxaemia is usually present. Sudden respiratory
Course Gradual worsening or Unpredictable; fatal arrest followed by cardiac arrest, can occur unpredictably.
improvement if not treated Cardiac arrest is likely to be asystolic in rhythm due to
either vagal stimulation or hypoxia secondary to airway
Season Autumn–winter Throughout the year
obstruction. 94
Adapted from (95).
Management
The most important aspect in the management of epiglot-
cases. 97,98 Nebulised adrenaline is efficacious to reduce titis is rapid diagnosis and minimal handling of the child
airway inflammation, with effects seen within five minutes until an airway is in place. Children with epiglottitis
and lasting up to two hours. Although inhalations can be require urgent intubation because acute airway obstruc-
repeated, the benefits lessen with subsequent treatments. tion followed by cardiac arrest is a potential hazard. Thus,
Adrenaline does not alter the course of croup. the aim of management at this time is to keep the child
as calm as possible until the airway is secured. 19,99 The
child should be nursed propped up with pillows or on a
parent’s lap while arrangements are made for the inser-
Practice tip tion of an ETT. Procedures such as cannulation and exam-
ination of the throat should be avoided until the child’s
If placement of a facemask to deliver oxygen causes increased 95
agitation and worsens respiratory distress in young children, airway is secure.
have the parent hold the mask near their child’s face and Prophylaxis with antibiotics is required for families and
increase the flow rate. ‘Blow-over’ oxygen will increase oxygen household contacts if there is an infant under 12 months
saturation, and as the child settles, mask or nasal cannulae can of age and/or a child in the household under the age of
be reintroduced. five years who is not fully immunised. Where the infected
child has attended childcare for more than 18 hours each
week, it is recommended that staff and other children at
the centre also receive antibiotic prophylaxis. 82
Epiglottitis
Epiglottitis is inflammation of the epiglottis, frequently
involving surrounding structures, with the classic descrip- FOREIGN BODY ASPIRATION
tion of a swollen, cherry-red, softened and floppy epi- Aspiration of a foreign body into the upper airway is
glottis, which tends to fall backwards, obstructing the another relatively common cause of obstruction in chil-
99
airway. Obstruction also occurs circumferentially, from dren. Infants tend to swallow food items such as nuts and
the oedematous, inflamed aryepiglottic folds surround- seeds, while toddler-aged children tend to swallow coins,
ing the larynx. It is typically caused by Hib and since the teeth, and small toys or toy parts. An inhaled foreign
103
introduction of childhood immunisation programmes body is likely to have a rapid onset with no previous
to protect against Hib infection, the incidence has symptoms. Sometimes the diagnosis is missed for days,
dropped from 23.8 cases per 100,000 children in 1991 weeks or even months, and the child’s symptoms may
100
to 2.81 per 100,000 in 2002 in the UK. A similar be non-specific, such as a cough with or without blood-
pattern was observed in Australia with a drop in stained sputum. 83,103