Epiglottite

Acute epiglottitis is a disease of the larynx caused by a haemophilic rod of type b, leading to acute respiratory failure (acute respiratory failure of the obstructive type); a rapidly progressive inflammation of the epiglottis and surrounding tissues of the laryngopharynx, characterized by growing symptoms of shortness of breath due to epiglottis edema and scaly-epiglottis folds.

Epidemiology

The source and reservoir of infection is a person. The disease is transmitted by airborne droplets. The causative agent is secreted from the nasopharynx of 80% of healthy people. A healthy carrier can last from several days to several months. Children most often fall ill at the age of six months to 4 years, less often newborns, older children and adults. The frequency of Haemophilus influenza type B among children in Russia is no more than 5% at the usual time, during the epidemic it increases dramatically.

[1], [2], [3], [4], [5], [6]

Causes of the epiglottitis

The main causative agent of epiglottitis in children (up to 90%) is Haemophilus influenzae (type B). In addition to Haemophilus influenzae, the following pathogens have been identified (with the disease progressing in an easier form) Staphylococcus aureus, Streptococcus pyogenes, Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus parainfluensae (Pfeiffer's stick). The latter belongs to the genus Haemophilus, which unites 16 species of bacteria, 8 of which are pathogenic to humans. The most dangerous are Haemophilus influenza, which causes damage to the respiratory tract, skin, eyes, epiglottis, endocarditis, meningitis, arthritis, and Haemophilus ducteyi.

[7], [8], [9], [10], [11]

Risk factors

Risk factors for the development of acute epiglottitis in children:

• age from 6 months to 4 years,
• male sex (boys fall 1.5-2 times more often than girls),
• previous allergization,
• perinatal encephalopathy,
• preventive vaccinations, coinciding with the onset of the development of the disease,
• concomitant lymphogranulomatosis (and associated chemotherapy), sickle cell anemia, agammaglobulinemia,
• condition after splenectomy.

Children are more often sick 2-12 years, rarely - adults.

[12], [13], [14]

Symptoms of the epiglottitis

Acute epiglottitis often begins with a respiratory infection, minor sore throat, fade disorders, difficulty swallowing, fever. Symptoms of acute epiglottitis can quickly progress to complete obstruction of the larynx, which develops within 4-6 hours from the time of onset. In this case, the child is in a sitting position with the chin advanced forward; the cervical spine is maximally straightened; the tongue protrudes from the oral cavity; copious salivation. Cough occurs rarely.

Characteristic sudden increase in temperature, severe pain in the throat, rapidly progressive obstruction of the airways, increased salivation. Expressed acrocyanosis, sweating, pale skin with a gray tinge. The child takes a forced semi-strong position. The head is in the characteristic position of "sniffing", "gasping" for air. Breathing is stenotic, all auxiliary muscles participate, voice is hoarse, cough rare, sufficiently sonorous, but dry, unproductive. The child can not swallow. When trying to put the child on his back, respiratory failure grows. Vomiting, including "coffee grounds", is possible. Heart tones are muffled, tachycardia, weak pulse. Zev during examination is hyperemic, filled with a lot of thick and viscous mucus and saliva, occasionally one can see an enlarged cherry-red epiglottis.

Anxiety is replaced by a sharp increase in cyanosis, a hypoxic coma develops with a fatal outcome.

Manifestality of the course and severe airway obstruction are the distinctive features of epiglottitis.

[15]

Forms

There are edematous, infiltrative and abscessing forms of acute epiglottitis. Infiltrative and abscessed forms can lead to the development of sepsis. Against the background of a septic condition, hemophilic meningitis often develops. As the symptoms of acute epiglottitis fade, stenosis of the larynx and subglottic space, purulent laryngotraheobronchitis, comes first.

[16], [17], [18]

Diagnostics of the epiglottitis

Diagnosis of acute epiglottitis in children is based on history, clinical picture of the disease, visualization of the epiglottis, etiological diagnosis of blood cultures and a swab from the oropharynx.

When breathing in and out, listen to sounds with a predominance of low tones. Severe stridor, retraction in the area above the breastbone and under it with the phenomena of cyanosis indicate a threat of complete obstruction of the airways.

When examining the pharynx: dark cherry infiltration of the root of the tongue, edematous and inflamed epiglottis.

With laryngoscopy: edematous arytenoid cartilage, inflamed over the connective structures of surrounding tissues. In some cases, the study may cause a laryngospasm in the child, requiring immediate intervention. The diagnosis is made by direct examination of the pharynx and larynx.

Radiography is performed only in case of a dubious diagnosis and provided that the child is accompanied by a doctor who owns the method of intubation. Diagnostic signs - a shadow of the epiglottis with an increased volume of swollen soft tissue, rounded and thickened edge of cherched folds.

Differential diagnosis

Differential diagnosis is performed with the following diseases:

• acute stenosing laryngotracheitis (syndrome of false croup),
• retropharyngeal abscess,
• abscess of the root of the tongue,
• BA,
• thermal and chemical lesions of the mucous oropharynx,
• foreign body of the larynx,
• backing hemangioma,
• papillomatosis of the larynx,
• multiple soft tissue oropharyngeal tumors,
• bronchiolitis,
• whooping cough.

Treatment of the epiglottitis

Children with epiglottitis need emergency hospitalization. Transportation is carried out only in the sitting position. If necessary, intubation of the trachea. Parenterally, amoxicillin / clavulanate is administered [40 mg / (kilogram)) | or ceftriaxone | 100-200 mg / (kghsut) |. The extreme measure is tracheostomy.

The main directions of treatment of acute epiglottitis:

• maintenance of patency of the upper respiratory tract,
• rational antibiotic therapy,
• infusion therapy,
• immunocorrecting therapy.

It is necessary to emphasize the danger of inhalation with warm moistened mixtures. Indications for hospitalization of the patient in the intensive care unit are increasing anxiety, progression of dyspnea, non-curable hyperthermia, hypercapnia. Attempting intubation of the trachea by ambulance doctors can end up lethal, so it is necessary to take the patient to the nearest children's intensive care unit. However, in the resuscitation department, there may be problems with intubation of the trachea. It is necessary to be ready to apply microtracetostoma for high-frequency ventilation of the lungs.

Dangerous transfer of the patient to a horizontal position is dangerous, since this can lead to obstruction of the respiratory tract by a sunken epiglottis. Intubation of the trachea should be done in a semi-sitting position. A certain danger is the use for inhalation of inhalational anesthetics, especially halothane. More rational is the inhalation of sevoflurane, rapid access to the peripheral vein. For sedation, use midazolam in a dose of 0.3-0.5 mg / kg, sodium oxybutyrate at a dose of 100 mg / kg.

The puncture of the central vein is performed after restoring airway patency.

Antibiotic therapy

Cephalosporins of the second generation of cefuroxime 150 mg / kggsut, cephalosporins of the third generation - cefotaxime 150 mg / kggsut, ceftriaxone 100 mg / kggsut, ceftazidime 100 mg / kgg) in combination with aminoglycosides nitromycin 7.5 mg / ( kgsut). Apply carbapenems - meropenem (meronem) 60 mg / (kghsut) in three steps. The duration of the course of antibacterial therapy - at least 7-10 days, fluid in the vascular bed and providing patients with sufficient calories and plastic substances.

With the improvement of pulmonary gas exchange and stabilization of the general condition of the patient, the emphasis of therapy should be shifted to providing energy and plastic needs with the help of parenteral nutrition or mixed (parenteral-enteral nutrition).

[19], [20], [21], [22], [23], [24]

Immunocorrective therapy

• immunoglobulin normal human for intravenous administration up to 1 g / kg for 3 days,
• pentaglobin 5 ml / kg once.

In the treatment of community-acquired pneumonia, the choice of antibiotics should be differentiated, taking into account the age, the severity of the condition, and the presence of concomitant diseases. When choosing an antibiotic in a patient with nosocomial pneumonia take into account the nature of the microflora of the department (general department or resuscitation), the use of ventilation and the development of ventilation pneumonia.

Community-acquired pneumonia

Drugs of choice

• amoxicillin + clavulanic acid or ampicillin + sulbactam in combination with macrolides (with a mild course),
• cephalosporins III-IV generation + macrolides intravenously + rifampicin (in severe course)

Alternative drugs

• fluoroquinolones intravenously, carbapenems

Nosocomial pneumonia

Drugs of choice

• Amoxicillin + clavulanic acid, ampicillin + sulbactam,
• cephalosporins of the ІІ-ІІІ generation

Alternative drugs

• fluoroquinolones, cefepime + aminoglycosides, vancomycin.

Antioxidant therapy (ascorbic acid, vitamin E)

[25], [26]

Treatment of complications

In non-cardiogenic AL, IVL, antifoam (ethyl alcohol), intravenous saluretics, aminophylline are used.

With pyopneumotorax, pleural drainage is established. With myocardial dystrophy prescribe drugs cardiotropic action - dobutamine 10-20 μgDkgmmin), dopamine 5-20 mkg / (kghmin).