15.9 Epiglottitis

Epiglottitis refers to life-threatening inflammation of the epiglottis and associated structures. This inflammation causes severe swelling that can lead to suffocation and respiratory arrest due to obstruction of the airway. A common age group that experiences this condition are those in the 6- to 12-year-old range, although adults can experience the condition as well. Other risk factors are male gender, people who are immunocompromised, and people who have not received the Haemophilus influenzae type B (HIB) vaccine.^[1],[2]

Pathophysiology

Prior to the development of a HIB vaccine, epiglottitis was a common condition caused by Haemophilus influenzae type B (HIB). Although HIB still causes the majority of cases, it can also be caused by other viruses, bacteria, fungi, or trauma. Due to differences in airway anatomy, children are more likely to experience epiglottitis than adults. When epiglottitis occurs, the epiglottis becomes edematous and increases in weight. In children the epiglottis is much less rigid than that of adults, which allows for easier airway obstruction. Due to the pliancy of the pediatric epiglottis, each inspiration in those suffering from epiglottitis causes the epiglottis to easily cover the airway, which results in symptoms.^[3]

Assessment (Recognizing Cues)

Physical Exam

Clients with epiglottitis typically have experienced a recent URI, but symptoms worsen quickly. The classic signs of epiglottitis are the “3 Ds” that stand for drooling, dysphagia (difficulty swallowing), and distress. Typically, the client sits upright in the tripod position and may have a muffled or hoarse voice. Airway swelling leads to stridor, retractions, and increased respiratory rate. The client may also have enlarged cervical lymph nodes. The presence of cyanosis is an ominous sign and signals a poor prognosis. It is essential that on physical exam, the nurse does not place anything (such as a tongue blade) into the throat, as this could trigger complete airway obstruction and respiratory arrest.^[4]

Potential complications of epiglottitis include abscess formation, septic shock, and respiratory failure. Death can also occur if sudden airway obstruction occurs and the client cannot be intubated or have an emergent tracheostomy performed.^[5]

Common Laboratory and Diagnostic Tests

A diagnosis of epiglottitis can be made clinically, but imaging is often done to help confirm the diagnosis. A lateral X-ray of the neck or ultrasound can be used to aid in diagnosis, but they should only be done on stable and cooperative clients. See Figure 15.8^[6] for an image of a lateral neck X-ray that illustrates a swollen epiglottis. Lab work, such as a complete blood count, blood cultures, or cultures of the epiglottis, may be performed after the client’s airway has been secured.^[7]

Nursing Diagnosis (Analyzing Cues)

Nursing priorities for clients with epiglottitis include symptom and airway management and preventing the spread of illness to others.

Nursing diagnoses for clients with epiglottitis are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client-specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment.

Possible nursing diagnoses for clients with epiglottitis are as follows^[8],[9]:

• Ineffective airway clearance r/t airway edema
• Ineffective breathing pattern r/t airway edema
• Anxiety r/t difficulty breathing
• Risk for suffocation r/t airway edema

Outcome Identification (Generate Solutions)

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, achievable, relevant, and timebound (SMART) with a set time frame based on the application of appropriate nursing interventions.

Sample expected outcomes include the following^[10]:

• The client will exhibit a patent airway and no signs of respiratory distress during the course of the illness.
• The client will demonstrate an appropriate respiratory rate for their age within 15 minutes of respiratory treatment.
• The client will demonstrate a calm demeanor within four hours of medical treatment.

Interventions (Generate Solutions & Take Action)

Medical Interventions

The primary intervention for clients with epiglottitis is to secure the airway and prevent sudden airway occlusion. If indicated, an endotracheal intubation is emergently performed by an experienced health care provider, and the client is admitted to the intensive care unit. If an endotracheal intubation is not possible due to the swelling of the epiglottis, a tracheotomy may be performed by a trained physician or surgeon.^[11]

Medications prescribed for epiglottitis include steroids and antibiotics. Steroid use has been shown to reduce swelling and reduce the amount of time spent in the intensive care unit. Antibiotics are initially prescribed and then adjusted later based on culture and sensitivity results. Commonly used antibiotics are cefuroxime, ceftriaxone, and cefotaxime.^[12]

Nursing Interventions

Registered nurses plan interventions based on the expected outcomes for each client. Prior to implementation, the nurse must determine if all previously planned interventions are still suitable based on the current situation of the client. When caring for a client with epiglottitis, nursing interventions can be divided into nursing assessments, nursing actions, and client teaching as described in the following subsections.^{[13],[14],[15]}

Nursing Assessments

• Monitor the respiratory status of the client, including lung sounds, respiratory rate and pattern, oxygen saturation levels, and arterial blood gas (ABG). Nasal flaring, increased respiratory rate, increased difficulty breathing, and worsening oxygen saturation levels or ABG results can indicate respiratory failure and the need for additional interventions such as intubation or tracheostomy.
• Assess the client’s ability to swallow because epiglottitis can impair swallowing and lead to aspiration.

Nursing Actions

• Ensure that clients with epiglottitis or suspected epiglottitis do not leave the unit without adequate monitoring and resuscitation equipment.
• If indicated, prepare the client to be intubated by a trained professional to improve oxygenation.
• Ensure a tracheostomy tray is available at the bedside at all times.
• Promote relaxation strategies because agitation can trigger airway compromise.
• Administer oxygen, antibiotics, and steroids as prescribed. Oxygen should be humidified to prevent further irritation to the epiglottis. Antibiotics should be administered as soon as possible, but not until after samples have been obtained for ordered cultures.
• Do not place the client in a supine position, as this can cause the epiglottis to further occlude the airway. The client should be allowed to choose a position of comfort, such as Fowler’s position or tripod position.
• If appropriate, encourage the client to frequently ingest ice chips or small sips of water, as this can aid with discomfort of the throat and ensure hydration. However, if the client is NPO, administer IV fluids per provider order.

Client Teaching

• Teach the client and their caregivers that close contracts who have not received the HIB vaccine should receive prophylactic antibiotics. They may also choose to receive the HIB vaccine after exposure, but this is not always an effective method of prevention.
• Educate the client and their parents/caregivers to reduce movement and talking because these actions increase the demand for oxygen and can worsen symptoms.
• Educate the client and their parents/caregivers about epiglottitis and the course of the disease, as this can help reduce anxiety levels. Clients and their caregivers should be taught that swelling of the epiglottitis will be reduced within 24 hours of initiating antibiotic therapy and that the epiglottis will return to a normal size in about three days.
• Educate the client and their parents/caregivers on methods to reduce anxiety, such as massage, guided imagery, deep breathing, and allowing the client to have a familiar comforting object, such as a toy.
• Educate the client and their parents/caregivers about effective handwashing and respiratory etiquette to help prevent the spread of infection to others.
• To prevent epiglottitis, parents are encouraged to vaccinate their children with the HIB vaccine.

Evaluation (Evaluate Outcomes)

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.