Paediatric epiglottitis: the influence of the Haemophilus influenzae b vaccine, a ten-year review in the Sheffield region

The impact of pediatric tracheostomy on the quality of life of caregivers

OBJECTIVE

Pediatric tracheostomy is a challenge in otolaryngology practice and it is associated with greater morbidity and mortality than in adults; hence, constant vigilance by the designated family caregiver is critical. This study was designed to assess the impact of on quality of life of caregivers in a homecare setting as a result of the presence of child with a tracheostomy.

METHODS

This was a combined retrospective and prospective cohort study with caregivers of children younger than 16 years who had undergone a tracheostomy, had been discharged home with a tracheostomy tube and completed 6 months of domiciliary tracheostomy care. The consenting primary caregivers were assessed for their quality of life based on the PedsQL v 4.0 questionnaires across various domains.

RESULTS

We identified the primary caregivers of 85 children who had undergone a tracheostomy during the study period. The children's median age was 3.5 years (range, 9 months to 14 years). The mean caregiver health-related quality of life (HRQOL) score was 59.3, the mean family functioning score was 62.8, and the mean total family impact score was 54.7 with relative deficits seen in caregiver's social functioning (56.9) and emotional functioning (53.2). Good or average quality of physical and social function was seen among 74 % and 65 % of caregivers respectively while only 55 % were reported having good or average emotional function. Emotional disturbance, interfering with everyday family activities, and sleep disturbance were the major concerns among caregivers.

CONCLUSION

The biopsychosocial consequences of caring for a child with a tracheostomy are profound for the family, affecting the quality of life of caregivers and adding to the emotional and social burden of the child's family.

Acute Infections That Produce Upper Airway Obstruction

This chapter discusses the common and potentially serious infective causes of acute upper airway obstruction in children. The laryngeal anatomy of young children makes them particularly susceptible to upper airway obstruction, and during acute infections this is exacerbated by inflammation and edema of the airway mucosa. The most common cause of infective upper airway obstruction in children is viral laryngotracheobronchitis, or croup, which is usually a mild and self-limiting illness, but management with corticosteroids may still be necessary. Bacterial causes of upper airway obstruction have fortunately become rare since the introduction of the Haemophilus influenzae B (HiB) immunization, but a few cases of epiglottitis do still occur due to nonimmunization, vaccine failure, and infection with non-HiB organisms. These cases constitute a medical emergency due to the risk of rapid progression to complete airway obstruction. Other rare conditions are discussed including bacterial tracheitis, diphtheria, retropharyngeal, and peritonsillar abscesses. Key learning points in this chapter include the main discriminating factors of the various causes of infective upper airway obstruction, the importance of a calm and minimally distressing approach to the child presenting with stridor, and the need for early anesthetic team involvement in cases with a suspected bacterial etiology or signs of impending airway obstruction.

Risk of acute epiglottitis in patients with preexisting diabetes mellitus: A population-based case-control study

Objective

Studies have revealed that 3.5%–26.6% of patients with epiglottitis have comorbid diabetes mellitus (DM). However, whether preexisting DM is a risk factor for acute epiglottitis remains unclear. In this study, our aim was to explore the relationship between preexisting DM and acute epiglottitis in different age and sex groups by using population-based data in Taiwan.

Methods

We analyzed data between January 2000 and December 2013 obtained from the Taiwan National Health Insurance Research Database. The case group consisted of 2,393 patients with acute epiglottitis. The control group comprised 9,572 individuals without epiglottitis, frequency matched by sex, age, urbanization level, and income. Underlying DM was retrospectively assessed in the cases and controls. Univariate and multivariate logistic regression analyses were used to investigate the associations between underlying DM and acute epiglottitis.

Results

Of the 2,393 patients, 180 (7.5%) had preexisting DM, whereas only 530 (5.5%) of the 9,572 controls had preexisting DM. Multivariate logistic regression analyses indicated that preexisting DM was significantly associated with acute epiglottitis (adjusted odds ratio [aOR] = 1.42, 95% confidence interval [CI] = 1.15–1.75, P = 0.004). Subgroup analysis showed that the association between DM and epiglottitis remained significant for men (aOR = 1.57, 95% CI: 1.19–2.08, p = 0.002) but not for women. Age-stratified analysis revealed a significant association between DM and acute epiglottitis in patients aged 35–64 years. Use of anti-diabetic agents was not significantly associated with the development of acute epiglottitis among diabetic patients, including oral hypoglycemic agents (OHA) alone (aOR = 0.88, 95% CI = 0.53–1.46, p = 0.616), and OHA combined with insulin/ insulin alone (aOR = 1.30, 95% CI = 0.76–2.22, p = 0.339). The association between presence of diabetes complications and the occurrence of acute epiglottitis was also not significant among diabetic patients in this study setting (aOR = 0.86, 95% CI = 0.59–1.26, p = 0.439).

Conclusions

The results of our large-scale population-based case–control study indicate that preexisting DM is one of the possible factors associated with the development of acute epiglottitis. Physicians should pay attention to the symptoms and signs of acute epiglottitis in DM patients, particularly in men aged 35–64 years.

Paediatric tracheostomy-An 11 year experience at a Scottish paediatric tertiary referral centre

AIMS

The aim of this paper was to review the indications, complications and outcomes for tracheostomy at a Scottish paediatric tertiary referral hospital.

METHODS

All patients undergoing tracheostomy between January 2001 and September 2012 were identified. A retrospective case note analysis was performed.

RESULTS

111 tracheostomies were done in the study period. The mean number per year was 11 (3-12). Full data was available for 95 patients. There were 56 (59%) males and 39 (41%) females. Age at time of tracheostomy ranged from one day to 15 years, the mean age of tracheostomy insertion was 69 weeks. The majority of patients, 75 (79%), were under one year old when they had their tracheostomy. The most common indication was long-term ventilation (20%), followed by craniofacial abnormality causing airway obstruction (18%), followed by subglottic stenosis (14%). 37% of patients were decannulated.

CONCLUSIONS

This series reflects current trends in the indications for paediatric tracheostomy, with chronic lung disease of prematurity being the most common indication.

Pediatric tracheotomy: a 30-year experience

BACKGROUND/PURPOSE

The aim of this study was to investigate changes of pediatric tracheotomy practice over time.

METHODS

A retrospective analysis of all tracheotomies at the University Children's Hospital Zurich from January 1990 to December 2009 was performed. Data analyzed included the indication for tracheotomy, patient comorbidities, age, duration of cannulation, and complications. The second part of the study consisted of comparing our results with data from an earlier study done at the same institution by Simma et al. (Eur J Pediatr 1994;153:291-296) reviewing the patients with tracheotomies treated from 1979 to 1989.

RESULTS

Between 1990 and 2009, 119 patients were included. The indication for tracheotomy was airway obstruction in 70% and prolonged ventilation in 30%. 70% of the patients were operated on before 1 year of age. Serious postoperative complications occurred in 25 patients (23%). There was one death related to tracheotomy. Successful decannulation was achieved in 60%, on average 28 months after tracheotomy. The decannulation rate in patients with airway obstruction was 74% compared to 52% for the patients in prolonged ventilation group; a statistically significant difference was observed (p < 0.05). The longitudinal analysis showed an increase of indications for prolonged ventilation and a trend toward decreased tracheotomy complications.

CONCLUSION

Over 30 years, a shift in the indications of pediatric tracheotomy, with an increasing number of procedures performed for prolonged ventilation, was found. The tracheotomy-related mortality was under 1%. Tracheotomy remains a valid and safe option for pediatric patients. Level of evidence 2c.

Symptoms and signs differentiating croup and epiglottitis

AIM

To determine differentiating symptoms and signs of epiglottitis and laryngotracheobronchitis (croup).

METHODS

Contemporaneous interview of parents and clinical examination of children with acute upper airway obstruction presenting to the intensive care unit of a paediatric hospital.

RESULTS

Two hundred and three children were examined over a 40-month period. One hundred and two had croup, of whom 49 had the diagnosis confirmed at intubation and another six by direct laryngeal inspection without intubation. One hundred and one had epiglottitis of whom 95 were diagnosed by direct inspection of the larynx at intubation, five by a lateral X-ray of the neck and one on direct inspection without intubation. One child with epiglottitis died. Although both illnesses presented with stridor, the additional presence of drooling had a high sensitivity (0.79, 95% CI 0.70-0.86) and specificity (0.94, 95% CI 0.88-0.97) for epiglottitis while coughing had a high sensitivity (1.00, 95% CI 0.96-1.00) and high specificity (0.98, 95% CI 0.93-0.99) for croup. Coughing predicted croup but drooling predicted epiglottitis. Additional reliable signs of epiglottitis were a preference to sit, refusal to swallow and dysphagia. Thirty-seven percent of children with epiglottitis and 16% with croup were treated as having another respiratory illness at least once before definitive diagnosis.

CONCLUSIONS

Epiglottitis and croup are often confused because they share symptoms and signs including stridor. However, differentiation in early illness is possible by additional observation of coughing and absence of drooling in croup and by the additional observation of drooling with absence of coughing in epiglottitis.

Diagnosis and management of supraglottitis (epiglottitis)

Acute supraglottitis is a serious, potentially fatal infection in both adults and children. Haemophilus influenzae type b (Hib) is the most common cause in children, even in this era of the Hib vaccine. Most cases of acute supraglottitis in adults are thought to be caused by other bacterial organisms, viral or combined viral-bacterial infections, and noninfectious etiologies. Early visualization of the larynx is essential, as is establishment of a secure airway in selected cases. Most cases will respond to intravenous antibiotic therapy and will not require an artificial airway. Admission to an area of high-intensity nursing is essential. Daily laryngoscopy is necessary to monitor response to treatment. Although the incidence of acute supraglottitis in children has decreased, isolated cases will be encountered and demand high vigilance.

Anesthetic experience of 100 pediatric tracheostomies

BACKGROUND

Tracheostomy is more hazardous in the pediatric population than in adults (Paediatr Nurs, 17, 2005, 38; Int J Pediatr Otorhinolaryngol, 67, 2003, 7; J R Soc Med, 89, 1996, 188). Airway management in these children and infants is potentially challenging. Previous case series of pediatric tracheostomy published in the surgical journals make little mention of anesthetic techniques used and do not describe airway management. The aim of this study was to review the anesthetic, and in particular the airway management of children undergoing tracheostomy at Great Ormond Street Hospital (GOSH).

METHODS

Between September 2004 and December 2007, the ENT surgical database showed that 109 children had a surgical tracheostomy performed at GOSH. We were only able to locate the notes of 100 of these cases. The anesthetic records of these 100 patients undergoing tracheostomy were analyzed retrospectively.

RESULTS

Ninety-four percent (94/100) of tracheostomies were elective, and 6% (6/100) were emergency. In this study, 26% (26/100) of children were recorded as difficult to intubate. These difficult airways were managed as follows: 10/26 used a laryngeal mask airway (LMA), 5/26 were managed with facemask alone, 3/26 had fiber-optic intubation, 5/26 had surgical intubation and 2/26 were intubated with the aid of a bougie and cricoid pressure.

CONCLUSIONS

This case series demonstrates that intubation is difficult in up to 26% of children presenting for tracheostomy. While intubation of the trachea remains the preferred option when anesthetizing children for tracheostomy, the LMA or facemask can provide a successful airway where intubation is not possible. The use of the LMA or facemask may therefore be life saving in the unintubatable child.

Pediatric tracheotomies: a 37-year experience in 282 children

OBJECTIVE

To study the outcomes, complications, and indications for pediatric tracheotomies performed at a tertiary referral center.

METHODS

A retrospective review of hospital records from 1968 to 2005 was conducted to assess all pediatric patients who had undergone tracheotomies.

RESULTS

A total of 282 tracheotomies were performed on patients under 16 years of age. The median age at tracheotomy was 27 months. Upper airway obstruction (infectious diseases, n=101; laryngeal anomalies, n=33; trauma, n=36; tumor, n=33) was the most common indication for tracheotomy (n=203; 72%). Lesser number of patients (n=79; 28%) required tracheotomy for prolonged ventilation. Decannulation was carried out successfully in 71 patients (35%). Total complication rate was 18%; only three patients (1%) died from tracheotomy-related complications, with an overall mortality rate of 19%.

CONCLUSIONS

Pediatric tracheotomies were associated with a low incidence of procedure-related mortality and morbidity and successful decannulation in 35% of cases. The majority of procedures were performed due to upper airway obstruction which were most commonly caused by infectious diseases.

Infections of the airway

Infections of the airway in children may present to the anesthetist as an emergency in several locations: the Emergency Department, the Operating Department or on Intensive Care. In all of these locations, relevant and up to date knowledge of presentations, diagnoses, potential complications and clinical management will help the anesthetist and the surgical team, not only with the performance of their interventions, but also in buying time before these are undertaken, avoiding complications and altering the eventual outcome for the child. Diseases such as epiglottitis and diphtheria may show diminished incidence but they have not gone away and their clinical features and essential management remain unchanged. Paradoxically, perhaps, some conditions such as Lemierre's syndrome appear to be making a comeback. In these instances, clinicians need to be alert to these less common conditions, not only in regard to the disease itself but also to potentially serious complications. This article describes those infections of the airway that are most likely to present to the anesthetist, their attendant complications and recommendations for treatment.

Croup

Most children who present with acute onset of barky cough, stridor, and chest-wall indrawing have croup. A careful history and physical examination is the best method to confirm the diagnosis and to rule out potentially serious alternative disorders such as bacterial tracheitis and other rare causes of upper-airway obstruction. Epinephrine delivered via a nebuliser is effective for temporary relief of symptoms of airway obstruction. Corticosteroids are the mainstay of treatment, and benefit is seen in children with all levels of severity of croup, including mild cases.

Current trends in paediatric tracheostomies

OBJECTIVE

In the 1970s, the most common indication for tracheostomy in children was acute inflammatory airway obstruction. Modern neonatal intensive care units have turned long-term intubation into an alternative to tracheostomy. Long-term intubation itself has become the most important indication for tracheostomy combined with subglottic stenosis.

METHODS

Retrospective analysis in a tertiary referral center. A total of 38 patients who underwent tracheostomy for respiratory failure and upper airway obstruction from 1 November 1998 to 30 November 2004.

RESULTS

Total complication rate was 42.1%. In children under 1 year of age the complication rate was 47.4%, in children over 1 year the complication rate was 26.3%. Decannulation was attempted in 12 patients with a cannulation time of 22 months.

CONCLUSIONS

Long-term intubation and its sequelae have now become one of the most important indication for tracheostomy. The change of indication has also entailed a decrease of the average age of children who require tracheostomy. A longer period before decannulation and a lower average age have changed the complication rate of tracheostomy in paediatric patients.

Acute epiglottitis: epidemiology, clinical presentation, management and outcome

Aims:

To describe the incidence trends, clinical presentation, management and outcome of acute epiglottitis in a Danish population after the introduction of Haemophilus influenzae type b vaccine.

Methods:

Retrospective review of the health records of all patients discharged with a diagnosis of acute epiglottitis from the otolaryngology department, Roskilde County Hospital, Denmark, from 1996 to 2005.

Results:

One infant and 34 adults were identified. The incidence of acute epiglottitis in children was 0.02 cases/100 000/year. Before introduction of the H influenzae type b vaccination (1983–1992), the mean national incidence of acute epiglottitis was 4.9 cases/100 000/year. The incidence of acute epiglottitis in adults was constant, with a mean value of 1.9 cases/100 000/year. Twenty-nine per cent of the patients required an artificial airway, and respiratory distress was found to be associated with airway intervention (p = 0.010). All patients recovered completely.

Conclusions:

In the H influenzae type b vaccine era, acute epiglottitis in children has almost disappeared. The incidence in the adult population has been constant. A discriminate approach to airway management seems safe in adults.

Airway infectious disease emergencies

Upper and lower respiratory infections are encountered commonly in the emergency department. Visits resulting from occurrences of respiratory disease account for 10% of all pediatric emergency department visits and 20% of all pediatric hospital admissions. Causes of upper airway infections include croup, epiglottitis, retropharyngeal abscess, cellulitis, pharyngitis, and peritonsillar abscesses. Lower airway viral and bacterial infections cause illnesses such as pneumonia and bronchiolitis. Signs and symptoms of upper and lower airway infections overlap, but the differentiation is important for appropriate treatment of these conditions. This article reviews the varied clinical characteristics of upper and lower airway infections.

Paediatric acute epiglottitis: not a disappearing entity

OBJECTIVE

Paediatric epiglottitis is a serious, potentially life-threatening condition. Since the widespread introduction of the Haemophilus influenzae type b (Hib) conjugate vaccine in the UK in October 1992, there has been a dramatic reduction in its incidence. Vaccine failure is rare. The purpose of this study is to examine the failure rate of H. influenzae type b vaccine as measured by the number of cases of Haemophilus epiglottitis in fully vaccinated children presenting to a tertiary paediatric centre. A secondary aim is to provide a retrospective review of all cases of epiglottitis over a 13-year period.

METHODS

A retrospective case-note review identifying all cases of epiglottitis presenting to Alder Hey Hospital was undertaken covering the time period December 1987-January 2001. Details of patient age, sex, source of referral, clinical presentation, management and complications along with microbiological and serological findings were obtained. There were 21 males and 19 females. The mean age was 36 months (range 6-125 months). A provisional diagnosis was made on the basis of the clinical features, confirmed by direct laryngoscopy in all but two cases and further supported in 28 cases by a positive blood culture. Of the 40 children presenting with epiglottitis, eight (20%) presented after the introduction of the Hib conjugate vaccine. H. influenzae antibody titres were measured both in the acute and convalescent phases of illness by the central Haemophilus Reference Unit in Oxford.

RESULTS

We present the clinical features, management and complications of 40 cases of acute epiglottitis. H. influenzae was isolated from blood cultures in 28 cases (70%). In 12 of these cases, H. influenzae type b was identified, seven prior to 1993 and five thereafter. Four of these five cases presenting after introduction of the Hib vaccine were known to have been fully vaccinated. One child had a history of prematurity and serum immunoglobulin estimation was abnormally low in another child. Acute Hib antibody titre was less than 1 microg/ml in two of the three cases in which this was available.

CONCLUSION

Whilst the incidence of Haemophilus type b epiglottitis has significantly diminished, vaccine failure does occur. We discuss the current understanding of clinical and immunological risk factors for vaccine failure and the significance of the Hib antibody titre. Further evaluation of vaccine failure would be of benefit. The series that we present highlights the importance of considering acute epiglottitis in the differential diagnosis of the child presenting with acute upper airway obstruction. This is particularly relevant when in future there will be fewer doctors familiar with the symptoms and signs of the disease.