Paediatric anaesthesia · Core17 / 17
Acute epiglottitis in an unimmunised child3-year-old boy, 14 kg, unimmunised, with 6 hours of high fever
Infective upper airway obstruction in a child: gas induction and surgical backup
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Know this first
- Epiglottitis: toxic child, drooling, muffled voice, tripod posture; stridor is a late sign.
- No throat examination, bloods or cannula before the airway is secure.
- Sitting gas induction, spontaneous breathing; CPAP 10–15 cmH2O helps.
- Tube 0.5–1 mm smaller than predicted; ENT ready for rigid bronchoscopy or tracheostomy.
- Cultures and antibiotics after intubation; ICU until the swelling settles.
The patient
3-year-old boy, 14 kg, unimmunised, with 6 hours of high fever, drooling and a muffled voice.
Sitting upright, leaning forward, chin thrust out; soft inspiratory stridor; no cough.
Transferred to theatre for airway securing with ENT; no cannula attempted.
Vitals: HR 160, SpO2 93% on blow-by oxygen, RR 36, temperature 39.6 °C; BP not taken, to keep him calm.
The examiner asks
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Consider
What are your considerations?
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- An unimmunised 3-year-old with likely epiglottitis and stridor, needing his airway secured. Patient
- At 3 his airway is tiny; a millimetre of swelling cuts its area sharply.
- Drooling, muffled voice, tripod posture and fever: classic supraglottitis. Disease
- Stridor is late: he is close to complete obstruction, which can kill within hours.
Prepare
How do you prepare?
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- Keep him calm and upright; no throat look, bloods or cannula. Stem trigger
- Senior anaesthetist and ENT surgeon in theatre before induction. Airway
- Styletted tubes 0.5–1 mm smaller than his age predicts.
- Rigid bronchoscope and tracheostomy set opened; videolaryngoscope ready.
- A parent stays with him for induction if it keeps him calm. Patient
Plan
How do you secure his airway?
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- Sitting gas induction with sevoflurane in oxygen, keeping him breathing. Airway
- CPAP 10–15 cmH2O to splint his pharynx as he deepens.
- IV access only once he's asleep.
- Oral intubation without relaxant; leak confirmed below 25 cmH2O.
- Then cultures and IV antibiotics; ICU, sedated, until the swelling settles. After surgery
Crisis
During induction his chest stops moving, the bag is still, and SpO2 falls to 70%. What do you do?
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- Complete obstruction: tell ENT; 100% oxygen, firm CPAP and jaw thrust. (Crisis)
- Gentle positive pressure may open his collapsing pharynx.
- Not improving: intubate now with the smaller tube.
- Can't intubate: ENT passes the rigid bronchoscope to ventilate him.
- Can't oxygenate: needle cricothyroidotomy or ENT tracheostomy.
- HR under 60 despite oxygenation and ventilation: start CPR.
Fatal mistakes
- Lying him flat or examining his throat.
- IV cannulation before the airway is controlled.
- Paralysis before the airway is secured.
Checked against: Stoelting 8e · Barash 9e · Miller 10e
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