Epiglottits / Croup - LTB Flashcards by Maerilee Rojas

The word ______ is a general term used to describe the inspiratory, barking or brassy sound associated with a partial upper airway obstruction.

croup

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Clinically, the inspiratory barking sound heard in a patient with a partial upper airway obstruction is called ______

inspiratory stridor

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Most experts use the term _____ and ______ —which is a subglottic airway obstruction— interchangeably.

croup and laryngotracheobronchitis (LTB)

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_________ —which is a supraglottic airway obstruction—is regarded as an entirely separate disease entity

Acute epiglottitis

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a patient with ____ is usually a loud and high-pitched brassy sound,

LTB

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the inspiratory stridor associated with a patient with _______ is often lower in pitch, muffled, or even absent.

acute epiglottis

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LTB as a

subglottic area

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acute epiglottitis as a

supraglottic area

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laryngotracheobronchitis can affect the lower

laryngeal area, trachea, and occasionally the bronchi,

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the term laryngotracheobronchitis is used as a synonym for “classic”
______

subglottic obstruction

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______ is an inflammatory process that causes edema and swelling of the mucous membranes.

LTB

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The______ also causes the mucous glands to increase their production of mucus and the cilia to lose their effective- ness as a mucociliary transport mechanism.

inflammation

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Because the subglottic area is the narrowest region of the larynx in an infant or small child, even a slight degree of edema can cause a significant reduction in _______ area of the airway.

cross-sectional

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The edema in this area is further aggravated by the rigid ______ which surrounds the subglottic trachea and prevents external swelling as fluid engorges the laryngeal tissues.

cricoid cartilage,

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The edema and swelling in the subglottic region decrease the ability of the vocal cords to ______ during inspiration.

abduct (move apart)

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____ is a life-threatening emergency.

Acute epiglottitis

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epiglottitis is an inflammation of the _____ region

supraglottic region,

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supraglottic region, which includes the

epiglottis, aryepiglottic folds, and false vocal cords

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_____ does not involve the pharynx, trachea, or other subglottic structures.

Epiglottitis

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As the edema in the epiglottis increases, the lateral borders curl and the tip of the epiglottis protrudes _____ and _______.

posteriorly and inferiorly

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During_______ the swollen epiglottis is pulled (or sucked) over the laryngeal inlet

inspiration

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Clinically, the classic finding is a (epiglottitis)

swollen,
cherry-red epiglottis,
severe respiratory distress and drooling.

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_______ —Airway obstruction caused by tissue swelling just below the vocal cords

LTB

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_______ —Airway obstruction caused by tissue swelling just above the vocal cords.

Epiglottitis

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The _________ cause most cases of LTB, with type 1 being the most common, type 3 less common, and type 2 infrequent.

parainfluenza viruses

____ also may be caused by influenza A and B, respiratory syncytial virus (RSV), herpes simplex virus, Mycoplasma pneumoniae, rhinovirus, and adenoviruses.

LTB

LTB is primarily seen in children _______ with peak prevalence in the second year of life.

6 months to 5 years of age

Boys are affected slightly more often than girls.

LTB

The onset of LTB is _____ (i.e., symptoms progressively increase over _______ ), and it is most common during the fall and winter.

slow /24 to 48 hours

A brassy or barking cough is commonly present. The child’s voice is hoarse, and the inspiratory stridor is typically loud and high in pitch.

Laryngotracheobronchitis / croup

The patient usually does not have a fever, drooling, swallowing difficulties, or a toxic appearance.

LTB / Croup

Acute epiglottitis is a bacterial infection that is almost always caused by _____

Haemophilus influenzae type B.

It is transmitted via aerosol droplets.

Epiglottitis

Since ____, when vaccinations with H. influenzae type B vaccine became widespread, the number of reported cases of epiglottitis has decreased by over 95%.

1985

Other causes of ____ include aspiration of hot liquid and trauma from repeated intubation attempts.

epiglottitis

has no clear-cut geographic or seasonal incidence.

Epiglottitis

Although acute epiglottitis may develop in all age groups (neonatal to adulthood), it most often occurs in chil- dren ______

2 to 6 years of age.

Boys are affected more often than girls.

Epiglottitis

The onset of epiglottitis is usually ____

abrupt

Although the initial clinical manifestations are usually mild, they progress rapidly over a _______ period.

2- to 4-hour

A common scenario includes a sore throat or mild upper respiratory problems that quickly progresses to a high fever, lethargy, and difficulty in swallowing and handling secretions. The child usually appears pale and septic. As the supraglottic area becomes swollen, breathing becomes noisy, the tongue is often thrust forward during inspiration, and the child may drool.

Epiglottitis

A cough is usually absent with ____

acute epiglottitis.

The voice and cry are usually muffled rather than hoarse. Older children commonly complain of a sore throat during swal- lowing.

Epiglottitis

______ in adults is typically seen in patients with neck trauma (e.g., blunt force neck injury or aspiration of hot liquid), in those who have been intubated repeatedly, and in drug abuse (crack cocaine) cases.

epiglottitis

Age( LTB-croup)

6 months–5 years (with the peak prevalence in the second year)

Age (epiglottitis)

2–6 years

Onset (LTB - croup) and epiglottitis

LTB - Usually slow or gradual (24–48 hours) Epiglottitis- Abrupt (2–4 hours)

Fever (LTB - croup) and epiglottitis

Epiglottitis - High grade fever LBT / croup - low grade croup

Drooling (epiglottitis and croup / LTB)

Epiglottitis- present LTB- absent

Radiograph findings ( croup and epiglottitis )

Croup - Haziness in subglottic area,“pencil point” or “steeple point” Epiglottitis- Haziness in supraglottic area, “thumb sign”

Inspiratory stridor LTB - croup and epiglottitis

LTB - High-pitched, brassy, loud sound Epiglottitis- Low-pitched and muffled, or absent

Cough LTB - croup and epiglottitis

Croup - Present (barking or brassy cough) Epiglottitis- absent

Hoarseness Croup and epiglottitis

Croup - always present Epiglottitis- rarely/ absent

Swallowing difficulty Croup- epiglottitis

Croup - absent Epiglottitis- present

White blood count Croup - epiglottitis

Croup - Normal (viral—parainfluenza viruses 1, 2, and 3; influenza A and B; respiratory syncytial virus) Epiglottitis- Elevated (bacterial—Haemophilus influenza type B)

Vital Signs

• Increased Respiratory Rate (Tachypnea) • Increased Heart Rate (Pulse) and Blood Pressure • Increased temperature (seconday to infection) • Increased stimulation of peripheral chemoreceptors • Anxiety

Chest Assessment Findings

Diminished breath sounds

The Physical Examination

•Inspiratory Stridor •Cyanosis •Use of Accessory Muscles During Inspiration •Substernal and Intercostal Retractions

LATERAL NECK RADIOGRAPH

• Haziness in the subglottic area (LTB) • Haziness in the supraglottic area (epiglottitis) • Classic “thumb sign” (epiglottitis)

ANTERIO-POSTERIOR NECK RADIOGRAPH

• “Steeple point” or “pencil point” narrowing of the upper airway (LTB)

the epiglottitis often appears on a _______ as the classic “thumb sign.”

lateral neck radiograph

The _______ is swollen and rounded, giving it an appearance of the distal portion of a thumb

Epiglottitis

When the patient has LTB, a white haziness is demonstrated in the subglottic area; the AP neck will show the classic “pencil point” or “steeple point” narrowing at the level of the ______

cricoid cartilage

Stridor (croup / LTB) scoring system

0- none 1- mild 2-moderate at rest 3- Severe with insp/exp or none with markedly decreased air entry

Retractions (LTB / Croup) scoring System

0 - none 1 - Mild 2 - Moderate 3 - Severe marked use of accessory muscles

Air Entry ( LTB / croup) scoring system

0 - normal 1 - Mild decrease 2 - Moderate decrease 3 - Marked decrease

Color (LTB/Croup) scoring system

0 - Normal 1 - Normal 2 - Normal 3 - Dusky or cyanotic

Level of Consciousness (croup/ LTB) Scoring system

0 - Normal 1 - Restless when disturbed 2 - Anxious, agitated, restless when undisturbed 3 - Lethargic, depressed

Scoring Guidelines (Mild, Moderate, Severe, Impending Ventilatory Failure)

Mild 0–2 Moderate 3–5 Severe 6–11 Impending Ventilatory Failure: >12

The typical ________ measures the patient’s stridor, retractions, air movement, color and level of consciousness

LTB score table

Early recognition of epiglottitis may save a patient’s life; it is a ________

true airway emergency.

Once the diagnosis is suspected or confirmed by the lateral neck radiograph, examination or inspection of the pharynx and larynx is only to be done in the _________ with a fully trained team.

operating room under general anesthesia

Under no circumstances should the mouth or throat be examined ______ (even though depression of the tongue may reveal a bright red epiglottis and confirm the diagnosis) unless personnel and equipment are available to rapidly intubate or tracheostomize the patient.

outside the operating room

The patient usually maintains their limited airway by _____

sitting up and leaning forward with their chin protruding

laying the patient down for examination will cause ___

complete airway obstruction within minutes.

The patient with a confirmed diagnosis of acute epiglottitis should be _______

intubated immediately

Because hypoxemia and significant work of breathing is associated with both LTB and epiglottitis, ________ may be required.

supplemental oxygen

_______ should be started when the patient’s SpO2 is under 92%

Oxygen therapy

Aerosolized _____ is administered to children with LTB based on the LTB Scoring System

racemic epinephrine

Using the patient’s LTB score, the administration of racemic epinephrine protocol is as follows: • 3–5: ____

• 3–5: Consider racemic epinephrine

• >6: _____

Administer racemic epinephrine 0.5 mL in 3 mL normal saline

________ , such as dexamethasone, have been shown to reduce the severity and duration of LTB, and are generally given when the patient presents with moderate to severe symptoms

Corticosteroids

Because acute epiglottitis is almost always caused by H. influenzae type B, appropriate ______ is part of the treatment plan.

antibiotic therapy

Antibiotic Therapy

Ceftriaxone (Rocephin) and Ampicillin/ sulbactam (Unasyn)

_____ and ______ often are prescribed to cover the most common organisms that cause acute epiglottitis.

Ceftriaxone (Rocephin) and Ampicillin/ sulbactam (Unasyn)

In the patient with a suspected acute epiglottitis, the exami- nation or inspection of the pharyngeal and laryngeal areas is only to be performed in the ______ in attendance.

operating room with a trained surgical team

In the patient with a suspected acute epiglottitis, the exami- nation or inspection of the pharyngeal and laryngeal areas is only to be performed in the operating room with a trained surgical team in attendance. This is because the epiglottis may ________ in response to even the slightest touch or supine positioning during inspection.

obstruct completely

The physician, nurse, and respiratory therapist should not leave the patient’s bedside until the ________ is secured.

endotracheal tube

If the patient is anxious, restless, or uncooperative, _____ and _____ may be needed to prevent accidental extubation.

restraints and sedation

After intubation, the patient should be transferred to the ______ and placed on ____

intensive care unit (ICU) and continuous positive airway pressure (CPAP) or pressure support ventilation.

_______ must be provided if paralysis is used to protect the airway in an uncooperative patient

Mechanical ventilation