Entorno prehospitalario y manejo en UCI de epiglotitis en un adulto / Approaching the airway in prehospital emergency is a common and potentially life-saving practice

El abordaje de la vía aérea en la unidad de urgencias prehospitalarias es una práctica común que potencialmente salva vidas. El manejo es complejo debido al entorno, lo cual significa un porcentaje mucho más elevado de vías aéreas difíciles que en un ambiente regulado, como en el caso del quirófano.El intento fallido o prolongado de intubación traqueal está asociado a resultados desfavorables y complicaciones graves.La epiglotitis aguda es un trastorno potencialmente letal, clasificado como urgencia médica dentro de las enfermedades de la vía aérea respiratoria superior, que se caracteriza por una evolución repentina y mortal si no se logra una intubación rápida que permita la oxigenación del paciente.Describimos el caso de un paciente de 36 años con estridor, disnea e hipoxemia debido a la obstrucción total de la vía aérea, causada por una epiglotitis aguda. Nuestro objetivo es subrayar esta lesión infrecuente y su manejo desde la unidad prehospitalaria hasta el alta, ilustrando la gravedad de la presentación clínica, el tratamiento actual y el resultado.(AU)

Management by the environment is complex, which means a much higher percentage of difficult airways than in a regulated environment such as the operating room. Failure or prolonged attempt to tracheal intubation is associated with unfavorable outcomes and serious complications. Acute epiglottitis is a life-threatening disorder, classified as a medical emergency within the diseases of the upper respiratory airway and characterized by its sudden and deadly evolution if rapid intubation is not achieved to allow oxygenation of the patient. We describe a 36-year-old male patient with stridor, dyspnea e hypoxemia due to total obstruction of airway, caused by an acute epiglottitis. We aim to highlight this unusual injury and its management from the prehospital until discharge illustrating the severity of the clinical presentation, current treatment and outcome.(AU)

Acute epiglottitis: Analysis of U.S. mortality trends from 1979 to 2017.

PURPOSE: Evaluate trends in mortality due to acute epiglottitis before and after adoption of Haemophilus influenza Type b vaccination (Hib) in pediatric and adult populations. MATERIALS AND METHODS: Patients who died from acute epiglottis from 1979 to 2017 identified using National Vital Statistics System. Mortality rates calculated using age-adjusted US census data expressed in rate per 100,000 individuals. Trends analyzed using the National Cancer Institute Joinpoint Regression Program (version 4.7.0; Bethesda, Maryland). RESULTS: 1187 epiglottitis-related deaths were identified over thirty-nine years. Total deaths decreased from 65 in 1979 to 15 in 2017. Adult deaths accounted for 63.5% and decreased from 0.015 per 100,000 individuals (24 deaths) in 1979 to 0.006 per 100,000 individuals (14 deaths) in 2017. Best fitting log-liner regression model showed APC of -3.5% (95% CI, -4.2 to -2.7%) from 1979 to 2017. Pediatric and adolescent deaths accounted for 443 (37.3%) deaths, decreasing from 0.064 per 100,000 individuals (41 deaths) in 1979 to 0.001 per 100,000 individuals (1 death) in 2017. APC was -11.1% (95% CI, -13.8% to -8.3%) in 1979 to 1990; 46.5% (95% CI, -16.6% to 157.3%) in 1990 to 1993; -61.6% (95% CI, -88% to 23%) in 1993 to 1996; and 1.1% (95% CI, -2.4% to 4.7%) in 1996 to 2017. CONCLUSIONS: Mortality from acute epiglottitis decreased after widespread adoption of Hib vaccination in the US. Adults are now more likely than children to die of acute epiglottitis. Further research including multi-institutional cohort studies must be done to elucidate causative factors contributing to remaining cases of mortality.

Adult epiglottitis: Trends and predictors of mortality in over 30 thousand cases from 2007 to 2014.

OBJECTIVES: To characterize trends of adult epiglottitis presenting to the emergency department (ED) and analyze mortality. METHODS: We utilized the National Emergency Department Sample to characterize adult epiglottitis from 2007 to 2014 and used provided weights to obtain nationally representative data (all presented data are weighted). Univariate and multivariate analyses were conducted to determine predictors of mortality. RESULTS: A total of 33,549 cases were identified (weighted). Over the study period, the average patient age increased significantly from 47 to 51 (R2 > 0.5), with an overall mean age of 49. A total of 11.8% of patients were coded as having obstruction, and 68.3% of cases were admitted to the hospital. Across all years, < 1% received laryngoscopic or airway procedures in the ED. Utilization of both X-ray and computed tomography was <10%. Over the 8 years, there were an average of 42 deaths per year (1.01% overall mortality). No clinical factors, except obstruction, were significant on univariate analysis (P < 0.05). Multivariate analysis indicated that patient age, degree of hospital urbanization, and smoking status also were nonsignificant. CONCLUSIONS: Epiglottitis is still a significant pathology seen in EDs, is stable over the study period, and carries a mortality risk. There is an exceptionally low rate of documented clinical interventions in the ED, especially compared with inpatient studies of epiglottis. This suggests a lack of recognition of the need and utilization of critical airway interventions early in the patient encounter. Future research is needed to characterize the reasons for the low rate of early airway visualization and intervention of epiglottitis in the ED. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1107-1112, 2019.

[Sudden cardiorespiratory arrest in adults with acute epiglottitis. Report of 2 cases]. / Parada cardiorrespiratoria súbita en adultos con epiglotitis aguda presentación de dos casos.

We report two adult cases of sudden cardiorespiratory arrest because an acute epiglottitis that ocurred in our hospital. Although it is an uncommon pathology nowdays with good prognosis generally, we try to call the attention about this complication which can happen of unforseeable way even in previous absence of respiratory obstruction. One of the patients required coniotomy in ICU due to impossibility of orotracheal intubation (OI) and the other died in spite of an urgent performance.

Mortality among patients admitted to hospitals on weekends as compared with weekdays.

BACKGROUND: The level of staffing in hospitals is often lower on weekends than on weekdays, despite a presumably consistent day-to-day burden of disease. It is uncertain whether in-hospital mortality rates among patients with serious conditions differ according to whether they are admitted on a weekend or on a weekday. METHODS: We analyzed all acute care admissions from emergency departments in Ontario, Canada, between 1988 and 1997 (a total of 3,789,917 admissions). We compared in-hospital mortality among patients admitted on a weekend with that among patients admitted on a weekday for three prespecified diseases: ruptured abdominal aortic aneurysm (5454 admissions), acute epiglottitis (1139), and pulmonary embolism (11,686) and for three control diseases: myocardial infarction (160,220), intracerebral hemorrhage (10,987), and acute hip fracture (59,670), as well as for the 100 conditions that were the most common causes of death (accounting for 1,820,885 admissions). RESULTS: Weekend admissions were associated with significantly higher in-hospital mortality rates than were weekday admissions among patients with ruptured abdominal aortic aneurysms (42 percent vs. 36 percent, P<0.001), acute epiglottitis (1.7 percent vs. 0.3 percent, P=0.04), and pulmonary embolism (13 percent vs. 11 percent, P=0.009). The differences in mortality persisted for all three diagnoses after adjustment for age, sex, and coexisting disorders. There were no significant differences in mortality between weekday and weekend admissions for the three control diagnoses. Weekend admissions were also associated with significantly higher mortality rates for 23 of the 100 leading causes of death and were not associated with significantly lower mortality rates for any of these conditions. CONCLUSIONS: Patients with some serious medical conditions are more likely to die in the hospital if they are admitted on a weekend than if they are admitted on a weekday.

Management of acute inflammatory childhood stridor.

BACKGROUND AND OBJECTIVE: Acute epiglottitis, bacterial tracheitis, and severe viral laryngotracheobronchitis continue to cause life-threatening airway obstruction in children. The aim of this retrospective study was to evaluate deficiencies in treatment, to clarify the role of airway endoscopy, and to identify current reasons for fatalities in these diseases. MATERIALS AND PATIENTS: During the observation period from 1980 to 1996, we identified 61 patients treated in the pediatric intensive care unit of the University Hospital of Cologne for severe inflammatory airway obstruction. RESULTS: Critical points in the appropriate airway management were (1) the confirmation of the admission diagnosis, (2) whether an artificial airway or rigid tracheobronchoscopy was required; and (3) appropriate timing of extubation. Since 1989 airway evaluation with flexible or small, rigid endoscopes was used to confirm the diagnosis and to determine the appropriate management. Endoscopic findings were extremely helpful to decide not to intubate and to monitor in the pediatric intensive care unit first. Three patients with acute epiglottitis died after out-of-hospital cardiorespiratory arrest. CONCLUSION: Endoscopy should be a part of every established treatment protocol of childhood stridor. The most decisive factor to decrease mortality seems to be timely presentation to a referral center.

Airway endoscopy in the interdisciplinary management of acute epiglottitis.

INTRODUCTION: Acute epiglottitis (AE) continues to cause life-threatening airway obstruction in children. The aim of this retrospective study was to evaluate deficiencies in the management of AE, to clarify the role of airway endoscopy, and to establish the cause of death in this disease. MATERIAL: The subjects of our retrospective study were 24 children with AE treated in the paediatric intensive care unit (PICU) of the University of Cologne between 1980 and 1994. The records of all patients were reviewed. RESULTS: Laryngoscopy with fibreoptic or small rigid endoscopes allowed accurate diagnosis of AE, particularly in patients presented with atypical clinical signs. Furthermore, endoscopic information of the degree of inflammation were helpful in the critical decision, whether artificial airway was required. The number of patients managed without intubation increased (8% vs. 45%) since airway endoscopy became available in 1989. No evidence of beta-lactamase-producing strains of Haemophilus influenzae was observed. The most remarkable finding was the high mortality in AE (12.5%). Affected children were admitted in poor post-hypoxia conditions following outdoor cardiorespiratory arrest. CONCLUSION: The most decisive factor to decrease mortality seems to be timely appropriate presentation at referring centres, if AE is suspected or stridor remains unclear. Fibreoptic airway endoscopy represents a major step forward in the management of acute epiglottitis, and this requires close interdisciplinary collaboration between paediatricians, anaesthetists and otorhinolaryngologists.

Incidence, aetiology, and prognosis of acute epiglottitis in children and adults in Sweden.

A retrospective study of the incidence, aetiology and case fatality rate of acute epiglottitis in children and adults was performed. The study covered the whole of Sweden (population 8.4 million) during the years 1987-89, before general vaccination against Haemophilus influenzae (Hi) type b was started. Patients were included if it was documented that they fulfilled all 3 of the following criteria: (a) red and swollen epiglottis visualized by indirect laryngoscopy, (b) inspiratory stridor or difficulties in swallowing, and (c) a temperature > or = 38 degrees C. A total of 306 children and adolescents (0-19 years) and 502 adults (> or = 20 years) were found. The age-specific incidence was highest in children aged 0-4 years, (14.7/100,000 per year). The total incidence was 3.2/100,000 per year. In the age group 0-19 years, blood cultures had been obtained from 195 (64%) and Hi was isolated from 154 (79%). In adults (> or = 20 years), 114 of 298 blood cultures yielded Hi, while pneumococci were isolated from 5 and group A streptococci from 3 patients. A total of 220 children (72%) and 114 adults (23%) needed an artificial airway. Five children and 12 adults died. In conclusion, the incidence of acute epiglottis in Sweden is very high. Compared to a previous country-wide study covering the years 1981-83 that used the same methods for case finding and case definition, the incidence in children had decreased while the incidence in adults had increased.

Comparison of the epidemiology and cost of Haemophilus influenzae type b disease in five western countries.

To determine and compare the cost of Haemophilus influenzae type b (Hib) disease in Australia, Finland, Israel, Switzerland and the United Kingdom a collaborative study was undertaken. The incidence of Hib disease varies in these 5 countries from 34 to 58.5 cases per 100,000 children less than 5 years of age. Although the incidence of meningitis in this age group is similar (between 18 and 26/100,000) in these countries, the incidence of epiglottitis varies from 0 to 22.7/100,000. The cost of hospitalization and the frequency of sequelae are similar for 4 of the 5 countries; however, the break even cost of a vaccination program to prevent 90% of Hib disease is estimated to vary from $22 to $84 per child (US$). Because of a lower incidence of Hib disease and lower cost for hospitalization, these costs are considerably less than those for the United States ($301.64 using similar calculations).

[Haemophilus influenzae infections in children]. / Haemophilus influenzae-infeksjoner hos barn.

Haemophilus influenzae may cause serious infections, especially in small children. During the period 1980-90, 45 children with systemic H influenzae infections were admitted to the University Clinic, Tromsø. 17 patients had epiglottitis in the same period, but are not included in this material. One of the four septicemia patients and two of the 35 children with meningitis died, giving an overall lethality of 4.8%. Five of the patients with meningitis experienced neurological sequelae (14% of the patients with meningitis). Two of the systemic isolates of H influenzae were resistant to ampicillin because of beta-lactamase production, but all the isolates were susceptible to chloramphenicol and 3rd generation cephalosporins.

Acute epiglottitis in adults: a potentially lethal cause of sore throat.

The diagnosis, management and outcome in 12 adults with acute epiglottitis was reviewed. Painful dysphagia was a universal symptom and respiratory distress affected eight patients, six of whom required urgent airway intervention. All patients received parenteral antibiotics, ten received steroids and four received adrenaline. Respiratory distress resolved in two patients given adrenaline and airway intervention was avoided. Indirect laryngoscopy is the investigation of choice and this is preferable to neck radiology. Two patients died and it is stressed that this condition must be distinguished from other more common causes of a severe sore throat. The patient should be managed in a unit with the facilities and expertise to effect acute airway intervention.

Spectrum of invasive Haemophilus influenzae type b disease in adults.

A prospective nationwide surveillance of invasive Haemophilus influenzae type b disease among adults (greater than or equal to 16 years old) was conducted in Finland during 1985 through 1988. Thirty-one cases were identified (annual incidence, 0.22/100,000). Of these infections, 71% occurred in patients with severe underlying conditions. The overall case fatality rate was 26%. Septicemia (13 patients) and pneumonia (seven patients) were the most common clinical manifestations of H influenzae type b infection; the others were epiglottitis (six patients), meningitis (three patients), and arthritis (two patients). Epiglottitis occurred in significantly younger patients, all of whom were women and four of whom were previously healthy. Subtyping of the H influenzae type b isolates according to the major outer membrane protein subtype, biotype, and lipopolysaccharide serotype showed that patterns that were uncommon (14%) among children were more common (27%) in the adults.

Acute epiglottitis in children and adults in Sweden 1981-3.

In a retrospective study of the incidence of acute epiglottitis in Sweden, 485 children and 356 adults fulfilled the following criteria: (a) red and swollen epiglottis visualised at laryngoscopy; (b) stridor or difficulties in swallowing own saliva or water; and (c) temperature greater than or equal to 38 degrees C. The age specific incidence in children (0-14 years) was 10 and in adults (greater than or equal to 15 years) 1.8/100,000/year. These incidence rates were higher than the incidence of Haemophilus influenzae meningitis in the same population. Blood cultures were obtained from 290 children (60%) and 185 adults (52%). H influenzae was isolated from 267 blood cultures (92%) from children and 98 blood cultures from adults (53%). Other organisms were isolated from six adults (3%). An artificial airway was established in 352 children (73%) and in 68 adults (19%); the remainder were treated conservatively. Six children and two adults died. Sweden has a high incidence of acute epiglottitis in children and the disease also occurs in adults. The importance of H influenzae in the aetiology of epiglottitis in all age groups is confirmed, but in adults many cases occur without septicaemia. The mortality is currently very low.

Haemophilus influenzae type b infections in Victoria, Australia, 1985 to 1987.

Invasive Haemophilus influenzae type b (HIB) infections occurring from 1985 to 1987 in children younger than 16 years of age living in the state of Victoria were reviewed. There were 547 cases which fulfilled the case definition, including 231 cases of meningitis, 219 of epiglottitis and 97 other infections; 14 (2.6%) children died, 8 with meningitis, 5 with epiglottitis and 1 with pneumonia. Ninety-five percent of cases occurred in children younger than 5 years of age, in whom the case attack rate was 58.5/100,000/annum. Nearly two-thirds of cases (46% of meningitis; 91% of epiglottitis; 45% of other infections) occurred in children more than 18 months of age (the age at which vaccine is presently given in the United States). Compared with the United States, the case attack rate for HIB disease in Victoria is lower, the mean age of affected children higher and the proportion with epiglottitis is greater. However, the incidence, age distribution and clinical manifestations of HIB disease in Victoria are similar to those described in Scandinavia before the successful introduction of vaccines. Effective conjugate vaccines against HIB disease are now available and the majority of cases are preventable (depending on the immunization schedule used). These data suggest that immunization of Victorian children against HIB infection should be cost-effective.

Acute infectious epiglottitis in children and adults: annual incidence and mortality.

The incidence and mortality of acute epiglottitis were retrospectively analysed covering a 12-year period, 1975-1987. The diagnosis was made by the laryngoscopic findings in 95% of patients. Based on 902 hospitalized patients, a mean annual incidence of 4.9 cases per 100,000 children and adults was found. Although adult patients predominated (60%), the incidence was far higher in children, 13.8 per 100,000 compared with 3.9 per 100,000 in adults. Two peaks in incidence were identified, one for the youngest children, and the second for young adults (15-29 years). Over the years the incidence varied little in adults, but decreased significantly in children over the last 6 years studied. The data presented indicate acute epiglottitis to be a more frequent disorder than previously believed but with less risk of a fatal outcome. The mortality rate was below 1% in children and adults and the annual incidence of death from acute epiglottitis was estimated at 0.5 cases per million. The primary admission of these patients to ENT units seems to be the single factor having the most powerful impact on mortality.