Modern Medicine’s Triumph Over Pediatric Epiglottitis

So a little different kind of post. . .

Pediatric epiglottis, a disease that carries a high morbidity and mortality, is now very rarely seen in emergency medicine training.¹ Assuming vaccination rates continue to be stable leading into the future, trainees will continue to read the texts and understand the theory of its presentation and likely never encounter it in clinical practice. Like the handful of other diseases phased out by modern medicine, the history of epiglottitis is worth visiting for its impact on our predecessors’ clinical practice.

In the 1940s, tracheostomy was understood to be the definitive management of this upper airway infectious entity.² Although a peculiar concept to grasp, even more bizarre is the description of the procedure being performed semi electively outside the operating room under local anesthesia with chloral hydrate or pentobarbital as sedation.

Pediatric intensivists begin reporting case reports of successful management of epiglottitis with nasotracheal intubations in the 1960s.³ This was discovered incidentally as a by-product of choosing to intubate patients prior to more controlled, elective tracheostomies. The table at the end reveals the gradual shift in use of intubations as the standard method of managing epiglottis.⁴ An interesting trend seen is the simultaneous decrease in fatality rate as rates of intubations increased.

However, practice methods are not thought to be the sole contributors to the decrease in fatality rates. At that time, increasing use of antibiotics like ampicillin, chloramphenicol and sulfonamides were also credited with the increased survival. Furthermore, these antimicrobials may have played a role in reducing duration of days for intubation.

In the 1980’s Haemopilus influenzae type B (Hib) vaccination was incorporated into routine pediatric immunization vaccine schedule, and pediatric epiglottis had all but vanished. Evidence for the efficacy of the HiB vaccine stems from one of the earlier randomized controlled trials of the vaccine in 1974, in Finland.⁵ Approximately 98,000 children, 3-71 months of age, half of whom received the Hib vaccine, were enrolled in a field trial and followed for a 4-year period for occurrence of Hib disease. Among children 18-71 months of age, there was a 90% protective efficacy (95% confidence limits, 55%-98%) in prevention of all forms of invasive Hib disease demonstrated in the 4-year follow-up period.

An interesting finding is the report of one pediatricians experience with the incidence of epiglottis in upstate New York. In his initial publication in 1979, there were 57 cases seen in 8 years from 1969 – 1977. In 2006, a similar 8-year retrospective analysis from 1995 to 2003 conducted by the same author, revealed only 2 cases of epiglottitis – none due to Haemophilus influenza.⁶

Although there is now no longer any exposure to pediatric epiglottis for most emergency trainees, simulation medicine can easily fill this void, allowing for cognitive and motor skill practice in the unlikely event that an unimmunized child presents to our care with acute epiglottis. Given its lethal history, medicine’s success over a disease like epiglottitis should be acknowledged and celebrated by all personnel caring for children.

Check this table out:

Hope you learned!

REFERENCES

1. Wheeler DS, Dauplaise DJ, Giuliano JS, Jr. An infant with fever and stridor. Pediatric emergency care. Jan 2008;24(1):46-49.
2. Milko DA, Marshak G, Striker TW. Nasotracheal intubation in the treatment of acute epiglottitis. Pediatrics. May 1974;53(5):674-677.
3. Geraci RP. Acute epiglottitis–management with prolonged nasotracheal intubation. Pediatrics. Jan 1968;41(1):143-145.
4. Faden HS. Treatment of Haemophilus influenzae type B epiglottitis. Pediatrics. Mar 1979;63(3):402-407.
5. Peltola H, Kayhty H, Virtanen M, Makela PH. Prevention of Hemophilus influenzae type b bacteremic infections with the capsular polysaccharide vaccine. The New England journal of medicine. Jun 14 1984;310(24):1561-1566.
6. Faden H. The dramatic change in the epidemiology of pediatric epiglottitis. Pediatric emergency care. Jun 2006;22(6):443-444.

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