Download Running Head: LITERATURE REVIEW Epiglottitis Tanjia Hynes

Running Head: LITERATURE REVIEW
1
Epiglottitis
Tanjia Hynes
State University of New York Polytechnic Institute
Running Head: LITERATURE REVIEW
2
Epiglottitis: Integrative Review
Epiglottitis is an acute inflammation of the epiglottis that can be life-threatening and
requires prompt and accurate management of the patient's airway (Riffat, Jefferson, Bari, and
McGuiness, 2011). Epiglottitis is now becoming a disease for the adult population (Qazi, Jafar,
Hadi, and Hussain, 2009). The incidence of acute epiglottitis in adults has shown a steady rise
and has accounted for approximately 3772 cases in the United States in 2006 (Shah and Stocks,
2010). Adults that present with symptoms concerning with epiglottitis might not present in the
same manner as the pediatric population. The differences in the way an adult presents can be
related to the anatomical differences as well as the differences in the infectious etiology (Price,
Preyra, Fernandes, Woolfrey and Worster, 2005).
Purpose
The purpose of this literature review will aim at finding the current best practice
guidelines for the treatment of epiglottitis that are concerned with appropriate airway
management, antibiotic and steroid use. The goal is to provide evidence based practice
guidelines that will improve the quality of care for the patients with epiglottitis by providing
direction and insight for all healthcare providers and healthcare organizations.
Method
Articles for the purpose of this integrative review were obtained utilizing the State
University of New York Institute of Technology, Cayan Library electronic database. The
CINAHL Plus with Full Text, Medline, and Health Source were the databases that were
primarily utilized to conduct the search. Google Scholar and PubMed were also utilized for
databases in the search for relevant articles. The Margaretville hospital library was also utilized
in the search.
Running Head: LITERATURE REVIEW
3
The key terms used in conducting the search for relevant articles were 'epiglottitis',
'epiglottitis treatment', and 'epiglottitis management'. The integrative review was restricted to
peer-review articles in the English Language. The search was also restricted to articles that were
published between 2005 and 2014. Literature dated before 2005 were utilized for comparison
and analysis. This search yielded about 23 articles. These articles were reviewed for relevance,
sorted by subject, and summarized. A total of 10 articles were selected that focused on the
management and treatment of epiglottitis and an analysis of these articles was completed (see
Appendix A).
Epidemiology Pre Vaccine
Historically, epiglottitis has been caused by the Haemophilus influenza type b (HIB)
(Shah & Stocks, 2010). This disease was predominantly in children over 18 months of age and
accounted for 20-30% of the cases (Wood, Menzies, and McIntyre, 2005). In 1993, the
introduction of the Haemophilus influenza vaccination to the childhood immunization schedule
has dramatically reduced the incident and mortality among the pediatric population from this
disease (Riffat et al., 2011; Wood et al., 2005).
Changes in Epidemiology since Vaccine
In the adult population the causative organisms for epiglottitis still seems to be an
ongoing investigation. Many of the studies reported that both blood and throat cultures were
negative for bacterial growth (Hermansen et al., 2014; Kim et al., 2009; Sakar et al., 2009; Riffat
et al., 2011; Qazi et al., 2009). The current research suggests that while there is a decrease in
epiglottitis caused by HIB it is still a possibility. Some of the other organisms that can be
responsible are: S. pnuemonia, S. aureus, hemolytic and non-hemolytic streptococcus,
Running Head: LITERATURE REVIEW
4
methicillin sensitive staphlococcus, and H. influenzae type a, Fusobacterium gonidiaformans
(Hermansen et al., 2014; Sarkar et al, 2009; Wood et al., 2005; Qazi et al., 2009).
Treatment
Antibiotics
Patient who are diagnosed with epiglottitis all receive antibiotics either orally or
intravenously and many of these patients also are co-treated with steroids. Patients whose
present with milder symptoms, mild to moderate edema generally tend to require admission to
the hospital for close airway monitoring and the administration of intravenous antibiotics and
corticosteroids (Sarkar et al., 2009; Lon et al., 2006). The utilization of broad-spectrum
antibiotics that cover gram-positive and gram-negative bacteria is recommended (Qazi et al.,
2009; Riffat et al., 2011). The antibiotic coverage should at least include a third-generation
cephalosporin in addition to an anti-staphylococcal agent (Riffat et al., 2011; Lon et al., 2006;
Qazi et al., 2009). Several research studies reported a combination of antibiotic use with a
broad-spectrum (third generation cephalosporin) and metronidazole (Sarkar et al., 2009;
Hermansen et al., 2014; Kim et al., 2009). The average course of treatment for intravenous
antibiotics were about 4 days then the patient was switched to oral antibiotics (Hermansen et al.,
2014; )
Corticosteroids
Steroid use in epiglottitis is utilized to reduce the airway inflammation that is caused by
capillary bed edema and local inflammation response (Riffat et al., 2011). The corticosteroids
that were routinely utilized in the studies were either dexamethasone acetate or hydrocortisone
(Riffat et al., 2011; Hermansen et al., 2014; Kim et al., 2009). Many studies revealed that
utilizing steroids decreased the incident of advanced airway placement and shorter lengths of
Running Head: LITERATURE REVIEW
5
stay in the intensive care units (Sarkar et al., 2009; Hermansen et al., 2014; Kim et al., 2009;
Riffat et al., 2011). No conclusion about which steroid performed better or for how long to
utilize them since it was mainly provider preferences.
Airway Management
Adult epiglottitis is caused by different etiologic agents and risk factors then that of the
pediatric population (Riffat et al., 2011; Qazi et al., 2009). Airway control for epiglottitis is of
the utmost importance. Patients with acute signs and symptoms should be managed with
endotracheal intubation (Price et al., 2005). The pediatric population has reported in the past
100% endotrachael intubation rate related to the epiglottis being relatively large, U-shaped, and
less rigid then that of the adult population (Price et al., 2005; Tibballs and Watson, 2010; Qazi et
al., 2009).
Acute epiglottitis in adults require less airway intervention (Price et al., 2005; Lon,
Lateef, and Sajad, 2006; Qazi et al., 2009; Riffat et al., 2011). This relation could be linked to the
fact that the adult airway is less prone to obstruction (Price et al., 2005). Yoon et al. (2010)
suggests that rapid progression, stridor, drooling, tachycardia, hoarseness, dyspnea, systemic
comorbidity, abscess formation, and upright posture are associated risks for airway compromise
in the adult patient. Patients that also suffer from an infected epiglottic cyst and are of older age
was another predictive factor that those patient's airway would need advanced airway
management (Yoon et al., 2010; Kim et al., 2009; Hermansen et al., 2014). Having a
comorbidity of diabetes mellitus and immunosuppressant increases the patients relative risk for
needing airway intervention as well (Sakar et al., 2009; Kim et al., 2009; Riffat et al., 2011).
Running Head: LITERATURE REVIEW
6
Gap in Research
Epiglottitis while on the decline is still relevant and poses a grave risk for patients who
are suffering from it. Airway management and infectious etiology in the adult population have
not fully been researched. While many studies suggest that monitoring an adult airway is
sufficient, more studies need to be conducted that address the specific causative etiology in those
patients that have required advanced airway management. The focus of these studies need to
determine if there is a connection between the infectious agent and the need for advanced airway
placement. Further studies need to attempt to figure out if there is a preferred corticosteroid in
teh treatment of epiglottitis as well.
Conclusion
The incident of pediatric epiglottitis is nearly non-existent related to the introduction of
the HIB vaccination. Unfortunately, the incident of adult epiglottitis still exists. Practitioners
need to recognize the growing incident of adult epiglottitis in order to properly manage their
airways to prevent mortality. The review of the literature suggest that the adult populations
airway can be managed with a watchful eye. The administration of broad-spectrum antibiotics
alone or in combination with metronidazole intravenously seem to be the best practice for
epiglottitis treatment according to the research. Combination of antibiotics with corticosteroids
are also highly effected and indicated for proper treatment of the disease and this treatment
regime decreases mortality and length of stay for those individuals that are infected.
Running Head: LITERATURE REVIEW
7
References
Hermansen, M. N., Schmidt, J. H., Krug, A. H., Larsen, K., & Kristensen, S. (2014). Low
incidence of children with acute epiglottis after introduction of vaccination. Danish
Medical Journal, 61(4), 1-5.
Kim, S. G., Lee, J. H., Park, D. J., Hong, J. W. Kim, T. H., Kim, M. G., Shim, J. S., & Yeo, S. G.
(2009). Efficacy of spinal needle aspiration for epiglottic abscess in 90 patients with
acute epiglottitis. Acta Oto-Laryngologica, 129, 760-67.
doi:10.1080/00016480802369302
Lon, S. A., Lateef, M., & Sajad, M. (2006). Acute epiglottitis: A review of 50 patients. Indian
Journal of Otolaryngology and Head and Neck Surgery, 58(2), 178-180.
Price, I. M., Preyra, I., Fernandes, C. M. B., Woolfrey, K., & Worster, A. (2005). Adult
epiglottitis: A five-year retrospective chart review in a major urban centre. Canadian
Journal of Emergency Medicine, 7(6), 387-90.
Qazi, I. M., Jafar, A. M., Hadi, K. A., & Hussain, Z. (2009). Acute epiglottitis: A retrospective
review of 47 patients in Kuwait. Indian Journal of Otolaryngol Head & Neck Surgery,
61, 301-05.
Riffat, F., Jefferson, N., Bari, N., & McGuinness, J. (2011). Acute supraglottitis in adults. Annals
of Otology, Rhinology, & Laryngology, 120(5), 296-99.
Sarkar, S., Roychoudhury, A., & Roychaudhuri, B. K. (2009). Acute epiglottitis in adults- A
recent review in an Indian hospital. Indian Journal of Otolaryngol Head & Neck Surgery,
61, 197-99.
Shah, R. K., & Stocks, C. (2010). Epiglottitis in the United States: National trends, variances,
prognosis, and management. The Laryngoscope, 120, 1256-62. doi:10.1002/lary.20921
Running Head: LITERATURE REVIEW
Tibballs, J., & Watson, T. (2011). Symptoms and signs differentiating croup and epiglottitis.
Journal of Pediatrics and Child Health, 47, 77-82. doi:10.1111/j.14401754.2010.01892.x
Wood, N., Menzies, R., & McIntyre, P. (2005). Epiglottitis in Sydney before and after the
introduction of vaccination against Haemophilus influenzae type b disease. Internal
Medicine Journal, 35,530-535.
Yoon, T. M., Choi, J. O., Lim, S. C., & Lee, J.K. (2009). The incidence of epiglottic cysts in a
cohort of adults with acute epiglottitis. Clinical Otolaryngology, 35, 18-24.
8
Running Head: LITERATURE REVIEW
9
Appendix A
Studies
Focus
Subject
Popula
Age
Method
Findings
Child
All
Retrospective
Epidemi-
study
ology - strep,
tion
Hermansen
Epidem-
N=41
et al., 2014
iology,
and
patients
symptoms,
adult
regard-
staph, gram-
treatment
admitt-
less of
negative rods
ed with
age
Treatment=
diagnos
combo
-is of
therapy of
DJ051
braodspectrum and
meronidazole
, steroids
Kim et al.,
Airway
(2009)
risk factors
N=90
Korea
Adult
Retrospective
Steroid and
chart review
antibiotic
treatment,
epiglottic
abcessess
Lon et al.,
Airway
(2006)
factors
N=50
Kashmi
2-70
Retrospective
Airway
r
years
chart review
interventions
Valley
old
Running Head: LITERATURE REVIEW
Price et al.,
Epiglottitis
(2005)
N=54
10
Age
Age
Comprehensive
Adult
in
greater
range
search with
epiglottitis
unvaccinat
than 18
was 18- randomized
presents
ed adults
and in
93 with
differently in
and their
the city
mean
adults then
outcomes
of
age of
children with
Hamilt
49
the common
on
selection
symptoms of
sore throat,
odynophagia,
and inability
to swallow
secretions.
The study
revealed that
a less
aggressive
airway
approach in
adults is
sufficient r/t
the
underlining
Running Head: LITERATURE REVIEW
11
cause and
anatomy of
the adult
population
Qazi et al.,
Clinical
(2009)
N=47
All
Age
Retrospective
More
features,
admitte
range 5
study
common in
manageme
d pt.
to 66
nt, and pt.
with
received
outcomes
Epiglott
antibiotics,
itis
were
betwee
intubated
n 2000
according to
to 2008
the Friedman
in
classification
Kuwait
of acute
adults, all pt
respiratory
distress
Riffat et al.,
Manageme
(2011)
N=169
Admitt
Median
Retrospective
Fiberoptic
nt and
ed pt to
age of
Review
laryngoscopy
outcome of
Liverpo 51
is gold
supraglottit
ol
standard in
is
Hospita
diagnosing
l
and
Running Head: LITERATURE REVIEW
12
betwee
conservative
n 199
airway
and
management
2009
is a viable
option, use of
steroids helps
alleviate
airway
swelling
Sarkar et al.,
Airway
N=12
Teachin Adult
(2009)
manageme
g
nt
hospital ion
Antibiotic
in India
Retrospective
populat
Pt with 50%
airway
obstruction
treatment
Shah &
National
Stock.,
(2010)
N=
United
Mean
Retrospective
Incident
trends,
States
age was review
variances
hospital 44.9
children <1
and
izations
years old,
greater in
outcomes
and >85
of patients
years,
admitted
mortalities
with
are in adult
epiglottitis
population
Running Head: LITERATURE REVIEW
13
Tibballs &
Differentiat N=203
Childre
No age
Focused study
Epiglottitis
Watson,
e
n at
was
and croup are
(2011)
symptoms
Royal
defined
often
of
Childre
confused but
epiglottitis
n's
correct
and
Hospita
identification
laryngotrac
l
was shown
heobronchi
by presence
tis
of cough
and/or
drooling
Wood et al.,
Accurately
(2005)
N=142
New
No
Retrospective
S.
describe
South
specific
chart review
Pneumoniae
clinical,
Whales
age
was
aetiological
noted,
determinate
and
adult
cause of
epidemiolo
Epiglottitis in
gical
adult
population
Yoon et al.,
Airway
(2010)
risk factors
N=117
South
Adult
Retrospective
Pre-existing
Korea,
patients
chart review
epiglottic
Acade
cyst increases
mic
risk of
Running Head: LITERATURE REVIEW
14
tertiary
airway
care
obstruction
Running Head: LITERATURE REVIEW
15