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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