Airway Management

Should the child develop ventilatory fatigue or if airway obstruction or apnea occurs before the airway has been secured, bag-valve-mask ventilation can be effective.

Patients with epiglottitis who are initially seen in the office, clinic, or emergency department (ED) without pediatric or ear-nose-throat (ENT) subspecialty support should be transported to a referral center by ground or air, whichever is more appropriate, accompanied by personnel who can manage the airway. Oxygen should be given, and continuous nebulized racemic epinephine can be given to decrease airway edema. The child should be kept seated upright. Heliox can also be a temporizing measure until specialists arrive (see discussion of croup, below). The referral center should be alerted as soon as possible, so that decisions concerning intubation or tracheostomy can be made in advance. Patients usually are intubated by the most skilled individual available as soon as the diagnosis is made. Sedation, paralytics, and vagolytics are used as indicated. To reduce the incidence of postextubation stridor, a tube one size smaller than usual should be used. Tube sizes above and below this size should be immediately available. One can determine that a correct size has been by checking for the pressure at which a leak develops around the tube. The tube should be secured immediately, with as little patient movement as possible afterward so as to minimize the likelihood of tube dislodgement.

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