Care of Toddlers Affected By Epiglottitis and Bronchiolitis - Research Paper Example

Care of Toddlers In APA Style Swarnambika S Academia Research In this paper, we would be discussing the similarities found in theassessment, diagnosis, treatment and care requirements of a toddler affected by acute Epiglottitis and a toddler affected by acute Bronchiolitis. Epiglottitis is a life-threatening infection of the epiglottis that may result in acute airway obstruction. Epiglottitis is caused by Haemophilus injluenzae type b and has virtually disappeared in North America as a result of widespread immunization. The disease may rarely be caused by group A streptococci. On the Other hand, Bronchiolitis is an acute viral infection of the respiratory tract that affects the small airways of the young infant. It accounts for significant morbidity and mortality, especially in those with underlying cardiac or pulmonary disease. The etiologic agent is respiratory syncytial virus (RSV), an RNA virus whose growth appears to be primarily in the respiratory tract epithelium. Other viruses, such as influenza virus, adenovirus, and parainfluenza virus, can produce similar clinical states. Almost all children have been infected by RSV by the age of 3 years. The peak rate of hospitalization occurs at before 6 months of age. Both the diseases affect children below 1 year. Care of Toddlers Introduction In this paper, we have made a study of two toddlers, one affected by acute Epiglottitis and the other by acute Bronchiolitis both under the age of 6, for the similarities in their symptoms, diagnosis, and treatment and care requirements. Epiglottitis is an acute swelling of the glottic structures caused by bacterial infection. It is a true medical emergency and requires rapid, accurate diagnosis and treatment to avoid airway obstruction. Epiglottitis involves infection of the supraglottic structures, usually with Haemophilus influenzae type b (HIB). On rare occasions other pathogens are involved, including Streptococcus pneumoniae, staphylococcus aureus, -hemolytic streptococcus, and H. influenzae type a. Epiglottitis is has virtually disappeared in North America as a result of widespread immunization. The disease may rarely be caused by group A streptococci. Epiglottitis occurs throughout the year but is more common in the winter months. Eighty percent of infected children are younger than 5 years of age, with the peak incidence between 2 and 6 years of age. Since the institution of the HIB vaccine, the incidence appears to be declining, and epiglottitis currently accounts for only 1 to 10 of every 10,000 pediatric admissions. Older children may be affected by supraglottitis that is more indolent and is caused by group A streptococcus. There may be genetic and immunogenic factors which predispose individuals to invasive HIB disease. On the other hand, Bronchiolitis is an inflammation of the small airways that results in expiratory obstruction and wheezing. The term "bronchiolitis" is usually applied to an illness of young infants and children, characterized by respiratory distress and hypoxemia. Older children may also have wheezing with viral infections. Bronchiolitis is typically caused by respiratory syncytial virus (RSV). Other agents that have been associated with bronchiolitis include adenoviruses, parainfluenza viruses, rhinoviruses, and Mycoplasma pneumoniae. Transmission occurs primarily by direct contact with infected secretions. Viral shedding typically lasts 6 to 10 days. Attack rates among family members are 45 per cent, and transmission in daycare centers approaches 100 per cent among infants previously uninfected. Symptoms In the case of the toddler with acute epiglottitis, the symptoms might include acute illness with high temperature (often 39.5C+) and associated toxic state for less than 2 days, acute onset of severe inspiratory and expiratory stridor which is rapidly progressive. The child appears anxious, still, swallowing is painful and so there often is drooling of saliva. The child with epiglottitis presents with an abrupt onset of fever, sore throat, and progressive respiratory distress. The clinical findings include minimal cough or other prodromal symptoms, sudden onset of high fever, toxic appearance, marked tachycardia, and often restless and irritable disposition. Sore throat with a muffled voice and progressive noisy or stridulous breathing, with dysphagia and drooling occurring as the airway becomes compromised. In the toddler with acute Bronchiolitis too, the illness begins with common cold symptoms, but, as small airways become obstructed, the symptoms become more severe. Key clinical findings include, fever, cough, Tachypnea, nasal flaring, retractions, prolonged expiration and wheezing and cyanosis. Both the diseases involve respiratory problems and include the presence of fever. Diagnosis Acute epiglottitis is a severe bacterial infection caused by Haemophilus Influenzae, Type B. The incidence has fallen following the introduction of Hib immunization. The peak-age incidence is 2-3 years, unlike croup which is seen most in the second year of life. It is documented in the same way as in acute viral croup. The severity of the child's condition is carefully assessed, as it may be necessary to bypass the obstruction immediately to prevent death. Whenever this condition is suspected the child must be admitted to hospital. Lateral X-ray of the neck will usually visualize the epiglottis, but the trip to the X-ray department may be hazardous. Direct inspection of the epiglottis by an experienced pediatric anesthetist, under general anesthetic and intubation if necessary, is the ideal course of action. Blood culture often confirms infection with H. influenzae. It is of paramount importance to observe very carefully as the obstruction can progress rapidly. The Laboratory diagnosis includes complete blood count with differential and blood culture, followed by culture of the epiglottis and aryepiglottic folds. Evaluation of urine for bacterial antigens may be helpful, especially if the patient is taking antibiotics at the time of evaluation. In the case of the child with acute Bronchiolitis, heart and respiratory rate are recorded and the degree of hyper inflation, recession, cyanosis and distress are assessed. Oxygen saturation is measured using a cutaneous probe if possible. Diagnosis of the etiologic agent (RSV) is done by performing either a nasal wash or a nasal swab. The sample of mucus and cells is sent to the laboratory for identification of RSV antigen by fluorescent staining or enzyme linked immunosorbent assay (ELISA). Nasopharyngeal swabs are not as effective as nasal swabs for obtaining adequate cell specimens. Children with asthma may wheeze in response to viral upper respiratory infections. Other diagnostic considerations in a child with respiratory distress and wheezing include pneumonia, foreign bodies, anatomic abnormalities of the airway, congestive heart failure, and gastroesophageal reflux. Treatment The treatment of the child with acute epiglottitis requires ready access to a secure artificial airway. The patient should be closely observed at all times in an environment of minimal manipulation and stimulation. The upright sitting or prone position is recommended in which often the child remains in the caretaker's lap. The supine position may cause abrupt airway closure. Direct visualization of the throat or epiglottis is not recommended because of the risk of precipitating complete airway obstruction. Supplemental humidified oxygen can be given way of having a caretaker slowly advance the mask toward the patient's face. Prompt plans for airway placement should be initiated with patient arrival. Observation of the patient without intubation is associated with increased mortality and is not recommended. The artificial airway should be placed in the operating room by an anesthesiologist skilled in the care of young children, accompanied by a surgeon who is prepared to perform a tracheostomy if necessary. Initially the child is taken to the operating room accompanied by the caretaker and is anesthetized. IV access is simultaneously secured. Oral intubation with a stylet is accomplished, followed by elective nasal intubation. Cultures and blood tests are then obtained. Recommended drugs are cefuroxime, 75 mg/kg/day, maximum 1.5 g/dose every 8 hrs; or cefotaxime, 150 mg/kg/day divided every 8 hrs, maximum 12 g/day, for 7 to 10 days. Oral antibiotics can usually be given after 7 days of intravenous therapy. The intubated patient with epiglottitis is transferred to the intensive care unit for further treatment. For a toddler affected by acute bronchiolitis, care includes administration of oxygen, monitoring for apnea, and, if necessary, mechanical ventilation. Bronchodilators are often used but have limited efficacy. Treatment with nebulized ribavirin, an antiviral agent with activity against RSV, was found in some but not all studies to improve oxygenation and to reduce duration of illness. Indications for its use are not certain at this time. It may be considered primarily for severely ill patients and for those with underlying conditions like prematurity, bronchopulmonary dysplasia, congenital heart disease, immune deficiencies that put them at risk for severe infection. Antiviral therapy has shown to be beneficial in this case. Ribavarin reduces viral shedding and shortens the clinical course of the disease. It is probably most useful in children with underlying respiratory or cardiac disease. Although ribavirin does not reduce mortality in these populations, it does reduce morbidity. Prevention Prevention of acute Epiglottitis may be accomplished by the administration of the HIB conjugate vaccine. Rifampin prophylaxis (10 to 20 mg/kg/day; maximum dose, 600 mg) should be given to all household members and possibly to daycare contacts if at least one contact is younger than 4 years old. Whereas the prevention measure for acute Bronchiolitis would be passive immunization with RSV immune globulin has been shown to protect high-risk infants from severe RSV disease and has recently been licensed for this indication. Research on the use of monoclonal antibodies and new vaccines for prevention of RSV disease is in progress. Conclusion We thus arrive at a conclusion that though acute Epiglottitis and acute Bronchilitis are infections of the children under the age of 6, yet the former is caused due to a bacterial infection while the latter is caused due to a viral infection. But the similarity lies in that both acute epiglottitis and acute bronchiolitis exhibit expiratory obstruction. The symptoms of both might show up a severe fever. The treatment of both the diseases requires artificial ventilation. References Butt W, Shann F, Walker C, et al: (1998). Acute epiglottitis: A differential approach to management. Crit Care Med. Mauro RD, Poole SR, Lockhan CH: (1988). Differentiation of epiglottitis from laryngotracheitis in the child with stridor. Am J Dis Child. Schloss MD, Gold JA, Rosales JK, Baxter JD: (1983). Acute epiglottitis: Current management. Laryngoscope; 93:489-493. Sivan Y, Newth C: In LoughlinGM. Eigen H (eds): (1994). Respiratory Disease in Children: Diagnosis and Management. Baltimore, Williams & Wilkins, pp 315-334. Cressman WR, Myer CM. (1994). Diagnosis and management of croup and epiglottitis. Pediatr Clin North Am. Panitch HB, Callahan CW, Schidlaw DV. (1993). Bronchiolitis in children. Clin Chest Med Shapiro GG. (1992). Childhood asthma: update. Pediatrics Rev. Stempel DA, Redding GJ. (1992) Management of acute asthma. Pediatr Clin North Am. Bersten AD, Edibam C, Hunt T, Moran J, Group TA: (2002). Incidence and Mortality of Acute Lung Injury and the Acute Respiratory Distress Syndrome in Three Australian States, Am J Respir Crit Care Med. Arold SP, Mora R, Lutchen KR, Ingenito EP, Suki B: (2002).Variable tidal volume ventilation improves lung mechanics and gas exchange in a rodent model of acute lung injury. Am J Respir Crit Care Med. Boker A, Ruth Graham M, Walley KR, McManus BM, Girling LG, Walker E, Lefevre GR, Mutch WA: (2002). Improved arterial oxygenation with biologically variable or fractal ventilation using low tidal volumes in a porcine model of acute respiratory distress syndrome. Am J Respir Crit Care Med. Australian Journal of Rural Health (Oct. 2005). 13(5):265-270. Bateson EM (1986) Tuberculosis in the Aboriginal: a radiological perspective. Australasian Radiology. Chang AB, Grimwood K, Mulholland EK, Torzillo PJ (2002). Bronchiectasis in Indigenous children in remote Australian communities. Medical Journal of Australia. Veale A, Peat J, Tovey E, Salome C, Thompson J, Woolcock A (1996). Asthma and atopy in four rural Australian Aboriginal communities. Medical Journal of Australia. The Australian Lung Foundation, The Thoracic Society of Australia and New Zealand (2003). The COPDX plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease 2003. Medical Journal of Australia;178(Supplement):S1-S39. Merck and Company (1999). The Merck manual of diagnosis and therapy. 17th ed. New Jersey: Merck and Company. Read More