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Acute epiglottitis, sevoflurane and HIB vaccination

2001; Wiley; Volume: 56; Issue: 8 Linguagem: Inglês

10.1046/j.1365-2044.2001.02181-15.x

1365-2044

I N Sobolev, N. Plunkett, Ian Barker,

Pneumonia and Respiratory Infections

The substantial decline in the incidence of childhood epiglottitis is a result of the Haemophilus influenza type B (HIB) vaccination programme. We present a case of acute epiglottitis in a fully vaccinated 6-year-old girl. She was admitted to the accident and emergency (A & E) Department at 4.00 a.m. with a classical history of short duration. She was sitting upright, tachypnoeic and unable to swallow. She had marked inspiratory and expiratory stridor. Her temperature was 39.1 °C and she had a reduced level of consciousness. Previously fit and well, her vaccination status was up-to-date including three doses of HIB vaccine. She was quickly transferred to the anaesthetic room. Anaesthesia was induced in the sitting position using incremental concentrations of sevoflurane to 6% in oxygen; 4% halothane was subsequently used to achieve an adequate depth of anaesthesia for intubation. Induction of anaesthesia was uneventful; she did not cough or hold her breath. Direct laryngoscopy demonstrated a red, grossly swollen epiglottis. The trachea was intubated without difficulty using an oral 5.5-mm tracheal tube, which was replaced by a nasal tube a few minutes later. An intravenous cannula was inserted and cefotaxime commenced. She remained intubated in PICU for 48 h, was uneventfully extubated and transferred to a medical ward. Her throat and blood cultures were positive for HIB. We wish to emphasise two points in this short case history: 1 Sevoflurane appears to be a safe and effective anaesthetic agent for induction in adult patients with acute epiglottitis [1, 2]. It has a more rapid onset of action and is better tolerated than halothane. However, sevoflurane has a more pronounced ventilatory depressant effect than other anaesthetic vapours. There appears to be a single reference to its use in a child with the condition [3]. In our experience, combining the rapid onset of action of sevoflurane with subsequent early substitution of halothane as a maintenance agent allowed a smooth and rapid induction without respiratory depression. 2 Haemophilus influenza type B is the most frequent causative agent of acute epiglottitis in children (95.2%) [5]. HIB vaccination has been extremely successful; however, there is evidence that 27% of cases of acute epiglottitis in children in the USA are due to vaccine failure [6]. We believe this to be one of very few cases of acute epiglottitis following HIB vaccination in the United Kingdom [7]. Clinicians must still have a high index of suspicion of acute epiglottitis when presented with a fully vaccinated child with stridor.