DIAGNOSTIC IMAGING REVIEW
Adult epiglottitis complicated by negative pressure pulmonary edema Eric S. Hochberg, MPAS, PA-C
CASE A 31-year-old man presented to the ED with a 1-day history of a sore throat associated with mild difficulty in swallowing and a hoarse voice. His past medical history was unremarkable. He denied fevers, cough, or shortness of breath. His vital signs were within normal limits except for mild tachypnea; his Spo2 was 99% on room air. On examination, he had no pharyngeal erythema, no stridor, and no significant lymphadenopathy. Laboratory studies were significant for a leukocytosis of 14,000/mcL with 82% neutrophils and 10% lymphocytes on automated differential. The remainder of his blood studies were within normal limits. A rapid strep screen was negative. A lateral radiograph of the neck revealed soft tissue thickening of the aryepiglottic folds and a thumb-like appearance (“thumb-print” sign) of the epiglottis (Figure 1). He was started on empiric broad-spectrum antibiotics and sent for a confirmatory CT scan of the head and neck (Figures 2 and 3). Shortly after the CT scan, he developed rapidly progressive dyspnea and pain. Within minutes, his Spo2 dropped and he briefly lost consciousness. He received an emergent cricothyrotomy and was taken to the OR, where he was endotracheally intubated and the cricothyrotomy was closed. On his arrival to the surgical ICU, routine postoperative arterial blood gas (ABG) analysis and a supine chest radiograph were obtained. He was hypoxemic with a widened A-a gradient on ABG analysis; the chest radiograph revealed diffuse bilateral perihilar alveolar infiltrates (Figure 4). Given the absence of preexisting heart disease and clear chest radiograph before intubation, negative pressure pulmonary edema (NPPE) was suspected. TREATMENT The patient’s chest radiograph cleared within several hours with only supportive care. He was maintained on broadspectrum antibiotics and corticosteroids for several days, Eric S. Hochberg practices in the surgical ICU at Sinai Hospital of Baltimore, Md. The author has disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000446991.94928.e2 Copyright © 2014 American Academy of Physician Assistants
50
www.JAAPA.com
FIGURE 1. Radiograph showing straightening of the cervical
lordosis, swollen epiglottis, hyoid bone, and mildly swollen aryepiglottic folds
was successfully extubated, and he was discharged home to complete his course of antibiotics. DISCUSSION Epiglottitis is swelling of the epiglottis, the structure at the base of the tongue that protects the lower airway during swallowing. This condition can rapidly progress to acute airway obstruction and death if not treated urgently. Epiglottitis is usually infectious; the most common cause is Haemophilus influenzae type B (Hib).1 Although epiglottitis historically has been more common in children, the incidence has decreased about 99% since the Hib vaccine went into widespread use in 1987.2 The incidence of epiglottitis has increased slightly in adults.1 Other causes of epiglottitis include bacteria common in other acute upper and lower airway infections, such as Moraxella, Streptococcus pneumoniae, and group A streptococci. Epiglottitis also can be caused by viruses, exposures, and inhalations. Patients can present with Volume 27 • Number 6 • June 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adult epiglottitis complicated by negative pressure pulmonary edema
fever, sore throat, odynophagia, drooling, or signs of overt airway compromise such as stridor, intercostal retractions, or cyanosis. Physical examination can reveal lymphadenopathy or pain in the anterior neck, specifically over the hyoid bone. Suspect epiglottitis in patients with sore throat and anterior neck pain without signs of pharyngitis. If epiglottitis is suspected, secure the patient’s airway and begin treatment rather than waiting for diagnostic studies. Treatment typically involves antibiotics such as a third- or fourth-generation cephalosporin or ampicillin/sulbactam; consider extended coverage if methicillin-resistant Staphylococcus aureus is suspected.3 Systemic corticosteroids may be used but are controversial. Diagnosis is confirmed by direct visualization of the epiglottitis and surrounding structures. This is best done in a controlled environment such as the OR because a tongue depressor or laryngoscopy can cause spasm of the already swollen airway, and the patient may need a surgically created airway. Imaging may include soft-tissue films of the neck in patients stable enough to delay direct visualization. The classical finding on a lateral neck radiograph is enlargement of the epiglottis (the “thumb-print” sign). Other radiographic findings may include enlargement of the aryepiglottic folds, distension of the hypopharynx, decreased vallecular air space, or straightening of the cervical spine lordosis.4,5 CT scanning may be helpful to rule out other pathologies such as retropharyngeal or peritonsillar abscess. NPPE and postobstructive pulmonary edema (POPE) are forms of acute noncardiogenic pulmonary edema. NPPE develops during or following forceful inspiration against an occluded upper airway, as can occur in epiglottitis; POPE develops after that obstruction is relieved.6,7 When intentional, forceful inspiration can be referred to as a Mueller maneuver or reverse Valsalva. The high negative intrathoracic pressure created increases blood return to the right side of the heart and pulmonary capillary bed, leaking fluid into the interstitium. The resulting hypoxemia causes a catecholamine surge that can raise end-diastolic filling pressures, worsening the process. In POPE, relief of the obstruction and resulting resolution of auto positive end-expiratory pressure (auto-PEEP) likely lends to the increased development of pulmonary edema. Although POPE is more common in postanesthesia patients, it occasionally happens in the population. Patients develop signs and symptoms typical of pulmonary edema: respiratory distress, hypoxia, cyanosis, frothy pink sputum, and sometimes frank hemoptysis. The hallmark finding on chest radiograph is bilateral perihilar alveolar infiltrates.7 In contrast, chest radiograph findings in patients with cardiogenic pulmonary edema show less-dramatic alveolar infiltrates with an interstitial
FIGURE 2. CT showing straightening of the cervical lordosis,
swollen epiglottis, hyoid bone, and mildly swollen aryepiglottic folds
FIGURE 3. Swollen epiglottis (arrow) and surrounding tissues
pattern, cephalization, apical diversion of blood flow, or Kerley B lines. Most commonly found in the middle and lower lung zones, Kerley B lines are short (1 cm or less) parenchymal lines perpendicular to the pleura. NPPE and POPE usually resolve spontaneously with supportive care. In clinical practice, however, diuretics are often given. JAAPA
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.JAAPA.com
51
DIAGNOSTIC IMAGING
REFERENCES
FIGURE 4. Chest radiograph showing diffuse bilateral perihilar
alveolar infiltrates consistent with pulmonary edema
1. Shah RK, Stocks C. Epiglottitis in the United States: national trends, variances, prognosis, and management. Laryngoscope. 2010;120(6):1256-1262. 2. Haemophilus influenzae type B. Epidemiology and prevention of vaccine-preventable diseases. The Pinkbook Online, 12th ed. http://www.cdc.gov/vaccines/pubs/pinkbook/hib.html. Accessed December 2, 2013. 3. Al-Qudah M, Shetty S, Alomari M, Alqdah M. Acute adult supraglottitis: current management and treatment. South Med J. 2010;103(8):800-804. 4. Jaffe JE. Acute epiglottitis. http://www.emedicine.com/Radio/ topic263.htm. Accessed November 29, 2013. 5. Schumaker HM, Doris PE, Birnbaum G. Radiographic parameters in adult epiglottitis. Ann Emerg Med. 1984;13(8):588-590. 6. Willms D, Shure D. Pulmonary edema due to upper airway obstruction in adults. Chest. 1988;94(5):1090-1092. 7. Gluecker T, Capasso P, Schnyder P, et al. Clinical and radiologic features of pulmonary edema. Radiographics. 1999;19(6):15071531.
Interested in writing for JAAPA? Visit www.jaapa.com, choose the Journal Information and Author Services tab, and click on Information for Authors and Reviewers
52
www.JAAPA.com
Volume 27 • Number 6 • June 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adult epiglottitis complicated by negative pressure pulmonary edema Eric S. Hochberg, MPAS, PA-C
CASE A 31-year-old man presented to the ED with a 1-day history of a sore throat associated with mild difficulty in swallowing and a hoarse voice. His past medical history was unremarkable. He denied fevers, cough, or shortness of breath. His vital signs were within normal limits except for mild tachypnea; his Spo2 was 99% on room air. On examination, he had no pharyngeal erythema, no stridor, and no significant lymphadenopathy. Laboratory studies were significant for a leukocytosis of 14,000/mcL with 82% neutrophils and 10% lymphocytes on automated differential. The remainder of his blood studies were within normal limits. A rapid strep screen was negative. A lateral radiograph of the neck revealed soft tissue thickening of the aryepiglottic folds and a thumb-like appearance (“thumb-print” sign) of the epiglottis (Figure 1). He was started on empiric broad-spectrum antibiotics and sent for a confirmatory CT scan of the head and neck (Figures 2 and 3). Shortly after the CT scan, he developed rapidly progressive dyspnea and pain. Within minutes, his Spo2 dropped and he briefly lost consciousness. He received an emergent cricothyrotomy and was taken to the OR, where he was endotracheally intubated and the cricothyrotomy was closed. On his arrival to the surgical ICU, routine postoperative arterial blood gas (ABG) analysis and a supine chest radiograph were obtained. He was hypoxemic with a widened A-a gradient on ABG analysis; the chest radiograph revealed diffuse bilateral perihilar alveolar infiltrates (Figure 4). Given the absence of preexisting heart disease and clear chest radiograph before intubation, negative pressure pulmonary edema (NPPE) was suspected. TREATMENT The patient’s chest radiograph cleared within several hours with only supportive care. He was maintained on broadspectrum antibiotics and corticosteroids for several days, Eric S. Hochberg practices in the surgical ICU at Sinai Hospital of Baltimore, Md. The author has disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000446991.94928.e2 Copyright © 2014 American Academy of Physician Assistants
50
www.JAAPA.com
FIGURE 1. Radiograph showing straightening of the cervical
lordosis, swollen epiglottis, hyoid bone, and mildly swollen aryepiglottic folds
was successfully extubated, and he was discharged home to complete his course of antibiotics. DISCUSSION Epiglottitis is swelling of the epiglottis, the structure at the base of the tongue that protects the lower airway during swallowing. This condition can rapidly progress to acute airway obstruction and death if not treated urgently. Epiglottitis is usually infectious; the most common cause is Haemophilus influenzae type B (Hib).1 Although epiglottitis historically has been more common in children, the incidence has decreased about 99% since the Hib vaccine went into widespread use in 1987.2 The incidence of epiglottitis has increased slightly in adults.1 Other causes of epiglottitis include bacteria common in other acute upper and lower airway infections, such as Moraxella, Streptococcus pneumoniae, and group A streptococci. Epiglottitis also can be caused by viruses, exposures, and inhalations. Patients can present with Volume 27 • Number 6 • June 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adult epiglottitis complicated by negative pressure pulmonary edema
fever, sore throat, odynophagia, drooling, or signs of overt airway compromise such as stridor, intercostal retractions, or cyanosis. Physical examination can reveal lymphadenopathy or pain in the anterior neck, specifically over the hyoid bone. Suspect epiglottitis in patients with sore throat and anterior neck pain without signs of pharyngitis. If epiglottitis is suspected, secure the patient’s airway and begin treatment rather than waiting for diagnostic studies. Treatment typically involves antibiotics such as a third- or fourth-generation cephalosporin or ampicillin/sulbactam; consider extended coverage if methicillin-resistant Staphylococcus aureus is suspected.3 Systemic corticosteroids may be used but are controversial. Diagnosis is confirmed by direct visualization of the epiglottitis and surrounding structures. This is best done in a controlled environment such as the OR because a tongue depressor or laryngoscopy can cause spasm of the already swollen airway, and the patient may need a surgically created airway. Imaging may include soft-tissue films of the neck in patients stable enough to delay direct visualization. The classical finding on a lateral neck radiograph is enlargement of the epiglottis (the “thumb-print” sign). Other radiographic findings may include enlargement of the aryepiglottic folds, distension of the hypopharynx, decreased vallecular air space, or straightening of the cervical spine lordosis.4,5 CT scanning may be helpful to rule out other pathologies such as retropharyngeal or peritonsillar abscess. NPPE and postobstructive pulmonary edema (POPE) are forms of acute noncardiogenic pulmonary edema. NPPE develops during or following forceful inspiration against an occluded upper airway, as can occur in epiglottitis; POPE develops after that obstruction is relieved.6,7 When intentional, forceful inspiration can be referred to as a Mueller maneuver or reverse Valsalva. The high negative intrathoracic pressure created increases blood return to the right side of the heart and pulmonary capillary bed, leaking fluid into the interstitium. The resulting hypoxemia causes a catecholamine surge that can raise end-diastolic filling pressures, worsening the process. In POPE, relief of the obstruction and resulting resolution of auto positive end-expiratory pressure (auto-PEEP) likely lends to the increased development of pulmonary edema. Although POPE is more common in postanesthesia patients, it occasionally happens in the population. Patients develop signs and symptoms typical of pulmonary edema: respiratory distress, hypoxia, cyanosis, frothy pink sputum, and sometimes frank hemoptysis. The hallmark finding on chest radiograph is bilateral perihilar alveolar infiltrates.7 In contrast, chest radiograph findings in patients with cardiogenic pulmonary edema show less-dramatic alveolar infiltrates with an interstitial
FIGURE 2. CT showing straightening of the cervical lordosis,
swollen epiglottis, hyoid bone, and mildly swollen aryepiglottic folds
FIGURE 3. Swollen epiglottis (arrow) and surrounding tissues
pattern, cephalization, apical diversion of blood flow, or Kerley B lines. Most commonly found in the middle and lower lung zones, Kerley B lines are short (1 cm or less) parenchymal lines perpendicular to the pleura. NPPE and POPE usually resolve spontaneously with supportive care. In clinical practice, however, diuretics are often given. JAAPA
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.JAAPA.com
51
DIAGNOSTIC IMAGING
REFERENCES
FIGURE 4. Chest radiograph showing diffuse bilateral perihilar
alveolar infiltrates consistent with pulmonary edema
1. Shah RK, Stocks C. Epiglottitis in the United States: national trends, variances, prognosis, and management. Laryngoscope. 2010;120(6):1256-1262. 2. Haemophilus influenzae type B. Epidemiology and prevention of vaccine-preventable diseases. The Pinkbook Online, 12th ed. http://www.cdc.gov/vaccines/pubs/pinkbook/hib.html. Accessed December 2, 2013. 3. Al-Qudah M, Shetty S, Alomari M, Alqdah M. Acute adult supraglottitis: current management and treatment. South Med J. 2010;103(8):800-804. 4. Jaffe JE. Acute epiglottitis. http://www.emedicine.com/Radio/ topic263.htm. Accessed November 29, 2013. 5. Schumaker HM, Doris PE, Birnbaum G. Radiographic parameters in adult epiglottitis. Ann Emerg Med. 1984;13(8):588-590. 6. Willms D, Shure D. Pulmonary edema due to upper airway obstruction in adults. Chest. 1988;94(5):1090-1092. 7. Gluecker T, Capasso P, Schnyder P, et al. Clinical and radiologic features of pulmonary edema. Radiographics. 1999;19(6):15071531.
Interested in writing for JAAPA? Visit www.jaapa.com, choose the Journal Information and Author Services tab, and click on Information for Authors and Reviewers
52
www.JAAPA.com
Volume 27 • Number 6 • June 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
