Epiglottitis, súlyos krupp, stridor és felső légúti elzáródás¶

An acute upper airway obstruction caused by infectious swelling of the throat tissues is one of the fastest-moving emergencies in pediatric and adult medicine. Within minutes to hours, bacterial inflammation of the epiglottis (acute epiglottitis), severe viral swelling below the vocal cords (laryngotracheobronchitis or croup), or a deep bacterial windpipe infection (bacterial tracheitis) can narrow the breathing passage down to a pinhole. Because a child's windpipe is roughly the diameter of their little finger, even 1 millimeter (0.04 inches) of mucosal swelling inside a child's airway reduces the cross-sectional breathing area by more than 60 percent and increases airflow resistance sixteen-fold.

Ha egy gyulladt felső légút kritikusan beszűkül, a beteg csak úgy éli túl, ha egyenesen ül, előrehajol, és nyakát olyan precíz helyzetben tartja, hogy egy kis légrés nyitva marad. A kórház előtti elsősegélynyújtás során a legnagyobb veszély a iatrogén, teljes légúti elzáródás, amelyet a jó szándékú mentők váltanak ki, akik pánikba esett gyermeket vagy felnőttet hanyatt fekvésre kényszerítenek, kanállal vagy zseblámpával próbálnak belenézni a szájába, vagy idegesítenek egy síró gyermeket. Ha tudjuk, hogyan lehet megkülönböztetni az epiglottitis hirtelen, néma, nyáladzó rémét a vírusos krupp réz, fókakéreg köhögésétől, miért kell a pácienst nyugodtan tartani a választott állványtartásban, és amikor a hideg pára vagy a párás levegő segít, nyitva tarthatjuk a légutakat a sürgősségi orvosi csapat megérkezéséig.

Tedd ezt most¶

1. Call your local emergency number immediately if anyone has noisy breathing at rest (stridor), drooling with inability to swallow, a muffled "hot potato" voice, tripod posture, or bluish lips. Dial 911 in the United States and Canada, 112 across the European Union, 999 in the United Kingdom, 000 in Australia, or check the directory of segélyhívó számok. Request an Advanced Life Support (ALS) ambulance and state clearly that you suspect acute upper airway swelling or epiglottitis so paramedics approach quietly without sirens blaring at the door.
2. NEVER force a person with stridor, drooling, or severe throat swelling to lie flat on their back. Let the patient sit completely upright in whatever position feels easiest to breathe, usually leaning forward on their hands with their chin thrust slightly forward (the tripod or sniffing position). For an infant or toddler, let them sit upright held calmly in their parent's lap and arms.
3. NEVER put a tongue depressor, spoon, finger, thermometer, or flashlight inside the mouth to look at the throat. Touching the back of the tongue or forcing the jaw open in suspected epiglottitis triggers an instant vagal laryngospasm or pushes the swollen, cherry-red epiglottis down like a cork into the windpipe, causing immediate and irreversible airway obstruction.
4. Keep a frightened child as calm and quiet as possible in their parent's arms. Crying, screaming, and fighting increase turbulent airflow through the narrowed throat (the Bernoulli effect), which sucks the swollen airway walls inward and worsens hypoxia. Do not separate the child from their caregiver, do not try to pull off their clothes unless necessary, and minimize bright lights or loud noises.
5. Keep the patient strictly NPO (nothing by mouth). Do not offer water, milk, juice, popsicles, honey, or oral fever syrups (such as liquid paracetamol or ibuprofen) to anyone who is drooling, struggling to swallow, or making high-pitched stridor sounds at rest. Attempting to swallow liquid past a swollen epiglottis triggers violent choking and fatal laryngospasm.
6. If the child has a classic "barking seal" cough (viral croup) WITHOUT drooling, sits comfortably, and has mild stridor only when crying, expose them to cool night air or bathroom mist while monitoring closely. Sitting in a cool-mist bathroom or breathing cool outdoor night air for 10 to 15 minutes while comforting the child often shrinks subglottic viral swelling enough to ease mild croup, though any stridor present while the child is calm and resting requires immediate medical evaluation and prescription corticosteroids.

Emergency decision tree for acute stridor and upper airway swelling¶

flowchart TD
    Start["Sudden Noisy Breathing (Stridor), Hoarseness, Barking Cough, or Severe Throat Pain"]
    ChokeCheck{"Did this start INSTANTLY (within seconds)<br/>while eating, playing with small toys, or holding an object in the mouth,<br/>with NO fever or prior illness?"}
    ForeignBody["SUSPECTED FOREIGN-BODY CHOKING / AIRWAY OBSTRUCTION<br/>1. If unable to speak, cough, or breathe: Perform Back Blows & Abdominal Thrusts<br/>   (or Back Blows & Chest Thrusts for infants under 1 year)<br/>2. If coughing forcefully or breathing with stridor: Call EMS immediately;<br/>   do NOT perform blind finger sweeps; keep patient upright"]
    AllergyCheck{"Was the patient exposed to a bee sting, peanut/food allergen,<br/>medication, or has a history of hereditary angioedema,<br/>with swollen lips, tongue, or hives?"}
    Anaphylaxis["ANAPHYLACTIC AIRWAY EDEMA / ANGIOEDEMA<br/>1. Inject Epinephrine Auto-Injector into outer mid-thigh immediately<br/>2. Call EMS (911 / 112 / 999) for urgent transport<br/>3. Keep patient sitting upright if airway/tongue is swollen (unless hypotensive)<br/>4. Give second epinephrine dose at 5 to 15 minutes if no improvement"]
    RedFlagCheck{"Are ANY Epiglottitis or Severe Obstruction Red Flags Present?<br/>- Drooling saliva / unable to swallow own spit<br/>- Sitting upright leaning forward (Tripod / Sniffing posture)<br/>- Muffled 'Hot Potato' voice & absence of barking cough<br/>- High-pitched stridor heard even when resting quietly<br/>- Sternal/rib retractions, lethargy, or bluish/pale skin"}
    EpiglottitisProtocol["CRITICAL UPPER AIRWAY EMERGENCY (EPIGLOTTITIS / SEVERE CROUP / TRACHEITIS)<br/>1. Call EMS (911 / 112 / 999) immediately; request quiet ALS approach<br/>2. Keep patient sitting 100% UPRIGHT (child held in parent's lap)<br/>3. DO NOT look in mouth, DO NOT use tongue blade, DO NOT lay flat<br/>4. Keep strictly NPO (no water, no oral fever medicine)<br/>5. Keep child calm; allow parent to hold blow-by oxygen near face if EMS provides it"]
    MildCroup["LIKELY MILD TO MODERATE VIRAL CROUP (LARYNGOTRACHEOBRONCHITIS)<br/>(Barking seal-like cough, hoarse voice, able to swallow, NO drooling,<br/>NO stridor when resting quietly, alert and drinking fluids)<br/>1. Hold child upright and calm them immediately to stop crying<br/>2. Expose to cool outdoor night air (wrapped warmly) or cool-mist humidifier for 15 min<br/>3. Contact physician or urgent care for single-dose oral Dexamethasone<br/>4. Watch continuously for resting stridor or rib retractions"]

    Start --> ChokeCheck
    ChokeCheck -->|Yes: Sudden Onset, No Fever| ForeignBody
    ChokeCheck -->|No: Preceded by Fever, Cold, or Sore Throat| AllergyCheck
    AllergyCheck -->|Yes: Hives, Lip/Tongue Swelling, Allergen| Anaphylaxis
    AllergyCheck -->|No: Infectious / Inflammatory Pattern| RedFlagCheck
    RedFlagCheck -->|Yes: ANY Red Flag Present| EpiglottitisProtocol
    RedFlagCheck -->|No: Barking Cough Only, Calm at Rest| MildCroup

Comparing life-threatening upper airway emergencies¶

When a child or adult develops noisy breathing (stridor) or throat distress, five major infectious and non-infectious conditions must be differentiated quickly. Unlike wheezing (a musical, whistling sound heard primarily during exhalation from narrowed lower bronchial tubes in asthma), stridor is a harsh, high-pitched, crowing or sawing sound heard primarily during inhalation (or both inhalation and exhalation in severe subglottic narrowing) caused by turbulent airflow through a partially blocked upper throat, voice box (larynx), or windpipe (trachea).

Anatomy and physics of upper airway obstruction¶

Why a 1-millimeter swelling is an inconvenience in an adult but a catastrophe in a child¶

To understand why an infant or toddler with croup or epiglottitis can deteriorate from noisy breathing to respiratory arrest in minutes, emergency clinicians apply Poiseuille's Law of Laminar and Turbulent Fluid Flow:

1. The Resistance-to-Radius Fourth-Power Rule (\(R \propto \frac{1}{r^4}\)): When airflow is smooth (laminar), airway resistance is inversely proportional to the fourth power of the airway radius (and when crying causes turbulent airflow, resistance scales with the fifth power of the radius).
2. Pediatric vs. Adult Airway Dimensions:
3. A normal infant or toddler's subglottic airway at the cricoid cartilage ring has an internal diameter of only 4 millimeters (0.16 inches) (a radius of 2 mm). If viral croup causes just 1 millimeter of circumferential mucosal swelling inside that rigid ring, the internal diameter drops from 4 mm to 2 mm (the radius drops by 50 percent from 2 mm to 1 mm). Because \(2^4 = 16\), cutting the airway radius in half reduces the breathing area by 75 percent and increases the work of breathing by 1,600 percent (16-fold).
4. By contrast, a normal adult trachea has an internal diameter of roughly 20 millimeters (0.79 inches) (a radius of 10 mm). The exact same 1 millimeter of circumferential swelling reduces the adult diameter from 20 mm to 18 mm, which increases airway resistance by only about 50 percent (1.5-fold).
5. Why Crying Makes the Airway Collapse (The Dynamic Bernoulli Effect): In children, the cartilage rings supporting the upper airway and larynx are soft and pliable. When a frightened child screams or cries and tries to suck air forcefully through a narrowed throat, the high velocity of air rushing past the swollen walls creates a strong negative vacuum pressure inside the airway lumen (the Venturi / Bernoulli effect). This negative pressure literally sucks the soft, floppy walls of the child's throat inward during inhalation, turning a partial obstruction into a near-total collapse. That is why keeping a child with stridor calm and quiet is not merely for comfort; it is a critical mechanical life-saving intervention.

The anatomical difference between Supraglottic and Subglottic swelling¶

• Supraglottic Obstruction (Epiglottitis): Occurs above the vocal cords in loose, distensible connective tissue. Because the tissue covering the epiglottis and aryepiglottic folds is loosely attached, bacterial fluid and white blood cells rapidly balloon the epiglottis into a massive swollen sphere that flops over the laryngeal inlet during inspiration. It causes quiet, soft, low-pitched inspiratory stridor, a muffled "hot potato" voice, and drooling because the patient cannot swallow past the swollen mass, but no barking cough.
• Subglottic Obstruction (Viral Croup): Occurs below the vocal cords inside the cricoid cartilage, the only cartilage in the entire human airway that forms a complete, rigid 360-degree signet ring. Because the cricoid ring cannot expand outward when the lining swells, all swelling is forced inward into the breathing tube, stretching the vocal cords above and producing a loud, brassy "barking seal" cough, a hoarse voice, and high-pitched, harsh inspiratory (or biphasic) stridor.

Deep dive: Acute Epiglottitis in children and adults¶

The changing face of Epiglottitis: Why adults are now at high risk¶

Before the routine introduction of the Haemophilus influenzae type b (Hib) conjugate vaccine in the late 1980s and 1990s, acute epiglottitis was predominantly a pediatric disease striking 2-to-7-year-old children. Today, two critical epidemiological realities must be understood by every family and first responder: 1. Pediatric Epiglottitis Still Occurs: It strikes children who are unimmunized or under-immunized against Hib, children in regions without universal Hib vaccination, and even fully vaccinated children when caused by other bacteria such as Streptococcus pneumoniae, Group A beta-hemolytic Streptococcus, or Staphylococcus aureus, or by thermal injury (drinking scalding liquids or inhaling steam). 2. Adult Supraglottitis / Epiglottitis is Rising: The majority of epiglottitis cases in vaccinated countries now occur in adults aged 20 to 65 years. Adult epiglottitis is frequently misdiagnosed at first as a "bad case of strep throat" because the adult throat looks deceptively normal when a doctor looks at the tonsils with a flashlight (since the epiglottis sits lower down, out of direct view).

The "Four Ds" of Acute Epiglottitis¶

Clinicians teach the classic Four Ds to recognize epiglottitis immediately at a glance without ever touching the patient: 1. Drooling (Sialorrhea): Saliva drips continuously from the chin because swallowing triggers agonizing throat pain and threatens to choke the airway. 2. Dysphagia és súlyos odynophagia: Teljes képtelenség folyadékot vagy szilárd ételt lenyelni. Felnőtteknél az epiglottitis első számú jellemzője a súlyos, elviselhetetlen torokfájás ("10-ből 10 fájdalom"), amely teljesen aránytalan a normális megjelenésű szájüreghez és mandulákhoz képest. 3. Dysphonia ("Hot Potato" Voice): The voice sounds thick, muffled, and hollow, as if the person is trying to speak while holding a scalding hot bite of potato in the back of their throat. 4. Distress (Inspiratory Stridor and Tripod Posture): The patient sits motionless, leaning forward with hands braced on their knees (tripod position), neck extended forward and chin tilted up (sniffing position), breathing slowly and carefully so as not to create turbulent airflow that sucks the swollen epiglottis shut.

Step-by-step first aid for suspected Epiglottitis¶

1. Call 911 / 112 / 999 immediately and request an ALS paramedic crew. Tell the dispatcher: "I have a child/adult with suspected epiglottitis who is drooling, sitting in a tripod position, and struggling to breathe."
2. Adopt a strict "Hands-Off, Calm-Environment" protocol:
3. Dim harsh overhead lights and turn off loud televisions or barking pets.
4. If the patient is a child, leave them in their parent's or caregiver's arms. Never try to pry an anxious toddler away from their mother or father to examine them.
5. Let the patient hold a towel or cup near their chin to catch drool so they do not feel an urge to swallow it.
6. Never lay the patient down and never look in the mouth: Do not ask the patient to "open wide and say ahh." Do not shine a phone light down their throat.
7. If the patient loses consciousness and stops breathing completely before paramedics arrive:
8. If the airway closes completely and the patient becomes unresponsive, cyanotic, and apneic, gently lay them supine to begin CPR (vagy pediatric CPR).
9. Rescue Breathing Rule in Complete Epiglottitis Arrest: Even when the swollen epiglottis blocks spontaneous inhalation, firm, slow positive-pressure rescue breaths (mouth-to-mouth or a paramedic's bag-valve-mask) can often force small, life-saving puffs of air past the swollen tissue into the lungs while chest compressions circulate oxygen until paramedics arrive to perform an emergency surgical airway.

Deep dive: Viral Croup (Laryngotracheobronchitis) and Spasmodic Croup¶

Recognizing the classic midnight presentation of Croup¶

Unlike epiglottitis, viral croup accounts for the vast majority of acute stridor cases in children between 6 months and 3 years of age. * Why Croup attacks between 11:00 PM and 4:00 AM: A toddler typically has a mild runny nose, slight hoarseness, and a low-grade fever during the daytime. In the middle of the night, the child wakes up gasping with a loud, metallic, seal-bark cough and a raspy, crowing sound when inhaling (inspiratory stridor). Croup peaks at night because endogenous cortisol (the body's natural anti-inflammatory hormone) drops to its lowest circadian trough between midnight and 4:00 AM, while lying flat in bed increases venous blood pooling in the subglottic lining. * Spasmodic Croup: A closely related variant in which a child goes to bed healthy without any fever and wakes up at 2:00 AM with a barking cough and stridor from sudden subglottic mucosal edema.

Grading Croup severity: The Westley Croup Severity Guide for parents and responders¶

Determining whether a child with a barking cough can be comforted with cool air and taken to a doctor, or requires an immediate 911 / 112 / 999 ambulance, depends on whether stridor and chest retractions are present when the child is calm and resting:

Safe home and prehospital first aid for Viral Croup¶

1. Pick the child up and hold them upright immediately: Sitting upright reduces blood engorgement in the swollen subglottic mucosa and uses gravity to assist the diaphragm.
2. Soothe and calm the child with quiet reassurance: Sing softly, read a favorite book, or put on a quiet video while holding the child on your lap. Stopping the child from crying immediately converts turbulent airflow back into smooth laminar airflow, often cutting their breathing effort in half within 2 minutes.
3. Apply the Cool Night Air or Cool-Mist Bathroom Protocol (10 to 15 minutes):
4. Option A (Cool Outdoor Night Air or Open Freezer Door): Wrap the child warmly in a blanket and carry them upright onto a porch, by an open window, or in front of an open refrigerator/freezer door to breathe cool, humid night air for 10 to 15 minutes. Cool air causes vasoconstriction of the dilated blood vessels in the subglottic lining, visibly shrinking the swelling and easing the barking cough.
5. Option B (Cool-Mist Humidifier or Bathroom Mist): Run a clean cool-mist humidifier right beside the child, or sit upright with the child in a closed bathroom while running the shower to create a humid mist.
6. CRITICAL BURN WARNING: Never hold a child over a pot of boiling water, a hot stove, or a hot steam vaporizer. Hot steam vaporizers and pots of boiling water cause catastrophic facial and airway scald égési sérüléseket in squirming toddlers, and hot steam can actually increase mucosal blood flow and worsen airway edema.
7. Why every child with croup should be evaluated by a clinician for corticosteroids:
8. Even if cool night air stops a mild croup attack at 2:00 AM, viral subglottic inflammation lasts 3 to 5 days and frequently rebounds the following night.
9. Current international pediatric guidelines (American Academy of Pediatrics, UK NICE, Canadian Paediatric Society, WHO) recommend that all children with croup (even mild croup) receive a single prescribed oral dose of a corticosteroid (typically Dexamethasone) from a physician or urgent care clinic. A single dose of dexamethasone begins shrinking airway swelling within 2 to 4 hours, lasts up to 72 hours, and slashes emergency department return visits and hospitalizations by more than 50 percent.

Hat végzetes hiba, amelyet el kell kerülni felső légúti vészhelyzetekben¶

1. 1. hiba: Megpróbálja megvizsgálni a torkát kanállal, ujjal vagy zseblámpával. Soha ne nyomja le a nyelvét, és soha ne kérje meg a nyáladzó, stridoros beteget, hogy nyissa ki. Az epiglottitisben a garat minimális mechanikai ingerlése a légutak teljes lezárását és a vagus bradycardiás leállást okozza.
2. 2. hiba: Szájon át szedett folyadék, méz vagy lázcsillapító gyógyszer adása nyugalmi stridor vagy nyáladzó betegnek. Ha a felső légúti elzáródásban szenvedő betegnek bármit szájon át ad be, az aspirációt, súlyos köhögési görcsöket és gégegörcsöt okozhat.
3. 3. hiba: Hasi lökés (Heimlich-manőver) fertőző krumplis vagy epiglottitisben szenvedő gyermeken. A hasi lökéseket kizárólag szilárd mechanikus idegentest kilökésére tervezték. Epiglottitisben vagy kruppban az elzáródás duzzadt élőszövet; A hasi lökés nem tudja kiszorítani a duzzadt szöveteket, és csak pánikba ejti a gyermeket, és gyorsabban összeomlik a légutak.
4. 4. hiba: Vény nélkül kapható köhögéscsillapítók, antihisztaminok vagy nyugtatók adása. A beszűkült légutakon keresztül keményen lélegző gyermek vagy felnőtt nyugtatása megszünteti a tudatos légzési késztetést, és ellazítja a garat izmait, amelyek nyitva tartják a torkát, ami gyors légzésleállást vált ki. Az antihisztaminok kiszárítják és besűrítik a légúti váladékot vírusos krupp és bakteriális légcsőgyulladás esetén is, ami vastag nyálkahártyákat okoz a keskeny légcsőben.
5. 5. hiba: Súlyos nyáladzás, nyáladzás vagy visszahúzódás esetén a gyermek kórházba vezetése egy magángépkocsi hátsó ülésén. Mindig hívja a 911/112/999-es segélyhívószámot, ha ALS-mentőt kér, ha nyugalmi nyálcsorgatás, nyáladzás vagy visszahúzódás tapasztalható.
6. 6. hiba: A felső légúti stridor összetévesztése egy asztmás rohammal, és az inhalátort a síró kisgyermek szájába kényszerítik. Az asztma kilégzési sípoló légzést (nehezíti a levegő kiszorítását az alsó tüdőből), míg a krupp és az epiglottitis **felső légúti elhúzódást vagy **belégzési zavart okoz torok). A standard kék szalbutamol vagy albuterol asztma inhalátorok ellazítják a hörgők simaizmát az alsó tüdőben; nulla hatásuk van a duzzadt porcrétegre a felső torokban, és fokozhatják a szívverést és az izgatottságot.

A felső légúti vészhelyzetek higgadt cselekvést és annak ismeretét kívánják meg, hogy mikor kell a beteget zavartalanul tartani. Fontolja meg, hogy vegyen részt egy okleveles elsősegélynyújtó tanfolyamon a Vöröskereszt vagy Vörös Félhold nemzeti szervezetén, az American Heart Association-n vagy a St John Ambulance-on keresztül.

Gyakran ismételt kérdések¶

A források ellenőrizve¶

• Amerikai Gyermekgyógyászati ​​Akadémia (AAP, Egyesült Államok) és Gyermekgyógyászati ​​Advanced Life Support (PALS / AHA): A felső légúti elzáródás, a vírusos csonk, az epiglottitis és a bakteriális tracheitis felismerése és kezelése.
• National Institute for Health and Care Excellence (NICE, Egyesült Királyság) és NHS: Klinikai ismeretek összefoglalása: Croup, Acute Epiglottitis és Stridor Assessment in Children and Adults.
• Kanadai Gyermekgyógyászati ​​Társaság (CPS, Kanada): A krupp akut kezelése a sürgősségi osztályon és a prehospital környezetben.
• Egészségügyi Világszervezet (WHO, International): Kórházi gondozás zsebkönyve gyermekeknek: Stridor, Croup és Epiglottitis.
• Melbourne-i Királyi Gyermekkórház (RCH, Ausztrália): Klinikai gyakorlati irányelvek: Akut felső légúti elzáródás és krupp.

Kapcsolódó útmutatók¶

• Gyermek- és csecsemőkori újraélesztés és fulladás
• Elsősegélynyújtás fulladás esetén felnőtteknek és gyermekeknek
• Elsősegélynyújtás allergiás reakciók és anafilaxiás reakciók esetén
• Asztmás roham sürgősségi ellátás
• Felnőtt CPR és mentőlégzés
• Emergency numbers and international dispatch