What is the recommended management for epiglottitis?

Management of Epiglottitis

Epiglottitis requires immediate airway management in a controlled setting with appropriate emergency response capabilities, with the decision to secure the airway based on the severity of obstruction and respiratory distress.

Initial Assessment and Diagnosis

• Clinical presentation: Assess for signs of respiratory distress, stridor, dysphagia, drooling, and voice changes
• Diagnostic approach:
  • Direct visualization via flexible laryngoscopy is the gold standard for diagnosis 1
  • Lateral neck radiographs can be useful but have lower sensitivity 1
  • Avoid throat swabbing in suspected epiglottitis as this may precipitate complete airway obstruction 2
  • Blood cultures are preferred for microbiological diagnosis in epiglottitis 2

Airway Management Algorithm

For Severe Respiratory Distress:

1. Immediate airway intervention in an operating room setting with appropriate equipment and personnel
2. Endotracheal intubation under general anesthesia is the preferred approach 3
   • Consider nasotracheal intubation for short-term airway management 3
   • Have tracheostomy equipment immediately available as backup
3. Avoid blind attempts at intubation which may worsen edema and obstruction

For Mild to Moderate Cases (Adults):

1. Close monitoring in an intensive care setting
2. Selective airway intervention based on:
   • Degree of obstruction (>50% obstruction warrants intervention) 4
   • Progression of symptoms
   • Respiratory status
3. Prepare for emergency airway management if clinical deterioration occurs 5

Medical Management

• Antimicrobial therapy:

  • Empiric broad-spectrum antibiotics covering Haemophilus influenzae and other common pathogens
  • Combination of cefotaxime and metronidazole is commonly used 4
  • Adjust based on culture results when available

• Supportive measures:

  • Oxygen supplementation
  • Intravenous hydration
  • Positioning (upright or semi-recumbent to maximize airway patency)
  • Corticosteroids to reduce inflammation (though evidence is limited)

Monitoring and Follow-up

• Continuous monitoring of respiratory status, oxygen saturation, and vital signs
• Serial airway assessment via flexible laryngoscopy to evaluate improvement
• Duration of intubation: Usually 24-72 hours depending on resolution of edema
• Extubation considerations:
  • Follow a structured approach per Difficult Airway Society guidelines 2
  • Consider extubation over an airway exchange catheter in high-risk cases
  • Ensure appropriate equipment and personnel are available for reintubation if needed

Special Considerations

• Pediatric vs. Adult Management:

  • Pediatric cases typically require more aggressive airway management
  • Adult cases may follow a more variable course, allowing for selective intervention 5
  • Mortality in adults remains around 7% despite advances in management 1

• Common Pitfalls:

  • Underestimating the severity and rapid progression of airway compromise
  • Performing blind finger sweeps or throat examinations that may precipitate complete obstruction
  • Delaying airway intervention in deteriorating patients
  • Inadequate monitoring of seemingly stable patients

Remember that epiglottitis is a potentially life-threatening condition that requires prompt recognition and management. Any clinical suspicion warrants an aggressive approach until the diagnosis is ruled out or the patient shows clear signs of recovery 1.