What is the management of acute epiglottitis?

Management of Acute Epiglottitis

In acute epiglottitis, immediate airway management is mandatory with either endotracheal intubation or tracheostomy to prevent potentially fatal airway obstruction, followed by appropriate antibiotic therapy targeting Haemophilus influenzae type B. 1, 2

Clinical Presentation and Diagnosis

• Acute epiglottitis presents as a rapidly progressive, potentially life-threatening inflammation of the supraglottic structures

• Key symptoms include:

  • Sore throat
  • Muffled/"hot potato" voice
  • Dysphagia
  • Progressive respiratory distress
  • Drooling
  • Fever
  • Preference for sitting forward position (tripod position)

• Diagnostic approach:

  • Lateral neck radiograph showing thickened epiglottis ("thumb sign") is quick, safe, and reliable 3
  • Blood cultures (positive for H. influenzae type B in 97% of cases) 3
  • CAUTION: Avoid attempts to examine the throat or obtain throat swabs in suspected cases as this may precipitate complete airway obstruction 4

Airway Management Algorithm

Step 1: Risk Assessment

• High-risk features requiring immediate airway intervention:
  • Respiratory distress
  • Stridor
  • Hypoxemia
  • Drooling
  • Inability to swallow
  • Progressive symptoms

Step 2: Airway Management

• For all pediatric patients: Secure artificial airway immediately (mortality rate 6.1% with observation alone vs <1% with artificial airway) 5
• For adults:
  • With respiratory distress: Immediate airway intervention
  • Without respiratory distress: May be monitored in ICU setting with immediate access to airway equipment 6

Step 3: Airway Intervention Technique

• Perform in operating room with full emergency equipment

• Options:

  1. Endotracheal intubation: Preferred first-line approach

     • Performed under general anesthesia
     • Nasotracheal intubation is effective for short-term management 3
     • Average duration: 2.3 days 2

  2. Tracheostomy: Alternative when intubation fails or is contraindicated

     • Average duration: 2.9 days 2
     • Higher risk of subcutaneous and mediastinal emphysema 2

• Both methods have similar outcomes:

  • Mortality rates (0.92% for intubation vs 0.86% for tracheostomy) 5
  • Similar hospital stay (6.7 vs 6 days) 2

Step 4: Medical Management

• Intravenous antibiotics targeting H. influenzae type B
• Maintain artificial airway for 2-3 days until resolution of supraglottic edema
• Monitor in ICU setting

Special Considerations

• Difficult airway management: Follow difficult airway society guidelines if intubation is challenging 4

  • Have supraglottic airway devices available as rescue devices
  • Be prepared for surgical airway if "can't intubate, can't ventilate" situation develops

• Pediatric considerations:

  • Children have smaller airways and progress to complete obstruction more rapidly
  • Never delay airway intervention in children with suspected epiglottitis
  • Avoid examination of the throat without airway equipment and personnel ready

• Adult considerations:

  • Adults without respiratory distress may be monitored in ICU without immediate intubation 6
  • Lower threshold for intervention with any signs of progression

Complications to Monitor

• Airway obstruction
• Septicemia
• Post-extubation stridor
• Laryngeal trauma
• Pulmonary edema
• Pneumonia

The mortality rate for acute epiglottitis has decreased significantly with proper airway management and antibiotic therapy, but it remains a medical emergency requiring prompt recognition and intervention.