What is the management of epiglottitis?

Management of Epiglottitis

Epiglottitis requires immediate airway management in a controlled setting with emergency airway equipment readily available, as it is a potentially life-threatening condition that can cause rapid airway obstruction. 1

Diagnosis

• Gold standard: Direct visualization via flexible laryngoscopy 2, 3
  • Note: Routine oropharyngeal examination may appear normal in up to 44% of cases 3
• Supporting diagnostic tools:
  • Lateral neck X-rays (though less sensitive than direct visualization) 2
  • Blood cultures (preferred over direct swabbing of the epiglottis) 1

Initial Assessment and Triage

1. Evaluate for signs of severe or life-threatening airway compromise:

   • Stridor (present in only 42% of cases) 3
   • Respiratory distress
   • Inability to swallow secretions (83% of cases) 3
   • Odynophagia (100% of cases) 3
   • Dyspnea (58% of cases) 3
   • Hoarseness (50% of cases) 3
   • Elevated body temperature (75% of cases) 3
   • Tachycardia (50% of cases) 3

2. Risk stratification:

   • Assess for signs of impending airway obstruction
   • Determine need for immediate airway intervention

Airway Management Algorithm

Immediate Actions:

1. Secure setting: Manage in a facility with intensive care capabilities 3
2. Prepare equipment: Have emergency airway equipment ready including:
   • Intubation equipment
   • Tracheotomy set at bedside
   • Difficult airway equipment as per Difficult Airway Society guidelines 4

Airway Intervention Decision:

• For severe respiratory distress or impending obstruction:

  • Proceed to immediate airway management
  • Avoid examination that may precipitate complete obstruction

• For stable patients with mild symptoms:

  • Close monitoring in ICU setting
  • Prepare for possible deterioration

Airway Securing Options:

1. Endotracheal intubation:

   • Performed under general anesthesia
   • Nasotracheal intubation has been found effective for short-term airway management 5
   • Consider using video laryngoscopy or flexible bronchoscopy for difficult cases

2. Tracheotomy:

   • Consider when intubation is anticipated to be difficult or impossible
   • May be less expensive overall compared to intubation (median cost €5,856 vs €11,547) 6
   • Note: May be associated with more complications and longer sick leave compared to intubation 6

Medical Management

1. Antimicrobial therapy:

   • Intravenous antibiotics effective against Haemophilus influenzae type B (historically the most common pathogen) 7, 5
   • Consider broader coverage for other potential pathogens

2. Supportive care:

   • NSAIDs for inflammation and pain control 3
   • Consider nebulized epinephrine (adrenaline) to reduce airway edema 3
   • Intravenous hydration
   • Corticosteroids (though evidence is limited)

Extubation Planning

When ready for extubation, follow a structured approach 4:

1. Ensure no further surgical stimulation
2. Balance adequate analgesia without respiratory depression
3. Confirm airway patency and adequacy of breathing
4. Have reintubation equipment immediately available
5. Consider a staged approach for high-risk cases

Monitoring and Follow-up

• Continue close monitoring after extubation for signs of recurrent obstruction
• Ensure complete resolution of infection with appropriate antibiotic course
• Follow up with laryngoscopy to confirm complete resolution

Pitfalls to Avoid

1. Misdiagnosis: Epiglottitis can be misdiagnosed as viral laryngotracheitis ("croup") or other conditions 7
2. Delayed airway management: Mortality remains around 7% in adults, primarily due to airway obstruction 2
3. Inappropriate examination: Avoid aggressive examination that may precipitate complete obstruction
4. Inadequate preparation: Always have emergency airway equipment available before examining suspected cases
5. Underestimating severity: Adult epiglottitis may present with variable severity but can progress rapidly 2, 3

Remember that epiglottitis in adults is often under-recognized but remains potentially life-threatening, requiring a high index of suspicion and prompt intervention when diagnosed 2.