When should patients with suspected epiglottitis be admitted to the hospital?

Hospital Admission for Epiglottitis

All patients with suspected epiglottitis should be admitted to a hospital with intensive care capabilities and emergency airway equipment immediately available, as epiglottitis is a potentially life-threatening condition that can lead to sudden airway obstruction. 1

Clinical Assessment and Risk Factors

When evaluating a patient with suspected epiglottitis, look for:

• Signs of impending airway obstruction:

  • Stridor (present in only 42% of cases) 2
  • Dyspnea (reported in 58% of cases) 2
  • Inability to swallow secretions (83% of cases) 2
  • Hoarseness (50% of cases) 2
  • Odynophagia (100% of cases) 2

• Vital sign abnormalities:

  • Fever >37.2°C (present in 75% of cases) 2
  • Tachycardia >100 bpm (present in 50% of cases) 2

Diagnostic Approach

• Direct visualization via flexible laryngoscopy is the gold standard for diagnosis 3
• Important: A normal oropharyngeal examination does not exclude epiglottitis, as up to 44% of patients may have a normal-appearing oropharynx 2, 1
• Examination should only be performed in a setting with emergency airway equipment readily available 1

Admission Protocol

1. All patients with confirmed epiglottitis require hospital admission regardless of symptom severity 3

2. Immediate ICU admission is indicated for patients with:

   • Any signs of respiratory distress
   • Stridor
   • Inability to handle secretions
   • Significant epiglottic swelling on visualization
   • Rapid progression of symptoms

3. Airway management preparation:

   • Have emergency airway equipment ready, including intubation equipment, tracheotomy set, and difficult airway equipment 1
   • Consider early airway intervention if signs of obstruction are present 4
   • The threshold for airway intervention should remain low, as it is the only way to prevent death in case of sudden obstruction 2

Treatment Approach

• Intravenous antibiotics
• Anti-inflammatory medications
• Close airway monitoring
• Possible adrenaline inhalation therapy 2

Critical Pitfalls to Avoid

1. Misdiagnosis: Epiglottitis in adults is often misdiagnosed due to its relative rarity compared to children 2

2. Delayed airway management: Despite the more variable presentation in adults, mortality remains around 7% 3

3. Inadequate setting for examination: Never examine the throat of a patient with suspected epiglottitis without immediate access to emergency airway equipment 1

4. Discharge without proper evaluation: Any clinical suspicion of epiglottitis warrants an aggressive approach until the condition is ruled out or the patient is recovering well 3

5. Failure to recognize the severity: A case report documents a 40-year-old man initially misdiagnosed with asthma exacerbation who later died when intubation was attempted without proper preparation 2

The maintenance of an adequate airway is the primary concern in managing epiglottitis. While prophylactic airway management is not necessarily indicated in all adults with epiglottitis, careful monitoring in a controlled intensive care environment is essential for all patients 3. The severity of clinical presentation should guide the physician's approach to airway management.