What is the treatment for epiglottitis?

Treatment of Epiglottitis

Epiglottitis requires immediate airway management as the top priority, with the patient kept upright and undisturbed until definitive airway control is achieved in a controlled setting with experienced personnel and difficult airway equipment immediately available. 1

Immediate Airway Management

The cornerstone of epiglottitis treatment is securing the airway before complete obstruction occurs. The approach must be aggressive and systematic:

• Never attempt throat examination with tongue depressors, as this can precipitate complete airway obstruction 1, 2
• Position the patient upright if conscious to maintain airway patency 1
• Immediately discuss with intensivists and prepare for rapid transfer to ICU 1
• Have difficult airway equipment at bedside including videolaryngoscope, supraglottic airway devices, and surgical airway equipment for emergency cricothyroidotomy 1

Decision for Intubation

The literature shows conflicting approaches between pediatric-style universal intubation versus selective management in adults. However, given the 7% mortality rate in adults (compared to 1% in aggressively managed pediatric cases), a low threshold for intubation is warranted 3, 4.

• Patients presenting with respiratory distress, stridor, inability to swallow secretions, or hypoxemia require immediate intubation 5, 6
• Even patients without overt respiratory symptoms should be monitored in ICU with immediate intubation capability, as the disease course is inherently unpredictable 6, 4
• No single presenting symptom or sign reliably predicts who will require intubation, making clinical staging protocols unreliable for prospective management 6

Intubation Technique

• Nasotracheal intubation is preferred when possible 5
• Follow difficult airway algorithms with backup plans for failed intubation 1
• Maintain oxygenation as the primary goal throughout the procedure 1
• Have tracheostomy capability immediately available at bedside 5

Medical Management

Once the airway is secured or the patient is in a monitored ICU setting:

• Obtain blood cultures before antibiotics to identify the causative organism (often Haemophilus influenzae) 1, 2
• Administer broad-spectrum antibiotics 5, 6
• Provide NSAIDs for inflammation 5
• Consider adrenaline inhalation 5

Critical Pitfalls to Avoid

• Attempting oropharyngeal examination or throat swabs can trigger complete airway obstruction - 44% of patients have normal-appearing oropharynx on routine examination 2, 5
• Failing to prepare difficult airway equipment before attempting intubation 1
• Relying on staging systems to predict clinical course - the disease is inherently unpredictable 6
• Underestimating adult epiglottitis as having a "milder course" - mortality remains 7% in adults versus 1% in aggressively managed children 3, 7
• Delaying diagnosis by attributing symptoms to other conditions (one fatal case was initially misdiagnosed as asthma exacerbation) 5

Monitoring and Disposition

• All patients require ICU admission for at least 24 hours 5, 4
• Continuous monitoring with immediate intubation capability even for initially stable patients 4
• The clinical threshold for airway intervention should remain low as it is the only way to prevent death 5