What is the treatment for epiglottitis?

Treatment of Epiglottitis

Epiglottitis requires immediate airway management as the top priority, with the patient kept upright and calm while preparing for potential emergency intubation or surgical airway, followed by broad-spectrum antibiotics and intensive care monitoring. 1

Immediate Airway Management (Priority #1)

The cornerstone of epiglottitis treatment is securing the airway before it becomes completely obstructed. 1

Critical Initial Actions:

• Keep the patient upright if conscious, as this position optimizes airway patency 1
• Avoid throat examination with tongue depressors, as this can precipitate complete airway obstruction 1, 2
• Immediately discuss with intensivist and anesthesia for emergency airway intervention 1
• Transfer to ICU or controlled environment with capability for emergency airway management 1, 3

Airway Equipment Preparation:

• Assemble difficult airway equipment immediately, including videolaryngoscope, supraglottic airway devices, and surgical airway equipment for emergency cricothyroidotomy 1
• Have tracheostomy set at bedside before any airway manipulation 4
• Follow structured difficult airway algorithms with clear plans for failed intubation 1

Intubation Decision-Making:

The decision to intubate depends on severity of presentation:

• Mandatory intubation indications: Stridor, severe respiratory distress, inability to handle secretions, hypoxemia, or signs of impending airway obstruction 5, 4
• Selective monitoring approach: Adults without respiratory distress may be safely monitored in ICU with continuous observation and immediate intubation capability 6, 4
• Preferred intubation method: Fiberoptic nasal intubation is the technique of choice when intubation is required 5, 4

Critical pitfall: One patient died when conventional oral intubation was attempted without a tracheostomy set at bedside 4. This underscores that any intubation attempt must have immediate surgical airway backup available.

Medical Management

Antibiotic Therapy:

• Obtain blood cultures before antibiotics, as these are the preferred diagnostic sample (throat swabs risk precipitating obstruction) 2
• Initiate broad-spectrum antibiotics immediately covering Haemophilus influenzae and other common pathogens 4, 7
• Ampicillin/sulbactam or third-generation cephalosporins are appropriate empiric choices 7

Adjunctive Medications:

• Systemic corticosteroids (dexamethasone) to reduce inflammation 5, 7
• NSAIDs for symptom control 4
• Adrenaline inhalation may provide temporary relief in some cases 4

Monitoring and Disposition

• ICU admission is mandatory for all patients with epiglottitis, even those without immediate respiratory distress 3, 6, 4
• Continuous monitoring for 24 hours minimum before considering transfer to regular ward 6
• Maintain low threshold for intubation throughout the monitoring period, as clinical deterioration can be rapid 4

Outcome Considerations

Adult mortality from epiglottitis remains approximately 7%, compared to 1% in children with aggressive management. 3 This higher mortality reflects both the variable presentation in adults (leading to delayed diagnosis) and the tendency toward less aggressive airway management. Stridor is present in only 42-58% of adult cases, making it an unreliable marker for excluding severe disease 5, 4. The most consistent symptoms are odynophagia (100%), inability to swallow secretions (83%), and sore throat (67%) 4.

Key principle: The severity of clinical presentation should guide aggressiveness of airway management, but all patients require ICU-level monitoring with immediate intubation capability, as progression can be unpredictable and rapid 3, 6, 4.