Treatment of Epiglottitis in Children
Immediate airway management is the cornerstone of treatment for pediatric epiglottitis, with nasotracheal intubation being the preferred method to secure the airway, followed by intravenous antibiotics targeting Haemophilus influenzae. 1, 2
Immediate Airway Management
The "watch and wait" approach should be abandoned - active and planned airway intervention is mandatory to reduce morbidity and mortality. 1
Intubation vs. Tracheotomy
- Nasotracheal intubation is the preferred method for securing the airway in children with epiglottitis 1, 2
- Both intubation and tracheotomy are acceptable options with similar outcomes when properly managed 1
- Average intubation duration: 2.3 days for intubation vs. 2.9 days for tracheotomy 1
- Hospital stay is comparable: 6.7 days (intubation) vs. 6 days (tracheotomy) 1
- Complication rates are low with both methods when properly managed 1
Critical Safety Considerations
- All airway interventions must be performed in a controlled environment (operating room preferred) with experienced personnel present 3, 4
- Acute airway obstruction can occur during induction, even with halothane anesthesia 4
- Have equipment ready for emergency cricothyrotomy if intubation fails 3
- Never perform blind finger sweeps of the pharynx as these can impact the epiglottis further into the larynx 3
Duration of Intubation
- Modern protocols support shorter intubation periods with daily laryngeal inspection 2
- Average intubation time has decreased from 63.8 hours (1979) to 42.1 hours (1984) with improved monitoring 2
- Extubation should be based on direct laryngeal inspection performed either in the operating room or intensive care unit 2
- Daily laryngeal inspection in the ICU aids in safe, earlier extubation 2
Antibiotic Therapy
Intravenous antibiotics should be initiated immediately after airway is secured, targeting Haemophilus influenzae as the primary pathogen. 1
Antibiotic Selection
While the provided evidence doesn't specify exact antibiotic regimens for epiglottitis, based on the causative organism (H. influenzae) 1:
- Third-generation cephalosporins (ceftriaxone or cefotaxime) are typically first-line
- Duration: Continue until clinical improvement and ability to maintain airway without support
Clinical Recognition
Suspect epiglottitis in any child, regardless of age, presenting with: 4
- Stridor
- Respiratory distress
- Dysphagia
- "Tripoding" posture (sitting upright, leaning forward with neck extended)
Diagnostic Confirmation
- Direct visualization by laryngoscopy is the gold standard for diagnosis 5
- Lateral neck X-rays have utility but less sensitivity than direct visualization 5
- Do not delay airway management for diagnostic imaging if clinical suspicion is high
Critical Pitfalls to Avoid
- Never adopt a "watch and wait" approach - this increases mortality risk 1
- Do not attempt intubation outside a controlled environment without backup airway equipment 3, 4
- Do not rely on age alone to rule out epiglottitis - it can occur in infants as young as 7 months 4
- Avoid manipulating the airway (including tongue depressors) in uncontrolled settings, as this can precipitate complete obstruction 4