What is the treatment for a patient with epiglottitis?

Treatment of Epiglottitis

Epiglottitis requires immediate airway management as the top priority, with the patient positioned upright, preparation for difficult intubation with specialist support, and empiric intravenous antibiotics targeting Haemophilus influenzae and Streptococcus species. 1, 2, 3

Immediate Airway Assessment and Stabilization

The maintenance of an adequate open airway is the primary concern and the only way to prevent death from this condition. 1, 2

Critical Initial Actions:

• Position the patient upright (if conscious) to optimize airway patency and allow secretions to drain forward 1
• Avoid examining the throat with tongue depressors, as this may precipitate complete airway obstruction 1, 4
• Immediately discuss with intensivist and anesthesia/otolaryngology specialists for emergency airway intervention, as this is a life-threatening emergency requiring rapid transfer to ICU 1, 3
• Maintain oxygenation as the primary goal while preparing for definitive airway management 1

Airway Management Strategy

The clinical threshold for securing an airway should remain low, as most adults may not show obvious signs of obstruction initially, but the disease can progress rapidly. 2, 5

Preparation for Difficult Airway:

• Have difficult airway equipment immediately available, including videolaryngoscope, supraglottic airway devices, and surgical airway equipment for emergency cricothyroidotomy 1
• Fiberoptic nasal intubation should be preferentially attempted with anesthesia and/or otolaryngology assistance if available, with the possibility of immediate surgical airway on hand 3, 6
• Follow a structured approach similar to difficult airway algorithms with plans for failed intubation 1

Indications for Immediate Intubation:

• Stridor is an important acute sign of upper airway obstruction that justifies early intubation 3, 6
• Respiratory symptoms with hypoxemia require immediate airway intervention 1
• Inability to swallow secretions, severe dyspnea, or signs of impending obstruction warrant prophylactic intubation 2, 5

Important caveat: No single presenting symptom or sign reliably predicts the need for intubation, making this an inherently unpredictable disease that requires vigilance 5. Approximately 30-40% of adult patients will require intubation 2, 5.

Medical Management

Antibiotic Therapy:

• Obtain blood cultures before antibiotics to identify the causative organism 1, 4
• Administer empiric intravenous antibiotics immediately targeting Haemophilus influenzae (historically most common), Streptococcus, and Staphylococcus species 2, 6, 7
• Continue antibiotics to treat systemic infection and septicemia 7

Adjunctive Therapies:

• Systemic corticosteroids (dexamethasone) should be considered, though evidence is limited 3, 6
• Nebulized epinephrine inhalation may be used as adjunctive therapy, though controversial 2, 6
• NSAIDs for symptom management 2

Disposition and Monitoring

• All patients must be admitted to intensive care facilities for close airway observation, regardless of initial presentation severity 2, 5, 6
• Continuous monitoring is essential as the disease can progress unpredictably even in patients initially managed conservatively 5

Critical Pitfalls to Avoid

• Never attempt conventional oral endotracheal intubation without a tracheotomy set at bedside and specialist backup, as failed intubation can be fatal 2
• Do not rely on staging systems to predict clinical course, as they are useful only for retrospective analysis but cannot predict which patients will deteriorate 5
• Do not be falsely reassured by normal oropharyngeal examination, as 44% of patients have normal oropharynx and diagnosis requires fiberoptic laryngoscopy 2
• Do not delay hospital transfer or airway preparation while waiting for diagnostic confirmation 1, 3