Treatment of Epiglottitis
Epiglottitis requires immediate airway management as the primary intervention, with the patient positioned upright and transferred to an ICU setting where emergency intubation or cricothyroidotomy can be performed by experienced personnel, followed by intravenous antibiotics targeting Haemophilus influenzae. 1
Immediate Airway Management (Priority #1)
The airway is the critical concern and must be secured before any other intervention. 1, 2
Initial Positioning and Transfer
- Keep the patient upright if conscious, as this position optimizes airway patency 1
- Immediately contact an intensivist and arrange rapid transfer to an ICU or facility with advanced airway capabilities 1
- Never attempt throat examination with a tongue depressor, as this can precipitate complete airway obstruction and death 3, 1, 2
Preparation for Difficult Airway
- Assemble difficult airway equipment immediately including videolaryngoscope, supraglottic airway devices, and surgical airway equipment for emergency cricothyroidotomy 1
- Have experienced personnel present (anesthesiologist, otolaryngologist, or intensivist skilled in difficult airways) before any airway manipulation 1, 4
- Follow a structured difficult airway algorithm with clear plans for failed intubation scenarios 1
Indications for Immediate Intubation
While not all adults require prophylactic intubation, secure the airway immediately if any of the following are present: 4, 2, 5
- Respiratory distress or hypoxemia
- Inability to swallow secretions (drooling)
- Stridor (though present in only 42% of cases)
- Altered mental status
- Rapid clinical deterioration
Important caveat: No single presenting symptom reliably predicts who will need intubation, and the disease course is inherently unpredictable in adults. 4 Mortality in adults remains approximately 7% despite treatment, significantly higher than the 1% in aggressively managed pediatric cases. 3, 5 When in doubt, maintain a low threshold for securing the airway, as this is the only way to prevent death. 2
Antibiotic Therapy
Immediate Empiric Treatment
- Start intravenous antibiotics immediately after blood cultures are obtained, targeting Haemophilus influenzae as the most common causative organism 1, 6
- Obtain blood cultures before antibiotics as the preferred diagnostic sample, since throat swabbing risks airway obstruction 3, 1
Antibiotic Selection
While specific regimens are not detailed in the provided guidelines, treatment should cover H. influenzae type B and continue for the duration needed to treat systemic infection and septicemia. 6
Supportive Care
- Administer NSAIDs for symptomatic relief of pain and inflammation 2
- Consider adrenaline inhalation in selected cases to reduce supraglottic edema 2
- Monitor continuously in ICU setting even if not intubated, as clinical deterioration can be sudden 2, 5
Critical Pitfalls to Avoid
Misdiagnosis due to normal oropharyngeal examination: 44% of patients have a normal-appearing oropharynx on routine examination; diagnosis requires direct visualization by fiberoptic laryngoscopy 2
Attempting intubation without preparation: The case of a 40-year-old man who died after failed intubation without a tracheotomy set at bedside illustrates this fatal error 2
Underestimating severity in adults: The milder initial presentation in many adults can lead to false reassurance, but mortality remains 7% 3, 5
Delaying ICU admission: All suspected cases warrant admission to a facility with intensive care capabilities where definitive airway management can be performed 2, 5
The severity of clinical presentation should guide aggressiveness of airway management, but any clinical suspicion warrants an aggressive approach until epiglottitis is ruled out or the patient is clearly recovering. 5