Treatment of Epiglottitis
Epiglottitis requires immediate airway management as the absolute priority, with endotracheal intubation being the preferred method for securing the airway, followed by intravenous antibiotics targeting Haemophilus influenzae. 1, 2
Immediate Airway Management
The cornerstone of epiglottitis treatment is securing the airway before respiratory arrest occurs. This is a life-threatening emergency where airway intervention takes precedence over all other interventions. 1, 2
Critical Initial Steps
- Avoid any throat examination with tongue depressors, as this can precipitate complete airway obstruction and sudden death. 1, 2
- Keep the patient in their position of comfort (typically upright or "tripod" position) and avoid any agitation during assessment or transport. 3
- Immediately discuss with intensivist and anesthesia for emergency airway intervention planning. 1
- Transfer rapidly to ICU or operating room with experienced personnel and difficult airway equipment ready. 1, 3
Airway Intervention Approach
Endotracheal intubation is the preferred method for airway control, with equivalent safety to tracheostomy but fewer complications. 4, 5, 6
- Intubation should be performed in a controlled operating room environment with surgical airway backup (cricothyroidotomy equipment) immediately available. 1, 3
- Have difficult airway equipment ready: videolaryngoscope, supraglottic airway devices, and emergency cricothyroidotomy kit. 1
- Maintain oxygenation as the primary goal throughout the procedure, providing supplemental oxygen gently without forcing mask application. 1, 3
- Duration of intubation averages 2-3 days in most cases before the airway edema resolves sufficiently for extubation. 5, 6
Evidence Comparing Airway Methods
The mortality data strongly supports active airway intervention over conservative management:
- Endotracheal intubation: 0.92% mortality (2 deaths in 216 cases) 4
- Tracheostomy: 0.86% mortality (3 deaths in 348 cases) 4
- Medical management without artificial airway: 6.1% mortality (13 deaths in 214 cases) 4
The choice between intubation and tracheostomy should be based on local expertise, as both methods have comparable safety when properly performed. 4, 5 However, intubation is generally preferred due to lower complication rates and shorter procedure time. 6
Antimicrobial Therapy
Start intravenous antibiotics immediately after securing the airway (or simultaneously if airway is stable enough). 7, 5
- Target Haemophilus influenzae, the most common causative organism. 2, 5
- Obtain blood cultures before antibiotics when possible, as these are the preferred diagnostic sample (throat swabs risk precipitating obstruction). 1, 2
- Continue antibiotics for full course even after extubation, typically until clinical improvement is evident. 7
Monitoring and Supportive Care
- Close monitoring in ICU setting is mandatory given the 7% mortality rate in adults despite treatment. 2
- Watch for abscess formation around the epiglottis, which may require surgical drainage. 7
- Hospital stay typically averages 6-7 days with proper management. 5
Pediatric-Specific Considerations
In children, recognize the classic "4 D's": dysphagia, drooling, distress, and dysphonia, often with high fever and tripod positioning. 3
- Never delay airway management for imaging in a child with impending respiratory failure. 3
- Intubation in children is equally safe as tracheostomy (2.3 vs 2.9 days average duration) with comparable hospital stays. 5
- Avoid steroids, as they provide no benefit in reducing intubation duration and are associated with gastrointestinal bleeding complications. 6
Critical Pitfalls to Avoid
- Never attempt throat examination in suspected epiglottitis—this can cause fatal airway obstruction. 1, 2
- Never adopt a "watch and wait" approach—active airway intervention reduces mortality from 6.1% to under 1%. 4, 5
- Never fail to prepare for difficult airway before attempting intubation—have backup plans and equipment ready. 1
- Never rely on clinical staging systems alone to predict which patients need intubation, as the disease course is inherently unpredictable. 8