ICU Management of Epiglottitis
All patients with epiglottitis must be admitted to the ICU for close airway monitoring, with immediate availability of an airway specialist (anesthesiologist, intensivist, or otolaryngologist) and equipment for emergency intubation or surgical airway. 1
Immediate Airway Assessment and Preparation
Critical Initial Steps
Maintain a low threshold for securing the airway prophylactically, as sudden complete airway obstruction can occur unpredictably and is the primary cause of mortality in epiglottitis. 2
Ensure an experienced airway specialist evaluates the patient immediately upon ICU admission to allow adequate time for airway preparation if intervention becomes necessary. 1
Prepare for difficult airway management by having a difficult airway trolley, videolaryngoscopy equipment, and front-of-neck airway (FONA) equipment immediately available at bedside, as epiglottic inflammation creates anatomically difficult conditions. 3
Airway Red Flags Requiring Immediate Intervention
Monitor continuously for these signs indicating impending complete obstruction 4:
- Stridor (present in only 42% of adult cases, so absence does not exclude severe disease) 2
- Tripod positioning (patient leaning forward with neck extended) 1
- Drooling or inability to swallow secretions (83% of cases) 2
- Muffled voice or hoarseness (50% of cases) 2
- Increasing respiratory distress or dyspnea 2
- Tachycardia >100 bpm (50% of cases) 2
Intubation Strategy When Required
Indications for Intubation
Proceed with intubation if any of the following are present 1, 2:
- Signs of impending airway obstruction (stridor, tripod position, severe dyspnea)
- Inability to manage secretions
- Hypoxemia despite supplemental oxygen
- Altered mental status
- Inability to visualize adequate airway opening on laryngoscopy
Intubation Technique
Nasotracheal intubation is the preferred method and has been demonstrated equally safe as tracheostomy for airway control in epiglottitis. 5, 6, 2
The procedure must be performed by an experienced pediatric anesthesiologist-intensivist (or equivalent adult airway specialist) using IV anesthetic agents and neuromuscular blocking agents. 6
Use videolaryngoscopy as first-line approach, as it is superior to direct laryngoscopy with better glottic view, higher success rate, and fewer complications in critically ill patients. 4, 3
Apply full neuromuscular blockade (rocuronium preferred over succinylcholine) to optimize intubation conditions and reduce complications. 3
Limit attempts to maximum of three laryngoscopy insertions—each blade entry constitutes one attempt. If unsuccessful after three attempts, declare failed intubation and proceed to emergency front-of-neck airway. 3
Critical Intubation Preparation
Complete the following before any intubation attempt 3:
- Preoxygenate with high-flow oxygen to achieve maximal saturation
- Position patient optimally (head elevated, neck extended unless contraindicated)
- Ensure waveform capnography is ready for mandatory tube placement confirmation
- Have emergency tracheostomy set at bedside before attempting intubation 2
- Assign one team member specifically to monitor hemodynamic status 4
- Prepare for rapid fluid resuscitation (500 mL crystalloid bolus) to mitigate intubation-related hypotension 4
Common Pitfall: A 40-year-old patient with epiglottitis died when conventional oral intubation was attempted without a tracheotomy set at bedside and without adequate preparation—this preventable death underscores the absolute necessity of proper preparation. 2
Post-Intubation ICU Management
Ventilation and Sedation
Paralyze, sedate, and mechanically ventilate all intubated epiglottitis patients to prevent self-extubation and optimize airway protection. 6
Monitor continuously with waveform capnography—absence or change in capnograph waveform is the primary airway red flag and may indicate tube displacement or obstruction. 4, 7
Duration of Intubation
Plan for 42-63 hours of intubation on average, with modern protocols favoring shorter durations (approximately 42 hours). 8
Perform daily laryngoscopic inspection in the ICU to assess epiglottic resolution and determine readiness for extubation—this approach safely reduces intubation duration. 8
Extubate only after direct visualization confirms adequate epiglottic resolution, typically showing reduction in inflammation and edema with restoration of normal supraglottic anatomy. 8
Ongoing Airway Monitoring
Watch for these airway red flags throughout ICU stay 4:
- Absence or change of capnograph waveform with ventilation
- Absence or change of chest wall movement with ventilation
- Increasing airway pressure
- Reducing tidal volume
- Inability to pass a suction catheter
- Obvious air leak
- Vocalization with cuffed tube in place and inflated
- Discrepancy between actual and recorded tube insertion depth
Tube Security and Maintenance
Document endotracheal tube depth at bedside and verify each shift, as tube displacement is the most common ICU airway complication (>80% of airway incidents occur after initial intubation). 4
Maintain cuff pressure at 20-30 cm H₂O and check regularly—apparent cuff leak should be assumed to be partial extubation until proven otherwise. 4
Use open suctioning systems for routine airway clearance, as closed systems provide no clinical benefit and increase costs 25-fold. 9
Medical Management
Antibiotic Therapy
- Administer IV antibiotics immediately targeting Haemophilus influenzae and other common pathogens (Streptococcus pneumoniae, Staphylococcus aureus). 1, 2
Adjunctive Therapies
NSAIDs for pain and inflammation control 2
Consider adrenaline inhalation for temporary airway edema reduction in select cases 2
Avoid corticosteroids—they provide no significant effect on duration of intubation or infectious complications and are associated with gastrointestinal bleeding. 5
Multidisciplinary ICU Rounds
Conduct structured daily rounds with the intensivist, respiratory therapist, nursing staff, and airway specialist to review airway status and extubation readiness. 7
Use standardized rounding checklists that specifically address airway assessment, including verification of capnography function and tube position. 7
Communicate airway difficulty status to all team members during ward round safety briefings, with patient-specific strategies for managing potential airway emergencies documented and visible at bedside. 4
Extubation Planning
Approach extubation as a high-risk intervention requiring the same level of preparation as initial intubation, with airway specialist and emergency equipment immediately available. 4
Complete an airway alert documenting the difficult airway and communicate this information to the patient, family, and primary physician for future reference. 4