What is the management of epiglottitis in the Intensive Care Unit (ICU)?

ICU Management of Epiglottitis

All patients with epiglottitis must be admitted to the ICU for continuous monitoring with immediate airway equipment at bedside, as sudden complete airway obstruction can occur unpredictably. 1

Immediate ICU Setup and Preparation

Upon ICU admission, establish the following critical infrastructure:

• Position a difficult airway trolley, videolaryngoscopy equipment, and front-of-neck airway (FONA) equipment immediately at bedside, as epiglottic inflammation creates anatomically difficult intubation conditions 2
• Ensure waveform capnography is ready and functional for mandatory tube placement confirmation if intubation becomes necessary 2
• Have an airway specialist (anesthesiologist, intensivist, or otolaryngologist) immediately available, as these patients require expert evaluation and management 1

Continuous Monitoring Parameters

Institute continuous monitoring for signs of impending complete airway obstruction:

• Stridor - though present in only 42% of adult cases, it indicates critical narrowing 3
• Tripod positioning - patient sitting upright, leaning forward with neck extended 2, 1
• Drooling or inability to swallow secretions - present in 83% of cases 2, 3
• Muffled voice or hoarseness - occurs in 50% of patients 2, 3
• Increasing respiratory distress or dyspnea - present in 58% of cases 2, 3
• Tachycardia >100 bpm - found in 50% of patients 2, 3

Intubation Decision-Making

Proceed immediately with intubation if ANY of the following develop:

• Signs of impending airway obstruction (stridor, tripod positioning, severe dyspnea) 2
• Inability to manage secretions 2
• Hypoxemia despite supplemental oxygen 2
• Altered mental status 2
• Inability to visualize adequate airway opening on laryngoscopy 2

Intubation Technique

When intubation is required, use this specific approach:

• Use videolaryngoscopy as first-line, as it provides superior glottic view and higher success rates compared to direct laryngoscopy in critically ill patients 2, 4
• Apply full neuromuscular blockade with rocuronium (preferred over succinylcholine due to fewer side effects) to optimize intubation conditions 2, 4
• Perform intubation with an experienced pediatric anesthesiologist-intensivist who can use IV anesthetic agents and muscle relaxants safely 5
• Limit attempts to maximum three laryngoscopy insertions, with each blade entry counting as one attempt 4
• Never attempt intubation without capnography confirmation - absence of capnograph waveform means the tube is not in the trachea 4

Post-Intubation ICU Management

Once intubated, implement these critical monitoring and care protocols:

Airway Security Monitoring

• Monitor continuously with waveform capnography - absence or change in capnograph waveform is the primary airway emergency indicator and may signal tube displacement or obstruction 2, 6
• Document endotracheal tube depth at bedside and verify each shift, as tube displacement accounts for >80% of ICU airway incidents 2
• Maintain cuff pressure at 20-30 cm H₂O and check regularly 2
• Assume any apparent cuff leak is partial extubation until proven otherwise 2

Sedation and Ventilation

• Provide continuous sedation and paralysis for mechanically ventilated patients to prevent self-extubation 5
• Watch for "airway red flags" including absence or change of capnograph waveform, increasing airway pressure, reducing tidal volume, or inability to pass a suction catheter 4

Duration of Intubation

• Typical intubation duration ranges from 42-64 hours, with shorter durations (42 hours) achieved when daily laryngeal inspection is performed in the ICU 7
• Perform daily direct laryngeal inspection in the ICU (rather than requiring operating room visits) to assess for extubation readiness 7
• Extubation decisions should be based on direct visualization showing resolution of epiglottic swelling 7

Multidisciplinary ICU Rounds

Conduct structured daily rounds with intensivist, respiratory therapist, nursing staff, and airway specialist to review airway status and extubation readiness 2

• Use standardized rounding checklists that specifically address airway assessment, including verification of capnography function and tube position 2, 6
• Communicate airway difficulty status to all team members during ward round safety briefings 2
• Document patient-specific strategies for managing potential airway emergencies visibly at bedside 2

Medical Management

Concurrent with airway management, provide:

• Intravenous antibiotics targeting typical pathogens (historically H. influenzae, though adult cases may have different organisms) 8, 3
• NSAIDs for symptom control 3
• Consider adrenaline inhalation for airway edema reduction 3
• Avoid corticosteroids - they provide no significant effect on intubation duration and are associated with gastrointestinal bleeding 8

Critical Pitfalls to Avoid

• Never send a patient with suspected epiglottitis for radiographs if airway compromise is evident - securing the airway takes absolute priority over diagnostic imaging 1
• Never assume the airway is secure based on normal oropharyngeal examination - 44% of patients have normal oropharynx, requiring fiberoptic laryngoscopy for diagnosis 3
• Never attempt intubation without a tracheotomy set at bedside - one reported fatality occurred when conventional intubation failed without backup airway access available 3
• Never delay ICU admission - even patients without obvious airway obstruction require ICU-level monitoring as obstruction can develop suddenly 1, 3