What are the clinical diagnosis and treatment approaches for epiglottitis and other emergency upper airway problems?

Clinical Diagnosis of Epiglottitis and Emergency Upper Airway Problems

Epiglottitis: Recognition and Immediate Action

Epiglottitis presents with sudden onset of severe sore throat and odynophagia (painful swallowing), and the critical diagnostic principle is to NEVER examine the throat with a tongue depressor or attempt direct visualization outside a controlled setting, as this can precipitate complete airway obstruction and death. 1, 2

Key Clinical Features to Recognize

The classic presentation includes:

• Odynophagia (100% of cases) - painful swallowing is the most consistent symptom 3
• Inability to swallow secretions (83%) - patients drool because they cannot manage their own saliva 3
• Severe sore throat (67%) - typically out of proportion to visible pharyngeal findings 4
• Dyspnea (58%) - respiratory difficulty develops as airway narrows 3
• Hoarseness (50%) - muffled or "hot potato" voice 3, 5

Critical pitfall: Stridor occurs in only 42% of adult cases, so its absence does NOT exclude epiglottitis 3. Additionally, 44% of patients have a completely normal oropharyngeal examination on routine inspection, making this a dangerous trap for clinicians 3.

Physical Examination Findings

• Fever >37.2°C in 75% of cases 3
• Tachycardia >100 bpm in 50% 3
• Patient positioning: Adults often prefer sitting upright and leaning forward 2
• The "thumb sign" on lateral neck X-ray shows swollen epiglottis, though this has lower sensitivity than direct visualization 6, 5

Diagnostic Approach - What to Do and NOT Do

DO:

• Obtain blood cultures immediately - this is the preferred diagnostic sample because it avoids airway manipulation 1, 2
• Perform flexible fiberoptic laryngoscopy ONLY in a controlled setting with full airway management capabilities present 3, 4, 5
• Order lateral neck radiographs if available quickly, but do not delay treatment for imaging 6, 5
• Direct visualization shows cherry-red, swollen epiglottis - this is the gold standard but must be done safely 1, 6

DO NOT:

• Never use a tongue depressor to examine the throat - this can trigger sudden complete airway obstruction 1, 2
• Never attempt throat swabbing for cultures - the American College of Physicians explicitly recommends against this 1
• Never send the patient for imaging alone - they must be accompanied by someone capable of emergency airway management 3

Mortality Context

Adult mortality remains approximately 7%, which is seven times higher than the 1% pediatric mortality with aggressive management - this underscores the seriousness of this condition in adults 1, 6. The higher adult mortality likely reflects delayed diagnosis and less aggressive airway management compared to pediatric protocols 6.

Immediate Management Priorities

Airway Assessment and Preparation

The moment epiglottitis is suspected, immediately discuss with an intensivist and prepare for emergency airway intervention, as maintaining oxygenation is the primary goal. 2

Assemble difficult airway equipment BEFORE any intervention:

• Videolaryngoscope (preferred over direct laryngoscopy) 2
• Supraglottic airway devices as backup 2
• Surgical airway equipment for emergency cricothyroidotomy 2
• Flexible fiberoptic intubating scope 5

Patient Positioning and Monitoring

• Keep patient upright if conscious - this position optimizes airway patency 2
• Provide supplemental humidified oxygen without forcing the patient into supine position 4
• Continuous monitoring in ICU setting is mandatory even if not immediately intubated 6, 5

Clinical Threshold for Intubation

The threshold for securing the airway should remain LOW in adults, as this is the only way to prevent death 3. While not all adults require prophylactic intubation (unlike pediatric protocols), any signs of respiratory distress, inability to manage secretions, or clinical deterioration warrant immediate airway intervention 6, 5.

Nasotracheal intubation was required in 33% of adult cases in one series 3, and the decision should be guided by:

• Severity of dyspnea
• Ability to handle secretions
• Oxygen saturation trends
• Clinical appearance of distress

Other Emergency Upper Airway Problems

Tracheostomy Emergencies

For patients with tracheostomy tubes, follow the ABCDE assessment and immediately attempt to pass a suction catheter - if it passes easily, the tube is patent; if not, the tube is blocked or displaced. 7

Key steps for tracheostomy emergencies:

• Call for help immediately and summon emergency airway equipment 7
• Apply oxygen to both face AND stoma simultaneously 7
• Deflate the cuff if suction catheter won't pass - this may allow airflow past a displaced tube 7
• Remove the tracheostomy tube if suction catheter fails to pass and cuff deflation doesn't improve the patient - a non-functioning tube offers no benefit and considerable potential for harm 7
• Reassess both upper airway (mouth) and stoma after tube removal 7

Emergency oxygenation can be achieved via:

• Oro-nasal route (remember to occlude the stoma) 7
• Stoma directly using pediatric facemask or LMA applied to skin 7
• The goal is oxygenation, not necessarily immediate re-intubation 7

Laryngectomy Patients

Laryngectomy patients have NO connection between upper airway and trachea - all ventilation must occur through the stoma 7. These patients require:

• Dedicated "red" bed-head signs indicating laryngectomy status 7
• Specialized equipment at bedside including appropriate-sized tubes 7
• Understanding that mouth-to-mouth resuscitation is futile - only stoma ventilation works 7

General Difficult Airway Principles

For any anticipated difficult airway, determine whether awake intubation or post-induction approach is safer by assessing four key factors: 7

1. Suspected difficult laryngoscopy/intubation? 7
2. Suspected difficult mask/supraglottic ventilation? 7
3. Increased aspiration risk? 7
4. Increased rapid desaturation risk? 7

Any single factor alone may warrant awake intubation 7. For emergency situations with failed intubation:

• Limit the number of attempts - be aware of passage of time and oxygen saturation 7
• Test mask ventilation after each attempt when feasible 7
• Move rapidly to alternative techniques if initial approach fails 7
• Prepare for emergency surgical airway (cricothyroidotomy) if non-invasive approaches fail 7

Differential Diagnosis: Exercise-Induced Laryngeal Dysfunction (EILD)

EILD can mimic upper airway emergencies but presents with inspiratory stridor during exercise that resolves within 5 minutes of stopping, and does NOT respond to bronchodilators. 7

Key distinguishing features:

• Symptoms peak DURING exercise (not after, unlike exercise-induced bronchoconstriction) 7
• Inspiratory stridor is the hallmark sign 7
• Flattening of inspiratory curve on spirometry 7
• Flexible laryngoscopy during exercise confirms diagnosis 7