What is the management approach for a patient with epiglottitis, potentially with a history of bleeding disorders or anticoagulant use?

Management of Epiglottitis

Epiglottitis is a life-threatening airway emergency requiring immediate airway assessment and securing, with special attention to avoiding airway manipulation that could precipitate complete obstruction; in patients with bleeding disorders or anticoagulation, resorbable packing should be used for any associated bleeding and reversal agents should be administered only for life-threatening hemorrhage.

Immediate Airway Management

The primary concern in epiglottitis is airway compromise, which takes absolute priority over bleeding management. 1

• Assess for signs of airway obstruction immediately: stridor, drooling, inability to swallow secretions, tripod positioning, and respiratory distress 1
• Avoid aggressive airway manipulation including tongue depressors or forced examination, as this can precipitate complete airway obstruction 1
• Secure the airway emergently if any signs of impending obstruction are present, ideally in a controlled setting (operating room) with experienced personnel and equipment for emergency surgical airway 1
• Patients with epiglottic edema and ecchymosis from coagulopathy may require intubation to prevent decompensation, as demonstrated in cases of epiglottic hematoma 2

Assessment of Bleeding Risk

Document anticoagulant and antiplatelet medications immediately, as these significantly increase bleeding complications and alter management. 1, 3

• Obtain focused history regarding: warfarin, DOACs (dabigatran, rivaroxaban, apixaban, edoxaban), antiplatelet agents (aspirin, clopidogrel), and any bleeding disorders 1, 3
• Check laboratory studies: INR/PT, PTT, platelet count, and hemoglobin 1, 4
• Patients on anticoagulation are at risk for epiglottic hematoma formation leading to airway obstruction, particularly with multiple anticoagulants 5

Management of Coagulopathy in Epiglottitis

For Life-Threatening Airway Compromise with Coagulopathy:

Stop all anticoagulant and antiplatelet medications immediately. 1

• For warfarin with elevated INR: Administer 5-10 mg IV vitamin K AND prothrombin complex concentrate (PCC) for rapid reversal 1
• For DOACs with life-threatening bleeding: Administer specific reversal agents:
  • Idarucizumab for dabigatran 1, 6
  • Andexanet alfa for apixaban or rivaroxaban 1, 7
• For antiplatelet agents: Stop immediately; platelet transfusion may be considered for life-threatening bleeding, though efficacy depends on timing of last dose 1
• Provide supportive care with volume resuscitation and hemodynamic support 1

For Stable Epiglottitis Without Active Bleeding:

Do not reverse anticoagulation if bleeding can be controlled with local measures and the airway is secure. 1

• Hold the next dose of anticoagulant while bleeding is active 1
• For warfarin, consider 2-5 mg oral or IV vitamin K for non-severe bleeding 1
• Do not administer reversal agents (PCC, idarucizumab, andexanet alfa) for non-life-threatening situations 1, 8

Local Hemostatic Measures

If there is associated oropharyngeal or supraglottic bleeding, use resorbable packing materials in patients with bleeding disorders or on anticoagulation. 1

• Apply direct pressure with gauze soaked in tranexamic acid for 3-5 minutes 8
• Resorbable packing reduces the risk of rebleeding upon removal compared to non-resorbable materials 1
• Topical vasoconstrictors may be helpful but should not delay definitive airway management 1

Consultation and Monitoring

• Obtain urgent ENT or anesthesia consultation for airway management 1
• Consult hematology for patients with suspected bleeding disorders or complex anticoagulation reversal 1
• Monitor closely in ICU setting with serial vital signs, hemoglobin checks, and airway assessments 1
• Assess for and manage comorbidities contributing to bleeding: thrombocytopenia, uremia, liver disease 1, 8

Critical Pitfalls to Avoid

• Never attempt forced visualization of the epiglottis in a patient with suspected epiglottitis, as this can precipitate complete obstruction 1
• Do not delay airway securing to obtain laboratory results or imaging in patients with signs of obstruction 1
• Do not use non-resorbable packing in anticoagulated patients, as removal can trigger rebleeding 1
• Avoid routine reversal of anticoagulation for non-life-threatening bleeding, as this increases thrombotic risk without clear benefit 1
• Most patients on warfarin presenting with bleeding complications have INR outside therapeutic range, emphasizing the importance of checking levels 4

Restarting Anticoagulation

Delay restarting anticoagulation until the airway is definitively stable and any bleeding source has been treated. 1, 7

• Consult with the team managing anticoagulation (cardiology, hematology) regarding timing 1
• Consider restarting within 7 days if high thrombotic risk (atrial fibrillation with CHA₂DS₂-VASc ≥2, recent VTE) and bleeding controlled 7
• Do not restart if high risk of rebleeding or death/disability with rebleeding 7, 9