What is the recommended management for a patient with suspected epiglottitis?

Management of Suspected Epiglottitis

Immediately involve an airway specialist (otolaryngologist, anesthesiologist, or intensivist) and transfer the patient to an ICU setting without delay, as epiglottitis can cause sudden complete airway obstruction and requires controlled airway management with difficult airway equipment immediately available. 1, 2

Critical Initial Actions

Do NOT Examine the Throat

• Never attempt oropharyngeal examination with tongue depressors, as this may precipitate complete airway obstruction 3, 1
• Routine oropharyngeal examination appears normal in 44% of epiglottitis cases and provides false reassurance 4
• Avoid any manipulation of the epiglottis, including swab specimen collection, as the dramatically swollen epiglottis can suddenly occlude the trachea 3

Immediate Specialist Consultation and Transfer

• Contact an intensivist immediately and arrange rapid transfer to ICU or intensive care environment 1, 2
• Ensure airway specialist evaluation occurs promptly to allow adequate time for airway preparation 2
• All patients with epiglottitis require ICU admission for close monitoring, regardless of initial presentation severity 2, 5

Airway Management Preparation

Equipment and Personnel Readiness

• Prepare difficult airway equipment before any intervention: videolaryngoscope, supraglottic airway devices, and surgical airway equipment for emergency cricothyroidotomy 1
• Have a structured approach with plans for failed intubation ready before attempting any airway intervention 1
• Position the patient upright if conscious, as this optimizes airway patency 1

Airway Intervention Threshold

• Maintain a low clinical threshold for intubation, as this is the only way to prevent death 4, 5
• While most adults present without overt airway obstruction, the potential for sudden deterioration mandates aggressive airway protection 4, 5
• Nasotracheal intubation is the preferred method when airway intervention is required 4, 6
• Four of twelve patients (33%) in one series required nasotracheal intubation 4

Diagnostic Approach

Confirm Diagnosis

• Direct visualization by fiberoptic laryngoscopy is the gold standard for diagnosis 4, 5
• Lateral neck radiographs have utility but lower sensitivity than direct visualization 5
• Radiographs should never supersede or postpone securing the airway 2

Obtain Blood Cultures

• Collect blood cultures to identify the causative organism (often Haemophilus influenzae) 3, 1
• Blood cultures are the preferred diagnostic specimen for epiglottitis 3
• In one series, all 15 blood cultures obtained were negative, highlighting the limitation of this test 7

Medical Management

Antimicrobial Therapy

• Initiate intravenous antibiotics immediately 4, 7
• A combination of cefotaxime and metronidazole is commonly used as empirical therapy 7
• Continue antibiotics throughout the acute phase 4

Supportive Care

• Administer NSAIDs for symptom control 4
• Consider adrenaline inhalation as an adjunctive measure 4
• Maintain oxygenation as the primary goal 1

Clinical Presentation Recognition

Key Symptoms to Identify

• Odynophagia (difficulty swallowing) occurs in 100% of cases 4
• Inability to swallow secretions/drooling in 83% 4
• Sore throat in 67-94% 4, 7
• Dyspnea in 58% 4
• Hoarseness in 50% 4
• Stridor is present in only 42% of cases and should not be relied upon for diagnosis 4

Physical Findings

• Fever (>37.2°C) in 75% of cases 4
• Tachycardia (>100 bpm) in 50% 4
• Tripod positioning and muffled voice suggest impending obstruction 2

Mortality and Prognosis

• Adult mortality remains approximately 7%, significantly higher than the 1% pediatric mortality with aggressive management 5
• Death can occur from failed intubation attempts without proper preparation—one patient died after attempted conventional oral intubation without tracheotomy equipment at bedside 4
• With appropriate antimicrobial therapy, close ICU monitoring, and selective airway intervention, prognosis is generally good 7