What is the appropriate management of epiglottitis?

Management of Epiglottitis

Epiglottitis is a life-threatening airway emergency requiring immediate specialist consultation, upright positioning, avoidance of throat examination, and preparation for emergency airway intervention in a controlled environment with difficult airway equipment immediately available. 1, 2

Immediate Recognition and Initial Actions

Critical First Steps

• Position the patient upright and leaning forward to optimize airway patency—never force a conscious patient supine 1, 2
• Obtain blood cultures immediately to identify the causative organism (typically Haemophilus influenzae) before any airway manipulation 1, 2
• Contact an intensivist immediately and arrange for rapid transfer to ICU or controlled operating room environment 2
• Provide supplemental humidified oxygen without forcing mask application 1

Critical Pitfalls to Avoid

• Never use a tongue depressor to examine the throat—this can trigger sudden complete airway obstruction 1, 2
• Never obtain throat swabs for culture in suspected epiglottitis 1
• Do not delay airway management for imaging if respiratory failure is imminent 3

Airway Management Strategy

Preparation Phase

• Assemble difficult airway equipment before any intervention, including videolaryngoscope, supraglottic airway devices, fiberoptic bronchoscope, and surgical airway equipment for emergency cricothyroidotomy 1, 2
• Have experienced personnel present, including anesthesiologist and surgeon capable of emergency surgical airway 2
• The rate of airway intervention is approximately 10-15%, but when intubation is required, the failure rate is approximately 4% (1 in 25 attempts) 4

Decision for Airway Intervention

Airway intervention is indicated when patients exhibit:

• Severe dyspnea or respiratory distress 5
• Inability to swallow secretions with drooling 3
• Stridor (inspiratory noise indicating critical narrowing) 6
• Hypoxemia despite supplemental oxygen 2
• Grade 4-5 epiglottic swelling on visualization (severe swelling of both epiglottis and arytenoids) 5

Intubation Approach

When airway intervention is necessary:

• Awake fiberoptic intubation is preferred in adults with severe disease—58.6% of successful cases used awake technique versus 41.4% under general anesthesia 4
• Maintain spontaneous ventilation throughout the procedure 4
• Have immediate surgical airway backup available 2, 7
• Consider tracheostomy over endotracheal intubation in cases of massive swelling or anticipated prolonged intubation (25 of 27 patients requiring airway management in one series underwent tracheostomy) 5

Medical Management

Antibiotic Therapy

• Initiate intravenous broad-spectrum antibiotics immediately after obtaining blood cultures 6
• Ampicillin/sulbactam is appropriate empiric coverage for H. influenzae 6
• Continue antibiotics for full course even after clinical improvement 6

Adjunctive Therapy

• Intravenous corticosteroids (dexamethasone) to reduce airway edema 6
• Maintain NPO status if airway intervention is anticipated 2

Monitoring and Disposition

Intensive Care Monitoring

• All patients with epiglottitis require ICU-level monitoring even without immediate airway intervention 2, 8
• Continuous pulse oximetry and cardiac monitoring 2
• Serial assessments of respiratory status, ability to handle secretions, and voice quality 8
• Adult mortality remains approximately 7% despite treatment, emphasizing the need for aggressive monitoring 8

Duration of Care

• Typical hospital stay is 3-4 days with appropriate treatment 6
• Patients without severe disease who respond to medical management may avoid intubation but require close observation for 24-48 hours 8, 5

Pediatric Considerations

In children, epiglottitis presents with the "4 D's": dysphagia, drooling, distress, and dysphonia, often with tripod positioning 3

• Transport to operating room for controlled intubation rather than emergency department intubation 3
• Keep child in position of comfort during transport 3
• Have surgical airway backup immediately available 3
• Avoid agitation—do not force examination or procedures 3

The key distinction from adult management is that pediatric cases warrant more aggressive prophylactic airway management in a controlled OR setting, while adults may be managed more conservatively with close ICU monitoring unless severe symptoms are present 3, 8.