Treatment for Epiglottitis
Epiglottitis is a life-threatening airway emergency requiring immediate airway protection as the absolute priority, with concurrent antibiotic therapy and avoidance of any maneuvers that could precipitate complete airway obstruction. 1, 2
Immediate Airway Management (First Priority)
The primary goal is maintaining oxygenation and securing the airway before respiratory collapse occurs. 2
Critical "Do Not" Actions
- Never examine the throat with a tongue depressor - this can trigger sudden complete airway obstruction 1, 2
- Never attempt throat swabbing for cultures - airway manipulation is extremely dangerous 1, 3
- Never force the patient supine if they are conscious 1
Immediate Positioning and Oxygenation
- Position adults upright and leaning forward to optimize airway patency 1
- Provide supplemental humidified oxygen without forcing position changes 1
- Allow the patient to maintain their position of comfort 4
Prepare for Emergency Airway Intervention
Immediately discuss with an intensivist and assemble difficult airway equipment before any intervention. 1, 2 This includes:
- Videolaryngoscope 1, 2
- Supraglottic airway devices 1, 2
- Surgical airway equipment for emergency cricothyroidotomy 1, 2
- Have tracheostomy set at bedside 4
Airway Intervention Decision-Making
Approximately 10-15% of adult epiglottitis patients require airway intervention, though this rate has decreased over recent decades. 5, 6
High-risk indicators requiring immediate airway intervention include: 6
- Stridor (increases risk 6-fold) 6
- Patient sitting bolt upright (increases risk 5-fold) 6
- Progressive respiratory distress 7
- Inability to handle secretions 4
The clinical threshold for airway insertion should remain low - it is the only way to prevent death in this condition. 4 When airway intervention is needed, be aware that tracheal intubation has a 1 in 25 failure rate in epiglottitis. 5
Intubation Approach
When intubation is necessary, awake fiberoptic intubation is generally preferred when feasible, though general anesthesia may be used in selected cases based on severity and clinical context. 5 The American Society of Anesthesiologists recommends determining the safest approach by assessing difficult laryngoscopy risk, difficult mask ventilation risk, aspiration risk, and rapid desaturation risk. 1
Antibiotic Therapy (Concurrent with Airway Management)
Obtain blood cultures immediately - these are the preferred diagnostic sample since throat examination is contraindicated. 1, 3
Start empiric intravenous antibiotics immediately to treat the causative organism, most commonly Haemophilus influenzae type B. 2, 8, 6 While specific antibiotic regimens are not detailed in the highest-quality guidelines, historical evidence supports broad-spectrum coverage effective against H. influenzae. 8, 7
Supportive Care
- Intravenous corticosteroids have been used historically as part of medical management 7
- NSAIDs for symptom control 4
- Humidified oxygen 7
- Adrenaline inhalation may be considered 4
Monitoring and Disposition
Mandatory physician observation during the first 4 hours of treatment is essential, as progression can be rapid. 7
All patients must be admitted to a hospital with intensive care facilities where diagnosis can be confirmed and emergency intubation performed if necessary. 4
Critical Pitfall to Avoid
The most dangerous error is delayed diagnosis or misdiagnosis. 4 One case series documented a death when epiglottitis was misdiagnosed as asthma exacerbation, and intubation was attempted without proper preparation or equipment. 4 Any adult with acute, painful dysphagia (odynophagia) requires fiberoptic laryngoscopy to rule out epiglottitis. 4, 7
Adult mortality remains approximately 7% when not managed aggressively, significantly higher than the 1% pediatric mortality with proper treatment. 3 However, with appropriate management including low threshold for airway intervention, mortality can be reduced to zero. 6