eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat
Epiglottitis, Adult: Treatment & Medication
Updated: Apr 10, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
- Do not attempt intubation in the field unless acute airway obstruction is present.
- In the event of respiratory failure or obstruction, if Emergency Medical Services (EMS) is unable to intubate, then cricothyroidotomy or needle-jet insufflation are the next lines of treatment.
Emergency Department Care
- Some authors have tried to grade degrees of epiglottitis severity to guide treatment. A patient in extremis requires immediate airway management. Signs and symptoms associated with a need for intubation include respiratory distress, airway compromise on exam, stridor, inability to swallow, drooling, sitting erect, and deterioration within 8-12 hours. Enlarged epiglottis on radiographs is associated with airway obstruction. When in doubt, securing the airway is likely the safest approach.
- Intubation or immediate formal tracheostomy or cricothyrotomy may be performed in the operating room if the case is less severe.
- Patients without signs of airway compromise, respiratory difficulty, stridor, or drooling, and who have only mild swelling on laryngoscopy may be managed without immediate airway intervention by close monitoring in the ICU. Because of the rapidity with which airway obstruction can occur in these patients, repeat serial evaluations of airway patency and maintenance of a low clinical threshold for airway placement are indicated.
- Avoid agitating the patient with acute epiglottitis. Let the patient take a position in which he or she feels comfortable.
- Administer supplemental humidified oxygen if possible, but do not force the patient, as the resultant agitation could worsen the condition.
- Equipment for intubation, cricothyroidotomy, or needle-jet ventilation should be available at the bedside.
- An anesthesiologist and an ear, nose, and throat (ENT) specialist or a general surgeon should be notified as soon as possible in case of emergency or if operative management is anticipated. Early anesthesiologist and otolaryngologist consultation facilitates initial safe airway management, which is then followed by appropriate antibiotic treatment.
- Avoid therapy such as sedation, inhalers, or racemic epinephrine.
Consultations
- Consult an anesthesiologist and ENT specialist or general surgeon.
Medication
Antibiotic therapy should begin after blood and epiglottic cultures have been obtained. Antipyretics may be necessary. Racemic epinephrine, corticosteroids, and beta-agonists have not been proven to be helpful. Although corticosteroid usage remains controversial, as anecdotal reports in the past had supported its use.
Antibiotics
Empiric coverage for group A Streptococcus pneumoniae, Staphylococcus pyogenes, and H influenzae should be provided (a third-generation cephalosporin or amoxicillin/clavulanic acid). Third-generation cephalosporins are preferred as first-line agents because of increasing resistance to ampicillin.
Ceftriaxone (Rocephin)
DOC; third-generation cephalosporin with broad-spectrum activity against gram-negative organisms, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. By binding to one or more penicillin-binding proteins, it arrests bacterial cell wall synthesis and bacterial growth.
Adult
1-2 g IV bid
Pediatric
75 mg/kg/d IV
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding and allergy to penicillin
Ampicillin (Omnipen, Marcillin)
Alternative agent; interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.
Adult
100 mg/kg/d PO divided qid
Pediatric
Not established
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Chloramphenicol (Chloromycetin)
If allergic to penicillin and cephalosporins. Binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria.
Adult
50-100 mg/kg/d PO divided qid
Pediatric
Not established
Concurrently with barbiturates, chloramphenicol serum levels may decrease while barbiturate levels may increase causing toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity; chloramphenicol levels may be increased or decreased
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use only for indicated infections or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and perform periodic blood studies approximately every 2 d while in therapy; discontinue upon appearance of reticulocytopenia, leukopenia, thrombocytopenia, anemia, or findings attributable to chloramphenicol; adjust dose in liver or kidney dysfunction; caution in pregnancy at term or during labor because of potential toxic effects on fetus (gray syndrome)
Analgesic-antipyretics
These agents are helpful in relieving associated lethargy, malaise, and fever associated with the disease.
Aspirin (Anacin, Ascriptin, Bayer Aspirin)
Blocks prostaglandin synthetase action, which, in turn, inhibits prostaglandin synthesis and prevents formation of platelet-aggregating thromboxane A2. Acts on the hypothalamus heat-regulating center to reduce fever.
Dissipation of heat is enhanced by vasodilating peripheral vessels, causing a decrease in body temperature.
Adult
325-650 mg PO q4-6h; not to exceed 4 g/d
Pediatric
10-15 mg/kg/d PO q4-6h; not to exceed 60-80 mg/kg/d
Effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinemic effects and increased bleeding time may occur with coadministration of anticoagulants; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses >2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; anticoagulant use; severe anemia; asthma; because of association of aspirin with Reye syndrome, do not use in children (<16 y) with flu
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause transient decrease in renal function and aggravate chronic kidney disease
Acetaminophen (Tylenol, Panadol, Aspirin-Free Anacin)
DOC for treating pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who take oral anticoagulants.
Reduces fever by a direct action on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-25 mg PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses q24h
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; contained in many OTC products and combined use with these products may result in cumulative doses exceeding recommended maximum dose
Ibuprofen (Ibuprin, Advil, Motrin)
Usually the DOC for treating mild to moderate pain, if no contraindications exist. Inhibits inflammatory reactions and pain, probably by decreasing the activity of cyclooxygenase enzyme, which inhibits prostaglandin synthesis. One of the few NSAIDs indicated for reduction of fever.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
More on Epiglottitis, Adult |
| Overview: Epiglottitis, Adult |
| Differential Diagnoses & Workup: Epiglottitis, Adult |
 Treatment & Medication: Epiglottitis, Adult |
| Follow-up: Epiglottitis, Adult |
| Multimedia: Epiglottitis, Adult |
| References |
| Further Reading |
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References
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Further Reading
Clinical guidelines
1) General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). 2) Update: recommendations from the Advisory Committee on Immunization Practices (ACIP) regarding administration of combination MMRV vaccine.
Centers for Disease Control and Prevention (CDC), Advisory Committee on Immunization Practices (ACIP). Update: recommendations from the Advisory Committee on Immunization Practices (ACIP) regarding administration of combination MMRV vaccine. MMWR Morb Mortal Wkly Rep 2008 Mar 14;57(10):258-60. PubMed
Kroger AT, Atkinson WL, Marcuse EK, Pickering LK, Advisory Committee on Immunization Practices (ACIP) Centers for Disease. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP) [published errata appear in MMWR Morb Mortal Wkly Rep 2007 Mar 23;56(11):256]. MMWR Recomm Rep 2006 Dec 1;55(RR-15):1-48.
Keywords
epiglottitis, supraglottitis, inflammation of the epiglottis, sudden airway obstruction, Haemophilus influenzae b vaccine, H influenzae, Haemophilus influenzae type b, Hib vaccine, Hib vaccination
