Approach Considerations
Avoid agitating the patient with acute epiglottitis. Let the patient take a position in which he or she feels comfortable.
Orotracheal intubation may be required with little warning. Equipment for intubation, cricothyroidotomy, or needle-jet ventilation should be made available at the bedside.
Avoid therapy such as sedation, inhalers, or racemic epinephrine.
Administer supplemental humidified oxygen if possible, but do not force the patient, as the resultant agitation could worsen the condition.
Clinical pitfalls include the following:
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Underestimating the potential for sudden deterioration (most common error)
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Inadequate monitoring in which deterioration goes unnoticed (second most common error)
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Rushing intubation without proper support (ensure the availability of an anesthesiologist or other individual experienced in difficult intubation)
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Performing unnecessary medical procedures that result in agitation and respiratory collapse
In a retrospective study of 216 adult cases of acute epiglottitis, Nonoyama et al found that most cases received conservative treatment, with just 39 patients (18.1%) requiring airway management. The investigators also found that the mean number of days between symptom onset and hospital visit for patients differed between the airway management and conservative treatment groups (1.9 vs 2.9 days, respectively). [27]
A systematic review and meta-analysis by Sideris et al suggested that airway securement is required in 10.9% of adult cases (down from 18.8% prior to the introduction of Haemophilus influenzae vaccine). [28]
A study by Hanna et al using the Nationwide Emergency Department Sample database found that out of more than 33,000 emergency-department (ED) cases of adult epiglottitis identified between 2007 and 2014, fewer than 1% underwent laryngoscopic or airway procedures in the ED. Moreover, the use of radiography and computed tomography (CT) scanning was less than 10%. The investigators suggested that this indicates, in ED management of adult epiglottitis, “a lack of recognition of the need and utilization of critical airway interventions early in the patient encounter.” [29]
Obstruction in acute epiglottitis can be reduced by using dexamethasone therapy or budesonide aerosols to treat pharyngeal edema. In addition, research suggests that length of stay in the intensive care unit (ICU) and in the hospital overall can be reduced with corticosteroid use. [30, 31]
See also Pediatric Epiglottitis and Emergent Management of Pediatric Epiglottitis.
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.
Airway Management
Some authors have tried to grade degrees of epiglottitis severity to guide treatment.
Unstable patients
A patient in extremis requires immediate airway management. Signs and symptoms associated with a need for intubation include respiratory distress, airway compromise on examination, stridor, inability to swallow, drooling, sitting erect, and deterioration within 8-12 hours. The aforementioned study by Sideris et al indicated that in adults with epiglottitis, patients with an abscess, stridor, or a history of diabetes are more likely to require airway intervention. [28]
Enlarged epiglottis on radiographs is associated with airway obstruction. When in doubt, securing the airway is likely the safest approach.
Patients may deteriorate precipitously, and airway equipment, including that for cricothyrotomy, should be present at the patient's bedside. Needle-jet insufflation (also known as percutaneous transtracheal jet ventilation [PTJV]) may also be considered to ventilate the patient temporarily. [5] Intubation or immediate formal tracheostomy or cricothyrotomy may be performed in the operating room if the case is less severe.
In cases of initial failure to intubate by direct laryngoscopy, PTJV may facilitate success in subsequent attempts at tracheal intubation by direct laryngoscopy. PTJV can produce high intratracheal pressures that appear to lift up and open the glottis with escape of the pressurized gasses causing the glottis edges to flutter, thereby allowing improved identification of the glottic aperture.
Stable patients
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 intensive care unit (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.
Watch for air leaks around the endotracheal tube.
Laryngoscopy is recommended before extubation. An ear, nose, and throat (ENT) specialist and an anesthesiologist should be immediately available.
Complications and Recurrence Prevention
Epiglottic abscess may occur, which may or may not benefit from aspiration. [32]
Close contacts of patients in whom Haemophilus influenzae type b is isolated should receive rifampin prophylaxis (20 mg/kg; not to exceed 600 mg/d for 4 d).
Although H influenzae vaccine is available, it is not 100% effective.
Occurrence of recurrent episodes of acute epiglottitis in adults is unusual and, when present, warrants immune system investigation, because a quantitative or specific antibiotic deficiency may be present. Treatment of patients with recurrent acute epiglottitis may involve immunization or antibody replacement.
Consultations
An anesthesiologist and an ear, nose, and throat (ENT) specialist or a general surgeon should be notified as soon as possible when epiglottitis is suspected. Early anesthesiologist and otolaryngologist consultation facilitates initial safe airway management, which is then followed by appropriate antibiotic treatment. An infectious disease subspecialist should be considered if the patient does not respond to empiric antibiotics.
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Soft-tissue lateral neck radiograph reveals edema of epiglottis consistent with acute epiglottitis.
