ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Epiglottitis (supraglottitis): Management

Epiglottitis (supraglottitis): Management
Literature review current through: Jan 2024.
This topic last updated: Dec 20, 2023.

INTRODUCTION — The treatment and prevention of epiglottitis will be reviewed here. The clinical features and diagnosis of epiglottitis are discussed separately. (See "Epiglottitis (supraglottitis): Clinical features and diagnosis".)

DEFINITION — Epiglottitis is inflammation of the epiglottis and adjacent supraglottic structures [1]. Without treatment, epiglottitis can progress to life-threatening airway obstruction. A rapid overview of the recognition and management of epiglottitis in children is provided in the table (table 1).

DIAGNOSIS — Maintenance of the airway is the mainstay of treatment of patients with epiglottitis. In patients with signs of total or near-total airway obstruction, airway control necessarily precedes diagnostic evaluation. The diagnostic evaluation of epiglottitis in children and adults is discussed in detail separately. (See "Epiglottitis (supraglottitis): Clinical features and diagnosis", section on 'Diagnostic confirmation'.)

Epiglottitis should be suspected in young children, especially those who are un- or under-immunized against Haemophilus influenzae, type b (Hib) and who present with the characteristic clinical features as follows:

"Tripod" position (picture 1)

Anxiety (picture 2)

Sore throat

Stridor

Drooling

Dysphagia

Respiratory distress

Because of the potential for rapid progression to complete airway obstruction, the threshold for suspicion of epiglottitis should be low.

Epiglottitis should be suspected in older children, adolescents, and adults in whom the severity of sore throat is out of proportion to the findings on oropharyngeal examination.

Visualization of an inflamed, swollen, and red epiglottitis (picture 3) confirms the diagnosis. Radiographs are not necessary to make the diagnosis.

APPROACH TO AIRWAY MANAGEMENT — The approach to airway management in patients with epiglottitis is determined by whether the patient is able to maintain their airway and by the patient's age (algorithm 1). A rapid overview of the recognition and management of epiglottitis in children is provided in the table (table 1).

Immediately manage the airway and involve airway specialists — Managing the airway is of utmost importance and should be the initial action when epiglottitis is suspected (algorithm 1) [2-4].

Regardless of the apparent severity of the disease at the time of diagnosis, deterioration can occur rapidly. Early consultation of specialists skilled in securing tenuous airways (eg, anesthesiologist, intensivist, and otolaryngologist), even if proven ultimately to have been unnecessary, is preferable to an alternative approach where the patient is observed for signs of deterioration before such consultation, which may not provide sufficient time to control the airway.

If available, a designated critical airway team with specialized airway skills and equipment should be activated immediately when a patient is presumptively diagnosed with epiglottitis.

Patient not able to maintain airway — In patients with signs of total or near-total airway obstruction due to epiglottitis, airway control precedes diagnostic evaluation (algorithm 1).

Bag-valve-mask ventilation — If not already performed, the physician should immediately call upon available subspecialists with the skills needed to manage a critical airway and first proceed with bag-valve-mask (BVM) ventilation with 100 percent oxygen and meticulous attention to technique, including mask size and seal (picture 4), patient positioning (picture 5), and tidal volume (volume just large enough to cause chest rise) (picture 6 and picture 7). Most patients with soft tissue swelling of this type can successfully be oxygenated with a BVM device. (See "Basic airway management in children" and "Basic airway management in adults".)

If feasible, the patient should be carefully moved to an operating room accompanied by airway specialists and necessary equipment and without concern for sterile gowning or preparation in this instance.

Oxygenation not maintained — If BVM ventilation, despite using optimal technique, does not maintain oxygenation (ie, pulse oximetry below the high 80s or rapidly falling), then immediately attempt to place an oral endotracheal tube while other physicians are assigned to prepare to establish a surgical airway if needed, according to the modified failed airway algorithm (algorithm 1).

Intubation generally should be undertaken with a video laryngoscope (preferred) or a direct laryngoscope (if a video laryngoscope is not available) by the most experienced operator present. The laryngoscope is used to directly elevate the epiglottis to expose the glottic aperture. Indirect lifting methods, such as tensing the hyoepiglottic ligament by placing the laryngoscope in the vallecula, should not be used, regardless of the shape or type of blade. (See "Video laryngoscopes and optical stylets for airway management for anesthesia in adults", section on 'Videolaryngoscopy technique' and "Video laryngoscopy and other devices for difficult endotracheal intubation in children", section on 'Video laryngoscope'.)

For patients with epiglottis, particularly for pediatric patients in whom surgical airway management is much more difficult, this approach permits a single attempt at intubation using the maximal level of technology available (eg, video laryngoscope) prior to initiating surgical airway management, as long as preparations for a surgical airway occur in parallel with the attempt.

If the first effort to intubate is unsuccessful but was attempted without use of the best equipment available in the center, a second effort with such equipment, prior to establishing a surgical airway, may be attempted if time allows. The principle is to avoid the time that may lapse with multiple unsuccessful attempts at intubation before proceeding to surgical airway management in a persistently hypoxic child.

Of note, when attempted by persons with experience in airway management in children, endotracheal intubation is almost always successful in children with epiglottitis. Although the supraglottic airway is narrowed by the swollen epiglottis and aryepiglottic folds in epiglottitis, the laryngeal introitus (lumen) is typically spared but difficult to see due to the supra-glottic swelling.

While preparation for establishing a surgical airway as immediate back-up plan for these children is always prudent, surgical airway management will rarely be necessary in centers in which advanced pediatric airway management expertise exists.

Do not attempt placement of a supraglottic airway device (eg, laryngeal mask airway) because these devices are not effective in patients with acute upper airway obstruction or distorted airway anatomy. (See "Approach to the failed airway in adults for emergency medicine and critical care", section on 'The failed airway algorithm and approach'.)

For the uncommon event that endotracheal intubation cannot be accomplished in timely manner, the suggested emergency surgical airway varies by age:

In children younger than 12 years of age, perform needle cricothyroidotomy (figure 1 and table 2). Needle cricothyroidotomy may be performed on patients of any age but is preferred to surgical cricothyroidotomy in infants and children up to 10 to 12 years of age because it is anatomically easier to perform with less potential damage to the larynx and surrounding structures. Once in place and transtracheal ventilation is established, emergency consultation with an anesthesiologist and otolaryngologist should occur, and a more definitive airway placed as soon as possible. (See "Needle cricothyroidotomy with percutaneous transtracheal ventilation", section on 'Procedure'.)

In older patients, perform surgical cricothyroidotomy using a Seldinger technique (picture 8) or surgical cricothyroidotomy using a standard or rapid technique as described separately. (See "Emergency cricothyrotomy (cricothyroidotomy) in adults", section on 'Traditional open technique' and "Emergency cricothyrotomy (cricothyroidotomy) in adults".)

Oxygenation maintained — If BVM ventilation maintains oxygenation (pulse oximetry in the high 80s or better and steady or improving), then the patient should undergo endotracheal intubation by the most capable provider. If at all possible, the patient should be intubated in the operating room with an otolaryngologist present (algorithm 1). Many institutions have clinical pathways and a variety of advanced airway instruments available for patients with a difficult airway. (See "The difficult pediatric airway for emergency medicine", section on 'Airway management' and "Approach to the failed airway in adults for emergency medicine and critical care", section on 'The failed airway algorithm and approach'.)

When performing emergency endotracheal intubation in patients with epiglottitis, the following actions are suggested:

While setting up for endotracheal intubation, prepare for a surgical airway:

Assemble the necessary equipment, ready to be opened rapidly in case of intubation failure (needle cricothyroidotomy up to age 12 years (figure 1 and picture 9 and table 2) and surgical cricothyroidotomy in older patients (picture 8)).

Ensure the most skilled and available physician, such as an otolaryngologist, general surgeon, or emergency physician, is ready to perform needle or surgical cricothyroidotomy.

If outside of the operating room, use rapid sequence intubation to optimize intubating conditions. (See "Rapid sequence intubation (RSI) in children for emergency medicine: Approach" and "Rapid sequence intubation in adults for emergency medicine and critical care".)

Use of a videolaryngoscope may permit a better view of the epiglottitis and the airway. Whether a video or direct laryngoscope is used, the direct method of elevating the epiglottis by lifting it with the blade should be employed.

If the anatomy is sufficiently distorted that the glottis is not reliably identifiable, have an assistant compress the chest to produce air bubbles that identify the glottic opening for the physician performing the intubation.

If the glottis is not adequately visible, placement of an intubating introducer (gum elastic bougie) (picture 10) may facilitate passage of the endotracheal tube. (See "Video laryngoscopy and other devices for difficult endotracheal intubation in children", section on 'Intubating introducers (gum elastic bougie)' and "Devices for difficult airway management in adults for emergency medicine and critical care", section on 'Endotracheal tube introducers (gum elastic bougie)'.)

Attempt intubation with a cuffed endotracheal tube that is one to two sizes smaller than predicted by child's age (table 3) (calculator 1) or, in patients older than 8 years, patient size.

When intubation is undertaken in an operating room, securing of the airway is generally accomplished using inhalational anesthesia without paralysis.

Patient able to maintain airway — If the patient is maintaining her/his own airway, then administer supplemental humidified oxygen [2] and assemble available specialists (eg, anesthesiologist, intensivist, and otolaryngologist). Activate the critical airway team, if available (algorithm 1).

In young children, avoid increasing anxiety by permitting them to sit in a position of comfort upon the parent’s lap. Interactions with children who have signs of severe respiratory distress (eg, anxiety, "sniffing" (picture 2) or "tripod" posture (picture 1)) should be conducted in a manner that minimizes apprehension.

Intravenous access, unnecessary physical examination (oropharyngeal or laryngeal examination with a tongue blade or other instruments), and diagnostic tests (eg, phlebotomy or epiglottic cultures) may provoke anxiety or crying with abrupt airway obstruction and should not be attempted until the airway is secure, unless the patient is in extremis and the airway cannot be secured or IV access will facilitate the management of the airway [2,5]. (See "Epiglottitis (supraglottitis): Clinical features and diagnosis", section on 'Diagnosis'.)

Simple visual inspection of the oropharynx upon asking the patient to open the mouth, if he/she is able to do so, may permit visualization of the swollen epiglottis without instrumentation, which avoids the risk of precipitating airway obstruction.

Further airway management is largely determined by age:

Children younger than 6 years of age – We suggest that children younger than six years of age with epiglottitis undergo endotracheal intubation as described for oxygenating patients who cannot maintain their airway [6], although some experienced pediatric intensivists in centers with 24 hour availability of airway specialist coverage may opt to observe patients in the pediatric intensive care unit without performing endotracheal intubation. (See 'Oxygenation maintained' above.)

Whenever possible, this procedure should be performed in the operating room by an anesthesiologist or other physician with similar expertise and with an otolaryngologist available to assist by performing rigid laryngoscopy or an emergency surgical airway. Depending upon operator preference, orotracheal intubation may be followed by exchange of the endotracheal tube using nasotracheal intubation under direct visualization and facilitated by Magill forceps. Some experts prefer nasotracheal intubation because it may be easier to maintain the endotracheal tube in proper position [7]. A cuffed nasotracheal tube with a diameter that is 1 to 2 mm smaller than would otherwise be used in the patient (table 3) (calculator 1) is suggested to reduce the risk of post-intubation sequelae [8-10]. Long-term complications of nasotracheal intubation are rare [8,11]. As for any patient with distorted upper airway anatomy, blind nasotracheal intubation is contraindicated in all patients with epiglottitis.

Young children are at higher risk for airway obstruction given the small diameter of the airway, which permits rapid progression to complete obstruction with inflammation. The strategy of routine placement of an artificial airway is supported by a systematic review of 749 cases of epiglottitis in children prior to the wide availability of vaccination against Haemophilus influenzae type b, which found mortality was increased among those who were managed without an artificial airway (6 versus <1 percent) [6].

Older children and adults – Children older than six years of age and adult patients with epiglottitis and severe respiratory distress (eg, stridor, drooling, sitting erect, cyanosis) or >50 percent obstruction of the laryngeal lumen by endoscopic evaluation also warrant endotracheal intubation [12-14]. Furthermore, prompt endotracheal intubation may be warranted in patients with rapid onset and progression of symptoms, immune deficiency, or epiglottic abscess [2,12,13,15-17]. For children age 6 to 12 years and depending upon operator preference, orotracheal intubation may be followed by exchange of the endotracheal tube using nasotracheal intubation under direct visualization and facilitated by Magill forceps because it can be easier to maintain the endotracheal tube in the proper position. However, orotracheal intubation is preferred in children age greater than 12 years and adults. (See "Rapid sequence intubation in adults for emergency medicine and critical care" and "Overview of advanced airway management in adults for emergency medicine and critical care".)

Some older children and most adults without signs of severe airway obstruction can be managed in an intensive care unit setting without undergoing placement of an artificial airway, provided that experienced airway managers capable of managing the airway rapidly are immediately available 24 hours a day. Decisions to select this method of management will depend upon local resources and the patient’s presentation.

Criteria for observation differ by age:

Older children – In children six years of age and older with infectious epiglottitis but mild respiratory distress, decisions regarding endotracheal intubation versus observation should be individualized. We support close observation in an intensive care unit rather than intubation for the following children:

-Nontoxic appearance

-Onset and progression of disease has not been rapid (ie, symptoms developing over at least 24 hours)

-Direct visualization, if performed, suggests that narrowing of the supraglottic airway diameter is <50 percent

-Clinical severity and radiographic findings without direct visualization suggest the airway is not critical

-No additional anticipated difficulty with the airway other than the epiglottitis

Prompt establishment of an artificial airway was the standard practice in the United States in the pre-conjugate Haemophilus influenzae type b (Hib) vaccine era. However, as the incidence of Hib epiglottitis declines and the median age of children with acute epiglottitis increases, there is some evidence that carefully selected children with epiglottitis can be managed without intubation [18]. (See "Epiglottitis (supraglottitis): Clinical features and diagnosis", section on 'Microbiology'.)

Successful management of a subset of children with epiglottitis with close observation in an intensive care unit setting without placement of an artificial airway has been described in a number of case series, including studies prior to the widespread availability of conjugate vaccines [3,12,18-20]. The proportion of children managed initially without an artificial airway ranged from 4 to 49 percent in this report. Decisions regarding airway management were based upon clinical appearance and/or visualization of the supraglottis [3,18]. In one series, children managed without artificial airways were older than those who were intubated (mean age 6.1 versus 3.4 years) [18]. In another, management without artificial airway was not related to age [20]. Among children initially managed without an artificial airway, approximately 10 to 20 percent eventually require placement of an artificial airway [3,12].

Adults – Adults without severe respiratory distress and with estimated narrowing of the supraglottic airway diameter of <50 percent (as determined by flexible endoscopic examination) can be initially monitored closely in an intensive care unit setting without placement of an artificial airway [2,12,13]. In retrospective case series of adults with epiglottitis, the proportion of patients successfully managed without placement of an artificial airway ranges from 70 to 96 percent [13,21-27].

Patients who are managed without placement of an artificial airway may develop delayed acute respiratory compromise that requires emergency airway intervention [2,3,12,13,28]. The potential for rapid deterioration reinforces the need for the presence of an experienced airway specialist who is immediately available at all times for these patients. In large case series, 3 to 8 percent of patients managed initially without airway placement eventually required airway intervention [3,12,13].

ANTIMICROBIAL THERAPY — Whenever possible, a blood culture and, in intubated patients, an epiglottic culture should be obtained prior to antibiotic administration.

After airway management is complete, patients with infectious epiglottitis should receive empiric antimicrobial therapy directed toward the most likely organisms (see "Epiglottitis (supraglottitis): Clinical features and diagnosis", section on 'Infectious'):

Haemophilus influenzae type b

Streptococcus pneumoniae, including strains that may be penicillin-resistant

Group A Streptococcus

Staphylococcus aureus, including community-acquired methicillin-resistant S. aureus (MRSA) strains

We suggest that patients with epiglottitis receive empiric combination therapy with a third-generation cephalosporin (eg, ceftriaxone or cefotaxime) AND an antistaphylococcal agent (eg, vancomycin or as determined by the local prevalence and sensitivities of MRSA isolates) (table 4) [29,30].

We suggest vancomycin as the antistaphylococcal agent in the following patients:

Patients with epiglottitis complicated by moderate to severe sepsis.

Patients who may have concomitant meningitis (such patients should also receive a third- or fourth-generation cephalosporin for coverage of pneumococci or, in unvaccinated children, H. influenzae type b). (See "Initial therapy and prognosis of community-acquired bacterial meningitis in adults" and "Treatment of bacterial meningitis caused by specific pathogens in adults" and "Bacterial meningitis in children older than one month: Treatment and prognosis", section on 'Empiric therapy'.)

Patients from areas with an increased prevalence of clindamycin-resistant MRSA isolates. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Treatment of bacteremia".)

When the patient history suggests potential for severe hypersensitivity reaction to penicillin or cephalosporin antibiotics, vancomycin plus a quinolone or carbapenem antibiotic is a potential option. Consultation with an expert in pediatric infectious disease may be helpful to guide antibiotic decisions and is also warranted for patients with an unusual infectious etiology (table 5) or poor response to initial empiric therapy.

The approach to choosing empiric antibiotics for serious infections potentially caused by MRSA strains of S. aureus is discussed in greater detail separately. In children with suspected or confirmed epiglottitis, initiation of antistaphylococcal therapy with agents other than vancomycin that are likely active against MRSA may be considered on a case-by-cases basis. However, data remain limited in children, and especially for potentially life-threatening infections. Such options for epiglottitis may include ceftaroline and linezolid. (See "Staphylococcus aureus in children: Overview of treatment of invasive infections", section on 'Choice of therapy' and "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Treatment of bacteremia".)

Epiglottitis can occur in immunocompromised hosts, including cancer patients with neutropenia and children with advanced HIV infection. The range of potential microbes causing epiglottitis in such patients is broad and, in addition to organisms mentioned above, requires appropriate testing and empiric therapy for bacteria such as Klebsiella, Serratia, Enterobacter, and Pseudomonas; viruses such as cytomegalovirus; and Candida and other fungal species [31]. (Refer to appropriate UpToDate topic reviews).

Once culture and susceptibility results are available, the regimen should be adjusted to provide optimal coverage of the organism isolated. (See "Epiglottitis (supraglottitis): Clinical features and diagnosis", section on 'Infectious'.)

The optimal duration of antibiotics for the treatment of epiglottitis is unknown. Most clinicians treat for 7 to 10 days depending upon patient response [11,32]. A longer course may be necessary in patients with bacteremia, meningitis, or immunodeficiency.

A portion of the course may be administered orally if the patient is clinically improved, and an appropriate oral antibiotic or combination of antibiotics is available to cover the presumed or isolated organism.

ADDITIONAL THERAPIES — Bronchodilators and parenteral glucocorticoids have both been used as adjunctive treatments for patients with epiglottitis, but these agents are not routinely necessary:

Glucocorticoids – We do not recommend the use glucocorticoids in the initial treatment of patients with epiglottitis. Direct evidence of a benefit from glucocorticoids for patients with epiglottitis is lacking [11,33]. In retrospective studies, glucocorticoid therapy has not been associated with reduced length of stay, duration of intubation, or duration of stay in the intensive care unit, perhaps because glucocorticoids were administered selectively to sicker patients [34].

There is little published information regarding adverse effects of glucocorticoids in epiglottitis. Gastrointestinal bleeding requiring blood transfusion has been reported [35,36]. Another concern is potential risk of progressive viral infection or secondary bacterial infection, but such cases not been reported to date. (See "Clinical features of varicella-zoster virus infection: Chickenpox" and "Treatment of varicella (chickenpox) infection".)

Racemic epinephrine – The benefit of administration of racemic epinephrine as a means to reduce edema in patients with epiglottitis prior to definitive airway intervention is not established [2,11,32]. Prompt, effective airway management is the key intervention. The use of nebulized medications in young children may cause some to become frightened and anxious, which may exacerbate the airway compromise.

ONGOING CARE — Patients with epiglottitis should be monitored in an intensive care unit (whether or not an artificial airway has been placed). Daily examination of the supraglottis is necessary to assess the response to therapy, look for complications (eg, epiglottic abscess), and monitor for delayed airway obstruction (in patients managed without an artificial airway) [3,13,34]. Children should be managed in a pediatric intensive care unit.

Patients who are intubated during treatment for epiglottitis require meticulous respiratory nursing care and suctioning. Inadvertent extubation must be avoided. Post-intubation care is discussed separately. (See "Technique of emergency endotracheal intubation in children", section on 'Post-intubation care' and "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients".)

Intubation for two to three days is usually necessary before extubation can be safely accomplished [5]. Criteria for extubation include [5,18,32,37]:

Resolution of epiglottic/supraglottal swelling as indicated by laryngoscopy and/or an air leak around the artificial airway

Defervescence

Ability to swallow comfortably

Epiglottic swelling is generally improved after two to three days of antimicrobial therapy for epiglottitis caused by Haemophilus influenzae type b (Hib). A more protracted course may be more common with etiologies other than Hib (table 5). Persistence of epiglottic swelling beyond 72 hours should be evaluated on a case-by-case basis, with the following causes in mind:

A potentially ineffective antimicrobial regimen

Development of an epiglottic abscess or other complication

A more indolent course consistent with the causative microbe (eg, S. pyogenes)

Persistent fever may be related to development of secondary focus of infection (eg, pneumonia), nosocomial infection, or a reaction to antimicrobial therapy (ie, drug fever, a diagnosis of exclusion). Patients should be examined for extra-epiglottic manifestations (eg, pneumonia), particularly if a pathogen that frequently causes invasive disease at other sites (eg, S. pneumoniae, Hib) is isolated. Additional evaluation for extra-epiglottic manifestations is guided by clinical findings. (See appropriate topic reviews).

Consultation with an infectious disease specialist may be helpful in cases of persistent epiglottic swelling or prolonged fever if the cause is not apparent.

ADDITIONAL EVALUATION — An immune deficiency is a possible reason why fully vaccinated children (ie, children who have received at least three vaccinations with conjugate vaccines) may develop Haemophilus influenzae type b (Hib) epiglottitis or pneumococcal epiglottitis with a serotype contained in the pneumococcal vaccine. In such children, we suggest consultation with an immunology specialist to determine the best evaluation. (See "Epidemiology, clinical manifestations, diagnosis, and treatment of Haemophilus influenzae", section on 'Risk factors'.)

Genetic explanations other than classical immunodeficiency conditions also may account for Hib vaccine failure. Single nucleotide polymorphisms (SNP) associated with increased risk of Hib disease in vaccinated children have been identified among 172 White children with Hib vaccine failure diagnosed October 1992 through December 2005 in the United Kingdom [38]. Six of nine children homozygous for recessive alleles in the rs1554286 SNP in the promoter region of the interleukin 10 gene developed epiglottitis. This represented a 5.8-fold increased risk for epiglottitis over other children in this vaccine failure cohort who were heterozygous or homozygous for dominant alleles at this site (95% CI: 2.4-14.2, P<.0001).

OUTCOMES — The majority of patients with acute epiglottitis recover without residual airway or other problems if the airway is promptly secured and appropriate antimicrobial therapy is administered [11,18].

Injury related to hypoxemia that occurs before airway intervention or that result from progression of associated sepsis after institution of therapy is not always reversible. Most deaths are the result of cardiorespiratory arrest (secondary to airway obstruction) and/or delays in presentation for care or in securing the airway [18]. Death also may result as a complication of hypoxemia or sepsis.

Tracheostomy is reserved for patients in whom endotracheal intubation is unsuccessful [37]. In case series, the proportion of patients requiring tracheostomy ranges from 0 to approximately 5 percent [19,22,24,25,37,39]. Patients who require tracheostomy may have tracheostomy-related complications (eg, wound problem, tracheocutaneous fistula) [40].

COMPLICATIONS — Complications following epiglottitis include:

Airway obstruction – Airway obstruction is unusual but may occur unpredictably at any point in the illness or treatment course [41].

Epiglottic abscess – Epiglottic abscess may result from coalescent epiglottic infection or secondary infection of an epiglottic mucocele [13,42]. Epiglottic abscess occurs predominantly in adults and may complicate as many as 30 percent of cases [13]. A 17-year-old patient with an abscess of the aryepiglottic fold presenting as epiglottitis has been described [43]. Patients with epiglottic abscess have more severe symptoms and are at increased risk of airway compromise compared with those without this complication [2,13,44,45].

Epiglottic abscess can be diagnosed by direct visualization or computed tomography (which should be performed only in patients with a stable airway). Treatment of epiglottic abscess requires drainage in addition to airway management and antibiotic therapy.

Secondary infection – Secondary infection (eg, pneumonia, cervical adenitis, cellulitis, septic arthritis, and meningitis) may result as a consequence of bacteremia or direct extension. Meningitis occurs rarely [46,47].

Necrotizing epiglottitis – Necrotizing epiglottitis is a rare complication of epiglottitis in patients with immunodeficiency (eg, HIV infection, hemophagocytic lymphohistiocytosis) [48-50].

Death – The mortality rates in children and adults are <1 and ≤3.3 percent, respectively [12,23-25,51,52]. Death is almost always due to acute airway obstruction. Most deaths occur en route to the hospital or soon after arrival.

PREVENTION — The prevention of Hib infections through infant immunization and/or chemoprophylaxis of contacts is discussed separately. (See "Prevention of Haemophilus influenzae type b infection".)

The prevention of S. pneumonia infections through immunization is discussed separately. (See "Pneumococcal vaccination in children" and "Pneumococcal vaccination in adults".)

SUMMARY AND RECOMMENDATIONS

Rapid overview and initial management – Epiglottitis (supraglottitis) describes inflammation of the epiglottis and adjacent supraglottic structures (picture 3). A rapid overview of the recognition and management of epiglottitis is provided in the table (table 1). The algorithm provides initial airway management (algorithm 1). In patients with signs of total or near-total airway obstruction, airway control should occur prior to diagnostic evaluation. (See 'Definition' above.)

Involve airway specialists – Regardless of the apparent severity of the disease at the time of diagnosis, deterioration can occur rapidly in patients with epiglottitis; early consultation of specialists skilled in airway management (eg, anesthesiologist, intensivist, and otolaryngologist) or, if available, a critical airway team should be immediately activated. (See 'Immediately manage the airway and involve airway specialists' above.)

Unable to maintain airway – For patients who are not maintaining their airway as indicated by drooling, "sniffing" (picture 2), or "tripod" posture (picture 1), and severe respiratory distress, the physician should first proceed with bag-valve-mask (BVM) ventilation with 100 percent oxygen. (See 'Bag-valve-mask ventilation' above.)

Additional interventions depend upon the degree of oxygenation with BVM ventilation (see 'Patient not able to maintain airway' above):

If BVM ventilation, despite optimal technique, does not maintain oxygenation (ie, pulse oximetry below the high 80s or rapidly falling), then, immediately attempt oral endotracheal intubation and prepare to establish a surgical airway according to the modified failed airway algorithm (algorithm 1). A single attempt at intubation with a direct or video laryngoscope should precede, but not delay, the surgical airway. Do not attempt placement of a supraglottic airway device (eg, laryngeal mask airway). (See "Approach to the failed airway in adults for emergency medicine and critical care", section on 'The failed airway algorithm and approach'.)

The preferred approach to establishing an emergency surgical airway depends upon patient age:

-In children younger than 12 years of age, perform needle cricothyroidotomy (figure 1 and table 2).

-In older patients, perform surgical cricothyroidotomy using a Seldinger technique (picture 8) or surgical cricothyroidotomy using a standard or rapid technique as described separately. (See "Emergency cricothyrotomy (cricothyroidotomy) in adults", section on 'Traditional open technique' and "Emergency cricothyrotomy (cricothyroidotomy) in adults".)

If BVM ventilation maintains oxygenation, then the patient should undergo endotracheal intubation by the most capable provider. If at all possible, the patient should be intubated in the operating room with an otolaryngologist present. (See 'Oxygenation maintained' above.)

Able to maintain airway – If the patient is maintaining their own airway, then administer supplemental humidified oxygen. In young children (eg, <6 years of age), avoid increasing anxiety by permitting them to sit in a position of comfort upon the parent's lap, and avoid all painful procedures because they may provoke anxiety or crying, which can cause abrupt airway obstruction. Further airway management is largely determined by age (see 'Patient able to maintain airway' above):

We suggest that children younger than six years of age undergo prompt endotracheal intubation, even in the absence of severe respiratory distress (Grade 2C). Whenever possible, this procedure should be performed in the operating room by an anesthesiologist or other physician with similar expertise and with an otolaryngologist present to assist by performing rigid laryngoscopy or an emergency surgical airway when needed. Some experienced pediatric critical care specialists who work in centers with 24-hour availability of airway specialist coverage may opt to observe patients in the pediatric intensive care unit without performing endotracheal intubation.

In children six years of age and older with infectious epiglottitis but mild respiratory distress, decisions regarding endotracheal intubation versus observation should be individualized. Otherwise healthy children who are nontoxic, have been immunized against Haemophilus influenzae type b, have a normal airway, and have <50 percent of airway obstruction by direct visualization are candidates for intensive care unit observation without endotracheal intubation.

Adults without severe respiratory distress and with <50 percent obstruction of the laryngeal lumen can be initially monitored closely in an intensive care unit setting without placement of an artificial airway.

Further evaluation and treatment – Whenever possible, a blood culture and, in intubated patients, an epiglottic culture should be obtained prior to antibiotic administration. We suggest that patients with epiglottitis receive combination therapy with a third-generation cephalosporin (eg, ceftriaxone or cefotaxime) AND an antistaphylococcal agent active against MRSA (eg, vancomycin or as determined by the local prevalence and sensitivities of MRSA isolates) (table 4) for 7 to 10 days, depending upon patient response (Grade 2C). Once culture and susceptibility results are available, the regimen should be adjusted to provide optimal coverage of the isolated organism. (See 'Antimicrobial therapy' above.)

Ongoing care – All patients with epiglottitis should be monitored in an intensive care unit. Children should be cared for in a pediatric intensive care unit. Daily examination of the supraglottis is necessary to assess the response to therapy, look for complications (eg, epiglottic abscess), and monitor for delayed airway obstruction (in patients managed without an artificial airway). Patients who are intubated during treatment for epiglottitis require meticulous respiratory nursing care and suctioning. Inadvertent extubation must be avoided. (See 'Ongoing care' above.)

Criteria for elective extubation include resolution of epiglottic/supraglottic swelling, as indicated by laryngoscopy, and/or an air leak around the endotracheal tube, resolution of fever, and ability to swallow comfortably. (See 'Ongoing care' above.)

Epiglottic swelling is generally improved after two to three days of antimicrobial therapy for epiglottitis caused by Haemophilus influenzae type b (Hib). A more protracted course may be more common with etiologies other than Hib (table 5). Persistence of epiglottic swelling beyond 72 hours should be evaluated on a case by case basis, with the following causes in mind (see 'Ongoing care' above):

A potentially ineffective antimicrobial regimen

Development of an epiglottic abscess or other complication

A more indolent clinical course consistent with the causative microbe (eg, S. pyogenes)

  1. Rafei K, Lichenstein R. Airway infectious disease emergencies. Pediatr Clin North Am 2006; 53:215.
  2. Sobol SE, Zapata S. Epiglottitis and croup. Otolaryngol Clin North Am 2008; 41:551.
  3. Andreassen UK, Baer S, Nielsen TG, et al. Acute epiglottitis--25 years experience with nasotracheal intubation, current management policy and future trends. J Laryngol Otol 1992; 106:1072.
  4. Andreassen UK, Husum B, Tos M, Leth N. Acute epiglottitis in adults. A management protocol based on a 17-year material. Acta Anaesthesiol Scand 1984; 28:155.
  5. Stroud RH, Friedman NR. An update on inflammatory disorders of the pediatric airway: epiglottitis, croup, and tracheitis. Am J Otolaryngol 2001; 22:268.
  6. Cantrell RW, Bell RA, Morioka WT. Acute epiglottitis: intubation versus tracheostomy. Laryngoscope 1978; 88:994.
  7. Schloss MD, Hannallah R, Baxter JD. Acute epiglottitis: 26 years' experience at the Montreal Children's Hospital. J Otolaryngol 1979; 8:259.
  8. Schuller DE, Birck HG. The safety of intubation in croup and epiglottitis: an eight-year follow-up. Laryngoscope 1975; 85:33.
  9. Heldtander P, Lee P. Treatment of acute epiglottitis in children by long-term intubation. Acta Otolaryngol 1973; 75:379.
  10. Allen TH, Steven IM. Prolonged nasotracheal intubation in infants and children. Br J Anaesth 1972; 44:835.
  11. Tovar Padua, LJ and Cherry JD. Croup (laryngitis, laryngotracheitis, spasmodic croup, laryngotracheobronchitis, bacterial tracheitis, and laryngotracheobronchopneumonitis) and epiglottitis (supraglottitis). In: Feigin and Cherry's Textbook of Pediatric Infectious Diseases, 8th edition, Cherry JD, Harrison GJ, Kaplan SL, Steinbach WJ, Hotez PJ (Eds), Elsevier, Philadelphia 2019. Vol 1, p.175.
  12. Mayo-Smith MF, Spinale JW, Donskey CJ, et al. Acute epiglottitis. An 18-year experience in Rhode Island. Chest 1995; 108:1640.
  13. Berger G, Landau T, Berger S, et al. The rising incidence of adult acute epiglottitis and epiglottic abscess. Am J Otolaryngol 2003; 24:374.
  14. Pineau PM, Gautier J, Pineau A, et al. Intubation decision criteria in adult epiglottitis. Eur Ann Otorhinolaryngol Head Neck Dis 2021; 138:329.
  15. Katori H, Tsukuda M. Acute epiglottitis: analysis of factors associated with airway intervention. J Laryngol Otol 2005; 119:967.
  16. Solomon P, Weisbrod M, Irish JC, Gullane PJ. Adult epiglottitis: the Toronto Hospital experience. J Otolaryngol 1998; 27:332.
  17. Deeb ZE, Yenson AC, DeFries HO. Acute epiglottitis in the adult. Laryngoscope 1985; 95:289.
  18. Damm M, Eckel HE, Jungehülsing M, Roth B. Airway endoscopy in the interdisciplinary management of acute epiglottitis. Int J Pediatr Otorhinolaryngol 1996; 38:41.
  19. McEwan J, Giridharan W, Clarke RW, Shears P. Paediatric acute epiglottitis: not a disappearing entity. Int J Pediatr Otorhinolaryngol 2003; 67:317.
  20. Trollfors B, Nylén O, Strangert K. Acute epiglottitis in children and adults in Sweden 1981-3. Arch Dis Child 1990; 65:491.
  21. Hébert PC, Ducic Y, Boisvert D, Lamothe A. Adult epiglottitis in a Canadian setting. Laryngoscope 1998; 108:64.
  22. Ng HL, Sin LM, Li MF, et al. Acute epiglottitis in adults: a retrospective review of 106 patients in Hong Kong. Emerg Med J 2008; 25:253.
  23. Chang YL, Lo SH, Wang PC, Shu YH. Adult acute epiglottitis: experiences in a Taiwanese setting. Otolaryngol Head Neck Surg 2005; 132:689.
  24. Guldfred LA, Lyhne D, Becker BC. Acute epiglottitis: epidemiology, clinical presentation, management and outcome. J Laryngol Otol 2008; 122:818.
  25. Frantz TD, Rasgon BM, Quesenberry CP Jr. Acute epiglottitis in adults. Analysis of 129 cases. JAMA 1994; 272:1358.
  26. Dort JC, Frohlich AM, Tate RB. Acute epiglottitis in adults: diagnosis and treatment in 43 patients. J Otolaryngol 1994; 23:281.
  27. Shapira Galitz Y, Shoffel-Havakuk H, Cohen O, et al. Adult acute supraglottitis: Analysis of 358 patients for predictors of airway intervention. Laryngoscope 2017; 127:2106.
  28. Gerrish SP, Jones AS, Watson DM, Wight RG. Adult epiglottitis. Br Med J (Clin Res Ed) 1987; 295:1183.
  29. Ward MA. Emergency department management of acute respiratory infections. Semin Respir Infect 2002; 17:65.
  30. Shah RK, Roberson DW, Jones DT. Epiglottitis in the Hemophilus influenzae type B vaccine era: changing trends. Laryngoscope 2004; 114:557.
  31. Chen C, Natarajan M, Bianchi D, et al. Acute Epiglottitis in the Immunocompromised Host: Case Report and Review of the Literature. Open Forum Infect Dis 2018; 5:ofy038.
  32. Asher MI. Infections of the upper respiratory tract. In: Pediatric Respiratory Medicine, Taussig LM, Landau LI (Eds), Mosby, St. Louis 1999. p.540.
  33. Baxter FJ, Dunn GL. Acute epiglottitis in adults. Can J Anaesth 1988; 35:428.
  34. Glynn F, Fenton JE. Diagnosis and management of supraglottitis (epiglottitis). Curr Infect Dis Rep 2008; 10:200.
  35. DiTirro FR, Silver MH, Hengerer AS. Acute epiglottitis: evolution of management in the community hospital. Int J Pediatr Otorhinolaryngol 1984; 7:145.
  36. Kyrcz RW, Indyk D. Atypical acute epiglottitis with gastrointestinal bleeding. J Fam Pract 1988; 27:102.
  37. Battaglia JD, Lockhart CH. Management of acute epiglottitis by nasotracheal intubation. Am J Dis Child 1975; 129:334.
  38. Ladhani SN, Davila S, Hibberd ML, et al. Association between single-nucleotide polymorphisms in Mal/TIRAP and interleukin-10 genes and susceptibility to invasive haemophilus influenzae serotype b infection in immunized children. Clin Infect Dis 2010; 51:761.
  39. Nakamura H, Tanaka H, Matsuda A, et al. Acute epiglottitis: a review of 80 patients. J Laryngol Otol 2001; 115:31.
  40. Corbett HJ, Mann KS, Mitra I, et al. Tracheostomy--a 10-year experience from a UK pediatric surgical center. J Pediatr Surg 2007; 42:1251.
  41. Glomb NWS and Cruz AT. Infectious disease emergencies. In: Fleisher and Ludwig's Textbook of Pediatric Emergency Medicine, 7th ed, Shaw KN, Bachur RG (Eds), Wolters Kluwer, Philadelphia 2016.
  42. Stack BC Jr, Ridley MB. Epiglottic abscess. Head Neck 1995; 17:263.
  43. Reed J, Shah RK, Jantausch B, Choi SS. Aryepiglottic abscess manifesting as epiglottitis. Arch Otolaryngol Head Neck Surg 2009; 135:953.
  44. Wolf M, Strauss B, Kronenberg J, Leventon G. Conservative management of adult epiglottitis. Laryngoscope 1990; 100:183.
  45. Cable BB, Biega T. Radiology forum. Quiz case 1. Adult epiglottitis with epiglottic abscess. Arch Otolaryngol Head Neck Surg 2001; 127:212, 214.
  46. Molteni RA. Epiglottitis: incidence of extraepiglottic infection: report of 72 cases and review of the literature. Pediatrics 1976; 58:526.
  47. Schuh S, Huang A, Fallis JC. Atypical epiglottitis. Ann Emerg Med 1988; 17:168.
  48. Tebruegge M, Connell T, Kong K, et al. Necrotizing epiglottitis in an infant: an unusual first presentation of human immunodeficiency virus infection. Pediatr Infect Dis J 2009; 28:164.
  49. Kong MS, Engel SH, Zalzal GH, Preciado D. Necrotizing epiglottitis and hemophagocytic lymphohistiocytosis. Int J Pediatr Otorhinolaryngol 2009; 73:119.
  50. Sengör A, Willke A, Aydin O, et al. Isolated necrotizing epiglottitis: report of a case in a neutropenic patient and review of the literature. Ann Otol Rhinol Laryngol 2004; 113:225.
  51. Kucera CM, Silverstein MD, Jacobson RM, et al. Epiglottitis in adults and children in Olmsted County, Minnesota, 1976 through 1990. Mayo Clin Proc 1996; 71:1155.
  52. Torkkeli T, Ruoppi P, Nuutinen J, Kari A. Changed clinical course and current treatment of acute epiglottitis in adults a 12-year experience. Laryngoscope 1994; 104:1503.
Topic 6076 Version 26.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟