Acute epiglottitis (supraglottitis): Rapid overview of emergency management

Clinical findings

Fever and stridor with marked retractions, tachypnea, and labored breathing

Anxious, restless, and/or toxic appearance

Refusing to lie down, "sniffing" or "tripod" posture

Muffled, "hot potato" voice or aphonia

Severe sore throat with normal posterior pharynx

Anterior neck pain at the level of the hyoid

Unimmunized or incompletely immunized patient

Immediate airway management

Preparation and airway assessment

Get emergency assistance from airway specialists (anesthesiologist/critical care specialist and otolaryngologist)
Prepare to manage the airway (assemble personnel, medications, and equipment)
Do not try to visualize the epiglottis (tongue blade or any other instrument)
In young children, do not perform invasive procedures (eg, IV placement, phlebotomy, or any other painful or frightening intervention) until after airway management

Sudden deterioration with complete airway obstruction

Attempt bag-valve mask ventilation with 100% oxygen:
- Unable to oxygenate (pulse oximetry lower than high 80s or falling): Attempt endotracheal intubation by RSI with second provider ready to establish a surgical airway (eg, surgical or, in children, needle cricothyrotomy) if RSI fails*
- Able to oxygenate (pulse oximetry high 80s and steady or improving): Endotracheal intubation by the most capable provider, preferably in the operating room with an otolaryngologist present^¶

Airway maintained

Administer supplemental, humidified oxygen^Δ
Keep the patient in an upright position of comfort (a child on a stretcher in the caregiver's lap)
Keep the patient in a setting where the airway can be rapidly managed with capable personnel and specialized airway equipment constantly available
Do not image patients with severe respiratory distress in whom it will delay definitive airway management
Otherwise, soft-tissue radiograph of the lateral neck (portable if possible) may be helpful; personnel and equipment to manage the airway must remain with the patient at all times during imaging
- Radiographic findings of epiglottitis:
  - Enlarged epiglottis ("thumb" sign)
  - Thickened aryepiglottic folds
  - Loss of vallecular air space
  - Distended hypopharynx
Ensure endotracheal intubation in the operating room with an otolaryngologist present

After airway is secured

Obtain surface cultures from the epiglottis

Obtain blood cultures

Administer IV antimicrobial therapy (refer to UpToDate content on management of epiglottitis)

IV: intravenous; RSI: rapid sequence intubation.

* Needle cricothyroidotomy may be performed on children of any age. The pediatric age at which one can safely perform a surgical cricothyrotomy on a child is not well established, and recommendations vary from 5 to 12 years old. Surgical cricothyrotomy is best performed in children in whom external landmarks of the neck (eg, the cricothyroid membrane) are easily palpable. Refer to UpToDate topics on needle cricothyroidotomy with percutaneous transtracheal ventilation and emergency surgical cricothyroidotomy (cricothyrotomy). 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.

¶ Refer to UpToDate content on management of acute epiglottitis and management of the failed airway.

Δ Highest concentration and mode of delivery that does not cause agitation; 100% humidified oxygen by a non-rebreathing face mask or similar delivery device preferred.

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Acute epiglottitis (supraglottitis): Rapid overview of emergency management