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    Epiglottitis – Management

    Critical Care / Resuscitation, Respiratory

    Last Updated Feb 11, 2020
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    Context

    • Epiglottitis is the acute inflammation of the epiglottis and the adjacent supraglottic structures.
    • It is an airway emergency which can lead to life-threatening airway obstruction without prompt recognition and treatment.
    • Severe complications like sepsis and meningitis can occur.
    • Among the vaccinated population, the annual incidence in children is 0.3 to 0.7 per 100,000 patients, with the frequency in adults now greater than in children.
    • Prior to type-b influenzae (HiB) vaccination, HiB was responsible for most cases. Now, pathogens include A, B, C, and G beta-hemolytic Streptococcus, S. aureus, M. catarrhalis, S. pneumonia, H. parainfluenzae, E. coli, EnterobacterKlebsiella, and Pseudomonas. Viruses (e.g. herpes simplex) and fungi (e.g. candida albicans) are also potential causes.
    • Non-infectious causes include trauma, foreign body ingestion, thermal injury, and caustic ingestion.

    Clinical presentations will vary:

    • Young children classically present with respiratory distress, anxiety, and tripod posture. Drooling is often present and cough is typically absent.
    • Older patients may simply present with a severe sore throat and exhibit a relatively normal oropharyngeal examination.

    Common findings in epiglottitis:

    • Dysphagia
    • Difficulty breathing
    • Dysphonia
    • Drooling
    • Odynophagia
    • Stridor
    • “Hot potato” voice
    • Fever
    • Tachycardia
    • Tripod position

    Diagnostic Process

    • Definitive diagnosis is confirmed via visualization of the epiglottis via direct laryngoscopy, nasolaryngoscopy, or on oropharyngeal examination.
    • Avoid doing any anxiety provoking investigations (e.g. tongue depressor, IV cannulation) without rescue airway equipment and airway specialists available.
    • Soft-tissue lateral neck radiographs can confirm epiglottitis but are not always required.

    Recommended Treatment

    • Immediately prepare to manage airway and consult ENT and anesthesia.
      • If not intubated, give humidified supplemental O2 in a position of comfort.
    • Bloodwork and blood cultures.
    • If intubated, obtain epiglottic culture.
    • Empiric antimicrobial therapy (should cover HiB, pneumoniae, GAS, S. aureus).
      • Third generation cephalosporin (ceftriaxone or cefotaxime) or amoxicillin/clavulanic acid commonly given for 7-10 days (local guidelines may differ).
      • Add MRSA coverage if necessary.
      • Consider rifampin prophylaxis for close contacts.
        • Adults: 600 mg PO once daily for 4 days.
        • Infants, Children, and Adolescents: 20 mg/kg/day PO once daily for 4 days, (max 600 mg/day).
    • Insufficient evidence for use of glucocorticoids.
    • Insufficient evidence for use of racemic epinephrine.

    Criteria For Hospital Admission

    • Patients diagnosed with or suspected to have epiglottitis are admitted.

    Criteria For Transfer To Another Facility

    • Dependent on local guidelines.

    Criteria For Close Observation And/or Consult

    • Patients should be monitored in an intensive care unit.
    • Consider involving the infectious disease service for antimicrobial stewardship.

    Context

    • If intubated, patients can be extubated once the initial insult and airway obstruction have resolved. This usually occurs after two to three days of antibiotics if the pathogen is HiB.

    Quality Of Evidence?

    Justification

    Early detection, airway management, empiric antibiotic therapy, and engagement with interprofessional team are critical in management patients with acute epiglottitis.

    High

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