Acute Epiglottitis Management

Algorithm Steps

1. ▶

   Start

   Suspected Acute Epiglottitis

   Patient with severe sore throat, muffled voice, drooling, dysphagia, fever. May have stridor or respiratory distress.

   1. ⚠

      Warning

      ⚠️ CRITICAL: Avoid Agitating Patient

      Do NOT examine oropharynx in unstable patients (especially children). Do NOT use tongue depressor. Keep patient calm with parent. Any agitation can precipitate complete airway obstruction.

      1. ◆

         Decision

         Airway Stability?

         Signs of impending obstruction: stridor at rest, tripod positioning, unable to lie flat, drooling/unable to swallow, cyanosis, altered mental status

         1. ⚠

            Warning

            ⚠️ Unstable Airway - OR NOW

            Call ENT and Anesthesia STAT. Transport to OR with difficult airway equipment. Parent stays with child. Prepare tracheostomy. Avoid sedation. Heliox if available.

            1. ●

               Action

               Controlled Intubation in OR

               Inhalational induction with sevoflurane maintaining spontaneous ventilation. Direct or video laryngoscopy. Use smaller ETT (edema). ENT scrubbed for emergency tracheostomy.

               • Maintain spontaneous ventilation
               • Have tracheostomy tray open
               • Smaller ETT than predicted
               • Do NOT paralyze before visualizing airway
               1. ●

                  Action

                  IV Antibiotics

                  Start immediately after airway secured or if stable with clear diagnosis. First-line: Ceftriaxone 2g IV (adults) or 50-100mg/kg (peds, max 2g). Alternative: Cefotaxime, Ampicillin-sulbactam.

                  • Cover H. influenzae, S. pneumoniae, S. aureus, strep
                  • Add vancomycin if MRSA concern
                  • Duration: 7-10 days (IV to PO step-down)
                  1. ●

                     Action

                     Consider Corticosteroids

                     Dexamethasone 0.6mg/kg (max 10mg) IV may reduce edema and shorten ICU stay. Evidence limited but commonly used. May facilitate earlier extubation.

                     1. ●

                        Action

                        ICU Admission

                        All patients with epiglottitis require close monitoring. Intubated patients: ICU mandatory. Non-intubated stable adults: monitored bed with emergent airway capability.

                        1. ◆

                           Decision

                           Ready for Extubation?

                           Consider after 48-72 hours if: afebrile, decreased secretions, cuff leak present (air escapes around deflated cuff). May perform direct visualization pre-extubation.

                           1. ✓

                              Outcome

                              Extubated & Recovered

                              Complete antibiotic course. Discharge when tolerating PO and stable. Ensure vaccinations up to date. Follow-up with ENT.

                        2. ●

                           Action

                           Contact Prophylaxis

                           If H. influenzae type b confirmed: Rifampin 20mg/kg/day (max 600mg) x 4 days for close household contacts with unvaccinated children <4 years.

                           1. ✓

                              Outcome

                              Non-Intubated Observation

                              ~90% of adults don't require intubation. Close monitoring, serial exams. IV antibiotics. Most improve within 48-72 hours.

         2. ●

            Action

            Stable: Careful Workup

            Keep patient upright. IV access (but don't distress patient). Labs: CBC, blood cultures. Consider nebulized epinephrine for stridor.

            1. ◆

               Decision

               Imaging Needed?

               Adults: Lateral neck XR or CT can help confirm. Children: Imaging only if stable and diagnosis uncertain. Classic 'thumb sign' on lateral XR.

               1. ●

                  Action

                  Lateral Neck XR or CT

                  Lateral XR: 'Thumb sign' (swollen epiglottis). CT with contrast: 88-100% sensitivity. Only if patient can remain upright and is stable.

                  • Portable XR preferred
                  • Do NOT send unstable patient to radiology
                  • CT shows extent of edema and abscess
                  1. ●

                     Action

                     Fiberoptic Nasopharyngoscopy

                     In stable adults: ENT can perform awake fiberoptic exam. Visualizes cherry-red swollen epiglottis. Confirms diagnosis. Should be done in OR-ready setting.