Acute Epiglottitis Management: Suspected acute epiglottitis (supraglottitis) → Do not upset the patient: no throat examination → Adult (16 years or olde...
Pathway Overview
19 steps
19 total
Severe sore throat or pain on swallowing out of proportion to the throat findings, muffled voice, drooling, fever. May have stridor or distress. Child: often not fully Hib-vaccinated or immunocompromised; toxic, anxious, sits upright, little cough.
Agitation, lying flat or sedation can cause complete airway obstruction. Let the patient sit in the position they choose (a child on the parent's lap). Call the most senior airway clinician now.
Adult: assess airway risk, then work up. Child under 16 years: secure the airway in theatre before any procedure.
Yes if any of: stridor at rest, respiratory distress, sitting forward or tripod, cannot lie flat, cannot swallow saliva, falling SpO2, cyanosis, altered mental state, or rapid progression over hours.
Adult with airway at risk: move with the airway team to theatre (or resuscitation bay if no time). About 1 in 25 intubation attempts fail: have front-of-neck access ready before any attempt. Do not send to radiology.
Adult: most experienced anaesthetist and ENT surgeon scrubbed, neck marked, tracheostomy set open. Choose by severity and skills: awake fibreoptic or video intubation, awake tracheostomy, or inhalational induction keeping spontaneous breathing.
Adult: ceftriaxone 2 g IV once daily. Child (from 4 weeks): ceftriaxone 50 mg/kg (max 2 g) IV once daily, after the airway is secure. Septic shock or meningitis: higher dose per local guideline.
May reduce swelling; observational data link steroids to shorter ICU and hospital stay. Never a substitute for securing the airway. Child: dexamethasone 0.6 mg/kg (max 16 mg) IV or IM after the airway is secure. Adult: dose per local protocol.
Hib is notifiable: tell the public health unit. Droplet precautions until 48 hours after a clearance antibiotic. Index case not treated with ceftriaxone or cefotaxime: rifampicin before discharge. Household contacts: only if the household has a vulnerable contact, then treat all household contacts.
All patients: ICU or high-dependency bed with an airway team available at once. Tracheostomy: ENT and ICU plan weaning and decannulation when the swelling settles.
Intubated: extubate only when fever and swelling have settled and a cuff leak is present. Usually a second look at the larynx under sedation or anaesthesia first; extubate where re-intubation and surgical airway are available.
Extubated: observe in ICU or HDU. Complete antibiotics. Discharge when swallowing and stable. ENT follow-up. Check vaccinations are up to date.
Not ready for extubation: continue ICU care and antibiotics; reassess daily. Look for abscess or other complications if not improving.
Not intubated: most adults (about 85 to 90%) need no airway intervention. Continuous SpO2, repeat ENT nasendoscopy, airway team available. New stridor, distress or rapid progression: anaesthetist and ENT, theatre. Step down, then discharge when swallowing, afebrile and improving; complete antibiotics; ENT follow-up.
Adult with airway not at risk: keep upright in a resuscitation-capable area with continuous SpO2. Tell anaesthesia and ENT now. IV access, FBC, blood cultures; start IV antibiotics without waiting for imaging.
Adult, airway not at risk: flexible nasendoscopy confirms the diagnosis and shows the degree of swelling. Do it sitting up, where the airway can be secured at once. Marked swelling, a narrowed airway or an abscess: anaesthetist and ENT decide together now whether to secure the airway in theatre.
Stable adult only, and only if nasendoscopy is not available, the diagnosis is unclear, or an abscess is suspected. A portable lateral neck X-ray may show the thumb sign but a normal film does not exclude epiglottitis. CT needs the patient to lie flat: only if the airway is secure or clearly stable, with an airway-skilled escort.
Child with suspected epiglottitis: keep calm with the parent. Defer cannula, bloods and X-ray until the airway is secure. Senior anaesthetist and ENT now; move together to theatre. No anaesthetist or ENT on site: call the paediatric retrieval service now. Oxygen as tolerated; it does not relieve obstruction.
Child: inhalational (gas) induction by a senior anaesthetist, keeping spontaneous breathing. ENT present and ready for a surgical airway.
Booth AWG et al. Airway management of adult epiglottitis: systematic review and meta-analysis. BJA Open 2024;9:100250 (adults); RCH Melbourne CPG Acute upper airway obstruction 2021 (children); CDNA SoNG Invasive Hib infection v2 2025 (contacts)
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
Contraindicated Populations
Applicable Regions
AU: Hib is notifiable; contact clearance follows the CDNA Series of National Guidelines (2025). Ampicillin-sulbactam is not on the ARTG. Paediatric retrieval: state retrieval service.
EU: Hib contact prophylaxis criteria differ between countries: follow the national public health agency.
US: Hib contact prophylaxis criteria differ from Australia: follow the local public health department.
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The Acute Epiglottitis Management is a emergency clinical algorithm for Otolaryngology. It provides a structured decision tree to guide clinical decision-making, based on Booth AWG et al. Airway management of adult epiglottitis: systematic review and meta-analysis. BJA Open 2024;9:100250 (adults); RCH Melbourne CPG Acute upper airway obstruction 2021 (children); CDNA SoNG Invasive Hib infection v2 2025 (contacts).
This algorithm is based on Booth AWG et al. Airway management of adult epiglottitis: systematic review and meta-analysis. BJA Open 2024;9:100250 (adults); RCH Melbourne CPG Acute upper airway obstruction 2021 (children); CDNA SoNG Invasive Hib infection v2 2025 (contacts) (DOI: 10.1016/j.bjao.2023.100250).
Known limitations include: No society guideline exists for epiglottitis: adult airway steps come from a 2024 systematic review, child steps from the RCH upper airway obstruction guideline.; Antibiotic course length and the adult dexamethasone dose are not given: follow the local antimicrobial guideline (in Australia, Therapeutic Guidelines: Antibiotic).; Hib contact prophylaxis follows Australian CDNA guidance; criteria differ in other countries.; Non-infective supraglottitis (thermal, caustic, immune checkpoint inhibitor) and epiglottitis in neutropenic patients need specialist advice.. Individual patient factors may require deviation from these recommendations.
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