Suspected Acute Epiglottitis
Patient with severe sore throat, muffled voice, drooling, dysphagia, fever. May have stridor or respiratory distress.
All Pathways
OtolaryngologyEmergency
Acute Epiglottitis Management
Acute Epiglottitis Management: Suspected Acute Epiglottitis → ⚠️ CRITICAL: Avoid Agitating Patient → Airway Stability? → ⚠️ Unstable Airway - OR NOW → C...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Warning ⚠️ 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.
03Decision Airway Stability?
Signs of impending obstruction: stridor at rest, tripod positioning, unable to lie flat, drooling/unable to swallow, cyanosis, altered mental status
04Warning ⚠️ 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.
05Action 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
06Action 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)
07Action 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.
08Action ICU Admission
All patients with epiglottitis require close monitoring. Intubated patients: ICU mandatory. Non-intubated stable adults: monitored bed with emergent airway capability.
09Decision 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.
10Outcome Extubated & Recovered
Complete antibiotic course. Discharge when tolerating PO and stable. Ensure vaccinations up to date. Follow-up with ENT.
11Action 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.
12Outcome Non-Intubated Observation
~90% of adults don't require intubation. Close monitoring, serial exams. IV antibiotics. Most improve within 48-72 hours.
- Path rejoins step 12Shared downstream outcome
13Action Stable: Careful Workup
Keep patient upright. IV access (but don't distress patient). Labs: CBC, blood cultures. Consider nebulized epinephrine for stridor.
14Decision 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.
15Action 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
16Action 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.
- Path rejoins step 06Shared downstream outcome
- Path rejoins step 16Shared downstream outcome
Guideline Source
BJA Open 2024 Airway Management SR + StatPearls 2024
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- No formal society CPG exists - based on systematic reviews and consensus
- Pediatric presentation differs significantly from adults
- Requires immediate ENT and anesthesia availability
- Hib vaccination has changed epidemiology (now more common in adults)
Applicable Regions
USEU
Version 1Next review: 2027-01-11
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Related Resources
Frequently Asked Questions
What is the Acute Epiglottitis Management?
The Acute Epiglottitis Management is a emergency clinical algorithm for Otolaryngology. It provides a structured decision tree to guide clinical decision-making, based on BJA Open 2024 Airway Management SR + StatPearls 2024.
What guideline is the Acute Epiglottitis Management based on?
This algorithm is based on BJA Open 2024 Airway Management SR + StatPearls 2024 (DOI: 10.1016/j.bjao.2023.100129).
What are the limitations of the Acute Epiglottitis Management?
Known limitations include: No formal society CPG exists - based on systematic reviews and consensus; Pediatric presentation differs significantly from adults; Requires immediate ENT and anesthesia availability; Hib vaccination has changed epidemiology (now more common in adults). Individual patient factors may require deviation from these recommendations.
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