Approach
No action should be taken that could stimulate a child with suspected epiglottitis. Cooperation between the otolaryngologist, intensivist, paediatrician, emergency department physician, and anaesthetist is crucial.
Initial treatment
Diagnostic procedures, examination of the oral cavity, starting intravenous lines, blood draws, or even separation of a child from a parent should not preclude or delay timely control of the airway if epiglottitis is suspected. Similar caution is required in fulminant acute epiglottitis in adults. If the child or adult is not perturbed, supplemental oxygen or heliox can help maintain oxygenation with an early compromised airway. The patient should be kept in an upright position as supine positioning can aggravate airway obstruction.[24]
If the patient is in extremis, or there is any doubt about the patient's airway, the airway should be secured. The airway should ideally be secured in the operating theatre after direct rigid laryngoscopy. The preference is for intubation. If possible, nasotracheal intubation is tried for young children under direct visualisation as it allows the child to maintain oromotor activity while intubated, and is less painful and traumatic for the child. However, in an emergency setting this may prove to be difficult. If the situation dictates and becomes urgent, a tracheotomy or cricothyroidotomy may be necessary, although many individuals can maintain the patency of an airway by skilled mask ventilation. This can afford sufficient time to arrange a definitive airway. A tracheotomy should only be performed as a life-saving measure. An alternative technique to secure the airway would be to intubate over a fibre-optic flexible endoscope passed via the nares. Great caution should be used in this technique.
Rarely, a patient will fail the initial extubation trial or the airway may not be ready for extubation after 72 hours and prolonged intubation until the patient meets criteria may be warranted.
Adult patients may have a more indolent presentation, and may not always require airway intervention (only about 10% of adults require airway intervention, whereas most children do).[4][25] Unnecessary airway intervention in adults may increase morbidity and mortality, given the relatively high intubation failure rate of one in 25.[25] However, adults may be at risk for airway obstruction and sudden decline due to supraglottic inflammation and oedema.They should be transferred to ICU level care (with the ability to perform airway intervention) for ventilatory management if they are intubated, or for observation if not intubated in case of deterioration.[26][27]
Antibiotics
Empirical intravenous antibiotics are given to intubated patients and oral antibiotics can be given to patients once extubated.[1][28] Institutions often have their own regimens of antibiotics, depending on local resistance. An infectious-disease physician can be consulted for proper anti-microbial coverage because combination antibiotic therapy is a potential consideration in a patient with epiglottitis. Empiric regimens include ampicillin/sulbactam or oxacillin or nafcillin or a cephalosporin or clindamycin, or vancomycin plus either ceftriaxone or cefotaxime. Classically, epiglottitis is associated with Haemophilus influenzae, but other potential pathogens include Streptococcus pneumonia, Staphylococcus aureus, and MRSA.[12][13] Rare bacterial pathogens such as Pasteurella multocida have been reported.[14]
Corticosteroids
While not proven in controlled trials, corticosteroids (dexamethasone) are used to reduce supraglottic inflammation.[10]
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