Acute epiglottitis in the adult: is intubation mandatory?

Airway management of adult epiglottitis: a systematic review and meta-analysis

Background

Adult epiglottitis is a life-threatening airway emergency where airway protection is the immediate priority. Despite its importance, the optimal approach to airway management remains unclear. We performed a systematic review of the airway management for adult epiglottitis, including meta-analysis of trends over time.

Methods

We systematically searched PubMed, Ovid MEDLINE®, and Embase® for adult epiglottitis studies that described the airway management between 1980 and 2020. The primary outcome was the prevalence of airway intervention. Secondary outcomes were prevalence of tracheal intubation, tracheostomy, and failed intubation. A random-effects model meta-analysis was performed with subgroups defined by decade of study publication. Cases that described the specific method of airway intervention and severity of epiglottitis were included in a separate technique summary.

Results

Fifty-six studies with 10 630 patients were included in the meta-analysis. The overall rate of airway intervention was 15.6% (95% confidence interval [CI] 12.9-18.8%) but the rate decreased from 20% to 10% between 1980 and 2020. The overall rate of tracheal intubation was 10.2% (95% CI 7.1-13.6%) and that of failed intubation was 4.2% (95% CI 1.4-8.0%). The airway technique summary included 128 cases, of which 75 (58.6%) were performed awake and 53 (41.4%) involved general anaesthesia. We identified 32 cases of primary technique failure.

Conclusion

The rate of airway intervention for adult epiglottitis has decreased over four decades to a current level of 10%. Tracheal intubation is a high-risk scenario with a 1 in 25 failure rate. Specific technique selection is most likely influenced by contextual factors including the severity of epiglottitis.

A systematic review and meta-analysis of predictors of airway intervention in adult epiglottitis

OBJECTIVE

Epiglottitis is typically considered a pediatric disease; however, there is growing evidence that the incidence of adult epiglottitis has changed since the introduction of the Haemophilus influenzae vaccine. The literature is composed of multiple small series with differing findings. To date, there has been no attempt to collaborate evidence on predictors of airway intervention in this disease.

METHODS

The population of interest was adults with a diagnosis of epiglottitis. The primary outcome in this review was incidence of airway intervention. A comprehensive literature search was conducted of the MEDLINE and Embase databases, and a separate random-effects model meta-analysis was undertaken for all outcome data. Moderator tests for comparison between prevaccine and postvaccine estimates were made, and absolute risk difference (RD) and relative risk (RR) calculations were made for all predictors of airway intervention.

RESULTS

Thirty studies and a total of 10,148 patients were finally included for meta-analysis. A significant decrease in airway intervention was seen post vaccine introduction introduction from 18.8% to 10.9% (P = 0.01). The presence of an abscess (RD 0.27, P = 0.04; RR 2.45, P < 0.001), stridor (RD 0.64, P < 0.001; RR 7.15, P < 0.001), or a history of diabetes mellitus (RD 0.11, P = 0.02; RR 2.15, P = 0.01) were associated with need for airway intervention.

CONCLUSION

In the postvaccine era, clinicians should expect to have to secure airways in 10.9% of cases. The presence of an epiglottic abscess, stridor, or a history of diabetes mellitus are the most reliable clinical features associated with need for airway intervention.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:465-473, 2020.

Adult Acute Epiglottitis: Predictors for Airway Intervention and Intensive Care Unit Admission

Objectives

(1) to characterise the clinical features of acute epiglottitis in adults in Hong Kong; (2) to identify predictors for airway intervention and uneventful recovery without intensive care unit (ICU) admission. Modified Early Warning Score (MEWS) was also applied in risk stratification.

Methods

A retrospective cohort study of 122 consecutive laryngoscopically confirmed cases admitted to Pamela Youde Nethersole Eastern Hospital from 1998 to 2007.

Results

The mean patient age was 51 years (range 18–84 years) and the male-to-female ratio was 1.9 to 1. Sore throat, dysphagia and odynophagia were the commonest symptoms and the median MEWS on presentation was 1 (range 0–10). Nine patients (7.4%) required airway intervention (5 orotracheal intubations, 2 nasotracheal intubations and 2 tracheostomies) and one patient died. Univariate analysis showed that recurrent attack (OR 35.0, 95% CI 2.77–442.69, p=0.013), dyspnoea (OR 17.41, 95%CI 2.09–144.79, p=0.001), stridor (OR 30.0, 95%CI 2.42–372.65, p=0.016) and MEWS equal to or greater than 4 (OR 5.81. 95%CI 1.16–29.17, p=0.049) were significantly associated with airway intervention. Only stridor remained a reliable predictor in multivariate analysis (OR 88.46, 95%CI 5.48–1427.45, p=0.001). Performance of MEWS in prediction for airway intervention was evaluated with the Receiver Operating Characteristic (ROC) curve. The area under curve (AUC) was 0.71 (95%CI 0.503–0.909). Forty-five patients did not require ICU admission (36.9%). Multiple logistic regression showed that absence of hoarseness (OR 3.10, 95%CI 1.10–8.79, p=0.033), absence of fever (OR 3.2, 95%CI 1.25–8.16, p=0.015) and MEWS <1 (OR 7.07, 95%CI 1.31–38.07, p=0.023) were predictors of uneventful recovery without ICU care.

Conclusion

A selective approach should be adopted in airway management but those with stridor on presentation should have their airway secured without delay. MEWS cannot replace clinical judgement but a low MEWS on presentation may help in identifying low risk patients who can be managed safely without ICU admission.

Case and Literature Review: Adult Acute Epiglottitis – Rising Incidence or Increasing Awareness?

Objective

The prevalence of adult acute epiglottitis is probably more common than is generally appreciated. A retrospective case review in a district hospital and a medical literature search may provide baseline information to guide future strategies.

Methods

Cases of acute epiglottitis in a period of 3 years and 4 months were traced from the hospital computer systems. Medical records were reviewed. Medical literature on “adult acute epiglottitis” was searched through Medline and EMBASE. Relevant full text articles were retrieved through hospital library network.

Results

From February 1998 to June 2001, 11 cases of acute epiglottitis were identified. The age range was 34–78 (mean 47.5, median 41). There was no paediatric case. The male to female ratio was 9:2. Eight presented with fever, sore throat and dysphagia, one presented with dyspnoea and two presented as foreign body in throat. Nine were treated successfully conservatively. Two were intubated prophylactically. There was no case fatality.

Conclusion

Adult acute epiglottitis has become much commoner than its paediatric counterpart. Acute epiglottitis should be suspected in all patients with a sore throat and dysphagia, especially if symptoms are out of proportion to the pharyngeal inflammation.

Laryngitis, Epiglottitis and Pharyngitis

•

Croup is the most common cause of stridor in children, caused by acute viral infection in most cases (parainfluenza) and mainly affects young children between 6 months and 3 years old.

•

Treatment with oral corticosteroids and nebulized adrenaline reduced the rate of hospitalization and complications.

•

The diagnoses of bacterial epiglottitis and viral laryngotracheobronchitis (croup) in infants and children may be confused.

•

Epiglottitis is an acute inflammation of the epiglottis or supraglottis that may lead to the rapid onset of life-threatening airway obstruction caused by Haemophilus influenzae type b (Hib) and is an otolaryngologic emergency. Since the widespread implementation of a conjugate vaccine for Hib, the incidence of epiglottitis significantly declined in children and there was a consequent shift in disease from young children to adults.

•

The management of epiglottitis includes securing the airways and appropriate antibiotics (ceftriaxone).

•

Group A streptococcus is a frequent cause of pharyngitis that can be diagnosed by rapid antigen-detection test. Antibiotic treatment reduces the risk of complications, including rheumatic fever and acute glomerulonephritis.

Adult acute epiglottitis: Experiences in a Taiwanese setting

OBJECTIVE: Acute epiglottitis is a potentially disastrous disease seen occasionally in otolaryngology emergency service. This study reports our experiences in managing adult patients with acute epiglottitis in a Taiwanese setting.

STUDY DESIGN: Admission medical records from 46 adult patients with acute epiglottitis over a period of 8 years in a tertiary referral otolaryngology service were retrospectively reviewed.

RESULTS: No mortality was reported; 4 (8.7%) patients were supported by artificial airway. A total of 16 (34.8%) patients had comorbid conditions; hypertension and diabetes mellitus were the most common systemic diseases. Patients who needed artificial airway support tended to have more systemic comorbidities ( P = 0.001) and a higher level of hyperglycemia ( P = 0.004) than those who did not need airway support. The incidences of drooling, stridor/dyspnea, and muffled voice were significantly higher in the airway-supported group ( P < 0.05). Stridor/dyspnea is a reliable clinical predictor of airway compromise (odds ratio 2.94; P = 0.0277).

CONCLUSION: Dyspnea is a warning sign of impending airway collapse during an episode of acute epiglottitis. Adult patients with more systemic comorbidities might bear higher risk of airway compromise; the role of diabetes mellitus can't be overlooked. (Otolaryngol Head Neck Surg 2005;132:689-693.)

Acute epiglottitis due to Serratia marcescens in an immunocompetent adult

Acute epiglottitis (AE) is inflammation of the epiglottis and contiguous tissues, which carries a potential for complete airway obstruction. With routine pediatric immunization for Hemophilus influenzae serotype b, epiglottitis is now more prevalent in adults, with a shift in the causative organisms and a change in the natural history of this disease. Over the past 5 decades, Serratia marcescens has gone from being recognized as a harmless saprophyte to an important opportunistic human pathogen. It is known to be associated with outbreaks of nosocomial infections, but it is an uncommon cause of serious invasive infections in patients presenting from the community. The authors present a fatal case of AE caused by S marcescens in a previously immunocompetent 58-year-old woman, which was complicated by fasciitis, myositis and bacteremia. To the authors' knowledge, till date, only 3 cases of AE by S marcescens have been reported, all in immunocompromised patients.

Acute supraglottitis in adults: what's the optimal airway intervention?

OBJECTIVES

To validate the Friedman stage and define the proper timing for airway intervention in adult cases of acute supraglottitis, we evaluated the clinical courses and management of adult patients.

METHODS

202 adult patients with acute supraglottitis were included in this study. The diagnosis of supraglottitis was established by flexible nasolaryngoscopic examination. Friedman stages were classified in each patient. In this study, the first three days of serial nasolaryngoscopic findings for each patient were evaluated.

RESULTS

All patients were treated successfully with only conservative methods. There were no significant differences between patients with Friedman stages I or II/III. Among the patients that had serial nasolaryngoscopic findings, only one patient presented with progressive swelling of the epiglottis, and there were no cases of persistent swelling.

CONCLUSION

The airway intervention threshold should be raised from Friedman stages II-III. And, airway intervention should not be needed if patients are tolerant of their respiratory discomfort.

Acute supraglottitis in adults

OBJECTIVES

Adult supraglottitis is a potentially life-threatening airway infection. We reviewed the management and outcome of supraglottitis in 169 adults admitted to Liverpool Hospital between 1999 and 2009.

METHODS

A retrospective review was conducted of all admissions with supraglottitis in patients at least 18 years of age. The diagnosis was confirmed by fiberoptic nasolaryngoscopy or direct laryngoscopy under general anesthesia. The main outcome measure was the need for intubation or tracheotomy. Univariate analysis was performed to determine factors that led to a worse outcome.

RESULTS

There were 80 men and 89 women in the cohort, with a median age of 51 years. Of these, 140 patients were admitted to the intensive care unit for a mean duration of 2 days. The common symptoms and signs at presentation were odynophagia and dysphagia (94%), dysphonia (65%), and stridor (33%). Endotracheal intubation was performed in 16 patients, and an awake tracheotomy was required in 4 patients. Dexamethasone acetate was used in 103 patients. Thirty-five patients had diabetes mellitus as a comorbidity. The presence of diabetes was predictive of the need for intubation or tracheotomy (p < 0.05), and the use of steroids was predictive of an intensive care unit stay of 24 hours or less (p < 0.05).

CONCLUSIONS

Fiberoptic laryngoscopy is the gold standard for diagnosis of supraglottitis, and close airway monitoring is crucial. Conservative management of the airway is a viable option, but the presence of diabetes makes airway intervention more likely. The use of steroids aids in symptom alleviation and hastens resolution of airway swelling, with no negative sequelae.

Aspergillus epiglottitis in a non-immunocompromised patient

The authors present a case that highlights an atypical example of a fungal epiglottis in an otherwise well adult patient with no medical history of fungal infection or an immunocompromised state. As current medical literature presents this fungus as only manifesting in the immunocompromised, the authors suggest, by this case report, that fungal pathogens be considered as a potential cause of epiglottitis in non-immunocompromised patients.

Acute epiglottitis: a retrospective review of 47 patients in Kuwait

OBJECTIVES

Acute epiglottitis is a potentially life threatening condition which can lead to fatal airway obstruction in previously healthy individuals. The present study was undertaken to assess the clinical features, management and patient outcomes of epiglottitis in Kuwait over an eight year period.

DESIGN

Case series.

SETTING

Al Sabah Hospital, Kuwait.

METHODS

All patients admitted to the ENT department of Al Sabah hospital between January 2000 and January 2008 with the diagnosis of acute epiglottitis were included in this retrospective study. The diagnosis of acute epiglottitis was established by visualization of inflamed epiglottis either on indirect laryngoscopy or flexible fibreoptic/direct laryngoscopy.

RESULTS

47 cases were identified, 5 children and 42 adults. There were 32 males and 15 females, in the age range of 5 to 66 years. Peak incidence was in the third decade. 31 patients had co-morbid conditions, 18 patients (38.2%) had diabetes, 8 patients (17%) had hypertension and 3 patients (6.3%) had dental caries. Majority of the patients (89.3%) presented with sore throat as their chief complaint. All patients were febrile on presentation. The classical "thumb sign" on lateral neck radiograph was seen in 32 patients (68%). Blood cultures were collected from 22 patients (46.8%), all were negative. Ceftriaxone was the commonest empirical antibiotic prescribed. 7 patients required airway intervention (5 with endotracheal intubation and 2 with tracheostomy). There were no deaths in our study.

CONCLUSION

In Kuwait, acute epiglottis is commoner in adults than in children. It is imperative to secure the airway and to start the patients on broad spectrum antibiotics and steroids as early as possible. In general, the prognosis is good with antimicrobial therapy, close monitoring and selective airway intervention, in the form of intubation / tracheostomy, for patients with stridor or shortness of breath.

[Pseudomembranous supraglottitis with airway compromise in a patient with recurrent tonsillar carcinoma]

PURPOSE

In this report, we discuss a patient with acute pseudomembranous supraglottitis complicating recurrent tonsillar carcinoma and describe the ramifications of these disorders on perioperative management.

CLINICAL FEATURES

The patient was an acutely ill man with a history of right tonsillar carcinoma originally treated with chemoradiation therapy and a radical neck dissection who presented with a brief history of fever, dyspnea, and stridor. The soft tissue of his neck was very stiff, his neck mobility was limited, and his mouth opening was restricted by pain and radiation-induced fibrosis. A nasal flexible fibreoptic laryngoscopy revealed a very large, indurated epiglottis almost completely obstructing the glottis. The aryepiglottic folds and false cords were edematous, and a gray pseudomembranous exudate was observed on the glottic surface, epiglottis, and true vocal cords. An elective tracheostomy was performed in the operating room using local anesthesia, and conscious sedation was avoided because of the potential for complete airway obstruction. General anesthesia was induced after the airway was secured, but trismus and tissue edema resulting from the acute infection made the glottis and surrounding structures nearly impossible to visualize during direct laryngoscopy. The patient was treated with intravenous antibiotics, and a subsequent direct laryngoscopy demonstrated tumour recurrence.

CONCLUSIONS

The case emphasizes that the perioperative management of imminent airway obstruction by acute supraglottitis complicating recurrent oropharyngeal cancer may optimally be approached by establishing a surgical airway under controlled operating conditions.

Airway intervention in adult supraglottitis

BACKGROUND

The timing of aggressive airway intervention in adult epiglottitis is controversial.

AIMS

To correlate Friedman's staging of epiglottitis on admission with the airway interventions undertaken.

METHODS

A retrospective study of 23 adult patients, mean age 51 years (range 29-81 years), who had been admitted with acute supraglottitis between March 1988 and December 2000 was undertaken.

RESULTS

Three patients (13%) had airway interventions; two with tracheostomy and one with tracheal intubation. All were Friedman stage III and had rapid symptom progression during the 24 hours prior to admission. Three other stage III patients with symptom progression longer than 24 hours and all the remaining patients (stage II or less) were managed with observation and intravenous therapy.

CONCLUSIONS

Friedman originally advocated airway intervention in any patient stage II or worse, but this intubation threshold should probably be lowered to those patients with rapid-onset stage Ill (moderate respiratory distress, stridor, respiratory rate > 30 per minute, pCO2 > 45mmHg) disease.

Upper airway diseases and airway management: a synopsis

This article summarizes some of the more important upper airway conditions likely to affect airway management. A number of upper airway conditions may present difficult challenges to the anesthesiologist. For instance, infected airway structures may lead to partial airway obstruction, stridor, or even complete airway obstruction. Partial airway obstruction may be mild, as in snoring or nasal congestion, or may be more severe, perhaps requiring the use of airway adjuncts, such as a nasopharyngeal airway. Complete airway obstruction is usually managed by prompt intubation, but surgical airways are sometimes needed as a last resort.

Acute epiglottitis in adults: the Royal Melbourne Hospital experience

BACKGROUND

To examine the common presentations and management of acute epiglottitis in adults.

METHOD

Retrospective clinical study of 17 consecutive adult patients who presented to the Royal Melbourne Hospital between January 1988 and December 2000 was undertaken.

RESULTS

The mean patient age was 47 years (range 20-87 years) and the male-to-female ratio was 1.8 : 1.0. Peak incidence occurred in September during early spring. All patients presented with sore throat and dysphagia; however, respiratory distress was only noted in 65%. The most common signs were temperature and tachycardia. Four patients (23%) required endotracheal intubation, which was performed electively in three and as an emergency in one. Three of 14 blood cultures were positive, two yielded Haemophilus influenzae type b and one yielded Streptococcus mitis. One of the four throat cultures was positive for Haemophilus influenzae type b. Twelve patients underwent awake flexible laryngoscopy under topical anaesthetic as part of their initial assessment, and there were no complications associated with this procedure. There was no mortality.

CONCLUSIONS

The diagnosis of acute epiglottitis in the adult population is difficult as respiratory distress may be absent. Patients who have a significant sore throat with no obvious aetiology should have direct visualization of their larynx by flexible laryngoscopy. Lateral X-ray of neck is of limited value. Once diagnosed, these patients should be hospitalized and monitored as airway obstruction may develop rapidly.

Practice patterns in managing the difficult airway by anesthesiologists in the United States

Despite the availability of several techniques and devices for the management of the difficult airway, little information has been published regarding the prevalence of their use by anesthesiologists in the United States. To determine current practice patterns, we surveyed clinicians using a questionnaire consisting of 14 difficult airway scenarios. Anesthesiologists were requested to indicate their likely approach to anesthetic induction (e.g., awake but sedated, general anesthesia with spontaneous ventilation, general anesthesia with apnea after assuring a patent airway, or general anesthesia with apnea) and the primary device they would use to intubate (e.g., direct laryngoscopy [DL], flexible fiberoptic bronchoscope [FOB], rigid fiberoptic device, surgical airway, retrograde intubation kit, laryngeal mask airway, gum elastic bougie, or Combitube). The availability of these devices was also determined (in room at all times, available "stat," available if arranged preoperatively, or not available). The survey was mailed to 1000 randomly chosen active members of the American Society of Anesthesiologists. Second and third surveys were mailed to non responders. Four hundred seventy-two completed surveys were returned. Responses by demographic groups were compared by using chi 2 analysis. DL and FOB-aided tracheal intubation techniques were chosen for most cases by most anesthesiologists (P < 0.05). Anesthesiologists with > 10 yr of clinical experience and those older than 55 yr of age preferred DL with apneic conditions (P < 0.05). Anesthesiologists who had attended workshops within the last 5 yr had greater availability of retrograde guidewire equipment and FOBs (P < 0.05). There was little use of newer alternative airway devices.

IMPLICATIONS

Although the teaching of alternative methods of securing a difficult airway has become ubiquitous, most anesthesiologists rely on direct laryngoscopy and fiberoptic-aided intubation in most clinical circumstances. Although workshops in the management of the difficult airway may have resulted in increased use of the fiberoptic bronchoscope and the availability of retrograde guidewire intubation equipment, other devices have not enjoyed such an increase.

Adult epiglottitis in a Canadian setting

The objective of this study was to determine stable estimates of the incidence, case fatality, and epidemiologic features of adult epiglottitis, and risk factors for intubation. The authors designed a retrospective cohort combined with a nested case-control study, followed by detailed analysis of cases from two tertiary care institutions. Among 813 cases, the incidence was 2.02 cases/10(5) population per year. Ten recorded deaths constituted a case fatality rate of 1.2% (95% confidence interval [CI]: 0.5% to 1.9%). The eight fully documented deaths indicated no sudden episodes of catastrophic upper airway obstructions without previous dyspnea. A detailed review of 51 cases revealed that 18% of patients underwent expeditious intubation. Patients managed without initially requiring intubation did not need emergency airway interventions. Only the presence of dyspnea (noted in 29% of patients) at the time of admission (P < 0.001) predicted the need for intubation. A low case fatality rate in a conservatively managed cohort and the absence of sudden upper airway catastrophes in patients without dyspnea suggest that prophylactic intubation and intensive care unit monitoring is not warranted in all patients. An early complaint of dyspnea may safely discriminate between patients requiring invasive airway management and close observation.

Epiglottitis in adults

Acute epiglottitis has become a disease of adults, probably as a result of immunization of children against Haemophilus influenzae. This article is a review of the literature on epiglottitis, including signs and symptoms, investigation, differential diagnosis, and treatment in the emergency department. The microbiology is discussed and the importance of prophylaxis in exposed persons is stressed.

Management of upper airway obstruction using a Seldinger minitracheotomy kit

Two adult patients with upper airway obstruction due to epiglottitis and infectious mononucleosis requiring urgent airway management are presented. Successful establishment of an open airway was achieved by performing a minitracheotomy using the Seldinger technique followed finally with nasotracheal fibreoptic intubation.

Recognition and management of hot liquid aspiration in children

Although infrequently reported, aspiration of hot liquid can occur in conjunction with upper-body scald burns, leading to acute compromise of the small pediatric airway with clinical features similar to those of acute infectious epiglottitis. This can be a very difficult problem if subtle signs of impending airway compromise are not appreciated. Reported here are four such cases managed over a 3-year period at a regional pediatric burn center, emphasizing points of history and physical examination that facilitate early recognition of this life-threatening problem. Aspiration of hot liquid should be suspected in children with burns in or around the mouth, particularly if there are any subtle signs of upper airway edema. If this complication is suspected, immediate endotracheal intubation should be performed in those with acute respiratory embarrassment, and prompt investigation by direct laryngoscopy in the operating room is appropriate in those who have not yet developed overt respiratory distress.

Adult epiglottitis: prompt diagnosis saves lives

Images

Adult epiglottitis and postobstructive pulmonary edema in a patient with severe coronary artery disease

Epiglottitis is a rare cause of upper airway obstruction that may lead to death in the adult. We report the case of a patient with severe coronary artery disease with adult epiglottitis who required emergency endotracheal intubation. Relief of the airway obstruction was followed by the development of postobstructive pulmonary edema. The literature is reviewed and the following recommendations are made: Patients with adult epiglottitis should be intubated in the presence of any respiratory signs or symptoms. All others should be observed in an intensive care unit with a skilled anesthesiologist available to carry out emergency endotracheal intubation. Inhalation induction with halothane in oxygen should be considered initially; failing that, rigid bronchoscopy, tracheostomy, or transtracheal ventilation should be available. Postobstructive pulmonary edema should be anticipated after relief of airway obstruction has occurred; it can be treated with fluid restriction, diuretics, and continuous positive airway pressure.