How is the airway managed in unstable patients with epiglottitis?

Updated: Apr 28, 2020
  • Author: Sandra G Gompf, MD, FACP, FIDSA; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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A patient in extremis requires immediate airway management. Signs and symptoms associated with a need for intubation include respiratory distress, airway compromise on examination, stridor, inability to swallow, drooling, sitting erect, and deterioration within 8-12 hours. The aforementioned study by Sideris et al indicated that in adults with epiglottitis, patients with an abscess, stridor, or a history of diabetes are more likely to require airway intervention. [27]

Enlarged epiglottis on radiographs is associated with airway obstruction. When in doubt, securing the airway is likely the safest approach.

Patients may deteriorate precipitously, and airway equipment, including that for cricothyrotomy, should be present at the patient's bedside. Needle-jet insufflation (also known as percutaneous transtracheal jet ventilation [PTJV]) may also be considered to ventilate the patient temporarily. [5] Intubation or immediate formal tracheostomy or cricothyrotomy may be performed in the operating room if the case is less severe.

In cases of initial failure to intubate by direct laryngoscopy, PTJV may facilitate success in subsequent attempts at tracheal intubation by direct laryngoscopy. PTJV can produce high intratracheal pressures that appear to lift up and open the glottis with escape of the pressurized gasses causing the glottis edges to flutter, thereby allowing improved identification of the glottic aperture.

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