APPROPRIATE HEALTH CARE: Acute epiglottitis is a medical emergency. Hospitalize during acute illness in ICU.
GENERAL MEASURES:
β’ Each institution should have emergency protocol involving a team of emergency room physicians,
pediatricians, anesthesiologists, surgeons, pediatric intensivists, and pediatric ICU nurses (principles are
similar for pediatric and adult patients)
β’ Call anesthesiologist to bedside
β’ Have equipment for intubation and needle cricothyrotomy or percutaneous tracheostomy at bedside
β’ Notify OR
β’ Notify pediatric surgery or ENT for standby in OR in case tracheostomy becomes necessary
β’ Keep patient quiet, calm, sitting up (in parentβs arms)
β’ Avoid venipuncture, blood gases, oxygen masks, intravenous lines, injections, monitors, and radiographs
β’ Judicious use of sedation that does not depress respirations may be appropriate
β’ Racemic epinephrine is without benefit
β’ Avoid examining the pharynx
β’ Transport patient and parent together to OR in a wheelchair
β’ Intubate all patients, preferably in OR under controlled circumstances by experienced anesthesiologist with
surgery or ENT on standby for emergency tracheostomy
β’ Tracheostomy not indicated unless intubation unsuccessful
β’ Tape airway securely in place and use a bite block if indicated
β’ Splint elbows and restrain arms to avoid self-extubation
β’ Use humidity in a tent and avoid T-piece (traction increases risk of accidental extubation)
β’ CPAP, mechanical ventilation, and sedation usually unnecessary
β’ Pay attention to supervision and pulmonary toilet/suctioning to minimize risk of endotracheal tube plugs
SURGICAL MEASURES : Emergency tracheotomy may be necessary
DIET : IV fluid initially, then nasogastric feedings while intubated
DRUG(S) OF CHOICE:
β’ Begin empiric antibiotic promptly after blood and epiglottic cultures are obtained. Antibiotics guided by
cultures thereafter. Duration of antimicrobial: 7 days
β’ Cefotaxime (Claforan) 100-200 mg/kg/day q 8 hours IV
β’ Ceftriaxone (Rocephin) 50-100 mg/kg/day q 12 hours IV
β’ Ampicillin-sulbactam (Unasyn) 150 mg/kg/day q 6 h IV
β’ Amoxicillin-clavulanate 100 mg/kg/day q 8 h IV
ALTERNATIVE DRUGS :
β’ Ampicillin 100 mg/kg/day divided q 6 hours IV and chloramphenicol 100 mg/kg/day divided q 6 hours.
Follow levels. May stop chloramphenicol only if H. influenzae b sensitive to ampicillin.
β’ Steroids and racemic epinephrine of no benefit
β’ Antipyretics if necessary
PATIENT MONITORING:
β’ Rule out secondary foci of infection
β’ Follow swallowing ability and presence of an air leak around endo/nasotracheal tube
β’ Followup laryngoscopy prior to extubation (advocated by some)
β’ Observe in ICU for 24 hours following extubation
PREVENTION/AVOIDANCE:
β’ H. infl uenzae vaccine is effective though not 100% protective
β’ Rifampin prophylaxis (20 mg/kg once daily for 4 days, maximum daily dose 600 mg) for all household and
day care contacts. Family and close contacts may be asymptomatic carriers of H. influenzae .
POSSIBLE COMPLICATIONS:
β’ Pneumonia, meningitis, cervical adenitis, septic arthritis, pericarditis, cellulitis (rare)
β’ Epiglottic abscess
β’ Septic shock (in about 1%)
β’ Pneumothorax, pneumomediastinum (very rare)
β’ Death from asphyxia
EXPECTED COURSE/PROGNOSIS:
β’ Most can be extubated after 24 to 48 hours
β’ Morbidity and mortality is low with appropriate intervention