S Mehmood, J Moriarty
acute airway obstruction in adults, acute epiglottitis
S Mehmood, J Moriarty. Case Series Of Acute Epiglottitis In Immunized Adults. The Internet Journal of Emergency and Intensive Care Medicine. 2005 Volume 9 Number 2.
Acute epiglottitis in adults is an uncommon condition but potentially life threatening. The condition is of particular concern to anaesthetists and intensivists as it can rapidly progress to upper airway obstruction. We describe the presentation and management of three cases of acute epiglottitis in immunized adults all of which were associated with significant upper airway obstruction.
Acute epiglottitis has traditionally been described as a paediatric disease. It is rare in developed countries and in adults. Its incidence is increasing with 0-7% mortality. Now a day it is due to either failed or lack of immunization. The common pathogens responsible for this disease are; Haemophilus influenzae, Haemophilus parainfluenzae and Streptococcus pneumoniae.
Although pharyngitis is the most common cause of sore throat in the adults, acute epiglottitis must be considered in the differential diagnosis when there is unrelenting throat pain and minimal objective signs of pharyngitis(1). Patients with acute painful dysphagia should be considered to have epiglottitis until proven otherwise. Early diagnosis and aggressive airway management can be life saving.
We review three cases of acute epiglottitis in immunized adults who presented at our institution during six months. It is important for anaesthetists and intensive care specialists to be able to manage upper airway obstruction resulting from acute epiglottitis and have a clear understanding of the aetiology and the pathophysiology of this condition.
A 24 year old male presented with one day history of sore throat, dysphagia, drooling of saliva and pyrexia. . His airway was assessed to be at risk. In the operating theatre inhalation induction was used ,but cords could not be visualized so anaesthesia was maintained with sevoflurane and a surgical tracheostomy was performed successfully. Patient was transferred to the intensive care unit and was discharged to ward on the third day. On fifth day nasal flexible endoscopy showed minimal swelling of epiglottis with normal cords. The tracheostomy was removed on ninth day and he was discharged home two days later. H.influenzae was isolated from blood culture and treated with Cefotaxime.
A 22 years old female presented to Emergency department with three days history of dysphagia and drooling of saliva. She was assessed immediately by ENT and aesthetic teams. Flexible nasal endoscopy showed an inflamed epiglottis. She received oxygen, hydrocortisone and cefotaxime. In operating theatre her airway was secured with an oral endotracheal tube following inhalation induction with sevoflurane in 100% oxygen. She was transferred to the Intensive Care Unit where she was ventilated for two days. Blood and throat swabs were sent for culture.
She was extubated on third day and discharged to ward. On fifth day flexible nasal endoscopy demonstrated some inflammation of the epiglottis. On seventh day she was discharged to home. Blood cultures were negative. Streptococcus pneumoniae was isolated from the throat swab and treated with cefotaxime for seven days.
A 33 years old male presented to the Emergency department with a four day history of being unwell with pyrexia and drooling of saliva. He was unable to phonate. He was treated immediately with intravenous hydrocortisone, oxygen, racemic adrenaline and cefotaxime. Flexible nasal endoscopy showed swelling of the supraglottic area, with oedema of the cords. He was intubated in theatre following an inhalation induction with sevoflurane in 100% oxygen. He was transferred to the Intensive Care unit, where he was extubated after forty eight hours and discharged to ward. Flexible nasal endoscopy on fifth day showed a normal epiglottis.Haemophilus.influenzae was isolated from blood culture and treated with cefotaxime.
As a result of childhood immunization against Haemophilus influenzae type b, acute epiglottitis has become primarily a disease of adults (2). The widespread use of the Hib vaccine in children has contributed to the dramatic reduction in the incidence of epiglottitis during the last decade. However, because most adults have not been immunized against Hib, they are still susceptible and may experience acute epiglottitis. In Singapore, Haemophilus influenzae Type b (Hib) immunization is not routine, and thus the increased prevalence in adults cannot be attributed to Hib immunization(3).Although supraglottitis is rare in adults, it is nevertheless associated with a significant mortality rate (1.2% to 7.1%).Early recognition of epiglottitis and timely intervention is critical. Acute epiglottitis is diagnosed by visualizing the epiglottis and supraglottic structures with a fibreoptic Naso- laryngoscope, which reveals red, swollen epiglottis. Laryngoscopy should be performed in an operating room, and preparation made for immediate intubation or emergency tracheostomy.
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 (4).
Measurement of arterial blood gases is not helpful in making early diagnosis or in predicting the severity of the disease, because they deteriorate late in the course. However, if PaCO2 starts rising then patient's airway patency may be jeopardized and prompt intubation is indicated.
A variety of organisms have been implicated in acute epiglottitis, but no definitive organism is identified in most cases. The most likely isolated organisms are; H influenzae, and beta-hemolytic streptococcus from the pharynx. In most cases, uncomplicated supraglottitis responds rapidly to medical management and resolves in few days. Ampicillin was the drug of choice in past, but with the development of increasing resistance against beta-lactamase, second and third generation cephalosporin's are now first line agents. Intravenous fluids are required to maintain hydration.
Intravenous corticosteroids are often used as anti-inflammatory agents. The use of corticosteroids, however, is controversial. Corticosteroid therapy is thought to act by an anti-inflammatory effect, coupled with stabilization of endothelial permeability, thus decreasing extra cellular and intracellular oedema. Many studies, however, have shown no reduction in the need for intubation, the duration of intubation, the duration of intensive care stay, or the duration of hospitalization after corticosteroids (5).
Racemic adrenaline should be used with caution because its rebound effect can result in rapid and fulminating airway obstruction. Successful management requires teamwork between the primary care physician and personnel skilled in intubation as well as timely consultation with an experienced otolaryngologist. Laryngoscopy and intubation always should be performed by the most skilled personnel because repeated attempts may increase obstruction(6). Awareness of the possibility of epiglottitis in adults and close monitoring of the airway are the keys to management of this potentially life threatening condition. There is disagreement in the medical literature as to the appropriate management of the airway in the adult with acute epiglottitis. Some authors advocate intubation in all patients while others propose more selective intervention, intubating the trachea only in those patients presenting with airway compromise(7).The role of airway intervention in adults is controversial.
There are authors who prefer a conservative management with antibiotics, corticosteroids and humidified oxygen, others plead for an aggressive airway management with early intubation.Mortality among children has dropped from 7.1 to 0.9% since the use of prophylactic airway intervention. A mortality of 1-7% among adults has been described but in patients with acute respiratory obstruction it was 17 %. Respiratory distress, strider, sitting erect, inability to swallow secretions and deterioration within 8-12 hours are the major signs and symptoms associated with the need for intubation.When in doubt we think early intubation is the safest approach to prevent death (5).
We recommend that all cases of suspected acute epiglottitis should be diagnosed by fibreoptic nasolaryngoscopy, followed by early endotracheal intubation and start antibiotic cover for H.influenzae irrespective of patient's vaccination status. Early intubation is the safest approach rather than conservative management, as this is a life threatening condition.
Dr. S. Mehmood Email: firstname.lastname@example.org