BMJ 2013;347:f5235 doi: 10.1136/bmj.
f5235 (Published 19 September 2013)
Endgames
CASE REPORT
Acute epiglottitis
Robert Charles core trainee year 2, anaesthetics, Marc Fadden foundation year 1 trainee, Jacqueline
Brook consultant, anaesthetics
Anaesthetic Department, Dewsbury District Hospital, Dewsbury WF13 4HS, UK
A 30 year old man presented to the emergency department with
a two day history of fever, sore throat, and progressive difficulty
in swallowing. He had no allergies and had taken one dose of
benzylpenicillin, prescribed by his general practitioner, earlier
that day. His medical history included recurrent tonsillitis, which
had been treated with antibiotics; he smoked 15 cigarettes a
day.
On initial examination he had tachycardia (115 beats/min) and
fever (38.5C). The remainder of his respiratory and
cardiovascular examination was normal. Oropharyngeal
examination showed a swollen uvula and enlarged red tonsils
without pus. There was no lip or tongue swelling and no obvious
rash.
Ten minutes later he developed progressively worsening stridor.
He was unable to complete sentences and was drooling. His
respiratory rate was 34 breaths/min and his oxygen saturation
was 89% on 15 L oxygen. A wheeze was present throughout
his chest. He was still tachycardic at 120 beats/min and his blood
pressure had increased to 170/100 mm Hg. Administration of
adrenaline nebulisers improved the stridor slightly. Blood
cultures were taken and intravenous antibiotics and steroids
administered. A working diagnosis of acute epiglottitis was
made; an urgent anaesthetic and ear, nose, and throat (ENT)
review was requested.
Questions
1 What are the causes and clinical features of acute
epiglottitis?
2 What other inhalational therapy could be instituted to
improve oxygenation?
3 How should this patient be managed further?
Correspondence to: R Charles robertcharles@nhs.net
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ENDGAMES
Answers
1 What are the causes and clinical features
of acute epiglottitis?
Short answer
Acute epiglottitis can be caused by bacteria (such as
Haemophilus influenzae type B), viruses (such as herpes
simplex), fungi (such as Candida albicans), and non-infectious
insults (such as physical trauma, chemicals, and heat). Clinical
features include stridor, dyspnoea, and drooling.
Long answer
Acute epiglottitis may progress rapidly into life threatening
upper airway obstruction. The incidence of epiglottitis in
children in the United Kingdom has fallen considerably since
the implementation of the Haemophilus influenzae type B (HIB)
vaccine in 1992.1 Incidence peaks at 2-8 years and 35-39 years
of age.2
The abrupt onset of oedema and inflammation of the epiglottis
and surrounding tissues can progress to total airway obstruction.
Clinical features of acute epiglottitis include stridor, dyspnoea,
hoarseness, fever, sore throat, odynophagia, dysphagia, drooling,
and cervical lymphadenopathy. General malaise and a globus
sensation often precede presentation. Signs of respiratory distress
or sepsis (or both) may be evident.3 It can be difficult to
distinguish epiglottitis from more benign causes of sore throat
and dysphagia. This may lead to delays in presentation or
referral from primary care and a subsequent increase in
mortality. The timing and severity of the progression should
give vital clues.2
The causes of acute epiglottitis can be broadly split into two
categoriesinfective and non-infective. The infective causes
are mainly bacterial, most notably HIB. The list of other
potential bacterial causes is extensive and includes -haemolytic
streptococci (groups A, B, and C), Staphylococcus aureus, and
Streptococcus pneumoniae. Viruses (including herpes simplex)
and fungi (Aspergillus spp and Candida albicans) should be
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BMJ 2013;347:f5235 doi: 10.1136/bmj.f5235 (Published 19 September 2013)
considered. Blood cultures taken before the administration of
antimicrobial therapy allow treatment to be tailored to the
particular organism responsible.1. Non-infective causes are
mostly associated with trauma to the upper airway, such as
foreign bodies, burns (inhalation and chemical), and chemical
irritation. Risk factors include absence of immunisation, an
immunocompromised state, and smoking.4
2 What other inhalational therapy could be
instituted to improve oxygenation?
Short answer
Owing to the physics of flow, in a partially obstructed airway,
heliox should reduce the work of breathing and result in larger
tidal volumes and improved gas exchange.
Long answer
Heliox is a mixture of helium and oxygen that is usually supplied
in cylinders with a helium to oxygen ratio of 79:21 or 70:30.
Helium is less dense than oxygen and also has a higher
viscosity.5-7 Although not widely available, it can be useful in
the management of upper airway obstruction. It is not a
definitive treatment but can buy valuable time.
Heliox has been used since the 1930s for respiratory conditions,
including upper airway obstruction, asthma, chronic obstructive
pulmonary disease, and croup. Its benefits may include
decreased work of breathing owing to decreased negative
pressure requirements to initiate inspiration, increased tidal
volumes, and improved gas exchange.5-7
The benefits of heliox are explained by the physics of flow.
Flow of a gas is laminar, transitional, or turbulent. Laminar flow
is the most efficient; it is more likely to occur at low flow rates
and is viscosity dependent.5 It is described by the
Hagen-Poiseuille formula:
Q = Pr4/8l
Where, flow (Q) in a tube is proportional to the pressure
difference (P) and the fourth power of the radius (r); and
inversely proportional to the viscosity () and length (l).
The Reynolds number (Re) determines the type of flow that is
likely to occur at any given point. It is a dimensionless value
and is determined by the following equation:
Re = vd/
Where, Re is proportional to the density (), velocity (v) and
diameter (d); and inversely proportional to the viscosity ().
A value less than 2000 indicates laminar flow and a value greater
than 4000 indicates turbulent flow. Between these values there
is a mixture of laminar and turbulent flow, called transitional
flow. The ratio of viscosity to density, the kinetic viscosity, is
greater for heliox than for air or oxygen.5 6 This means that
heliox will produce a lower Re and is more likely to produce
laminar flow for a given velocity and tube diameter than air or
oxygen. Heliox is more efficacious at higher helium
concentrations and for very tight constrictions.6 7
Epiglottitis produces an upper airway obstruction resulting in
turbulent flow and therefore increased work of breathing. The
use of heliox should make laminar flow more likely and reduce
the work of breathing.7
Heliox should be delivered through a high flow system including
a tight fitting mask. This ensures sufficient flow to meet the
patients requirements and avoids air entrainment. Supplemental
oxygen can be delivered via a nasal cannula, although hypoxia
is likely to be a sign of imminent airway obstruction. Entrained
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ENDGAMES
air or supplemental oxygen will increase the density of the heliox
mix and reduce its beneficial effects.6-8
3 How should this patient be managed
further?
Short answer
Actual or impending airway obstruction requires an immediate
definitive airway, which needs to be carefully planned. The
procedure should occur in a safe place, such as the operating
theatre, with the appropriate senior staff, equipment, and skill
sets. In less severe cases, patients may be managed
conservatively.
Long answer
It was decided that this patient had impending airway obstruction
and required an immediate definitive airway, either as an
endotracheal tube or a tracheostomy, ideally performed in the
operating theatre. Management of milder airway obstruction is
open to debate but may be managed conservatively with
success.4 Management options must be carefully considered
because rapid complete airway obstruction is a possibility.
There are no definitive predictors of sudden airway obstruction
in epiglottitis, although symptoms such as stridor indicate a
degree of airway compromise.2 4 9 It could be argued that elective
intubation in a controlled environment is the safest option.2
However, this is not without serious risk and may be associated
with prolonged hospital stay and greater morbidity.7
Conservative management and observation in a place of safety,
such as a critical care unit, carries the risk of sudden complete
airway obstruction.2 4
If a definitive airway is required, the patient should be
considered to have a difficult airway. The airway procedure
should be planned and subsequent backup plans included. This
should ideally take place in the operating theatre, where senior
anaesthetic, surgical, and nursing staff are present and the
appropriate equipment is available.4 10-12 Fibreoptic flexible
nasendoscopy should be considered to facilitate diagnosis and
assess the degree of obstruction.2 10
The relative merits of awake intubation versus intubation after
induction of general anaesthesia should be considered. Awake
fibreoptic intubation may be preferred but requires a cooperative
patient and skilled personnel.2 10 Risks associated with this
procedure include failure, inadequate topical anaesthesia, over
sedation (if used), complete occlusion of an already narrowed
airway, and damage to surrounding inflamed structures.2 4 If the
decision is made to intubate during general anaesthesia,
inhalational induction may be preferable to intravenous
induction, with the patient breathing spontaneously.2 This allows
rapid reversal if difficulty arises. The risks associated with this
include a comparatively long excitement phase during which
the patient may develop laryngospasm or aspirate.4 9 Rapid
sequence induction has been performed in patients with
epiglottitis. This may be associated with multiple or prolonged
attempts at direct laryngoscopy, with an increased risk of
morbidity and mortality.10 11 Tracheostomy under local
anaesthetic may be a safer option.10
Any of these strategies may fail, so an alternative plan should
be available. In all cases, if oxygenation and ventilation are
compromised, the Difficult Airway Society guidelines for a
cant intubate, cant ventilate situation should be followed.11
This may necessitate a surgical tracheostomy.2 10
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BMJ 2013;347:f5235 doi: 10.1136/bmj.f5235 (Published 19 September 2013)
Patient outcome
As predicted, the patient had a difficult airway. He was taken
to theatre for inhalational induction with ENT support on
standby. In spite of poor views with the fibreoptic scope and
laryngoscope, the airway was successfully secured with an
endotracheal tube. He was transferred to intensive care, where
he continued to receive antibiotics and steroids. He was
successfully extubated after 48 hours. Discharge was arranged
with ENT follow-up four days after the initial presentation.
Competing interests: We have read and understood the BMJ Group
policy on declaration of interests and have no relevant interests to
declare.
Provenance and peer review: Not commissioned; externally peer
reviewed.
Patient consent obtained.
1 McVernon J, Trotter C, Slack M, Ramsey M. Trends in Haemophilus influenzae type b
infections in adults in England and Wales. BMJ 2004;329:655-8.
2 Mathoera RB, Wever PC, van Dorsten FRC, Balter SGT, de Jager CPC. Epiglottitis in
the adult patient. Neth J Med 2008;66:373-7.
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ENDGAMES
3 Sack J, Brock C. Identifying acute epiglottitis in adults. High degree of awareness, close
monitoring are key. Postgrad Med 2002;112:181-6.
4 Park KW, Darvish A, Lowenstein E. Airway management for adult patients with acute
epiglottitis: a 12-year experience at an academic medical center (1984-1995).
Anaesthesiology 1998;88:254-61.
5 Hess DR, Fink JB, Venkartaraman ST, Kim IK, Myer RT, Tano BD. The history of and
physics of heliox. Respir Care 2006;51:608-12.
6 Reuben AD, Harris AR. Heliox for asthma in the emergency department: a review of the
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7 Smith SW, Buros M. Relief of imminent respiratory failure from upper airway obstruction
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8 Fink FB. Opportunities and risks of using heliox in your clinical practice. Respir Care
2006;51:651-60.
9 Ames WA, Ward VMM, Tranter RMD, Street M. Adult epiglottitis: an under-recognized,
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10 Cook TM, Woodall N, Frerk C, eds. Fourth national audit project of the Royal College of
Anaesthetists and the Difficult Airway Society. Major complications of airway management
in the UK: report and findings. 2011:204-16. www.rcoa.ac.uk/system/files/CSQ-NAP4-
Full.pdf.
11 Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult airway society guidelines for
management of the unanticipated difficult intubation. Anaesthesia 2004;59:675-94.
12 American Society of Anesthesiologists Tasks Force on Management of the Difficult Airway.
Practice guidelines for management of the difficult airway. Anaesthesiology
2003;98:1269-77.
Cite this as: BMJ 2013;347:f5235
BMJ Publishing Group Ltd 2013
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