Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

initial presentation

1st line – secure airway

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ACUTE
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initial presentation
1st line – 

secure airway

No action should be taken that could stimulate a child with suspected epiglottitis. Epiglottitis is a clinical diagnosis and laboratory or other interventions should not preclude or delay timely control of the airway if epiglottitis is suspected. This includes examination of the oral cavity, starting intravenous lines, blood draws, or even separation of a child from a parent. Similar caution is required in fulminant acute epiglottitis in adults. The patient should be kept in an upright position as supine positioning can aggravate airway obstruction.[23]

Direct rigid laryngoscopy and intubation are most commonly performed. Flexible fiber-optic examination should only be performed with great caution in adults only.

The treatment chosen will be dictated by the patient's clinical situation and the facility's capabilities. Mask ventilation followed by intubation is often the first choice.

Adult patients may have a more indolent presentation, and may not always require airway intervention (only about 10% of adults require airway intervention whereas most children do).[4]​​[24] Unnecessary airway intervention in adults may increase morbidity and mortality, given the relatively high intubation failure rate of one in 25.[24] However, adults may be at risk for airway obstruction and sudden decline due to supraglottic inflammation and edema. They should be transferred to ICU level care (with the ability to perform airway intervention) for ventilatory management if they are intubated, or for observation if not intubated in case of deterioration.[25][26]

Tracheotomy/cricothyroidotomy may be performed in an emergency in patients who cannot be safely intubated.

Rarely, a patient will fail the initial extubation trial or the airway may not be ready for extubation after 72 hours and prolonged intubation until the patient meets criteria may be warranted.

Plus – intravenous antibiotics

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ACUTE
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initial presentation
Plus – 

intravenous antibiotics

Treatment recommended for ALL patients in selected patient group

Antibiotics are advocated as empiric therapy and their use will depend on susceptibility of cultures taken.[1][27]​​ Vancomycin or clindamycin may be used in patients who are allergic to penicillin.[28]​​

Institutions often have their own regimens of antibiotics, depending on local resistance. An infectious disease physician can be consulted and local guidelines followed for proper antimicrobial coverage because combination antibiotic therapy is a potential consideration in a patient with epiglottitis. Until culture-driven therapy is possible, broad-spectrum coverage may be recommended to include Haemophilus influenzae and Staphylococcus aureus.

Primary options

cefotaxime: children: 150-200 mg/kg/day intravenously given in divided doses every 6-8 hours; adults: 1-2 g intravenously every 6-12 hours; maximum 12 g/day

OR

ceftriaxone: children with mild to moderate infections: 50-75 mg/kg/day intravenously given in divided doses every 12-24 hours; children with severe infections: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours; adults: 1-2 g intravenously given in divided doses every 12-24 hours; maximum 4 g/day

OR

ampicillin/sulbactam: children: 100-200 mg/kg/day intravenously given in divided doses every 6 hours; adults: 1.5 to 3 g intravenously every 6 hours; maximum 12 g/day

OR

oxacillin: children: 200 mg/kg/day intravenously given in divided doses every 6 hours; adults: 2 g intravenously every 6 hours; maximum 12 g/day

OR

nafcillin: children: 100 mg/kg/day intravenously given in divided doses every 6 hours; adults: 2 g intravenously every 6 hours; maximum 12 g/day

OR

clindamycin: children: 15-25 mg/kg/day intravenously given in divided doses every 6 hours; adults: 600 mg intravenously every 6 hours

OR

vancomycin: children: 40 mg/kg/day intravenously given in divided doses every 6-8 hours; adults: 2 g/day intravenously given in divided doses every 6-12 hours

-- AND --

cefotaxime: children: 150-200 mg/kg/day intravenously given in divided doses every 6-8 hours; adults: 1-2 g intravenously every 6-12 hours; maximum 12 g/day

or

ceftriaxone: children with mild to moderate infections: 50-75 mg/kg/day intravenously given in divided doses every 12-24 hours; children with severe infections: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours; adults: 1-2 g intravenously given in divided doses every 12-24 hours; maximum 4 g/day

Consider – supplemental oxygen

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ACUTE
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initial presentation
Consider – 

supplemental oxygen

Treatment recommended for SOME patients in selected patient group

Supplemental oxygen and possibly heliox may be used as a temporizing measure. This is a viable option in a stable patient without signs of impending airway compromise.

Consider – corticosteroids

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ACUTE
|
initial presentation
Consider – 

corticosteroids

Treatment recommended for SOME patients in selected patient group

While not proven in controlled trials, corticosteroids may be used to reduce supraglottic inflammation per clinician discretion.[9]

Primary options

dexamethasone: children: 0.08 to 0.3 mg/kg/day orally given in divided doses every 6-12 hours; adults: 0.75 to 9 mg/day orally given in divided doses every 6-12 hours according to response

ONGOING

once stable and extubated

1st line – oral antibiotics

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ONGOING
|
once stable and extubated
1st line – 

oral antibiotics

Once the patient is not intubated and tolerating orals, further antibiotics can be given to be taken at home.

Primary options

amoxicillin/clavulanate: children: 25-45 mg/kg/day orally given in divided doses every 12 hours; adults: 500-875 mg orally every 12 hours

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OR

cefaclor: children: 20-40 mg/kg/day orally given in divided doses every 8-12 hours; adults: 250-500 mg orally every 8 hours

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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