Acute epiglottitis in the adult: is intubation mandatory?

Acute epiglottitis (AE) in the adult results in inflammation of the supraglottic structures and carries the potential for complete airway obstruction. There is disagreement in the medical literature as to the appropriate management of the airway in the adult with AE. Some authors advocate intubation in all patients while others propose more selective intervention, intubating the trachea only in those patients presenting with airway compromise. We reviewed our institutional experience with 21 patients over the last seven years admitted with a proven diagnosis of AE. Six patients presented with respiratory distress, three in severe distress with symptoms and signs of upper airway obstruction. The three patients in severe distress were taken to the operating room, in two the tracheas were intubated and one underwent tracheostomy after failed intubation. All other patients were monitored but their tracheas were not intubated. The majority of the patients were monitored for 24 hr in the ICU before transfer to wards. No patient initially monitored required tracheal intubation for progression of disease. There were no deaths. Recommendations for the care of the airway in the adult with AE based on our experience and a review of approximately 1000 cases reported in the last ten years are presented. It is our opinion that adults presenting without respiratory symptoms may be safely monitored in an intensive care setting given that provision is made for tracheal intubation or tracheostomy should respiratory distress become evident.