Advances and controversies in the management of supraglottitis and laryngotracheobronchitis.

Recent advances in pediatric airway intubation and the introduction of pharmacotherapeutic agents, active within the larynx and tracheobronchial tree, have created significant controversies in the treatment of acute obstructive inflammatory laryngeal disease. Although the etiology, pathophysiology, and clinical patterns of supraglottitis and laryngotracheobronchitis are no longer confused, decisions concerning their medical management and method of airway control remain controversial. Both inflammatory disorders are critically examined, with a reveiw of current concepts regarding the choice between endotracheal intubation and tracheotomy. Specific problems of anesthetic technique, criteria for extubation or decannulation, and the rationale for the use of corticosteroids, antibiotics, or racemic epinephrine are evaluated. If mechanical airway control is required, careful attention to initial intubation with a relatively small, cuffless polyvinyl chloride endotracheal tube and precise surgical technique when employing tracheotomy will minimize the overall morbidity. Short term intubation in acute obstructive inflammation of the larynx appears to be well tolerated. Tracheotomy is reserved for the few patients with laryngotracheobronchitis who demonstrate persistent significant subglottic edema.