Nasotracheal intubation in the Treatment of Acute Epiglottitis

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Nasotracheal

intubation

in the Treatment

of Acute

Epiglottitis

David A. Milko, M.D., Gabriel Marshak, M.D., MS., and Theodore W. Striker, M.D.

From the Departments of Otolaryngology and Maxillofacial Surgery, Pediatrics and Anesthesia,

University of Cincinnati College of Medicine, Cincinnati, Ohio

ABSTRACT. Acute epiglottitis is characterized by fever, rapidly progressing dyspnea and dysphagia. In case of

diffi-culty in confirming the diagnosis of this well-defined entity, a “direct” bedside evaluation of the larynx is safe and defin-itive. In the rare case where respiratory difficulty is present,

conservative medical management is suggested, but only

by an expert team. However, when respiratory difficulty is

present or develops in a patient with confirmed epiglottitis,

a short-term nasotracheal intubation with accompanying

antibiotics is a suitable therapeutic regimen. Pediatrics,

53 :674, 1974, EPIGLOTTITIS, INTUBATION, TRACHEOSTOMY.

Acute epiglottitis is a well-recognized pediatric-otolaryngologic emergency. It is characterized by fever, rapidly progressing dyspnea and dysphagia.

This disease usually starts as a sore throat and

within 12 to 24 hours may result in death by

suffocation if the respiratory difficulty is left

un-attended.

The symptoms of dyspnea and dysphagia are due

to inflammatory edema of the epiglottis and/or

false vocal cords causing obstruction of the

laryn-geal inlet and painful swallowing. The causative

organism is usually Hemophilus influenzae.

Tracheostomy has been the accepted method of

treating the upper airway obstruction associated

with this disease since it was first described by

Sinclair.1 During the past 30 years, several authors

have reported their results of treating acute

epi-glottitis with tracheostomy.13 The mortality rates

were significant, ranging from 10% to 40%. This may

be explained by the failure to recognize the early

symptoms of the disease, the performance of the

tracheostomy under local anesthesia and the

intra-operative and postoperative complications of such

a procedure.

The availability of appropriate antibiotics has

played an important role in reducing the mortality

associated with acute epiglottitis; thus, since 1960

no deaths have been reported in treating this

dis-ease with antibiotics and tracheostomy.46 However,

in contrast to the method in which the

tracheos-tomies were performed in earlier series, these were

performed under general anesthesia with an

in-dwelling endoctracheal tube in place.

In 1969 Traff and Tos reported treating several

patients with acute epiglottitis by nasotracheal

in-tubation rather than tracheostomy.7 They found

that most patients could be extubated within 48

hours with no immediate or late complications.

Tos has recently reported successfully treating

20 patients with acute epiglottitis by nasotracheal

intubation.8 In all of his patients, intubation was

performed in the operating room with general

anes-thesia

(

halothane and nitrous oxide

)

. These

en-couraging reports have prompted us to use this

modality and to review all cases of acute epiglottitis treated at the Children’s Hospital Medical Center in Cincinnati during the last five years.

MATERIAL AND METHODS

From January 1968 until August 1973, a total

of 41 cases of acute epiglottitis was treated at the Children’s Hospital Medical Center. The age and sex distribution of these patients is shown in Table I. This confirms the reports of many authors that

acute epiglottitis is primarily a disease of young

children in the 2- to 4-year age group, with a slight male preponderance.

The earliest symptoms were sore throat and

(Received July 16; revision accepted for publication

Sep-tember 12, 1973.)

ADDRESS FOR REPRINTS: (C.M.) Department of

Oto-laryngology, Cincinnati Ceneral Hospital, 234 Goodman

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TABLE I

SEX-AGE DISTRIBUTION OF PATIENTS WITH EPIGLOTTITIS

ARTICLES 675

fever beginning 12 to 24 hours prior to admission.

These symptoms then rapidly progressed to stridor,

dyspnea, dysphagia, drooling of saliva and

de-velopment of a voice of muffled quality.

Respiratory embarrassment was present in 37

pa-tients at the time of admission. In four patients

respiratory difficulty was absent; these patients

were treated successfully with systemic antibiotics and supportive therapy.

One child was admitted in extremis with cyanosis

and bradycardia. He died in spite of emergency

tracheostomy and all other resuscitating measures.

Table II lists the methods of treatment of the airway obstruction.

The tracheostomies in our series were performed

under general anesthesia after an endotracheal tube

had been inserted in all but two patients; in these

two patients the tracheostomy was performed

rapid-ly under local anesthesia. The tracheostomy tubes

were left in place an average of 7% days, and the

duration of hospitalization averaged 8% days with

no long-term complications.

Five of our patients with acute epiglottitis were treated with nasotracheal intubation. After a

prepar-atory oxygenation period of three to five minutes,

the patient was given a short-acting barbiturate (thiopental), 0.5 mg/kg; atropine, 0.025 mg/kg;

and a depolarizing relaxant (succinylcholine), 2

mg/kg. A polyvinyl nasotracheal tube (Portex),

one size smaller than that predicted for the

pa-tient’s age, was then inserted in the intensive care

unit (ICU

)

. The patients were kept in the ICU

in a saturated, humidified atmosphere and

main-tamed on intravenous fluids, occasionally

supple-mented with oral fluids. The nasotracheal tube,

which was safely secured to the nose with a suture,

required as meticulous care as a tracheostomy.

Sedation was utilized in all patients who were not

hypercarbic and usually was accomplished by

in-travenous administration of pentobarbital (4 to 8

mg/kg) . Restraints were not used.

All patients were examined by direct

laryn-goscopy during the course of intubation at least

daily to determine the adequacy of the airway and

the time for extubation. Following extubation, the

patients were kept in a high-humidity atmosphere

for 24 to 48 hours. Sedation was continued for 24

hours after extubation to reduce reactivity.

The nasotracheal tubes were left in place an

average of 36 to 40 hours. The average length of

the entire hospitalization for these patients was 6%

days, and no complications were observed. As more

experience was gained, however, we realized that,

indeed, patients could be discharged one to two

days after extubation.

Four of our patients were treated by observation.

Age (r ) .t’Iales I’ema1es Total

0-2 11 6 17

3-4 9 C) 18

5-6 4 2 6

7-12 Total 0 24 () 17 0 41

These patients were not in respiratory distress on

admission; but acute epiglottitis was suspected by

the history and confirmed by the physical

examina-tion. The presence of H. influenzae in the blood

and hypopharynx was later established by the

laboratory. The average length of hospitalization for these patients was four days.

Cultures were obtained from all patients treated

for epiglottitis : H. influenzae type b was isolated

from the blood and the hypopharynx in 33 patients

(80%) . In the other eight patients where blood

cultures were not obtained, streptococcus strains,

Staphylococcus aureus, and Diplococcus pneumoniae

were isolated from the hypopharynx.

All patients were treated with systemic

anti-biotics, most frequently ampicillin, after

appropri-ate cultures had been obtained. Systemic steroids

were administered on admission, only when

respir-atory embarrassment was severe, but were not

given as a continuous or prolonged therapy plan.

DISCUSSION

Acute epiglottitis of childhood is a characteristic

clinical entity consisting of signs of involvement

of the hypopharynx

(

dysphagia, odynophagia and

drooling), the upper airway

(

dyspnea, muffled

voice

)

and infection. “Stridor,” if present, is

dif-ferent from the one caused by vocal cord disease

and is also quite typical. Thus, there should be

little, if any, difficulty recognizing this symptom complex. The diagnosis can almost always be

con-firmed by examination of the hypopharynx with a

tongue depressor, as was the case in all our

pa-tients. Lateral neck 910 could be

help-ful in cases where the diagnosis cannot be

con-firmed in this manner, providing the patient will

be monitored continuously by personnel capable

TABLE II

TREATMENT OF THE AIRWAY OBSTRUCTION IN PATIENTS WITH EPIGLOTTITIS

Trac/zeostomy Intubation Observation Total

32 5 4 41

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of securing an airway. This should be considered

as cortditio sine qua non because of the rapidity

with which laryngeal obstruction may occur. We

also feel that the bedside direct visualization of

the larynx

(

and intubation, if necessary) outlined

here could probably be of great help in cases

where the diagnosis cannot be established by in-direct examination.

In recent series of patients with acute epiglottitis treated with antibiotics and tracheostomy, there were no reported deaths.46 However, the great majority of these patients had been intubated prior

to the tracheostomy. Indeed, intubation is a major

factor in the favorable results, because the airway has been secured prior to starting the procedure,

in addition to making the operative procedure

easier. After securing the airway by intubation, tracheostomy is still an operation entailing a cer-tam intraoperative risk; deaths during the

proce-dure have been reported even in recent

It is also known that tracheal stenosis may occur

at the site of stoma’2 (most common in young

children), as well as at the level of the distal end of the tracheostomy 13 However, these

com-plications are rarely seen in a short-term

tracheos-tomy. The problem of decannulation is well known

and, indeed, increases the longer the child has

worn the tracheostomy tube.

Endotracheal intubation is also associated with complications, the most serious of which is laryn-geal and/or tracheal 415 These, however, are rarely seen in short-term intubation.1#{176} Several

studies have shown that these are most likely to

occur if the tube is large and/or rigid, or if there

is a constant movement between the tube and

mucosa, as with positive-pressure mechanical

respi-ration or in an active, restless hil718

This report and rs78 have shown that the

life-threatening upper airway obstruction of acute epiglottitis is of short duration once treatment has

been initiated; the mean duration of intubation

was 36 to 40 hours. The size of the nasotracheal

tube used was smaller than that predicted by the

child’s age, thin-walled and malleable at body

tem-perature. In addition, all patients were sedated, thus

reducing movement of the tube against the

laryn-gotracheal mucosa, and minimizing the psychologic

problems associated with the intensive care

situa-tion and provision of an artificial airway. Drugs

used for sedation should be chosen to avoid

respira-tory depression : one choice being pentobarbital

in-travenously administered (4 to 8 mg/kg) or chloral

hydrate

(

5 to 10 mg/kg).

No immediate or delayed complications were seen, but a transient, mild hoarseness has been reported and should be considered as a sequela

of the postintubation pe16 Although the need

for prolonged intubation did not arise, nor was

re-ported, we feel that in that case a tracheostomy should be seriously considered. In early stages of the disease where there is no respiratory distress, we feel, as does Smith,19 that conservative medical

management without securing the airway should be

considered, but only in the presence of an expert

team. When a patient with confirmed epiglottitis

presents or develops respiratory difficulty, the treat-ment of choice should be nasotracheal intubation.

SUMMARY

Acute epiglottitis of childhood is a well-defined, clinical entity characterized by rapidly progressing

dyspnea and dysphagia. In case of difficulty in

confirming the diagnosis by hypopharyngeal

exami-nation

(

which was not the case in our series

)

, a

“direct” bedside evaluation of the larynx as

out-lined is recommended. Lateral neck radiographs

can be of help but only when constant monitoring

of the patient by an expert team is available. This

is mandatory because of the rapidity with which

respiratory difficulty appears.

During the last five years, 41 patients with acute

epiglottitis were admitted to the Children’s

Hos-pital Medical Center in Cincinnati. One patient

died and 40 patients recovered without complica-lions. Four required only antibiotics and supportive

measures and 37 required artificial upper airway:

thirty-two by tracheostomy and 5 with nasotracheal intubation.

Because the critical period of the epiglottic and supraglottic edema is less than 48 hours, a short-term nasotracheal intubation with accompanying

antibiotic is a suitable therapeutic regimen. The

intubation can be performed in the ICU where

the patient should be kept for observation by the

appropriate personnel including anesthesiologists, otolaryngologists and pediatricians. This technique should not be considered to supplant the

perfor-mance of tracheostomy in the hands of those

opera-tors more familiar with its performance and

main-tenance.

REFERENCES

1. Sinclair, S. E. : Haemophilus influenzae type b in acute

laryngitis with bacteremia. J.A.M.A., 117:170, 1941.

2. Miller, A. H. : Haemophilus influenzae type b epiglottitis

or supraglottic laryngitis in children.

Laryngo-scope, 58:514, 1948.

3. Alexander, H. E., and Ellis, C. Leidy: Treatment of

type specific Hemophilus influenzae infections in

infancy and childhood. J. Pediat., 20:673, 1942.

4. Berenberg, W., and Kevy, S. : Acute epiglottitis in

child-hood : Serious emergency readily recognized at

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ARTICLES 677

5. Vetto, R. R. : Epiglottitis: A report of thirty-seven cases.

J.A.M.A., 173-990, 1960.

6. Baxter, J. D. : Acute epiglottitis in children.

Laryngo-scope, 77:1358, 1967.

7. Traff, B., and Tos, M. : Nasotracheal intubation in acute

epiglottitis. Acta Otolaryng., 68:363, 1969.

8. Tos, M. : Nasotracheal intubation in acute epiglottitis.

Arch. Otolaryng., 97:373, 1973.

9. Rapkin, R. H. : Acute epiglottitis: Pitfalls in diagnosis

and management. Clin. Pediat., 10:312, 1971.

10. Rapkin, R. H. : The diagnosis of epiglottitis: Simplicity

and reliability of radiographs of the neck in the

differential diagnosis of the Croup syndrome. J.

Pediat., 80:96, 1972.

11. Tucker, J. A., and Silberman, H. D. : Tracheotomy. In

Ferguson, C. F., and Kendig, E. L., Jr. (eds.):

Pediatric Otolaryngology. Philadelphia: W. B.

Saunders Company, 1972, pp. 1219-1230.

12. Stowe, D. C., Kenan, P. D., and Hudson, W. B. :

Corn-plications of tracheostomy. Amer. J. Surg., 36:34,

1970.

13. Meade, J. W. : Tracheotomy: Its complications and their

management: A study of 212 cases. New Eng. J.

Med., 265:519, 1961.

14. Lindholrn, C. E. : Prolonged endotracheal intubation.

Acta Anaesth. Suppl., 33:1, 1969.

15. Fearon, B. : Airway problems in children following

pro-longed endotracheal intubation. Ann. Otol., 75:

964, 1966.

16. Striker, T. W., Stool, S., and Downes, J. J. : Prolonged

nasotracheal intubation in infants and children.

Arch. Otolaryng., 85:210, 1967.

17. Harley, H. R. S. : Laryngotracheal obstruction

compli-cating tracheostomy or endotracheal intubation.

Thorax, 26:493, 1971.

18. McGovern, F. H., Fitz-Hugh, C. S., and Edgemon, L.

J.: The hazards of endotracheal intubation. Ann.

Otol., 80:556, 1971.

19. Smith, D. S. : Editorial comment. J. Pediat., 81:1153,

1972.

“A farsighted administrator can and does take action

to prevent excessive compartmentalization. He

or-ganizes to break down calcified organizational lines.

He shifts personnel

(

perhaps even establishes a system of rotation) to eliminate unnecessary specialization

and to broaden perspectives.”

I. W. Gardner

SELF-RENEWAL: THE INDIVIDUAL AND THE INNOVATIVE SOCIETY

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1974;53;674

Pediatrics

David A. Milko, Gabriel Marshak and Theodore W. Striker