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)
. Theseen-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
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 ICUin 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 anddrooling), the upper airway
(
dyspnea, muffledvoice
)
and infection. “Stridor,” if present, isdif-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) outlinedhere 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
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 specializationand to broaden perspectives.”
I. W. Gardner
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1974;53;674
Pediatrics
David A. Milko, Gabriel Marshak and Theodore W. Striker
Nasotracheal intubation in the Treatment of Acute Epiglottitis
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