Epiglottitis and Awake Intubation

Mikhail Podlog, DO                Anna Van Tuyl, MD

Let's start with a case..

HPI:  41 year old male with no PMH presents to ED for sore throat and fever measured at home for 3 days. Patent was seen at urgent care yesterday and was prescribed azithromycin and prednisone for pharyngitis. Today patient started complaining of swelling in his throat and difficulty breathing so came to the emergency department for evaluation. No cough, chest pain, abdominal pain, nausea, or vomiting. No allergies, new food, or new medication.

Vital signs:       T 100.6 Oral     HR 103    RR 26    BP 170/87    SaO2 95% on RA

Physical Exam:  “Erythematous pharynx with elongation of the uvula. Muffled voice. Tender anterior cervical adenopathy”. Otherwise unremarkable exam.

Progress Notes:  ENT called to bedside for laryngoscopy. Patient found to have swollen and beefy red epiglottis with tight airway. Recommendation made for prophylactic intubation

Diagnosis:  Epiglottitis

Management: Treatment consists of three parts: airway, antibiotics, steroids.

airway.jpg

The first priority is protecting the airway. The swelling can cause airway obstruction; therefore prophylactic intubation is frequently performed. Because intubation can be difficult, the safest approach is to perform it in the operating room with surgery on standby if an emergency surgical airway is needed. If this is not an option, the safest approach is to perform an awake intubation. During an awake intubation, the patient is consciously sedation but because they are not paralyzed they maintain their respiratory drive. Therefore, if the intubation is unsuccessful, they can continue to maintain their respiratory drive.

Awake intubation steps

  1. Dry the oropharynx - This not only helps with better visualization during intubation but allows the numbing medication to work better
    1. Glycopyrrolate 0.2 mg IV push - anticholinergic agent without CNS effect, takes about 10-20 minutes to take effect
    2. Use gauze in patients mouth to dry it as much as possible
  2. Blunt gag reflex
    1. Zofran 4-8 mg IV push
  3. Numb the oropharynx - once mucosa is dry
    1. Nebulized lidocaine
      1. 5 cc of 2-4% lidocaine
      2. Can use 2% lidocaine with epinephrine to vasoconstrict mucosa and decrease swelling
    2. Viscous lidocaine
      1. Draw up 3-5 cc of 2% viscous lidocaine in syringe and use plastic angiocath to drip down back of tongue
      2. Can alternatively place 3-5 cc of 2% viscous lidocaine on tongue depressor and place upside down on tongue and let drip down
    3. Mucosal atomization device
      1. Advance blade into pharynx slowly and spray about 5 cc of 2-4% lidocaine as you progress towards the vallecula, epiglottis, and cords
  4. Sedate
    1. Similar to procedural sedation
    2. Can use ketamine alone
      1. Start with 10-20 mg IV and push an additional 5-10 mg every minute or so as needed
    3. Ketafol (ketamine with propofol in a 1:1 to a 3:1 ratio)
      1. If using a 10 mg/mL concentration of both sedatives, mix in desired ration and place mixture in 10 cc syringe
      2. Start with 1-2 mL IV and push an additional 5-10 mg every minute or so as needed
    4. Other options include midazolam with fentanyl, or dexmedetomidine
  5. Oxygenation
    1. Preoxygenate with NRB or CPAP (with NC)
    2. Optimally position for oxygenation
    3. Maintain NC at 15L/min for entire procedure
  6. Intubation
    1. Option 1 - Video laryngoscopy
      1. Use buogie and then place endotracheal tube over bougie
    2. Option 2 - Nasal fiberoptic intubation - if you have a fiberoptic scope you can use this route
      1. Spray nasal phenylephrine prior to sedation
      2. Use nasal trumpte coated with viscous lidocaine during preoxygenation to numb nasal cavity, then remove when ready to intubate
      3. Preload endotracheal tube onto fiberoptic cable and nasally intubate
      4. Preloading the endotracheal tube allows you to confirm that it is inserted past the vocal cord by visualizing them as you withdraw the fiberoptic cable
    3. Confirm tube placement!
  7. Sedate

Patient should then be started on empiric combination therapy with a third generation cephalosporin (ceftrimraxone, cefotaxime) and staphylococcal coverage with strong consideration for MRSA coverage (clindamycin, vancomycin).  Corticosteroids such as dexamethasone are frequently administered and have been show to decrease length of stay in the ICU and overall.

Back to the case..

Patient's course: Awake intubation was attempted in the emergency department by the ED attending. Below is a short clip of what was seen on video laryngoscopy.

Even after multiple attempts, awake intubation was unsuccessful so patient was taken to the operating room for fiberoptic intubation with surgery on standby. The patient was successfully intubated and started on Clindamycin, vancomycin, and Decadron. The patient was successfully extubated 2 days later, down graded to a regular floor, and discharged home 2 days later on oral antibiotics. Patient was doing well at one month follow up.