Adult Acute Epiglottitis: Predictors for Airway Intervention and Intensive Care Unit Admission

Abstract

Objectives

(1) to characterise the clinical features of acute epiglottitis in adults in Hong Kong; (2) to identify predictors for airway intervention and uneventful recovery without intensive care unit (ICU) admission. Modified Early Warning Score (MEWS) was also applied in risk stratification.

Methods

A retrospective cohort study of 122 consecutive laryngoscopically confirmed cases admitted to Pamela Youde Nethersole Eastern Hospital from 1998 to 2007.

Results

The mean patient age was 51 years (range 18–84 years) and the male-to-female ratio was 1.9 to 1. Sore throat, dysphagia and odynophagia were the commonest symptoms and the median MEWS on presentation was 1 (range 0–10). Nine patients (7.4%) required airway intervention (5 orotracheal intubations, 2 nasotracheal intubations and 2 tracheostomies) and one patient died. Univariate analysis showed that recurrent attack (OR 35.0, 95% CI 2.77–442.69, p=0.013), dyspnoea (OR 17.41, 95%CI 2.09–144.79, p=0.001), stridor (OR 30.0, 95%CI 2.42–372.65, p=0.016) and MEWS equal to or greater than 4 (OR 5.81. 95%CI 1.16–29.17, p=0.049) were significantly associated with airway intervention. Only stridor remained a reliable predictor in multivariate analysis (OR 88.46, 95%CI 5.48–1427.45, p=0.001). Performance of MEWS in prediction for airway intervention was evaluated with the Receiver Operating Characteristic (ROC) curve. The area under curve (AUC) was 0.71 (95%CI 0.503–0.909). Forty-five patients did not require ICU admission (36.9%). Multiple logistic regression showed that absence of hoarseness (OR 3.10, 95%CI 1.10–8.79, p=0.033), absence of fever (OR 3.2, 95%CI 1.25–8.16, p=0.015) and MEWS <1 (OR 7.07, 95%CI 1.31–38.07, p=0.023) were predictors of uneventful recovery without ICU care.

Conclusion

A selective approach should be adopted in airway management but those with stridor on presentation should have their airway secured without delay. MEWS cannot replace clinical judgement but a low MEWS on presentation may help in identifying low risk patients who can be managed safely without ICU admission.

Keywords

Adult Airway Obstruction Intratracheal intubation Risk Factors

References

Chung

C.H.

Case and literature review: adult acute epiglottitis - rising incidence or increasing awareness?

Hong Kong J Emerg Med 2001; 8(3): 227–31.

Wong

Y.T.

, Chiu

L.H.

, Lau

M.Y.

A&E clinical guideline No.15. Management of acute epiglottitis. The Hospital Authority of Hong Kong. [updated 2006 Nov]. [cited 2009 Jun 3]. Available from: The Hospital Authority of Hong Kong Intranet: http://ha.home/ho/ps/cp/Epiglottitis.pdf.

Frantz

T.D.

, Rasgon

B.M.

Acute epiglottitis: changing epidemiologic patterns. Otolaryngol Head Neck Surg 1993; 109(3 Pt 1): 457–60.

Andreassen

U.K.

, Baer

, Nielsen

T.G.

, Dahm

S.L.

, Arndal

Acute epiglottitis - 25 years experience with nasotracheal intubation, current management policy and future trends. J Laryngol Otol 1992; 106(12): 1072–5.

Black

M.J.

, Harbour

, Remsen

K.A.

, Baxter

J.D.

Acute epiglottitis in adults. J Otolaryngol 1981; 10(1): 23–7.

Murrage

K.J.

, Janzen

V.D.

, Ruby

R.R.

Epiglottitis: adult and pediatric comparisons. J Otolaryngol 1988: 17(4): 194–8.

Mayo-Smith

Fatal respiratory arrest in adult epiglottitis in the intensive care unit. Implications for airway management. Chest 1993; 104(3): 964–5.

Ames

W.A.

, Ward

V.M.

, Tranter

R.M.

, Street

Adult epiglottitis: an under-recognised, life-threatening condition. Br J Anaesth 2000; 85(5): 795–7.

Deeb

Z.E.

, Yenson

Y.C.

, Defries

H.O.

Acute epiglottitis in the adult. Laryngoscope 1985; 95(3): 289–91.

10.

Subbe

C.P.

, Kruger

, Rutherford

, Gemmel

Validation of a modified early warning score in medical admissions. QJM 2001; 94(10): 521–6.

11.

Gardner-Thorpe

, Love

, Wrightson

, Walsh

, Keeling

The value of modified Early Warning Score (MEWS) in surgical in-patients: a prospective observational study. Ann R Coll Surg Engl 2006; 88(6): 571–5.

12.

Lam

T.S.

, Mak

P.S.K.

, Siu

W.S.

, Lam

M.Y.

, Cheung

T.F.

, Rainer

T.H.

Validation of a Modified Early Warning Score (MEWS) in emergency department observation ward patients. Hong Kong J Emerg Med 2006; 13(1): 24–30.

13.

Shapiro

, Eavey

R.D.

, Baker

A.S.

Adult supraglottitis. A prospective analysis. JAMA 1988; 259(4): 563–7.

14.

Torkkeli

, Ruoppi

, Nuutinen

, Kari

Changed clinical course and current treatment of acute epiglottitis in adults: a 12-year experience. Laryngoscope 1994; 104(12): 1503–6.

15.

Woo

J.K.

, van Hasselt

C.A.

Adult epiglottitis: A misnomer. Otolaryngol Head Neck Surg 1994; 111(4): 538–9.

16.

Senior

B.A.

, Radkowski

, MacArthur

, Sprecher

R.C.

, Jones

Changing patterns in pediatric supraglottitis: a multi-institutional review, 1980 to 1992. Laryngoscope 1994; 104(11 Pt 1): 1314–22.

17.

Gorelick

M.H.

, Baker

M.D.

Epiglottitis in children, 1979 through 1992. Effect of Haemophilus influenzae type b immunization. Arch Pediatr Adolesc Med 1994; 148(1): 47–50.

18.

Gonzalez Valdepena

, Wald

E.R.

, Rose

, Ungkanont

, Casselbrant

M.L.

Epiglottitis and Haemophilus influenzae immunization: the Pittsburgh experience - a five-year review. Pediatrics 1995; 96(3 Pt 1): 424–7.

19.

Takala

A.K.

, Peltola

, Eskola

Disappearance of epiglottitis during large-scale vaccination with Hemophilus influenzae type B conjugate vaccine among children in Finland. Laryngoscope 1994; 104(6 Pt 1): 731–5.

20.

Alho

O.P.

, Jokinen

, Pirilä

, Ilo

, Oja

Acute epiglottitis and infant conjugate Haemophilus influenzae type b vaccination in northern Finland. Arch Otolaryngol Head Neck Surg 1995; 121(8): 898–902.

21.

Hugosson

, Olcén

, Ekedahl

Acute epiglottitis - aetiology, epidemiology and outcome in a population before large-scale Hemophilus influenzae type b vaccination. Clin Otolaryngol 1994; 19(5): 441–5.

22.

Kucera

C.M.

, Silverstein

M.D.

, Jacobson

R.M.

, Wollan

P.C.

, Jacobsen

S.J.

Epiglottitis in adults and children in Olmsted County, Minnesota, 1976 through 1990. Mayo Clin Proc 1996; 71(12): 1155–61.

23.

Nakamura

, Tanaka

, Matsuda

, Fukushima

, Hasegawa

Acute epiglottitis: a review of 80 patients. J Laryngol Otol 2001; 115(1): 31–4.

24.

Katori

, Tsukuda

Acute epiglottitis: analysis of factors associated with airway intervention. J Laryngol Otol 2005; 119(12): 967–72.

25.

Lau

Y.L.

, Low

L.C.

, Yung

, Ng

K.W.

, Leung

C.W.

, Lee

W.H.

Invasive Hemophilus influenzae type b infections in children hospitalized in Hong Kong, 1986–1990. Hong Kong Hib Study Group. Acta Paediatr 1995; 84(2): 173–6.

26.

Berger

, Landau

, Berger

, Finkelstein

, Bernheim

, Ophir

The rising incidence of adult acute epiglottitis and epiglottic abscess. Am J Otolaryngol 2003; 24(6): 374–83.

27.

MayoSmith

M.F.

, Spinale

J.W.

, Donskey

C.J.

, Yukawa

, Li

R.H.

, Schiffman

F.J.

Acute epiglottitis. An 18-year experience in Rhode Island. Chest 1995; 108(6): 1640–7.

28.

Frantz

T.D.

, Rasgon

B.M.

, Quesenberry

C.P.

Jr Acute epiglottitis in adults. Analysis of 129 cases. JAMA 1994; 272(17): 1358–60.

29.

H.L.

, Sin

L.M.

, Li

M.F.

, Que

T.L.

, Anandaciva

Acute epiglottitis in adults: A retrospective review of 106 patients in Hong Kong. Emerg Med J 2008; 25(5): 253–5.

30.

Chang

Y.L.

, Lo

S.H.

, Wang

P.C.

, Shu

Y.H.

Adult acute epiglottitis: experiences in a Taiwanese setting. Otolaryngol Head Neck Surg 2005; 132(5): 689–93.

31.

Hébert

P.C.

, Ducic

, Boisvert

, Lamothe

Adult epiglottitis in a Canadian setting. Laryngoscope 1998 (1 Pt 1);108: 64–9.

32.

Price

I.M.

, Preyra

, Fernandes

C.M.

, Woolfrey

, Worster

Adult epiglottitis: a five-year retrospective chart review in a major urban centre. Can J Emerg Med 2005; 7(6): 387–90.

33.

Baxter

F.J.

, Dunn

G.L.

Acute epiglottitis in adults. Can J Anaesth 1988; 35(4): 428–35.

34.

Ducic

, Hebert

P.C.

, MacLachlan

, Neufeld

, Lamothe

Description and evaluation of the vallecula sign: a new radiologic sign in the diagnosis of adult epiglottitis. Ann Emerg Med 1997; 30(1): 1–6.

35.

Trollfors

, Nylén

, Carenfelt

, Foglé-Hansson

, Freijd

, Geterud

Aetiology of acute epiglottitis in adults. Scand J Infect Dis 1998; 30(1): 49–51.

36.

Musharrafieh

U.M.

, Araj

G.F.

, Fuleihan

N.S.

Viral supraglottitis in an adult: a case presentation and literature update. J Infect 1999; 39(2): 157–60.

37.

Chan

K.O.

, Pang

Y.T.

, Tan

K.K.

Acute epiglottitis in the tropics: is it an adult disease?

J Laryngol Otol 2001; 115(9): 715–8.

38.

MayoSmith

M.F.

, Hirsch

P.J.

, Wodzinski

S.F.

, Schiffman

F.J.

Acute epiglottitis in adults. An eight year experience in the state of Rhode Island. N Engl J Med 1986; 314(18): 1133–9.

39.

Navarrette

M.L.

, Quesada

, Garcia

, Lorente

Acute epiglottitis in the adult. J Laryngol Otol 1991; 105(10): 839–41.

40.

Kass

E.G.

, McFadden

E.A.

, Jacobson

, Toohill

R.J.

Acute epiglottitis in the adult: experience with a seasonal variation. Laryngoscope 1993; 103(8): 841–4.

41.

Dort

J.C.

, Frohlich

A.M.

, Tate

R.B.

Acute epiglottitis in adults: diagnosis and treatment in 43 patients. J Otolaryngol 1994; 23(4): 281–5.

42.

Solomon

, Weisbrod

, Irish

J.C.

, Gullane

P.J.

Adult epiglottitis: the Toronto Hospital experience. J Otolaryngol 1998; 27(6): 332–6.

43.

Park

K.W.

, Darvish

, Lowenstein

Airway management for adult patients with acute epiglottitis: a 12-year experience at an academic medical center (1984–1995). Anesthesiology 1998; 88(1): 254–261.

44.

Crosby

, Reid

Acute epiglottitis in the adult: is intubation mandatory?

Can J Anaesth 1991; 38(7): 914–8.

45.

Department of Health. Comprehensive critical care: a review of adult critical care services. London: Department of Health; 2000. [cited 2009 Jun 1]. Availale from: http://www.publications.doh.gov.uk/pdfs/criticalcare.pdf.

46.

Intensive Care Society. Guidelines for the introduction of outreach service. London: Intensive Care Society, 2002. [cited 2009 Jun 1]. Available from: http://www.ics.ac.uk/icmprof/downloads/icsstandards-outreach.pdf.

47.

Baudouin

, Evans

Improving outcomes for severely ill medical patients. Clin Med 2002; 2(2): 92–4.

48.

Knaus

W.A.

, Draper

E.A.

, Wagner

D.P.

, Zimmerman

J.E.

APACHE II: a severity of disease classification system. Crit Care Med 1985; 13(10): 818–29.

49.

Le Gall

J.R.

, Loirat

, Alperovitch

, Glaser

, Granthil

, Mathieu

A simplified acute physiology score for ICU patients. Crit Care Med 1984; 12(11): 975–7.

50.

Subbe

C.P.

, Davies

R.G.

, Williams

, Rutherford

, Gemmell

Effect of introducing the Modified Early Warning Score on clinical outcomes, cardio-pulmonary arrest and intensive care utilisation in acute medical admissions. Anaesthesia 2003; 58(8): 797–803.