A Review of Airway Management in 73 Cases of Acute Epiglottitis

<p>　　Acute epiglottis can cause sudden upper airway obstruction and death, so that prompt and accurate diagnosis and timely treatment are essential. In previous years, tracheostomy was used to secure the airway in most cases, however, in recent years, endotracheal intubation using an endoscope (endoscopic intubation) has been increasingly adopted. Endoscopic intubation may be effective for securing the airway even in cases with relatively severe laryngeal edema.</p><p>　　We retrospectively reviewed the data of 73 patients diagnosed as having acute epiglottis at our hospital. The subjects were 48 men and 25 women aged 21 to 90 years. The patients were classified according to the endoscopic severity score of Katori et al., as grade 1 (slight swelling of the epiglottis, n=36), grade 2 (moderate swelling of the epiglottis, n=23), or grade 3 (severe swelling of the epiglottis, n=14). The endoscopic severity score of Tanaka et al. was rated as 1 (n=33), 2 (n=9), 3 (n=17), 4 (n=8), or 5 (n=6). Airway intervention was necessary in 13 of the 73 cases, including tracheostomy in 6 cases and endoscopic intubation in 7 cases. Not only tracheostomy, but also endoscopic intubation was confirmed to be useful for securing the airway, even in cases with relatively severe laryngeal edema in which intubation was predicted to be difficult. We believe that treatment of acute epiglottitis by endoscopic intubation requires close co-operation among otolaryngologists, anesthesiologists, and intensive care physicians. In all the 12 cases with grade 3B acute epiglottitis according to Katori's classification, worsening of the laryngeal edema and progression of airway stenosis were observed immediately before the airway intervention, but no significant decrease of the percutaneous arterial oxygen saturation (Sp0₂) or cyanosis was observed in any of the cases. In 7 of 12 cases, even aggravation of the subjective symptoms was not observed. In view of the high frequency of cases in which neither decrease of the percutaneous arterial oxygen saturation nor aggravation of subjective symptoms is observed until just before suffocation, it is considered safe to secure the airway as soon as possible in cases with grade 3B acute epiglottitis. The indications for airway intervention to secure were (1) orthopnea, (2) stridor, (3) dyspnea within 24 hours after the onset of symptoms, (4) severe swelling of the epiglottis and arytenoids (grade 3B according to Katori's classification, and/or a score of 4 or higher according to Tanaka's classification), and (5) grade 2 or greater swelling of the epiglottis according to Katori's classification associated with marked abscess formation. Any one of (1) to (5) is considered as an indication for airway intervention to secure the airway as early as possible.</p>