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.