Emergency airway management (1)

Abstract

Stone are to be commended on their prudent and practical review of the topic of airway management outside of the operating room. ~ However, the one conclusion that we did not find ourselves in agreement with the authors on concerned the management of the adult patient with epiglottis. Bogdonoff and Stone seem to support routine intubation of the adult with epiglottitis. This differs from our management which has been one of selective intubation. 2It has been our institutional experience that adults with epiglottitis always present with severe sore throat and less commonly (29% of patients) is respiratory distress a presenting feature. It is our impression that adults usually come to hospital earlier in the course of the illness than do children, are more able to communicate their distress than are young children and are less likely to present with the dramatic airway compromise seen in the paediatric patient with epiglottitis. The diagnosis in the adult may be safely made with indirect (mirror) examination or with nasal fibreoptic laryngoscopy and, although this is well tolerated in the adult, direct examination of the paediatric airway in the emergency room is ill-advised. Adult patients without evidence of respiratory distress should be provided with supplemental humidified oxygen, intravenous antibiotics are started and they should be observed in a critical care setting. There must be the capability to intervene quickly to secure the airway should airway compromise occur. It is our opinion, shared by others, that "sudden respiratory arrest" usually occurs in patients presenting already in extremis or in those presenting in respiratory distress, who are then admitted to hospital without close observation. 3 Our experience, which is supported by a review of 812 cases from the otolaryngology literature, suggests that intubation, properly carded out in adult patients presenting with respiratory distress, will be required in about 20% of patients.