Presentation outside ICU/operating theatre:

1. High FIO2

2. If collapsed or in extremis: immediate orotracheal intubation. If impossible, emergency cricothyroidotomy or tracheostomy.

3. If symptomatic but not in extremis: consider cause and treat as appropriate, e.g. fibreoptic or rigid bronchoscopy for removal of foreign body, surgery for thyroid mass. Elective orotracheal intubation or tracheostomy may be required.

4. With acute epiglottitis, the use of a tongue depressor or nasendoscopy may precipitate complete obstruction so should be undertaken in an operating theatre ready to perform emergency tracheostomy. The responsible organism is usually Haemophilus influenzae and early treatment with chloramphenicol should be begun. Acute epiglottitis is recognised in adults, even those of advanced age.

5. Consider Heliox (79%He/21%O2) alone or as a supplement to oxygen to reduce viscosity and improve airflow.

Presentation within ICU/operating theatre:

1. If intubated:

• Pass suction catheter down the endotracheal tube, assess ease of passage and the contents suctioned. If the tube is patent, attempt repeated suction interspersed with 5ml boluses of 0.9% saline. Urgent fibreoptic bronchoscopy may be necessary for diagnosis and, if possible, removal of a foreign body. If this cannot be removed by fibreoptic bronchoscopy, urgent rigid bronchoscopy should be performed by an experienced operator. If the endotracheal tube is obstructed, remove the tube, oxygenate by face mask then reintubate.

2. If not intubated :

• As for out-of-ICU presentation.

• If recently extubated, consider laryngeal oedema. Post-extubation laryngeal oedema is unpredictable though occurs more commonly after prolonged or repeated intubation; the incidence may be reduced by proper tethering of the endotracheal tube and prevention of excessive coughing. If diagnosed (by nasendoscopy), dexamethasone 4mg x 3 doses over 24h may reduce the swelling though re-intubation is often necessary in the interim.


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