Chapter 1: Airway

Case 1-1: Adult supraglottitis

Patient Presentation

A young adult presented with difficulty breathing. The patient became ill 24 hours prior to presentation with a fever and a progressively worsening sore throat.

Clinical Features

The patient was extremely anxious appearing, sitting upright, and drooling. The patient was in severe respiratory distress with marked inspiratory stridor and unable to phonate. Breath sounds were clear but diminished and difficult to hear secondary to transmitted upper airway noise.

Differential Dx

• Supraglottitis

• Epiglottitis

• Foreign body

• Viral laryngotracheitis

• Retropharyngeal abscess

• Odontogenic infection

• Bacterial tracheitis

• Uvulitis

• Ludwig angina

• Angioedema

• Peritonsillar abscess

Emergency Care

This patient’s severe respiratory distress with upper airway obstruction mandated immediate airway management with the working diagnosis of supraglottitis. Rapid sequence intubation was performed utilizing video laryngoscopy. Supraglottitis was visualized with a severely swollen epiglottis and arytenoids. A bougie device was inserted blindly into what was thought to be the glottic opening, and an endotracheal tube was placed over the bougie device into the trachea. The vocal cords of this patient were never visualized. Antibiotics and steroids were administered, and the patient was admitted to the intensive care unit.

Outcome

The patient made an uneventful recovery.

Key Learning Points

• Airway management in adult supraglottitis is challenging.

• The bougie device is a simple yet invaluable tool in difficult airway management. As in this case, it can be blindly placed by slipping it under the epiglottis with the coudé tip of the bougie pointed anteriorly. The intubator can get tactile confirmation of tracheal bougie placement as the coudé tip rubs against the anterior tracheal rings. In addition, a firm endpoint encountered upon bougie advancement also indicates correct placement.

• Additional airway adjuncts should be available at the bedside in the management of adult supraglottitis, including the intubating laryngeal mask airway (ILMA), the King airway, as well as equipment for surgical airway management via cricothyrotomy.

Further Reading