A 28-year-old man comes to the emergency department due to respiratory distress. A week ago, he developed a sore throat that has progressively worsened. Over the last hour, he has had difficulty breathing. The patient was diagnosed with HIV at age 23 and has been inconsistent with daily antiretroviral therapy. Temperature is 38.3 C (101 F), pulse is 126/min, and respirations are 30/min. Pulse oximetry is 78% on room air. The patient is leaning forward with his neck extended; he is also drooling and speaking in a hoarse voice. The posterior oropharynx has overlying white plaques. There are suprasternal retractions. Examination of the lungs reveals diminished breath sounds bilaterally. Pulse oximetry remains at 78% with 100% oxygen bag-valve-mask ventilation. Endotracheal intubation using a video laryngoscope is attempted but is unsuccessful. Pulse oximetry subsequently decreases to 70% with continued bag-valve-mask ventilation. Which of the following is the best next step in management of this patient?

Question

A 28-year-old man comes to the emergency department due to respiratory distress.  A week ago, he developed a sore throat that has progressively worsened.  Over the last hour, he has had difficulty breathing.  The patient was diagnosed with HIV at age 23 and has been inconsistent with daily antiretroviral therapy.  Temperature is 38.3 C (101 F), pulse is 126/min, and respirations are 30/min.  Pulse oximetry is 78% on room air.  The patient is leaning forward with his neck extended; he is also drooling and speaking in a hoarse voice.  The posterior oropharynx has overlying white plaques.  There are suprasternal retractions.  Examination of the lungs reveals diminished breath sounds bilaterally.  Pulse oximetry remains at 78% with 100% oxygen bag-valve-mask ventilation.  Endotracheal intubation using a video laryngoscope is attempted but is unsuccessful.  Pulse oximetry subsequently decreases to 70% with continued bag-valve-mask ventilation.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient with HIV had a week of progressive sore throat and then developed acute hypoxemic respiratory failure with tripod position, drooling, and hoarseness, raising strong suspicion for epiglottitis, a cellulitis of the epiglottis, aryepiglottic folds, and other adjacent tissue. Swelling of these structures often leads to rapid airway deterioration; therefore, airway management is the main priority. In patients unable to maintain adequate oxygen saturations, bag-valve-mask ventilation (BVM) with 100% oxygen (to keep oxygen saturation ≥~88%) should be initiated. If BVM does not result in adequate oxygenation (ie, oxygen saturation remains low, as in this patient), endotracheal intubation using a video laryngoscope (to facilitate direct visualization of the epiglottis) should be attempted. However, given the risk of rapid respiratory deterioration, failure of a single attempt at endotracheal intubation with a video laryngoscope (as in this patient) should immediately prompt the establishment of a surgical cricothyrotomy by the most experienced provider available (preferably an otolaryngologist or general surgeon). Cricothyrotomy establishes an airway below the epiglottal swelling and potential obstruction. Once the airway is stabilized, antimicrobial therapy is needed to clear the infection. This patient with untreated HIV has evidence of epiglottitis due to Candida (eg, white plaques on the oropharynx). In addition to antifungal therapy, he would also likely receive broad-spectrum antibacterial agents (eg, vancomycin, ceftriaxone) given the severity of the condition and the possibility of a secondary bacterial infection. (Choice B) Laryngeal mask airway should not be used because it is a supraglottic airway device (above the obstruction). (Choice C) Bilevel positive pressure is not able to overcome a significant epiglottal obstruction and is not recommended in patients who are hypoxic and fail an endotracheal airway. Surgical airway is required. (Choice D) Multiple attempts at endotracheal intubation with a video laryngoscope are not recommended because this would delay adequate oxygenation in a patient who is severely hypoxic. A surgical airway should be established when a single attempt at video-assisted endotracheal intubation fails. If intubation without a video laryngoscope fails, intubation with a video laryngoscope could be attempted. (Choice E) Blind nasotracheal intubation is not recommended because the swollen epiglottis must be visualized in order to effectively pass an endotracheal tube. Educational objective: Patients with epiglottitis who develop rapid-onset respiratory failure (eg, tripod position, hypoxia, drooling, tachypnea) require urgent airway management. This includes bag-valve-mask ventilation with 100% oxygen followed by endotracheal intubation with advanced equipment (eg, video laryngoscope). A single failed attempt at video-assisted endotracheal intubation should prompt surgical cricothyrotomy, which bypasses the epiglottal swelling and potential obstruction.

A 28-Year-Old Man Comes to the Emergency Department Due to Respiratory