ORIGINAL RESEARCH—PEDIATRIC OTOLARYNGOLOGY
Airway management in pediatric epiglottitis:
A national perspective
Jason L. Acevedo, MD, Lina Lander, ScD, Sukgi Choi, MD, and
Rahul K. Shah, MD, Washington, DC; and Omaha, NE
rent demographics and resource utilization in the treatment of
Case series from a national database.
SUBJECTS AND METHODS:
was systematically searched to extract patients under 19 years old
admitted with a diagnosis of epiglottitis and undergoing an airway
Three hundred forty-two sampled admissions were
for epiglottitis; 40 of these patients were under the age of 19 and
had an airway intervention (intubation or tracheotomy). On aver-
age, patients were 4.3 years old (SD ? 6.0 years). The average
length of stay was 15.6 days (SD ? 33.9 and range ? 0-199) with
average total charges of $74,931 (SD ? $163,387, range ? $3342-
$938,512). Multivariate analysis revealed that admission to a chil-
dren’s facility, admission other than via the emergency room, and
nonemergent admission were associated with increased total
charges. Twenty-two states reported an admission for pediatric
epiglottitis that required airway intervention.
In our sample, only 40 patients were identi-
fied who were under the age of 19 years and required an airway
intervention for the treatment of epiglottitis. Epiglottitis is a rare,
expensive, and protracted disease to treat in the postvaccine era.
The unique nature of this disease has implications for training
future surgeons on proper management of this potentially fatal
The purpose of this study was to describe cur-
The Kids’ Inpatient Database
No sponsorships or competing interests have been disclosed for
© 2009 American Academy of Otolaryngology–Head and Neck
Surgery Foundation. All rights reserved.
(HiB) vaccine in 1985, the incidence of epiglottitis has
rapidly changed. After the introduction of the vaccine, the
rate of epiglottitis, as would be expected, dropped precipi-
tously. In Australia, the rate of epiglottis in children under
5 years of age decreased to 3.3 per 100,000, from a rate of
6.6 per 100,000.1A 1990 Canadian study by Wurtele2
suggested a postvaccination incidence of 6 per 100,000 in
children and 1 per 100,000 in adults, as well as a relative
ince the introduction of the Haemophilus influenzae
increase in the ratio of adult to pediatric cases, a finding
echoed in another Australian series by Wood et al.3Changes
have also been described in the United States, as noted by
Shah et al,4who described an increase in the average age of
pediatric epiglottitis patients in Boston, MA, which was
largely attributed to the HiB vaccine. Although the literature
clearly describes an overall decrease in the incidence of
epiglottitis, several authors have been cautious to point out
that this does not represent elimination of this disease.4,5
Despite advances in therapy, epiglottitis remains relevant,
and the otolaryngologist continues to be instrumental in the
management of this disease.
There have been reported changes in the epidemiology of
epiglottitis, but there are currently no national studies de-
scribing the demographics of pediatric epiglottitis in the
post-HiB era. More specifically, no studies exist describing
the demographic of patients requiring airway intervention in
the treatment of epiglottitis, a topic of interest to the oto-
laryngologist. These changing demographics may have sig-
nificant implications for resident training, patient triage, and
Of interest, there are also no studies describing resource
utilization in the treatment of this disease process. Resource
utilization is a concept that is increasingly gaining momen-
tum in the medical literature. It is based on the concept of a
rigid analysis of the cost of treating a disease in relation to
patient and hospital variables. This methodology has been
used to broaden the knowledge regarding disease states in
the otolaryngology literature as well as in cardiology and
pediatrics.6-8To date, there are no studies describing either
resource utilization or a national perspective in the manage-
ment of pediatric epiglottitis.
Institutional review board approval was obtained. The source
of the data used is the Kids’ Inpatient Database (KID) from the
Healthcare Cost and Utilization Project created by the Agency
Received September 18, 2008; revised December 8, 2008; accepted December 16, 2008.
Otolaryngology–Head and Neck Surgery (2009) 140, 548-551
0194-5998/$36.00 © 2009 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
for Healthcare Research and Quality.9The KID is an all-payer
national database of inpatient pediatric admissions, encom-
passing 36 states in the year 2003. The KID includes 3,428
hospitals and 2,984,129 pediatric discharges. The KID was
systematically searched using the International Classifica-
tion of Disease, Ninth Revision (ICD-9) diagnosis codes
464.30 (acute epiglottis without mention of obstruction) and
464.31 (acute epiglottitis with mention of obstruction).
From this subset of patients, the incidence at varying ages
from 0 years old to 19 years old was examined.
To reduce the potential for coding inconsistencies and
to select for the patients with an acute airway, the addi-
tional inclusion criterion of airway intervention was ap-
plied. This was accomplished using the ICD-9 Classifi-
cation of Procedure code for either intubation (96.04) or
tracheotomy, temporary or permanent (31.1 and 31.29).
A final sample of patients who met both inclusion criteria
was evaluated in this study. No exclusion criteria were
applied. Total charges were used as a surrogate for re-
source utilization. A P value of ?0.05 was used to
indicate a significant predictor of increased total charges.
Univariate and multivariate regression models were fit to
determine which factors were associated with increased
In the KID 2003, 342 patient admissions were identified
with a diagnosis of epiglottitis. Of these, 40 patients were
identified who required either intubation or tracheotomy and
were under the age of 19. The mean age of these patients
was 4.3 years, with 63 percent under the age of 2. Sex
distribution was roughly equal; 53 percent of patients were
male. The racial breakdown showed that 48 percent of patients
were white. The mean length of stay was 15.6 days, with a
that are associated with increased total charges are presented
(Table 1). Seasonal variation was noted, with January and
August being the most common months for admission. Re-
gional variations were also noted; Texas, Massachusetts, and
New York had the most inpatient admissions. The average
total charges were $74,931, with a range from $3,343 to
$938,512. Private insurance companies were the primary pay-
ers in 45 percent of admissions. Academic institutions bore the
brunt of management of these complex patients, with 55 per-
cent of patients managed at teaching hospitals.
In a univariate analysis, only the National Association of
Children’s Hospitals and Related Institutions hospital type
revealed statistically significant differences in total charges.
Univariate analysis of predictors of increased total charges in the airway management of pediatric epiglottitis
Variable Number of patientsTotal charges (mean, SD)P value
Median income quartile
Source of admission
Type of admission
1st or 2nd
3rd or 4th
Children’s hospital or ward
$ 41,981 (46,495)
$ 57,879 (104,523)
$ 49,285 (56,001)
$ 95,836 (211,558)
$ 55,791 (94,608)
$ 93,065 (210,295)
$ 48,649 (87,769)
$ 54,154 (53,593)
$ 83,063 (228,839)
$ 68,736 (93,182)
$ 50,477 (91,982)
$ 35,181 (42,287)
$ 24,089 (31,837)
$ 96,490 (205,870)
$ 39,733 (62,951)
549Acevedo et al Airway management in pediatric epiglottitis . . .
Total charges with admission to a children’s hospital or
ward were approximately 6 times as high as total charges
for admissions to nonchildren’s hospitals ($151,272 vs
$24,089, P ? 0.05). The length of stay at nonchildren’s
facilities was much shorter (mean 7.45 days; range, 0-73
days) than at children’s facilities (mean 28.53 days; range,
3-199 days; P ? 0.07). Although large differences were
noted for other variables (Table 1), none met statistical
significance (P ? 0.05).
In a multivariate analysis (Table 2), admission to a chil-
dren’s specific facility was associated with a statistically
significant increase in total charges. Admission source and
admission type were also associated with significant in-
creases in total charges. The source of admission refers to
admission via the emergency room in comparison to another
source (ie, transfer from another hospital). Admission from
a source other than the emergency room was associated with
an increase in total charges. Nonemergent admission was
also associated with increased total charges.
Per the KID data-use agreement, it is not permissible to use
patient identifiers for reasons of patient confidentiality. Fur-
thermore, with the KID data-use agreement, we are prohib-
ited from discussing in greater detail when the sample size
of variable is less than 10 patients (which limits subgroup
analysis in patients undergoing airway intervention). De-
spite these limitations, several interesting findings were
evident in our results. In this national database of inpatient
pediatric admissions encompassing an entire year, there
were 342 admissions for epiglottitis. Of these, 40 were
children under the age of 19 requiring an airway interven-
tion for the treatment of epiglottitis. Although these low
numbers show that the HiB vaccine has made epiglottitis an
exceedingly rare disease process, it shows that this disease
has not been eliminated. Also, it must be appreciated that
with such relative infrequency will come a lack of famil-
iarity, not only among otolaryngologists but also among
emergency room physicians, pediatricians, and anesthesiol-
ogists. As the foremost experts on the airway, it is incum-
bent on the otolaryngologist to be facile in the treatment of
this disease. Although rare, this disease process will persist
among the nonvaccinated as well as in those with vaccine
failure (a well-documented occurrence).4It is imperative to
continue to teach medical students, residents, and emer-
gency room physicians to maintain a high index of suspi-
cion for epiglottitis.
This sample of patients was slanted toward younger
patients, with 63% being age 2 or younger, increasing the
acuity of the airway situation. Other studies have suggested
that older patients may be treated more conservatively; this
younger patient sample would suggest that aggressive air-
way management may be necessary in many cases.
The majority of patients was initially seen at nonchil-
dren’s facilities. Significant cost differentials at children’s
facilities indicate that perhaps the majority of the manage-
ment may have occurred at children’s facilities. We surmise
this as the length of stay at the children’s hospitals is much
longer than that at the nonchildren’s hospitals. It is also
reasonable to assume that the majority of pediatric patients
with severe diseases or complicated cases are managed at
pediatric facilities as opposed to community hospitals.
Several weaknesses exist in our study methodology.
First, it is a retrospective study. This lends less weight than
a prospective study and introduces the possibility of selec-
tion bias. Unfortunately, it would be extremely challenging
to perform a prospective study for this disease process, and
on a national scale this would be essentially impossible.
Second, ICD-9 codes were used, introducing the possibility
of coding errors. We attempted to mitigate this as a source
of error by also using the codes of patients that required
airway intervention. Finally, we were limited by restrictions
Indicators for increased total charges for epiglottitis admissions in a multivariate analysis of admission
characteristics of patients
Variable Regression coefficient (95% CI)P value Partial R2
Type of admission
Source of admission
Month of admission
Admission day is a weekend
NACHRI hospital type
Median household income quartile
?2,051.4 (?6,874.5, 2,771.7)
?3,100.1 (?66,610, 60,410)
102,884 (12,162, 193,606)
?168,837 (?268,910, ?68,765)
?5,452.1 (?16,266, 5,362.0)
?40,526 (?111,615, 30,563)
144,698 (72,534, 216,861)
?60,737 (?125,515, 4,041.2)
70,498 (?4,878.8, 145,874)
6,023.1 (?34,569, 46,615)
?4,115.9 (?81,065, 72,833)
NACHRI, National Association of Children’s Hospitals and Related Institutions.
Statistical significance P ? 0.05 indicated by bold typeface. Model R2? 0.61, P ? 0.036.
550 Otolaryngology–Head and Neck Surgery, Vol 140, No 4, April 2009
set forth in the data-use agreement for the KID, which
prohibits analysis of variables in which the sample size is
fewer than 10 patients.
In the post-HiB era, epiglottitis has become an exceedingly
rare entity. Only 40 children required an airway intervention
for epiglottitis (from 22 of the 36 states sampled in 2003).
Airway intervention for epiglottitis was associated with
both high total charges and prolonged hospitalization. De-
spite large variances in total charges, only hospital type
(pediatric vs nonpediatric facilities), admission source, and
admission type were significantly associated with increased
total charges. Epiglottitis is a very rare, expensive, and
protracted disease to treat in the HiB vaccine era. The
infrequency of this disease has significant implications for
resident education and training.
From the Department of Otolaryngology–Head and Neck Surgery, Na-
tional Capitol Consortium (Dr Acevedo); Department of Epidemiology,
University of Nebraska Medical Center (Dr Lander); and Division of
Otolaryngology, Children’s National Medical Center, The George Wash-
ington University Medical Center (Drs Choi and Shah).
Corresponding author: Jason L. Acevedo, MD, Otolaryngology–Head and
Neck Surgery, Walter Reed Army Medical Center, 6900 Georgia Avenue,
Washington, DC 20307.
E-mail address: email@example.com.
The opinions and assertions of the authors contained herein are the private
views of the authors and are not to be construed as reflecting the views of
the Department of Defense or the Department of the Army
Presented at American Academy of Otolaryngology–Head and Neck Sur-
gery Annual Meeting, Chicago, IL, September 19-22, 2008.
Jason Acevedo, study design, writer; Lina Lander, study design, data
collection; Sukgi Choi, study design, writer; Rahul Shah, study design,
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551 Acevedo et al Airway management in pediatric epiglottitis . . .