Acute upper airway obstruction

PIC Endorsed

Key points

Allow children with acute upper airway obstruction to adopt a position of their choice and avoid causing distress
Decompensation of acute upper airway obstruction can be rapid and requires emergency airway management
In any child with severe acute upper airway obstruction, nebulised adrenaline may provide temporary relief while awaiting other definitive measures

Background

Due to their size, infants are most at risk of severe upper airway obstruction
Children with pre-existing narrowing of the upper airway may fully obstruct with otherwise minor acute upper airway swelling
Although croup is the most common cause of acute upper airway obstruction, other diagnoses must always be considered

Assessment

Allow the child to settle quietly on parent’s lap in a position of their choice, and observe closely with minimal examination

Rapidly assess airway patency and respiratory status:

Mild obstruction	Moderate obstruction	Severe to complete obstruction
Able to speak or cry, may be hoarse Intermittent stridor or occasional stertor Minimal or no work of breathing Good air entry	Tachypnoea Stridor Prolonged inspiratory time Moderate work of breathing, nasal flaring, grunting, paradoxical chest movement Decreased air entry	Hypoxia (late sign) Slow respiratory rate or marked tachypnoea Sniffing or tripod position Agitated or drowsy conscious state Severe work of breathing Markedly reduced or no air movement Silent gagging or coughing Total obstruction will rapidly progress to unconsciousness and cardiorespiratory arrest

Differential diagnoses (the table below is not an exhaustive list)
Presentations, particularly the bacterial causes, often overlap

Possible diagnosis	Features
Croup	Young child (rare <3 months) Rapid onset harsh barking cough Hoarse voice/cry Stridor May be febrile and miserable but systemically well
Anaphylaxis	Swelling of the face and tongue Wheeze Urticarial rash Allergen exposure Haemodynamic compromise
Inhaled foreign body	Young child (or developmentally similar) Very sudden onset Coughing, choking, vomiting episode (may not be witnessed) May have unilateral chest findings, wheeze
Reduced pharyngeal tone or size	Reduced conscious state eg after drug or alcohol ingestion, recent seizure, head injury (including NAI) Pre-existing narrow or floppy upper airway
Retropharyngeal abscess	Sore throat Fever Neck pain and stiffness or torticollis Fullness and redness of posterior pharyngeal wall; may be midline but can be laterally behind tonsil Dysphagia and drooling
Peritonsillar abscess (quinsy)	Severe sore throat (often unilateral) Hot potato/muffled voice Trismus Swollen posterior palate and tonsil, with medial displacement of tonsil and deviation of the uvula
Epiglottitis	Inadequate Hib immunisation or immunocompromised High fever and systemically unwell Muffled voice Hyperextension of neck Dysphagia Pooling of secretions, drooling Absent cough Low pitched expiratory stridor or stertor
Bacterial tracheitis	Systemically unwell More severe and rapidly progressive symptoms Recent URTI Markedly tender trachea Cough may be productive with thick secretions
Ludwig angina (infection of the sublingual and submandibular spaces)	Swollen, tender floor of mouth and under tongue Facial laceration or dental abscess Submandibular swelling
Airway burns	Burns elsewhere, especially facial Singed nasal hairs Sooty sputum
Trauma	Bruising and swelling of the neck Subcutaneous emphysema May progress to pneumothorax / pneumomediastinum

Management

Investigations

Children with moderate to severe upper airway obstruction are at high risk of deterioration and complete obstruction if they are upset, sedated or repositioned. Investigations should be deferred until the airway is secure
If IV access is required use appropriate analgesia and distraction techniques to minimise distress
Children with croup do not require any investigations
X-ray (chest and/or soft tissue neck) or CT may be helpful in identifying the location and nature of upper airway obstruction

Treatment

If emergency airway management is required, it will be a “difficult airway”. Involve the most senior clinician available ± anaesthetic or ENT support
If awaiting other definitive measures:
- Oxygen can be given. It may improve saturations but does not relieve obstruction
- Consider nebulised adrenaline to provide temporary relief in any life-threatening upper airway obstruction
- Consider dexamethasone 0.6 mg/kg (max 16 mg) IM/IV/oral to reduce swelling if present
For intubation, use an endotracheal tube ½ to 1 size smaller than usual for age. Cuffed tubes allow for cuff inflation if leak develops when obstruction begins to resolve. Gaseous induction methods are preferred
See croup for specific management
Treat the specific cause. For bacterial infections refer to local antimicrobial guidelines

Consider consultation with local paediatric team when

Child has moderate acute upper airway obstruction

Consider consultation with anaesthetics and/or ENT:

Child with severe acute upper airway obstruction
Child is at risk of deteriorating due to known difficult airway

Consider transfer when

Child is at risk of deteriorating and requires airway management beyond the capability of available local services

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

The cause for the acute upper airway obstruction has been identified and symptoms and signs of acute upper airway obstruction have resolved, or are mild and improving
Appropriate management undertaken and an adequate follow up plan is in place

Parent information

Croup

Last updated March 2021

Reference List

Eskander A et al. Acute Upper Airway Obstruction. New England Journal of Medicine. 2019. 381 pp1940-1949

Grundfast K. The 10 commandments of management for acute upper airway obstruction in infants and children. JAMA Otolaryngology - Head&Neck Surgery. 2017. 143(6) pp539

Loftis L. Emergency evaluation of acute upper airway obstruction in children. UpToDate. https://www.uptodate.com/contents/emergency-evaluation-of-acute-upper-airway-obstruction-in-children (viewed October 2020)

Virbalas, J. Upper Airway Obstruction. Pediatrics in Review. 2015. 36 (2) pp62

The Royal Children's Hospital Melbourne

Clinical Practice Guidelines