Acute Upper Airways Obstruction

Examination and assessment

A harsh barking cough with stridor in a child with minimally raised temperature suggests croup (see below). Cough with low pitched expiratory stridor and drooling suggests epiglottitis. Sudden onset of coughing, choking, drooling and aphonia suggests a laryngeal foreign body (this is extremely rare). Swelling of the face and tongue with wheeze and urticarial rash suggests anaphylaxis. The differential diagnosis is seen in

Examination

The mouth and throat should not be examined if signs of partial upper airway obstruction are present, as complete obstruction can ensue during the examination. Partial acute upper airways obstruction is characterised by stridor and increased work of breathing. Signs of deterioration are those of hypoxia (worried, restless), fatigue, decreased conscious state, and increased and then decreased work of breathing. Heart rate may be rapid or indeed slow. A child’s general appearance is more useful.

Treatment

Allow the child to settle quietly on the parent’s lap and observe closely with minimal interference. Treat specific cause (see croup/anaphylaxis guidelines). Call the Pediatric Intensive Care Unit (ICU) if the child’s condition is worsening or there is severe obstruction, or call for senior doctors (ENT/anesthetics) if an ICU is not available in your hospital

Oxygen may be given while you are awaiting transfer transport. It can be falsely reassuring because a child with quite severe obstruction may look pink with oxygen. 

Note that:

• Intravenous access should be deferred—upset can cause increasing obstruction.

• Lateral X-rays do not assist in management. In severe airways obstruction, X-rays cause undue delay in definitive treatment and may be dangerous (positioning may precipitate respiratory arrest).

• Do not examine the throat with a tongue depressor.

• If intubation is considered necessary, this should be done by the most experienced medical personnel present, using a smaller than normal endotracheal tube 

This should ideally be done in the operating room with tracheostomy equipment and a surgeon in attendance.

• Once the airway is protected, then full blood count (FBC)/blood cultures, i.v. cannulation and antibiotics can be started.