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Acute Upper Airway Obstruction

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In one line

·Something blocks the passage that brings air from the nose and mouth down into the windpipe, so air cannot reach the lungs.

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Normal physiology

·The upper airway is a flexible tube that starts at the nose and mouth, passes through the pharynx (throat), crosses the larynx (voice box where the vocal cords sit), and enters the trachea (windpipe). The epiglottis is a leaf-shaped flap of cartilage that tips backward to cover the larynx when you swallow, keeping food and liquid out of the airway. When you breathe in, the vocal cords pull wide apart, the epiglottis stands upright, and smooth muscles keep the pharynx from collapsing inward. The mucosa (soft inner lining) is smooth and thin, so air flows quietly and easily.

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What goes wrong

·One mechanical problem—something shrinks the space inside the upper airway—causes every downstream finding. The narrower the opening, the louder the a high-pitched noise on breathing in (stridor), the harder the work of breathing, and the closer the child is to complete blockage and respiratory arrest.

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Hallmark signs

·A high-pitched noise on breathing in (Stridor)
·Retractions (skin pulling in at the neck notch, between the ribs, below the ribs)
·Drooling and refusing to swallow
·Tripod positioning (sitting upright, leaning forward, hands on knees)
·Muffled, hoarse, or no voice at all
·Fast breathing and fast heart rate
·Nasal flaring (nostrils spreading wide with each breath)
·Agitation, anxiety, or confusion

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Red flags · escalate now

·Blue lips, tongue, or fingernails (cyanosis)—shows severe oxygen starvation and the child is minutes from collapse
·Heart rate suddenly slowing or dropping (bradycardia)—the oxygen-starved heart is failing and arrest is imminent
·Decreased consciousness, extreme sleepiness, or no response—the brain is shutting down from lack of oxygen
·Silent chest with little or no air moving despite hard breathing effort—the airway is almost completely blocked
·Cannot speak, cry, make sound, or cough—the airway is totally or nearly totally closed off

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Workup

·Pulse oximetry (oxygen saturation measurement) at bedside—continuous monitoring via finger or toe probe
·Lateral neck X-ray (only if child is stable, cooperative, and diagnosis is uncertain—never if child is distressed)
·Direct laryngoscopy (camera or lighted scope to look directly at the voice box) in operating room with anesthesia and ENT surgeon standing by
·Blood culture and complete blood count (CBC) with differential if bacterial infection is suspected (epiglottitis, bacterial tracheitis, retropharyngeal or peritonsillar abscess)
·Arterial or capillary blood gas (ABG or CBG) if child is stable enough for blood draw and ventilatory status is uncertain
·Chest X-ray (posteroanterior and lateral views) if foreign body aspiration is suspected and object may be radiopaque (visible on X-ray)

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Treatment

·Position child upright in caregiver's lap, provide humidified oxygen by blow-by or mask (never force), and keep environment calm—do not agitate, do not force child to lie flat, do not attempt IV placement or throat examination unless airway is secure
·Administer dexamethasone 0.6 mg/kg by mouth, IV, or IM (maximum single dose 16 mg) for croup, angioedema (allergic swelling), or any inflammatory upper airway obstruction
·Give racemic epinephrine 0.5 mL of 2.25% solution via nebulizer (or L-epinephrine 5 mL of 1:1000 if racemic unavailable) with supplemental oxygen for severe croup, acute epiglottitis as bridge to intubation, or laryngeal swelling (edema)
·If foreign body is suspected and child is conscious with partial obstruction and able to cough or speak, encourage coughing and do not interfere; if complete obstruction (cannot cough, speak, or breathe), immediately perform back blows and chest thrusts (infants under 1 year) or abdominal thrusts—Heimlich maneuver (children over 1 year) per AHA pediatric basic life support guidelines
·Administer broad-spectrum IV antibiotics—ceftriaxone 50 mg/kg once daily or cefotaxime 50 mg/kg every 6 to 8 hours PLUS vancomycin 15 mg/kg every 6 hours if MRSA (methicillin-resistant Staphylococcus aureus) is suspected—for epiglottitis, bacterial tracheitis, retropharyngeal abscess, or peritonsillar abscess; prepare for emergency intubation in operating room with ENT and anesthesia, or surgical drainage of abscess
·Keep child calm, allow parent to hold child at bedside, and avoid all unnecessary physical examination (do not examine throat, do not force tongue depressor, do not lay child flat) or procedures (no IV placement, no blood draws, no pulse oximetry probe application if child resists) until airway is secured in controlled setting
·If complete airway obstruction occurs and ventilation cannot be achieved by bag-mask, immediately perform emergency cricothyrotomy (surgical airway through cricothyroid membrane) or needle cricothyrotomy (large-bore IV catheter through cricothyroid membrane for temporary oxygenation) per ATLS and PALS guidelines; if expertise available, perform emergency tracheostomy in operating room

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NCLEX trap

·Never force a child with a high-pitched noise on breathing in (stridor) (a high-pitched sound when breathing, caused by a narrowed upper airway) to lie down or change position. Let the child sit upright and lean forward—gravity helps keep the airway as open as possible. Do not stick anything into the mouth or upset the child until you have skilled people and equipment ready to open the airway surgically if needed. Getting upset increases the body's need for oxygen and can flip partial blockage (some air still moving) into complete blockage (no air moving at all).
·Acute upper airway obstruction can go from partial blockage (some air moving) to complete blockage (no air moving) in minutes. The word 'acute' means it starts suddenly and moves fast. Watch the child's breathing rate, how hard they are working to breathe, oxygen level (SpO₂, the percent of hemoglobin—the oxygen-carrying protein in red blood cells—that is loaded with oxygen), and alertness every few minutes without a break.
·A high-pitched noise on breathing in (Stridor) means there is a physical narrowing or blockage above the vocal cords in the larynx (voice box) or trachea (windpipe), not tight muscle in the small airways down in the lungs (bronchospasm). Quick-relief inhalers relax muscle in the lower airways but do nothing for a blocked upper airway. Treatment must fix the cause: give oxygen, use heliox (a helium-oxygen mix that flows more easily through tight spaces), give racemic or nebulized epinephrine for croup or anaphylaxis (a life-threatening allergic reaction), give corticosteroids (anti-swelling medicines) for croup or angioedema (deep swelling under the skin), remove a foreign object, or open the airway surgically with a cricothyrotomy (cutting a hole in the front of the neck to reach the windpipe).
·Acute upper airway obstruction is a true airway emergency. Call emergency medical services, anesthesia (the doctors who manage airways and breathing), and ENT (ear, nose, and throat surgeons) right away—before the airway closes all the way and you cannot insert a breathing tube or give breaths anymore.
·A high-pitched noise on breathing in (Stridor), chest and neck pulling inward with each breath (suprasternal and intercostal retractions), drooling, muffled voice, anxiety, and blue lips and nail beds (cyanosis, from low oxygen) together tell you how bad the blockage is. Drowsiness and blue color are late signs—they mean blood oxygen is dangerously low and the child is running out of reserve. Without action, the child will stop breathing (respiratory arrest) very soon.
·Before you try to intubate (insert a breathing tube), give 100 percent oxygen, gather tools for a surgical airway (scalpel, cricothyrotomy kit), and bring together a team including anesthesia and ENT if you can. Figure out the likely cause—foreign body, anaphylaxis, croup, epiglottitis (bacterial infection of the epiglottis, the flap that covers the windpipe)—so you can choose the right approach. Have several smaller tube sizes ready. If intubation fails or the airway anatomy is twisted by swelling or blood, be ready to do an emergency cricothyrotomy (cut through the front of the neck to put a tube directly into the windpipe). Current Pediatric Advanced Life Support (PALS) guidelines say prepare for both intubation and surgical airway at the same time—a 'double setup.'

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