Acute upper airway obstruction

Definition and immediate risk

Acute upper airway obstruction is narrowing or blockage above the lower trachea. Causes include foreign body aspiration, viral croup, epiglottitis, bacterial tracheitis, retropharyngeal or tonsillar abscess, anaphylaxis, burns, smoke inhalation, and trauma.

A patient who is initially stable with partial obstruction can deteriorate quickly, especially a young child. The clinical priority is to recognise severity, avoid agitation, maintain oxygenation, and get airway-capable help early.

Do not force distressing examination of the mouth or throat in a child with suspected epiglottitis or severe obstruction; agitation can precipitate complete obstruction.

Classify severity

• Stridor is a high-pitched inspiratory sound and usually indicates significant upper-airway narrowing.
• Cyanosis, exhaustion, altered consciousness, inability to speak or cry, drooling, severe recession, and low oxygen saturation require urgent airway management.

Management in all cases

• Let children stay in the position they find easiest for breathing, often sitting on a caregiver's lap.
• Assess severity without upsetting the patient. Monitor oxygen saturation except in mild obstruction.
• Give continuous oxygen when cyanosis, respiratory distress, or oxygen saturation of 90% or lower is present, targeting 94% to 98% when monitoring is available. If no pulse oximeter is available, give at least 5 litres/minute or enough to relieve hypoxia and improve breathing.
• Hospitalise all except mild obstruction; use intensive care or airway-capable referral when danger signs are present.
• Monitor mental status, heart rate, respiratory rate, oxygen saturation, obstruction severity, hydration, and fatigue.
• Maintain hydration orally if safe. Use IV hydration if the patient cannot drink, but avoid delaying airway care for fluids.

Foreign body aspiration

Suspect foreign body aspiration when obstruction starts suddenly, often while a child 6 months to 5 years is eating or playing with a small object. Consciousness is often preserved at first.

• Perform obstruction-relief manoeuvres only if the patient cannot speak, cough, cry, or make any sound.
• Children over 1 year and adults: use abdominal thrusts. Stand behind the patient, place a closed fist above the navel and below the ribs, cover it with the other hand, and give one to five quick upward thrusts.
• Infants under 1 year: place the infant face down along the forearm with the head supported and give one to five back blows between the shoulder blades. If unsuccessful, turn the infant supine and give five forceful chest compressions just below the nipple line, pressing about one-third of chest depth.
• Repeat until the object is expelled and spontaneous breathing, crying, coughing, or talking returns.
• If the patient loses consciousness, start ventilation and cardiopulmonary resuscitation. If ventilation is impossible, emergency surgical airway may be required by trained staff.

Infectious differential diagnosis

• Croup, epiglottitis, and bacterial tracheitis each need their specific treatment pathway.
• Retropharyngeal, tonsillar, or lateral pharyngeal abscess requires urgent referral for surgical drainage.
• Consider diphtheria when an adherent grey membrane, unvaccinated status, neck swelling, or compatible outbreak exposure is present.

Other cause-specific pathways

• Anaphylaxis with angioedema follows the anaphylactic shock pathway and requires immediate IM epinephrine plus airway monitoring.
• Burns to the face or neck and smoke inhalation can cause progressive airway oedema; manage using the burns pathway and refer early for airway-capable care.
• Trauma can cause bleeding, swelling, fracture, or expanding haematoma. Immobilise cervical spine when indicated and involve surgical/airway teams early.
• Complete obstruction, failed ventilation, or impending arrest requires intubation or emergency surgical airway where trained staff and equipment are available.

Complications, prevention, and handover

• Complications include hypoxia, aspiration, respiratory arrest, cardiac arrest, cerebral injury, dehydration, shock, airway trauma, and death.
• Prevention includes keeping small objects and hard foods away from young children, vaccination against Hib and diphtheria, prompt care for severe sore throat or croup, allergy avoidance and action plans, burn prevention, and safe smoke exposure practices.
• Refer urgently for all moderate, severe, imminent, or complete obstruction; any child under 6 months; drooling; cyanosis; low oxygen saturation; altered consciousness; dehydration; suspected epiglottitis, bacterial tracheitis, abscess, anaphylaxis, burn, trauma, or foreign body that is not rapidly cleared.
• Handover should include onset, suspected cause, severity, stridor at rest or with agitation, oxygen saturation, oxygen delivered, choking manoeuvres attempted, medicines given, hydration route, fever, drooling, ability to swallow, mental status, and response to treatment.