Acute Upper Airway Obstruction

Acute Upper Airway Obstruction

Upper airway obstruction is most commonly caused by foreign-body aspiration or infection.

Epiglottitis

Epiglottitis is an emergency.

Any manipulation, including aggressive physical examination, attempt to visualize the epiglottis, venipuncture, or IV placement, may precipitate complete obstruction.

If epiglottitis is suspected, definitive airway placement should precede all diagnostic procedures.

An “epiglottitis protocol” may include the following:

give O₂

Place patient on NPO status.

Have parent accompany child to allay anxiety.

Have physician accompany patient at all times.

Summon “epiglottitis team” (senior pediatrician, anesthesiologist, and otolaryngologist in hospital).

Management options

If patient is unstable (unresponsive, cyanotic, bradycardic),

 emergently intubate.

If patient is stable with high suspicion,

escort patient with team to operating room for endoscopy and intubation under general anesthesia.

If patient is stable with moderate or low suspicion,

obtain lateral neck radiographic examination to confirm. An epiglottitis team must accompany the patient at all times.

After airway is secured, obtain cultures of blood and epiglottic surface. Begin antibiotics to cover Haemophilus influenzae type B, Streptococcus pneumoniae, and group A streptococci.

Croup

Mild (no stridor at rest): Treat with cool mist therapy, minimal disturbance, hydration, and antipyretics. Consider steroids (see below).

Moderate to severe

Mist or humidified oxygen mask near child’s face may be used, although the efficacy of mist therapy is not established. A mist tent may increase a child’s anxiety and decrease the physician’s ability to observe the patient.

Administer racemic epinephrine (2.25%) 0.05 mL/kg/dose (maximum dose is 0.5 mL) in 3 mL NS, no more than every 1 to 2 hr, or nebulized epinephrine 0.5 mL/kg of 1:1000 (1 mg/mL) in 3 mL NS (maximum dose is 2.5 mL for ≤4 years old, 5 mL for > 4 years old). Hospitalize if more than one nebulization is required. Observe for a minimum of 2 to 4 hours if discharge is planned after administering nebulized epinephrine.

Administer dexamethasone 0.6 mg/kg IM or PO once. Prednisolone or prednisone may be adequate but should be administered for several days because of the shorter half-life of these steroid preparations.

Nebulized budesonide (2 mg) has been shown to be effective in mild to moderate croup.

A helium-oxygen mixture may decrease the work of breathing by decreasing resistance to turbulent gas flow through a narrowed airway. Inspired helium concentration must be >70% to be effective.

If a child fails to respond as expected to therapy, consider airway radiography, computed tomography (CT), or evaluation by otolaryngology or anesthesiology.

Consider retropharyngeal abscess, bacterial tracheitis, subglottic stenosis, epiglottitis, or foreign body.

Foreign body aspiration

Foreign body aspiration occurs most often in children <5 years old. It frequently involves candy, peanuts, grapes, balloons, and other small objects.

If the patient is stable (i.e., forcefully coughing, well-oxygenated), removal of the foreign body by bronchoscopy or laryngoscopy should be attempted in a controlled environment.

If the patient is unable to speak, moves air poorly, or is cyanotic, intervene immediately.

Infant: Place infant over arm or rest on lap. Give five back blows between the scapulae. If unsuccessful, turn infant over and give five chest thrusts (in the same location as external chest compressions). Use tongue-jaw lift to open mouth. Remove object only if visualized. Attempt to ventilate if unconscious. Repeat sequence as often as necessary.

Child: Perform five abdominal thrusts (Heimlich maneuver) from behind a sitting or standing child or straddled over a child lying supine. Direct thrusts upward in the midline and not to either side of the abdomen.

After back, chest, and/or abdominal thrusts, open mouth and remove foreign body if visualized. Blind finger sweeps are not recommended. Magill forceps may allow removal of foreign bodies in the posterior pharynx.

If the patient is unconscious, remove the foreign body using Magill forceps if needed after direct visualization or laryngoscopy. If there is complete airway obstruction, consider percutaneous (needle)

cricothyrotomy - if attempts to ventilate via bag-valve mask or ETT are unsuccessful.

Percutaneous (needle) cricothyrotomy. Extend neck, attach a 3-mL syringe to a 14-to 18-gauge IV catheter and introduce catheter through the cricothyroid membrane (inferior to the thyroid cartilage, superior to the cricoid cartilage). Aspirate air to confirm position. Remove the syringe and needle, attach the catheter to an adaptor from a 3.0-mm ETT, which can then be used for positive-pressure oxygenation.