Indian J Pediatr (October 2011) 78(10):1256–1261
DOI 10.1007/s12098-011-0414-0
SYMPOSIUM ON PGIMER PROTOCOLS ON RESPIRATORY EMERGENCIES
Acute Upper Airway Obstruction
K. Sasidaran & Arun Bansal & Sunit Singhi
Received: 27 January 2011 / Accepted: 8 March 2011 / Published online: 11 May 2011
# Dr. K C Chaudhuri Foundation 2011
Abstract Upper airway obstruction is defined as blockage
of any portion of the airway above the thoracic inlet.
Stridor, suprasternal retractions, and change of voice are the
sentinel signs of upper airway obstruction. Most of the
common causes among children presenting to emergency
department are of acute infectious etiology. Among these,
croup is the commonest while diphteria remains the most
serious life-threatening cause. Recent reports indicate that
bacterial tracheitis has become increasingly common. In ER
evaluation the key clinical data in determining the cause
and the site of obstruction are the onset, presence of fever,
character of the stridor, retractions, the voice and the ability
to handle secretions. After assessment of the severity of
respiratory distress and resuscitative or supportive therapy
including oxygen and emergent airway, specific treatment is
directed at underlying etiology. All patients with audible
stridor require early endotracheal intubation/tracheostomy. In
croup the mainstay of treatment are cold humidified oxygen,
budesonide nebulization ( in mild cases), Dexamethasone
0.6 mg/kg iv or im (in moderate and severe cases), and
Adrenaline 5 ml 1:1000 (5 mg) solution as nebulization ( in
severe cases). In diphtheria, early tracheostomy, anti-
diphtheric serum and injectable penicillin are critical.
Bacterial Tracheitis and Retropharyngeal abscess need
early administration of injectable Cloxacillin, Amikacin
and Clindamycin. ENT consultation should be obtained
for early surgical drainage of retropharyngeal abscess.
Angioneurotic edema is treated with subcutaneous adren-
aline (1:1000, 0.01 ml/kg); hydrocortisone 10 mg/kg IV
and antihistamines. Patients with severe obstruction and
K. Sasidaran : A. Bansal : S. Singhi (*)
Department of Pediatrics, Advanced Pediatrics Centre, PGIMER,
Postgraduate Institute of Medical Education and Research,
Chandigarh 160012, India
e-mail: sunit.singhi@gmail.com
those with endotracheal tube/ trachesotomy should be
transferred to PICU.
Keywords Children . Upper airway obstruction . Croup .
Diphtheria . Bacterial tracheitis . Retropharyngeal abscess .
Angioneurotic edema
Introduction
Acute airway obstruction in children is one of the most
common life-threatening emergencies in pediatric practice.
It usually generates a great deal of anxiety since there is
little time for deliberation, and it may lead to significant
morbidity and indeed mortality.
Upper airway obstruction is defined as blockage of any
portion of the airway above the thoracic inlet. Stridor,
suprasternal retractions, and change of voice are the
sentinel signs denoting upper airway obstruction.
Stridor is a harsh, vibratory sound of variable pitch
caused by partial obstruction of the respiratory passages
that result in turbulent airflow through the airway.
Inspiratory stridor is a harsh, high pitched sound produced
when child inspires through a spasmodically closed glottis.
Expiratory stridor is a singing sound due to semi-
approximated vocal cords offering resistance to exhalation
or to due to tracheobronchial obstruction.
Biphasic stridor is a harsh sound of vibratory quality
produced due to little change in airway size with respiration
caused by a fixed obstruction and, heard during both phases
of respiration. Pathophysiologic events leading to various
kinds of stridor in upper airway obstruction in children are
shown in Fig. 1.
If a child’s stridor becomes softer but the work of
breathing remains increased, the obstruction may be
getting worse; if the child is unable to sustain increased
work of breathing he is getting tired.
Indian J Pediatr (October 2011) 78(10):1256–1261 1257

Fig. 1 Pathophysiology of
Normal airway Laminar air flow pattern
upper airway obstruction
in children
Progressive airway inflammation Exposure to inciting agent

Narrowing of airway lumen

Venturi effect Turbulent airflow

Increased airflow velocity

Drop in pressure normally exerted against airway wall

Increase in intra luminal negative pressure

Airway collapse 1. Supraglottic level – Inspiratory stridor

2. Intra thoracic trachea or major bronchi – Expiratory stridor

3. Fixed obstruction at cricoids – Biphasic stridor

Causes of Upper Airway Obstruction & Pattern of fever, duration as well as the severity
& History of trauma to head or neck—Neurogenic stridor
Causes of upper airway obstruction can be classified & History of choking—to exclude foreign body aspiration
according to the age group, duration of symptoms (acute & Epidemiological conglomeration of similar cases—
or chronic) and whether it is of infectious origin or not as Diphtheria, Viral croup
shown in Table 1. Acute infectious cause is the commonest
among children presenting to emergency department with
upper airway obstruction. Table 1 Common causes of upper airway obstruction in children
Croup and bacterial tracheitis remain as the two common Infectious Non-infectious
causes of acute onset upper airway obstruction in children.
Recent reports indicate that bacterial tracheitis is becoming Acute
increasingly common [1]. Diphtheria remains as one of the Croup Airway burns
common causes in India. (Caustic or Thermal)
Diphtheria Upper airway foreign body
Bacterial tracheitis Angioneurotic edema of upper
Evaluation of a Child with Stridor airway
Retropharyngeal abscess Trauma
A prepared clinician can often make the diagnosis based Peritonsillar abscess Vocal cord paralysis
Acute severe tonsillitis
solely on the history and physical examination (Fig. 2);
Infectious mononucleosis
using radiographs and laboratory examinations to aid in
Epiglottitis
diagnosis when the clinical picture is unclear [2].
Chronic
Chronic tonsillitis Laryngomalacia
History (age specific—in infants)
Adenotonsillar hypertrophy Vascular ring
& Characteristics of the onset of illness, and the course of Neoplasms of upper airway
(Hemangioma, cystic hygroma
development of respiratory signs should be carefully cysts of larynx)
obtained Tracheal stenosis
& Characteristics of voice and voice change—if present
1258 Indian J Pediatr (October 2011) 78(10):1256–1261

Fig. 2 Diagnostic algorithm in

Stridor
a child with stridor

Is the child febrile ?

Yes No

History of trauma or
Severe distress or drooling ?
Foreign body ?

Yes No
Yes

Hoarseness of voice Muffled voice

Laryngeal problem +
Foreign body
No
Caustic/thermal injury
Pharyngeal problem +
Laryngotracheal trauma

Croup Severe tonsillitis

Angioneurotic edema
Bacterial tracheitis Peritonsillar abscess
Spasmodic croup
Retropharyngeal Parapharyngeal abscess
abscess

Diphtheria

Epiglottitis

Physical Examination Laboratory Testing and Imaging

Physical examination is important and should be performed
in a warm, well-lit room, preferably with the child in parent’s lap
and the child’s chest exposed. The key physical findings in
determining the site of obstruction involve the character of the
stridor, retractions, the voice and the ability to handle secretions
& General appearance and posture
& Cry or voice (pitch, aphonia, muffled, hoarse)
& Difficulty in a child’s ability to handle oral secretions.
& Nasal flaring
& Degree of dyspnea and respiratory pattern
& Use of accessory muscles of respiration (degree of
retractions)
& Look for craniofacial anomalies (maxillary hypoplasia,
nasal septal deviation, micrognathia, retrognathia, pla-
tybasia, or macroglossia)
& Throat examination: look for acute inflammation of
tonsils, faucial pillars, evident exudates and membrane.
& Neck examination: look for any extrinsic mass, evidence
of trauma and tracheal position
Laryngoscopy or any procedure that may agitate the patient
is postponed till the emergency airway is established.
No investigation is warranted before stabilizing the airway.
A physician who is competent in providing airway support
may accompany stable patients to the X-ray department.
Classic features of common disorders causing upper
airway obstruction are shown in Table 2
A diagnostic approach to child with stridor is shown in Fig. 2.
Specific Management Guidelines
Croup Syndrome Management
Assess the child for severity of respiratory distress and give
resuscitative or supportive therapy accordingly. Westley’s
clinical croup score (Table 3) may be used to aid in the
decision as to which children should be hospitalized and to
decide upon the treatment protocol.
The mainstay of treatment are cold humidified oxygen,
Budesonide nebulization (1,000 μg given 30 min apart in
mild cases) [4], Dexamethasone [4, 5] 0.6 mg/kg iv or im
(one dose in mild and moderate cases, otherwise 6 hourly),
and Adrenaline 5 ml 1:1000 (5 mg) solution as nebulization
( in severe cases). Avoid situations that may precipitate
Indian J Pediatr (October 2011) 78(10):1256–1261 1259

Table 2 Classic features of common upper airway disorders

Disease process Age group Mode of onset of respiratory distress

Viral croup
Bacterial tracheitis
Diphtheria
Retropharyngeal abscess
Peritonsillar abscess
Foreign body aspiration
3 month–3 years. Gradual onset of stridor and barking cough after mild URI
2–7 years. Acute onset high grade fever, toxic appearance, respiratory distress
Any age Gradual onset of stridor preceded by swelling over neck and URI in
an unimmunized child, membrane on throat examination
Infancy—3 years. Fever, toxicity, and distress after URI or pharyngitis
Usually >8 years Acute onset high grade fever, toxicity, distress with unilateral throat pain,
“hot potato speech”
Late infancy—4 years Choking episode resulting in immediate or delayed respiratory distress

distress and monitor for the response. Management guidelines Because prompt treatment is crucial, it is prudent to start
for croup based on Westley’s croup score are given in Table 4. therapy on the basis of clinical findings and microbial
culture would confirm the diagnosis later. Nevertheless,
Diphtheria Management send a throat swab for bacteriological studies (Albert’s
stain and culture) to confirm the diagnosis.
Laryngeal Diphtheria Membranous pharyngitis progress
over a period of 2 to 3 days to manifest with hoarseness & Give Oxygen. Try not to upset child and do not
of voice, dysphagia and minimal to severe inspiratory attempt to look inside the mouth as this may
stridor. The patient is usually nontoxic in appearance but precipitate airway obstruction. Send throat swab for
may have low grade fever. bacteriological studies (Albert’s stain and culture) to
confirm the diagnosis.
& Airway management: Endotracheal intubation should
be avoided, and early tracheostomy to establish emer-
Table 3 Westley’s clinical croup score [3] gency airway is advised.
& Give diphtheria antitoxin 80,000 to 120,000 units IV
Category Score
infused over 1 h.
Level of consciousness & Crystalline penicillin 40,000 U/kg/dose iv, q 6 hourly ×
Normal (including sleep) 0 14 days; Erythromycin 15 mg/kg/dose q 8 hourly (not
Disoriented 5 to exceed 2 g/day) × 14 days may be used in those
Cyanosis sensitive to penicillin.
None 0 & Patients should be isolated until three consecutive
Cyanosis with agitation 4 cultures at the completion of therapy have documented
Cyanosis at rest 5 elimination of the organism from oropharynx. Contacts
Stridor
should receive erythromycin15 mg/kg/dose q 8 hourly
None 0
for 7 days.
When agitated 1
At rest 2
Retropharyngeal Abscess Management
Air entry
Normal 0
& Start oxygen in nonthreatening manner. Try not to upset
Decreased 1
child
Markedly decreased 2
& Airway management: Endotracheal intubation should
Retractions
be done in any child with audible stridor at presentation.
None 0
Orotracheal intubation is preferred because of the risk
Mild 1
of rupture of abscess.
Moderate 2
& Start with Cloxacillin (50 mg/kg/dose q 6 hourly)
Severe 3
Amikacin (15 mg/kg/day in once a day dose) along with
Categories: Mild croup—Score 0–2; Moderate croup—Score 3–5; clindamycin (10 mg/kg/dose TID).
Severe croup—Score 6–11; Impending respiratory failure—Score 12–17. & Surgical drainage.
1260 Indian J Pediatr (October 2011) 78(10):1256–1261

Table 4 Management guidelines for croup based on Westley’s croup score

Score Category Management guidelines

0–2 Mild Budesonide nebulization therapy one dose [3] or Dexamethasone one dose of 0.6 mg/kg iv
or im [3]; If child is older than 6 months and parents are reliable, child can be discharged.
Advise cold mist therapy at home.
3–5 Moderate Dexamethasone 0.6 mg/kg im or iv stat [4]; Cold humidified oxygen; Minimize
situations that may precipitate distress in the child.
Monitor using Westley’s score at 30 min interval and re-classify. Child can be discharged
only if he improves to mild category at the end of 6 h, has age more than 6 months and
parents are reliable.
6–11 Severe Dexamethasone 0.6 mg/kg im or iv stat [4]; Cold humidified oxygen; Minimize situations
that may precipitate distress in the child; Administer Adrenaline 5 ml 1:1000 (5 mg)
solution as nebulization. Monitor using Westley’s score at 30 min interval and re-classify
according to score.
Responsive to initial therapy
Child can be observed in ER if the score improves to be classified as moderate category.
Recurrence of respiratory distress can be treated with repeat adrenaline nebulization,
Dexamethasone 0.6 mg/kg/dose q6 hourly × four doses
Poor response to initial therapy
Airway stabilization and ICU care are indicated in a child who remains in severe category
even after the above mentioned therapy
12–17 Acute life-threatening Proceed to Airway stabilization (Intubation/Tracheostomy) and ICU care

Bacterial Tracheitis & Send a blood culture. Start Cefotaxime 50 mg/kg/dose,

& Give oxygen in nonthreatening manner
& Active management of airways. Endotracheal intubation
should be done in any child with audible stridor at
presentation.
& It is recommended to start with Cloxacillin (100–200 mg/
kg in four divided doses per day), amikacin (15 mg/kg/day
in once a day dose) and clindamycin (10 mg/kg/dose
TID).
Acute Epiglottitis Management
& Give Oxygen: Start high flow oxygen through re-
breathing mask. Try not to upset the child and do not
attempt to look inside the mouth as this may precipitate
airway obstruction
& Call for anesthetist and/ or ENT specialist for help.
While waiting for help, give adrenaline nebulization
5 ml of 1:1000 (1 mg/ml) solution.
& Airway assessment. Try to answer following questions:
& Unsecure airway?
& Obstruction severe?
& Epiglottitis on direct laryngoscopy?
If answer to any of these questions is yes, child
should be intubated by a specialist preferably in
operation theatre under inhalational anesthesia.
IV q 6 hourly following a loading dose of 100 mg/kg.
Continue the supportive management and arrange for
PICU transfer. Prophylactic Rifampicin 20 mg/kg/dose
OD × 4 days to be given for all household contacts.
Angioneurotic Edema Management
& Give oxygen in nonthreatening manner
& Active management of airways. Endotracheal intubation
should be done in any child with audible stridor at
presentation.
& This condition is treated by administration of adrenaline
(1:1000), subcutaneously 0.01 ml/kg (maximum
0.3 ml); hydrocortisone 10 mg/kg IV and antihistamines
like chlorpheniramine.
Airway Burns Management
& Give oxygen in nonthreatening manner
& Early tracheostomy is indicated in any child with audible
stridor at presentation. Child with facial burns and
suspected smoke inhalation having soon to-be obstructed
airway should receive endotracheal intubation. Preferably
intubation should be done in a controlled atmosphere by a
specialist.
& Endotracheal intubation can later be converted to
tracheostomy after the management of surface burns.
Indian J Pediatr (October 2011) 78(10):1256–1261
Conflict of Interest None.
Role of Funding Source None.
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