UPPER AIRWAY OBSTRUCTION

Ref.: Nelson essentials of pediatrics 7th. edit.

Nelson`s textbook of pediatrics 20th. edit.

ETIOLOGY
Upper airway obstruction (UAO), which is defined as blockage of any part of the airway located
above the thoracic inlet, ranges from nasal obstruction due to the common cold to life-threatening
obstruction of the larynx or upper trachea (subglottic space).
UAO is more pronounced during inspiration because the negative pressure generated collapses the
upper airway, increasing resistance to airflow and leading to inspiratory noise.
The respiratory noise most commonly associated with UAO is stridor, a harsh sound caused by the
vibration of the airway structures. Stridor often decreases during sleep, because of lower inspiratory
flow rates, and increases during feeding, excitement, and agitation, because of higher flow rates.
Occasionally stridor may also be present on exhalation. Laryngomalacia (floppy larynx) is the most
common cause of inspiratory stridor in infants and may be aggravated by swallowing problems and
gastroesophageal reflux. Hoarseness suggests vocal cord involvement. Children with UAO may
have increased inspiratory work of breathing manifested by suprasternal retractions.
The term croup refers to a heterogeneous group of mainly acute and infectious processes that are
characterized by a bark like or brassy cough and may be associated with hoarseness, inspiratory
stridor, and respiratory distress.
Stridor is a harsh, high-pitched respiratory sound, which is usually inspiratory but can be biphasic
and is produced by turbulent airflow; it is not a diagnosis but a sign of upper airway obstruction

Age-Related Differential Diagnosis of Upper Airway obstruction: Obstruction

NEWBORN
Choanal atresia
Micrognathia (Pierre Robin syndrome, Treacher Collins syndrome,
DiGeorge syndrome)
Macroglossia (Beckwith-Wiedemann syndrome, hypothyroidism,
Pompe disease, trisomy 21, hemangioma)
Pharyngeal collapse
Laryngeal web, cleft, atresia
Vocal cord paralysis/paresis (weak cry; unilateral or bilateral, with
or without increased intracranial pressure from Arnold-Chiari
malformation or other central nervous system pathology)
Congenital subglottic stenosis

INFANCY
Laryngomalacia (most common non-infectious etiology)
Viral croup (most common infectious etiology)
Subglottic stenosis (congenital or acquired, e.g., after intubation)
Laryngeal web or cyst
Laryngeal papillomatosis
Vascular rings/slings
Airway hemangioma
Rhinitis
TODDLERS
Viral croup (most common etiology in children 6 mo to 4 yr of age)
Spasmodic/recurrent croup
Bacterial tracheitis (toxic, high fever)
Foreign body (airway or esophageal)
Laryngeal papillomatosis
Retropharyngeal abscess
Hypertrophied tonsils and adenoids

OLDER CHILDREN
Epiglottitis (infection, uncommon)
Inhalation injury (burns, toxic gas, hydrocarbons)
Foreign bodies
Angioedema (familial history, cutaneous angioedema)
Anaphylaxis (allergic history, wheezing, hypotension)
Trauma (tracheal or laryngeal fracture)
Peritonsillar abscess (adolescents)
Mononucleosis
Ludwig angina

Croup (Laryngotracheobronchitis)

Viruses typically cause croup, the most common form of acute upper respiratory obstruction. The
term laryngotracheobronchitis refers to viral infection of the glottic and subglottic regions.
Most patients have an upper respiratory tract infection with some combination of rhinorrhea,
pharyngitis, mild cough, and low-grade fever for 1-3 days before the signs and symptoms of upper
airway obstruction become apparent.
The child then develops the characteristic barking cough, hoarseness, and inspiratory stridor.
The lowgrade fever can persist, although temperatures may occasionally reach
39-40C , some children are afebrile.
Symptoms are characteristically worse at night and often recur with decreasing intensity for several
days and resolve completely within a week.
Agitation and crying greatly aggravate the symptoms and signs. The child may prefer
to sit up in bed or be held upright. Older children usually are not seriously ill. Other family members
might have mild respiratory illnesses with laryngitis. Most young patients with croup progress only
as far as stridor and slight dyspnea before they start to recover.
Physical examination can reveal a hoarse voice, coryza, normal to moderately inflamed pharynx, and
a slightly increased respiratory rate.
Patients vary substantially in their degrees of respiratory distress.
Rarely, the upper airway obstruction progresses and is accompanied by an increasing respiratory
rate; nasal flaring; suprasternal, infrasternal, and intercostal retractions; and continuous stridor.
Croup is a disease of the upper airway, and alveolar gas exchange is usually normal. Hypoxia and
low oxygen saturation are seen only when complete airway obstruction is imminent.
The child who is hypoxic, cyanotic, pale, or obtunded needs immediate airway management.
Occasionally, the pattern of severe laryngotracheobronchitis is difficult to differentiate from
epiglottitis, despite the usually more acute onset and rapid course of the latter.
Croup is a clinical diagnosis and does not require a radiograph of the neck.
Radiographs of the neck can show the typical subglottic narrowing, or steeple sign, of croup on the
posteroanterior view .
Acute Infectious Laryngitis
Laryngitis is a common illness. Viruses cause most cases; diphtheria is an exception but is extremely
rare in industrialized countries .
The onset is usually characterized by an upper respiratory tract infection during which sore throat,
cough, and hoarseness appear. The illness is generally mild; respiratory distress is unusual except in
the young infant. Hoarseness and loss of voice may be out of proportion to systemic signs and
symptoms.
The physical examination is usually not remarkable except for evidence of pharyngeal inflammation.
Inflammatory edema of the vocal cords and subglottic tissue may be demonstrated laryngoscopically.
The principal site of obstruction is usually the subglottic area.

Spasmodic Croup
Spasmodic croup occurs most often in children 1-3 yr of age and is clinically similar to acute
laryngotracheobronchitis, except that the history of a viral prodrome and fever in the patient and
family are often absent.
The cause is viral in some cases, but allergic and psychologic factors may be important in others.
Occurring most commonly in the evening or nighttime, spasmodic croup begins with a sudden onset
that may be preceded by mild to moderate coryza and hoarseness. The child awakens with a
characteristic barking, metallic cough, noisy inspiration, and respiratory distress and appears anxious
and frightened.
The patient is usually afebrile. The severity of the symptoms generally diminishes within several hr,
and the following day, the patient often appears well except for slight hoarseness and cough.
Similar, but usually less severe, attacks without extreme respiratory distress can occur for another
night or two.
Such episodes often recur several times. Spasmodic croup might represent more of an allergic
reaction to viral antigens than direct infection, although the pathogenesis is unknown.

Acute Epiglottitis (Supraglottitis)

In the past, Haemophilus influenzae type b was the most commonly identified etiology of
acute epiglottitis. Since the widespread use of the H. influenzae type b vaccine, invasive disease
caused by H. influenza type b in pediatric patients has been reduced by 99% . Therefore, other
agents, such as Streptococcus pyogenes, Streptococcus pneumoniae, nontypeable H. influenzae, and
Staphylococcus aureus, represent a larger portion of pediatric cases of epiglottitis in vaccinated
children.
This now rare, but still dramatic and potentially lethal condition is characterized by an acute
rapidly progressive and potentially fulminating course of high fever, sore throat, dyspnea, and
rapidly progressing respiratory obstruction. The degree of respiratory distress at presentation is
variable.
Often, the otherwise healthy child suddenly develops a sore throat and fever. Within a matter of
hours, the patient appears toxic, swallowing is difficult, and breathing is labored. Drooling is usually
present and the neck is hyperextended in an attempt to maintain the airway.
The child may assume the tripod position, sitting upright and leaning forward with the chin up and
mouth open while bracing on the arms.
A brief period of air hunger with restlessness may be followed by rapidly increasing cyanosis and
coma. Stridor is a late finding and suggests near-complete airway obstruction.
Complete obstruction of the airway and death can ensue unless adequate treatment is provided.
The barking cough typical of croup is rare.
Usually, no other family members are ill with acute respiratory symptoms.
The diagnosis requires visualization under controlled circumstances of a large, cherry red, swollen
epiglottis by laryngoscopy. Direct inspection of the oral cavity should be avoided until the airway
is secured.
If epiglottitis is thought to be possible but not certain in a patient with acute upper airway
obstruction, the patient may undergo lateral radiographs of the upper airway first. Classic
radiographs of a child who has epiglottitis show the thumb Sign.
The patient is usually febrile. The severity of the symptoms generally diminishes within several hr,
and the following day, the patient often appears well except for slight hoarseness and cough. Similar,
but usually less severe, attacks without extreme respiratory distress can occur for another night or
two. Such episodes often recur several times.

TREATMENT:
The mainstay of treatment for children with croup is airway management and treatment of hypoxia
Most children with either acute spasmodic croup or infectious croup can be managed safely at home.
Despite the observation that cold night air is beneficial, a Cochrane review has found no evidence
supporting the use of cool mist in the emergency department for the treatment of croup.
Nebulized racemic epinephrine is an accepted treatment for moderate or severe croup. A dose of
0.25-0.5 mL of 2.25% racemic epinephrine in 3 mL of normal saline can be used as often as every 20
min.
The effectiveness of oral corticosteroids in viral croup is well established.
Corticosteroids decrease the edema in the laryngeal mucosa through their antiinflammatory action.
Oral steroids are beneficial, even in mild croup, as measured by reduced hospitalization, shorter
duration of hospitalization, and reduced need for subsequent interventions such as epinephrine
administration.
Most studies that demonstrated the efficacy of oral dexamethasone used a single dose of 0.6 mg/ kg,
a dose as low as 0.15 mg/kg may be just as effective.
Antibiotics are not indicated in croup.
A helium-oxygen mixture (heliox) may be considered in the treatment of children with severe croup
for whom intubation is being considered although the evidence is inconclusive.
Children with croup should be hospitalized for any of the following:
progressive stridor, severe stridor at rest, respiratory distress, hypoxia, cyanosis, depressed mental
status, poor oral intake, or the need for reliable observation.

Epiglottitis is a medical emergency and warrants immediate treatment with an artificial airway
placed under controlled conditions, either in an operating room or intensive care unit. All patients
should receive oxygen en route unless the mask causes excessive agitation.
Racemic epinephrine and corticosteroids are ineffective.
Cultures of blood, epiglottic surface, and, in selected cases, cerebrospinal fluid should be collected
after the airway is stabilized.
Cefotaxime, ceftriaxone, or meropenem should be given parenterally, pending culture and
susceptibility reports, because 10-40% of H. influenzae type b cases are resistant to ampicillin.
After insertion of the artificial airway, the patient should improve immediately, and respiratory
distress and cyanosis should disappear.
Epiglottitis resolves after a few days of antibiotics, and the patient may be extubated; antibiotics
should be continued for at least 10 days.
Chemoprophylaxis is not routinely recommended for household, childcare, or nursery contacts of
patients with invasive H. influenzae type b infections, but careful observation is mandatory, with
prompt medical evaluation when exposed children develop a febrile illness.
Indications for rifampin prophylaxis (20 mg/kg orally once a day for 4 days; maximum dose: 600
mg) for all household members include a child within the home who is younger than 4 yr of age and
incompletely immunized, younger than 12 mo of age and has not completed the primary vaccination
series, or immunocompromised.

Acute laryngeal swelling on an allergic basis responds to epinephrine (1 : 1,000 dilution in dosage
of 0.01 mL/kg to a maximum of 0.5 mL/dose) administered intramuscularly or racemic epinephrine
(dose of 0.5 mL of 2.25% racemic epinephrine in 3 mL of normal saline) .
Corticosteroids are often required (1-2 mg/ kg/24 hr of prednisone for 3-5 days).
After recovery, the patient and parents should be discharged with a preloaded syringe of epinephrine
to be used in emergencies.
Reactive mucosal swelling, severe stridor, and respiratory distress unresponsive to mist therapy may
follow endotracheal intubation for general anesthesia in children.
Racemic epinephrine and corticosteroids are helpful.

Prepared by : Prof. Yusra AR Mahmood

Dec.2016