Airway Obstruction

Airway swelling	Airway obstruction	Airway collapse
Infective: URTI in an infant Viral croup (laryngotracheobronchitis) Bacterial tracheitis Retropharyngeal abscess Epiglottitis Diphtheria Severe tonsillitis Non infective: Anaphylaxis (see anaphylaxis protocol) Adenoidal hypertrophy Inhalational burns	Congenital: Laryngomalacia Choanal atresia Subglottic stenosis Laryngeal web Acquired: Foreign body Vocal cord papillomas Mediastinal tumour Extrinsic haematoma	Reduced conscious level Drug intoxication Opiates Benzodiazepines Chlorpromazine Organophosphate poisoning Bulbar palsy Myopathy

Airway swelling

Airway obstruction

Airway collapse

Infective:

Non infective:

Congenital:

Acquired:

Important points in history

Length of history of stridor (Stridor since birth suggests a congenital anomaly)
Present all the time or only when upset / feeding / lying down?
Coryzal symptoms
Fever
Barking cough, hoarse voice (suggests croup)
Sudden onset when playing or history of choking (suggests foreign body)
Recurring episodes (suggests vocal cord papilloma)
Pain on swallowing (suggests retropharyngeal abscess)
Ingestion of drug or food (suggests allergy or poisoning)
Immunization history
HIV status (suggests Kaposi's sarcoma or laryngeal papillomas)

Toxic, shock, temperature (suggests epiglottitis)
Hoarse voice, barking cough (suggests croup)
Severity of respiratory distress / central cyanosis
Agitation/ drowsiness
Respiratory rate/ heart rate
Drooling (suggests epiglottitis, retropharyngeal abscess)
Posture - e.g. sitting up, leaning forward
Unilateral hyperexpansion or wheeze (suggests foreign body)
Bull neck appearance, blood stained nasal discharge, grey pharyngeal membrane (suggest diphtheria)
Associated urticaria or lip swelling (suggests naphylaxis)
Facial burns, singed nasal hairs, oral/ nasal soot (suggests inhalational burn)

Remember: The loudness of the stridor does not reflect the severity of the airway obstruction

	Mild	Moderate	Severe
Upper airway noise	Hoarse voice Barking cough Mild/loud stridor	More severe stridor	Quiet/ soft stridor
Work of breathing	Mild respiratory distress Mild recession Mild tracheal tug	Moderate respiratory distress Nasal flaring Tracheal tug Moderate recession	Severe respiratory distress: Severe recession Severe tracheal tug Exhaustion Respiratory arrest
Efficacy of breathing	Alert Not distressed	Alert Distressed Hypoxia	Reduced conscious level Cyanosis
Cardiovascular effects	Mild tachycardia	Moderate tachycardia	Severe tachycardia Bradycardia if exhausted

Remember: Avoid painful/ frightening procedures (including MPS & PCV) until airway is stable or secure

All but the mildest case of croup will need to be admitted.
If severe upper airway obstruction d/w senior/ anaesthetist about admittion to ICU.

TRY AND KEEP CHILD CALM - let child sit on parent's knee
Severe obstruction: Nebulised adrenaline (1-2ml 0f 1:1000 in 2mls of saline), dexamethasone (0.6mg/kg, max 10mg) or prednisolone (2mg/kg), call for senior help (registrar, consultant, anaesthetist, ENT)
Croup oxygen, steroids (dexamethason 0.6mg/kg or prednisolone 2mg/kg), adrenaline nebuliser if indicated.
Bacterial infection (tracheitis, retropharyngeal abscess): ceftriaxone
Foreign body: call ENT/ surgeons for bronchoscopy
Epiglottitis: keep calm, oxygen, call for senior support - needs transfer to ICU for intubation. DO NOT EXAMINE THROAT, OR PUT IN AN IV LINE OR DO ANY BLOOD TESTS.
Anaphylaxis: see anaphylaxis protocol
Laryngomalacia: usually resolves as child gets older

When child fully recovered and no longer has respiratory distress 12 hours after last adrenaline nebulisation.