Airway Obstruction

Causes (common causes in bold)

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)

Important points in examination

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)

Severity of upper airway obstruction

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

Investigations

Remember: Avoid painful/ frightening procedures (including MPS & PCV) until airway is stable or secureIf query croup/ epiglottitis no investigations required, check SaO2

If query foreign body/ tumour/ retropharyngeal abscess - CXR, lateral neck X-ray

CXR - May see foreign body if radio-opaque
Unilateral hyper-expansion suggests FB in main bronchus with air-trapping
If a coin seen above the carina:
Seen as a circle - likely in the oesophagus
Seen as a straight line - likely between the vocal chords
Lateral neck - retropharyngeal abscess: distance between the anterior vertebral body wall and the air column in the pharynx is increased (at C3 this distance should be no more than 1/2 of the vertebral body diameter).
If query toxic - blood culture ONLY once airway stable.

Indications for admission

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.

Treatment

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

Supportive care