Airway Obstruction

• 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

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.

• 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

• Ensure adequate analgesia, fluid and nutritional intake.

• Admit to HDU
• Inform senior about every child that requires adrenaline nebulisers
• If transferred from ICU monitor closely for deterioration

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