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Acute Upper Airway Obstruction

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    The signs of partial acute upper airway obstruction are:

    • Stridor.
    • Increased work of breathing as evidenced by suprasternal, intercostal, and subcostal retraction along with an increased use of accessory muscles of respiration.

    Signs of deterioration and indications for urgent intervention are:

    • Hypoxia - worried, unsettled appearance, restlessness.
    • Fatigue or decreasing conscious state.
    • Increasing work of breathing.

    Discuss all children with severe or deteriorating upper airway obstruction with a consultant urgently

    • call ICU x5211
    • or PETS 93455211

    Assessment

    • A harsh, barking cough in a febrile, miserable, but otherwise well child suggests croup (see  Croup guideline).
    • Absent cough with low pitched expiratory stridor (often snoring) and drooling suggests epiglottitis.
    • Sudden onset in an otherwise well child with coughing, choking and aphonia suggests an inhaled foreign body (see Foreign Body in the Airway guideline).
    • Swelling of face and tongue, wheeze or urticarial rash suggests anaphylaxis (see Anaphylaxis guideline).

    Other Possible Diagnoses

    Symptoms Possible Diagnosis
    High Fever
    Hyperextension of neck
    Dysphagia, pooling of secretions in throat
    retropharyngeal / peritonsillar abscess
    "Toxic" appearing child
    Markedly tender trachea
    bacterial tracheitis
    Pre-existing stridor (infant) congenital abnormality, eg. floppy larynx,
    haemangioma / subglottic stenosis

    Note: There is a high degree of overlap in clinical presentation between epiglottitis, bacterial tracheitis and upper airway abscess.

    Management

    • Allow child to settle quietly on parent's lap in the position the child feels most comfortable.
    • Observe closely with minimal interference.
    • Treat specific cause - refer to  CroupAnaphylaxis and Foreign Body in the Airway guidelines.
    • Call PICU if worsening or severe obstruction.
    • Oxygen may be given while awaiting definitive treatment. This can be falsely reassuring because a child with quite severe obstruction may look pink in oxygen.

    Notes

    1. Intravenous access should be deferred - upsetting the child can cause increasing obstruction.
    2. Lateral cervical soft tissue x-rays do not assist in management.
      In severe airways obstruction x-rays cause undue delay in definitive treatment and may be dangerous (positioning may precipitate respiratory arrest).
    ET tube size in upper airway obstruction
    Neonate 2.5 - 3 mm
    < 6 months 3.0mm
    6 months - 2 yr 3.5mm
    2 - 5 yr 4.0mm
    > 5 yr 1/2 to 1 size smaller than usual
    (usual size (mm) = 4 + age/4)

     

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