Acute upper airway obstruction

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  • See also

    Emergency airway management
    Resuscitation: hospital management of cardiopulmonary arrest
    Foreign body inhaled

    Key points

    1. Allow children with acute upper airway obstruction to adopt a position of their choice and avoid causing distress
    2. Decompensation of acute upper airway obstruction can be rapid and requires emergency airway management
    3. In any child with severe acute upper airway obstruction, nebulised adrenaline may provide temporary relief while awaiting other definitive measures


    • Due to their size, infants are most at risk of severe upper airway obstruction
    • Children with pre-existing narrowing of the upper airway may fully obstruct with otherwise minor acute upper airway swelling
    • Although croup is the most common cause of acute upper airway obstruction, other diagnoses must always be considered


    Allow the child to settle quietly on parent’s lap in a position of their choice, and observe closely with minimal examination

    Rapidly assess airway patency and respiratory status:

    Mild obstruction

    Moderate obstruction

    Severe to complete obstruction

    Able to speak or cry, may be hoarse
    Intermittent stridor or occasional stertor
    Minimal or no work of breathing
    Good air entry

    Prolonged inspiratory time
    Moderate work of breathing, nasal flaring, grunting, paradoxical chest movement
    Decreased air entry


    Hypoxia (late sign)
    Slow respiratory rate or marked tachypnoea
    Sniffing or tripod position
    Agitated or drowsy conscious state
    Severe work of breathing
    Markedly reduced or no air movement
    Silent gagging or coughing

    Total obstruction will rapidly progress to unconsciousness and cardiorespiratory arrest

    Differential diagnoses (the table below is not an exhaustive list)
    Presentations, particularly the bacterial causes, often overlap

    Possible diagnosis



    Young child (rare <3 months)
    Rapid onset harsh barking cough
    Hoarse voice/cry
    May be febrile and miserable but systemically well


    Swelling of the face and tongue
    Urticarial rash
    Allergen exposure
    Haemodynamic compromise

    Inhaled foreign body

    Young child (or developmentally similar)
    Very sudden onset
    Coughing, choking, vomiting episode (may not be witnessed)
    May have unilateral chest findings, wheeze

    Reduced pharyngeal tone or size

    Reduced conscious state eg after drug or alcohol ingestion, recent seizure, head injury (including NAI)
    Pre-existing narrow or floppy upper airway

    Retropharyngeal abscess

    Sore throat
    Neck pain and stiffness or torticollis
    Fullness and redness of posterior pharyngeal wall; may be midline but can be laterally behind tonsil
    Dysphagia and drooling

    Peritonsillar abscess (quinsy)

    Severe sore throat (often unilateral)
    Hot potato/muffled voice
    Swollen posterior palate and tonsil, with medial displacement of tonsil and deviation of the uvula




    Inadequate Hib immunisation or immunocompromised
    High fever and systemically unwell
    Muffled voice
    Hyperextension of neck
    Pooling of secretions, drooling
    Absent cough
    Low pitched expiratory stridor or stertor

    Bacterial tracheitis

    Systemically unwell
    More severe and rapidly progressive symptoms
    Recent URTI
    Markedly tender trachea
    Cough may be productive with thick secretions

    Ludwig angina (infection of the sublingual and submandibular spaces)

    Swollen, tender floor of mouth and under tongue
    Facial laceration or dental abscess
    Submandibular swelling

    Airway burns

    Burns elsewhere, especially facial
    Singed nasal hairs
    Sooty sputum


    Bruising and swelling of the neck
    Subcutaneous emphysema
    May progress to pneumothorax / pneumomediastinum



    • Children with moderate to severe upper airway obstruction are at high risk of deterioration and complete obstruction if they are upset, sedated or repositioned. Investigations should be deferred until the airway is secure
    • If IV access is required use appropriate analgesia and distraction techniques to minimise distress
    • Children with croup do not require any investigations
    • X-ray (chest and/or soft tissue neck) or CT may be helpful in identifying the location and nature of upper airway obstruction


    • If emergency airway management is required, it will be a “difficult airway”. Involve the most senior clinician available ± anaesthetic or ENT support
    • If awaiting other definitive measures:
      • Oxygen can be given. It may improve saturations but does not relieve obstruction
      • Consider nebulised adrenaline to provide temporary relief in any life-threatening upper airway obstruction
      • Consider dexamethasone 0.6 mg/kg (max 16 mg) IM/IV/oral to reduce swelling if present
    • For intubation, use an endotracheal tube ½ to 1 size smaller than usual for age. Cuffed tubes allow for cuff inflation if leak develops when obstruction begins to resolve. Gaseous induction methods are preferred
    • See croup for specific management
    • Treat the specific cause. For bacterial infections refer to local antimicrobial guidelines

    Consider consultation with local paediatric team when

    Child has moderate acute upper airway obstruction

    Consider consultation with anaesthetics and/or ENT:

    • Child with severe acute upper airway obstruction
    • Child is at risk of deteriorating due to known difficult airway

    Consider transfer when

    Child is at risk of deteriorating and requires airway management beyond the capability of available local services

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Consider discharge when

    • The cause for the acute upper airway obstruction has been identified and symptoms and signs of acute upper airway obstruction have resolved, or are mild and improving
    • Appropriate management undertaken and an adequate follow up plan is in place

    Parent information


    Last updated March 2021

  • Reference List

    1. Eskander A et al. Acute Upper Airway Obstruction. New England Journal of Medicine. 2019. 381 pp1940-1949
    2. Grundfast K. The 10 commandments of management for acute upper airway obstruction in infants and children. JAMA Otolaryngology - Head&Neck Surgery. 2017. 143(6) pp539
    3. Loftis L. Emergency evaluation of acute upper airway obstruction in children. UpToDate. (viewed October 2020)
    4. Virbalas, J. Upper Airway Obstruction. Pediatrics in Review. 2015. 36 (2) pp62