PAEDIATRICS

Acute and chronic airway

obstruction
Stephanie Bew

Children are predisposed to symptomatic airway obstruction by

their anatomy and physiology. The smallest diameter of the upper
airway at the cricoid is only 4–5 mm in a neonate. Even 1 mm of
cricoid oedema reduces the cross-sectional area by 75%. During
laminar flow, resistance is proportional to the fourth power of the
radius (Poiseuille’s law), so 1 mm of oedema increases the resist-
ance 16-fold. The upper airway mucosa is loosely adherent to the
submucosa and prone to swelling, except over the vocal cords
and laryngeal surface of the epiglottis. The tongue base is large
relative to the mandible and the oropharyngeal space is smaller,
so for the first 3 months of life infants are obligate nasal breathers.
Cartilaginous structures are compliant, and increased respiratory
effort causes subcostal and sternal recession with decreased
mechanical efficiency of the chest wall. Airway structures are
easily compressed by external masses.
Any child with airway obstruction can deteriorate quickly; par-
ticularly small infants. Metabolic rate and oxygen consumption are
higher, functional residual capacity is smaller and the diaphragm
has fewer fatigue-resistant fibres. Overall, respiratory reserve is
small and fatigue occurs sooner.
Early recognition of the airway at risk is vital. A management
plan needs to be made on the basis of urgency and the differential
diagnosis. This may involve an early call for experienced anaes-
thetic and ENT help, and moving the child to a high-dependency
area, resuscitation area or theatre. In severe cases, if the child
shows signs of exhaustion or inadequate respiratory effort, secur-
ing the airway with a tracheal tube is the initial treatment.

Assessment
Assessment is predominantly clinical, based on history and exami-
nation (Figure 1). Chest and neck radiographs may be helpful,
but in an acute situation even these are not indicated. Imaging,
especially CT or MRI, is only for a stable child or one in whom the
airway has already been secured. A gentle approach to the child
is essential with minimal disturbance. You may be anxious, but
remember how frightened the parents and child will be. Crying and
agitation increase the respiratory effort, making air flow turbulent,
and occasionally precipitate complete airway obstruction.
Listen to the child. Respiratory noises may indicate the site of
obstruction (Figure 2). Volume and pitch vary with age and effort
and do not correlate with the severity of obstruction.

Stephanie Bew is Consultant Paediatric Anaesthetist at the Leeds General

Infirmary, Leeds, UK. She qualified from Cambridge University and the
Royal London Hospital, and trained in anaesthesia in London. Her special
interest is in the paediatric airway.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 7:5 164 © 2006 Elsevier Ltd
 PAEDIATRICS

Assessing the child with airway obstruction Common causes of airway obstruction

History Examination Infection Congenital

• Onset • Signs of increased work of • Croup • Choanal atresia
breathing: • Epiglottitis • Laryngomalacia
• Duration Respiratory rate • Tracheitis • Tracheomalacia
• Exacerbating/relieving Grunting • Papillomas • Cysts
factors Nasal flaring • Airway abcess • Congenital tumours
• Exercise tolerance or, for Subcostal or sternal recession Foreign body aspiration • Vocal cord paralysis
babies, ability to feed Tracheal tug Trauma • Subglottic stenosis
• Voice change • Posture Burns • Micrognathia
Altered consciousness • Macroglossia
• Obstructive sleep apnoea • Signs of hypoxaemia or
• Fever hypercarbia
• Dysphagia Tachycardia 3
• Neck pain Agitation or confusion
• Drooling Pallor or mottling work just as well. Deterioration is relatively slow, allowing time
to prepare for intubation. Visualization of the larynx should not
1 be difficult, but the tracheal tube is usually several sizes smaller
than expected for age. The infection lasts 3–5 days, and children
are generally extubated as soon as a leak develops around the
tube.
Indicative respiratory noises
Epiglottitis
Sound Site of problem
Epiglottitis is a bacterial infection of the supraglottis, in which the
Stridor Inspiratory Above vocal cords
swollen epiglottis can cause life-threatening obstruction. It affects
Expiratory Below vocal cords, intrathoracic mainly children 1–6 years of age with rapidly progressing fever,
Biphasic At or below vocal cords dysphagia, drooling, tachypnoea and stridor. Children adopt a
Hoarse voice/aphonia/voice Vocal cords tripod posture, sitting up, leaning forward on their hands, to best
change maintain a patent airway and increase mechanical efficiency of the
Croupy cough Subglottic chest wall. Do not attempt to move them. Many hospitals have a
Wheeze Lower respiratory tract local protocol for management.
• Keep the child in a comfortable position, with oxygen delivered
2
as tolerated, often with the parents holding the mask.
• Obtain experienced anaesthetic and ENT help, and move the
child to the safest place for a gas induction. Someone capable of
Pulse oximetry is tolerated by most children, but taking a sample managing the airway must be with the child at all times.
of blood for gas analysis can cause great distress. • Avoid cannulation and radiographs.
In stable patients, chest and neck radiographs, barium swal- • Nebulized epinephrine is given as for croup and may buy time
low (to look for tracheal compression), CT or MRI scans may aid as preparations for intubation are made.
diagnosis (Figure 3). Previously there was wide experience of the use of halothane
for epiglottitis. Now, because epiglottitis is so rare, experience
with the modern agent, sevoflurane, is limited. Halothane has
Acute airway obstruction
theoretical advantages in terms of potency and slower offset, but
Croup (laryngotracheobronchitis) disadvantages in its arrhythmogenic potential. In the UK, many
Croup begins with an upper respiratory infection characterized anaesthetists in training have only ever used sevoflurane for gas
by a barking cough resulting from subglottic narrowing. Stridor induction. It is generally recommended that the anaesthetist use
occurs in severe cases. Neck radiographs may show a narrow the agent with which they are most familiar and comfortable in
subglottis (steeple sign), but the diagnosis is clinical. Croup is situations such as this.
usually caused by a parainfluenza virus; annually, it affects 3% • Gas induction is with the child sitting up.
of children under the age of 6 years. Of these, 2% are admitted to • Continue to maintain spontaneous respiration, obtain intra-
hospital, and 0.5–1.5% of these need intubation. venous access and deepen anaesthesia for intubation. Be patient.
Treatment includes humidification of respiratory gases, though • Uptake of volatile agent is slow and it may take up to 10 minutes
this is of doubtful efficacy. Oral or intravenous dexamethasone, for the pupils to become small and central. Lie the child flat just
0.3–0.6 mg/kg, or nebulized budesonide, 2 mg, and nebulized before intubation.
epinephrine, 0.4 ml/kg of 1/1000 up to a maximum of 5 mg, • A tube smaller than expected for age is needed, and the intuba-
improve symptoms and reduce hospital stay. Racemic epinephrine tion may be very difficult with movement of respiratory secretions or
is traditionally recommended, but the ordinary L form appears to a bubble of gas being the only clue to the location of the larynx.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 7:5 165 © 2006 Elsevier Ltd
 PAEDIATRICS
• Further treatment is with intravenous antibiotics, usually cefo-
taxime, 50 mg/kg/dose 8 hourly, but guided by blood culture and
throat swab. The child must remain intubated, with or without
sedation and ventilation, until a leak develops around the tube.
Epiglottitis was much more common until 1992 when vaccina-
tion against Haemophilus influenzae type b was introduced in the
UK. It is now a rare disease, though still seen in unvaccinated chil-
dren, cases of vaccine failure, or if caused by other organisms.
Bacterial tracheitis (pseudomembranous croup)
Bacterial tracheitis is a relatively rare secondary bacterial infection
often caused by Staphylococus aureus, which can be difficult to
differentiate from croup and epiglottitis, The onset is often over
2–5 days, but the patient is more feverish and toxic than with croup.
However, they can usually lie flat and do not have dysphagia or
drooling. Profuse mucopurulent secretions and sloughing of the
tracheal epithelium are typically seen.
Severe respiratory distress may require intubation, as for epiglot-
titis, though the larynx may be easier to visualize as the epiglottis
should not be swollen. Frequent tracheal suctioning is essential
to avoid the tracheal tube blocking with secretions. Intubation is
generally needed for longer than for croup.
Retropharyngeal abscess
Retropharyngeal abscess is caused by lymphatic spread of infec-
tion from sinuses, teeth or middle ear into the area between the
posterior pharyngeal wall and the prevertebral fascia. It mainly
affects children under 6 years who present with fever, sore throat,
neck pain and swelling, with limitation of movement. A lateral
neck radiograph shows retropharyngeal thickening, but a CT
scan (Figure 4) differentiates cellulitis from abscess and helps to
indicate the need for surgery. Intubation is seldom required other
than for surgery.
Foreign body aspiration
Children with aspirated foreign body who survive to reach hospital
are usually stable enough to wait until appropriate equipment and
a
4 Large multilocular collection (a) displacing the trachea and
oesophagus (b) laterally (CT scan at C4 level).
ANAESTHESIA AND INTENSIVE CARE MEDICINE 7:5
experienced surgeons are available to perform rigid bronchoscopy
(Figure 5). It may be appropriate to transfer the child to a paediatric
centre if skills and equipment are not available locally. Aspiration
occurs most commonly between the ages of 1–3 years; the foreign
body is usually an item of food.
The history is usually of a coughing or choking episode with
cyanosis followed by some persisting respiratory distress, though
symptoms may be mild when the child reaches hospital. Tachy-
pnoea, low oxygen saturation and unilateral wheeze or dimin-
ished breath sounds may be found. Stridor or voice change may
indicate a foreign body that has lodged at or above the cords.
Chest radiographs seldom show the foreign body, but may show
hyperinflation of the affected side in expiratory films, due to a
ball-valve effect. Without a history of aspiration, symptoms can be
difficult to differentiate from acute asthma. Similarly, in refractory
or atypical asthma, the diagnosis of a missed foreign body must
be considered.
In the UK, rigid bronchoscopy with spontaneous ventilation
under deep inhalational anaesthesia is the preferred technique.
Some anaesthetists favour atropine premedication, but prac-
tice varies. Intramuscular atropine is seldom used now, but
oral atropine, 20–30 µg/kg, works well if given at least 1 hour
preoperatively. It is a useful drying agent and obtunds vagally
mediated bradycardias. Atropine, 20 µg/kg, given intravenously
post-induction also serves the latter function. Choice of vapour for
induction should be based on familiarity and experience with the
agent. After induction with vapour in oxygen, intravenous access
is established if not already done, and anaesthesia deepened,
maintaining spontaneous ventilation. The larynx is sprayed with
a maximum of lidocaine, 4 mg/kg; 2% lidocaine provides good
anaesthesia; the 10% spray is very irritant but lasts longer. To
avoid coughing and laryngospasm, 10% lidocaine can be applied
after the larynx has been anaesthetized with 1% lidocaine. The
surgeon generally uses a Storz rigid bronchoscope which has a
side port to attach the Ayre’s T-piece, allowing spontaneous res-
piration and anaesthesia to continue. After one foreign body has
been retrieved it is important to look again for further pieces. If the
a
5 Cardamon pod (a) in right main bronchus.
166 © 2006 Elsevier Ltd
 PAEDIATRICS

procedure is lengthy, causing oedema and bleeding, intravenous

dexamethasone, 0.4 mg/kg repeated 8 hour later, may be given,
with nebulized salbutamol, 2.5 mg 6 hourly, and physiotherapy
for 24–48 hours.

Obstructive sleep apnoea

In children the most common cause of obstructive sleep apnoea
(airway obstruction and apnoea during sleep) is adenotonsillar
hypertrophy. Mild degrees of obstructive sleep apnoea are common b
in children presenting electively for adenotonsillectomy. It is often
more severe in children with predisposing conditions such as
Down’s syndrome, cerebral palsy or achondroplasia. Any child
may have an acute exacerbation owing to infection and present
toxic and dehydrated with mouth breathing, dysphagia and severe
airway obstruction when asleep. These children need urgent tonsil- a
lectomy, and invariably have airway obstruction on induction of
anaesthesia. This is usually relieved by use of a Guedel airway. 6 Suspension laryngoscope with light source (a) and side
For many children the operation is curative, but some degree of port (b) for oxygen and anaesthetic vapour.
obstruction continues in the early postoperative period, particu-
larly in children with predisposing conditions. It is important to the airway and improves gas exchange, particularly in conditions
avoid long-acting opioids or sedatives. High-dependency nursing involving airway collapse.
for 24 hours postoperatively may be needed. • Good topical anaesthesia of the larynx with lidocaine, 4 mg/kg,
is essential.
Thermal injury • Most patients do not need intubation, and the airway can be
Inhalational injury is often associated with facial burns, cough, maintained with a face mask until the surgeon inserts the rigid
hoarse cry and sooty sputum, but should be suspected if there is bronchoscope or suspension laryngoscope.
a history of smoke exposure, especially in a closed space. Heated • Storz rigid bronchoscopes range in size from 2.5 mm to 6 mm
gases and steam can cause thermal damage to the mucosa of the internal diameter with the external diameter about 2 mm larger.
upper airway above the vocal cords, causing an epiglottitis-like The Hopkins rod telescope (Figure 7) fits down the bronchoscope
picture. Airway obstruction can develop after 3–8 hours, and and gives better resolution, magnification and a wide-angle view.
close monitoring is essential. In an obviously severe injury, the If a camera attachment is used, the images can be seen on screen.
airway should be secured early before severe facial, pharyngeal Remember that the telescope takes up some of the lumen of the
and laryngeal swelling occurs. bronchoscope and increases the resistance to gas flow. The suspen-
sion laryngoscope is a tubular instrument that allows examination
of the larynx during spontaneous respiration while oxygen and
Congenital airway obstruction
anaesthetic vapour are entrained from a side port.
Many infants with chronic airway obstruction require general • The passage of a rigid bronchoscope or airway surgery may
anaesthesia for elective laryngoscopy and bronchoscopy. They may make the airway obstruction worse in the immediate postoperative
also present acutely either from birth or with increasing respiratory period. These children need close observation and are best kept in
distress often secondary to an upper respiratory infection. For some the recovery area for an extended period until it is certain that the
conditions, surgery to relieve the obstruction may be performed airway is safe. Intravenous dexamethasone, 0.4 mg/kg repeated
through the suspension laryngoscope (Figure 6) while the infant after 8 hours, and epinephrine nebulizers, as for croup, may be
breathes spontaneously.
The following basic principles apply for anaesthesia for all these
conditions.
c d
• Careful assessment of the infant. The obstruction may get worse
on induction of anaesthesia. Plan for this. b
• Good communication with the surgeon and theatre staff is a
essential. Management of the airway will change several times
during the procedure and the full range of equipment in all sizes
must be available instantly.
• Consider giving atropine premedication. Oral atropine,
20–30 µg/kg, is useful for neonates and infants with severe airway
compromise.
• Gas induction is with either halothane or sevoflurane in
oxygen. Intravenous access is established if not appropriate before
induction.
• Maintain spontaneous respiration. Continuous positive airway 7 Hopkins rod telescope (a) and Storz rigid bronchoscope (b) with light
pressure (CPAP) applied by face mask effectively splints open source (c) and Ayre’s T-piece (d) attached.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 7:5 167 © 2006 Elsevier Ltd
 PAEDIATRICS
needed. Remember that the airway may still be anaesthetized for
some time after the procedure and children must be given nil by
mouth for at least 2 hours after topical lidocaine if concentrations
of 2% or greater are used.
Laryngomalacia
Laryngomalacia is prolapse of the epiglottis and/or arytenoid car-
tilage (Figure 8) during inspiration. It is the most common cause
of congenital stridor. It presents soon after birth with inspiratory
stridor, subcostal and suprasternal recession. Feeding difficulties
and reflux are common with more severe forms. Mild forms require
no treatment because the condition resolves as the babies grow.
In severe forms, surgery is performed to release tight aryepiglottic
folds and remove excess arytenoid tissue.
Tracheobronchomalacia
Tracheobronchomalacia is narrowing or collapse of the trachea on
expiration due to a defect in the cartilaginous rings. These infants
present with ‘dying spells’ involving wheeze, stridor, cyanosis
and collapse. The diagnosis is made on rigid bronchoscopy when
tracheal collapse is seen during spontaneous ventilation. Medical
treatment is by CPAP, sometimes for a protracted period until the
cartilage becomes more rigid, and a tracheostomy may be needed.
Tracheomalacia is often secondary to compression by a vascular
ring which can be resected, but a short period of ventilatory sup-
port with CPAP is often needed.
Subglottic stenosis
Subglottic stenosis may be congenital or secondary to intubation.
Children present with respiratory distress and both inspiratory and
expiratory noise. It is easy to underestimate the degree of stenosis
from the symptoms, particularly in a small infant. If surgery is
required, a range of procedures are performed to reconstruct the
trachea, often requiring a temporary tracheostomy.
Laryngeal papillomas
Laryngeal papillomas are benign tumours caused by the human
papilloma virus (Figure 9). Presentation is usually at 2–5 years
of age with slow onset of progressive dyspnoea, often treated as
asthma, and a hoarse voice. Acutely, they present with increased
signs of respiratory distress and stridor. By this time the airway
b b
8 Laryngomalacia with prolapse of arytenoids. Epiglottis (a) with
arytenoid tissue (b) sucked into laryngeal inlet on inspiration.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 7:5
a
c
c
c
b
9 Laryngeal papillomas. (a) Epiglottis; (b) arytenoid; (c) papilloma
obscuring laryngeal inlet.
is severely compromised with a florid growth of cauliflower-like
papillomas. Treatment is by laser resection, but recurrences are
common and may require treatment several times a year, until
puberty, when the papillomas regress spontaneously. Some
respond to interferon. These children need treating with caution
every time they are anaesthetized because it is difficult to assess
the extent of regrowth before laryngoscopy.
Cysts and congenital tumours
The symptoms and presentation of cysts and tumours depend
on the size and location of the lesion. Haemangiomas are often
subglottic and present with a croupy cough. The child often has
haemangiomas at other sites. Cysts may be in the vallecula or
around the larynx. Treatment may be simple aspiration, resection
or laser ablation, but tracheostomy may be required until the size
of the lesion has reduced. 
FURTHER READING
Morton N S. Large airway obstruction in children Part 1: Causes and
assessment. Royal College of Anaesthetists Newsletter July 1999; 47:
159–62.
Morton N S. Large airway obstruction in children Part 2: Management.
Royal College of Anaesthetists Newsletter September 1999; 48:
202–5.
Sumner E, Hatch D J. Paediatric anaesthesia. London: Arnold, 2002.
168 © 2006 Elsevier Ltd