Emergency evaluation of acute upper airway obstruction in children

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Emergency evaluation of acute upper airway obstruction in children

Author: Laura L Loftis, MD
Section Editors: Stephen J Teach, MD, MPH, Adrienne G Randolph, MD, MSc
Deputy Editor: James F Wiley, II, MD, MPH
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2020. | This topic last updated: Jun 20, 2019.
INTRODUCTION
This topic will review an emergency diagnostic and therapeutic approach to acute upper airway obstruction in children. The emergent evaluation
of children with acute respiratory distress and airway management techniques for the difficult pediatric airway are discussed separately.
● (See "Acute respiratory distress in children: Emergency evaluation and initial stabilization".)
● (See "The difficult pediatric airway".)
● (See "Devices for difficult endotracheal intubation in children".)
● (See "Emergency rescue devices for difficult pediatric airway management".)
CAUSES
Any condition that causes upper airway obstruction can be life-threatening (table 1). Patients with an upper airway foreign body (FB), smoke
inhalation, laryngotracheal injury, and epiglottitis (infectious, thermal, or chemical) are at particular risk for sudden decompensation and also
frequently require emergency airway intervention.
The discussion will emphasize causes that can result in acute, severe, and rapidly progressive symptoms. The causes of hoarseness, and the
assessment of stridor are discussed elsewhere. (See "Hoarseness in children: Evaluation" and "Assessment of stridor in children".)
Infection — Most infectious processes that affect the upper airway cause a gradual onset of symptoms such as cough, change in voice, and
difficulty swallowing. Infection directly involving structures of the upper airway, such as the epiglottis, larynx, or subglottic trachea, can cause
sudden, life-threatening symptoms.
The most common infections that may impinge on the airway include:
Croup — Croup, also known as laryngitis, laryngotracheitis, and laryngotracheobronchitis, is the most common infectious cause of upper
airway obstruction in children 6 to 36 months of age. Spasmodic croup causes symptoms that are the same as those of laryngotracheitis, but
without signs of infection. There may be an allergic component to spasmodic croup.
Croup cause inflammation of the subglottic trachea that results in cough, hoarseness, stridor, and respiratory distress. The severity of the
distress depends upon the degree of obstruction. The diagnosis usually can be made based upon a characteristic "barking" cough with
hoarseness. If performed, radiographs have characteristic findings of subglottic haziness (image 1), a narrowing of the superior trachea ("steeple
sign" (image 2)), and a normal epiglottitis. The evaluation and management of croup is discussed separately. (See "Croup: Clinical features,
evaluation, and diagnosis", section on 'Clinical presentation' and "Management of croup".)
Bacterial tracheitis — Bacterial tracheitis may be a complication of viral laryngotracheitis or a primary bacterial infection. Children are
generally older than those with croup, have more severe symptoms, and are highly febrile. Radiographs may show an intraluminal tracheal
membrane or tracheal wall irregularity (scalloping) (image 3). (See "Bacterial tracheitis in children: Clinical features and diagnosis".)
Most children with bacterial tracheitis warrant emergency endoscopy and endotracheal intubation. (See "Bacterial tracheitis in children:
Treatment and prevention", section on 'Ongoing assessment of the airway'.)
Retropharyngeal abscess — Retropharyngeal abscess most commonly affects young children two to four years of age. Prominent
presenting complaints are usually fever, neck pain, neck stiffness, and sore throat rather than acute, severe airway obstruction. A lateral
radiograph can help differentiate retropharyngeal abscess from other infectious causes of upper airway obstruction (image 4). However,
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computed tomography (CT) of the neck with intravenous contrast is required to definitively make the diagnosis. (See "Retropharyngeal infections
in children", section on 'Evaluation and diagnosis'.)
Rarely, a retropharyngeal abscess may extrinsically compress structures in the upper airway. These patients require definitive airway
management before diagnostic imaging.
Peritonsillar abscess — Peritonsillar abscess (PTA) is a collection of pus located between the capsule of the palatine tonsil and the
pharyngeal muscles. It generally occurs in later childhood and adolescence.
The typical clinical presentation of PTA is a severe sore throat (usually unilateral), fever, and a "hot potato" or muffled voice. Pooling of saliva or
drooling may be present. Trismus, related to irritation and reflex spasm of the internal pterygoid muscle, occurs in nearly two-thirds of patients;
the sudden onset of severe respiratory distress or significant airway obstruction is rare.
The diagnosis of PTA can usually be made clinically without laboratory data or imaging of any kind in the patient with medial displacement of the
tonsil and deviation of the uvula (picture 1). (See "Peritonsillar cellulitis and abscess", section on 'Evaluation' and "Peritonsillar cellulitis and
abscess", section on 'Management'.)
Infectious mononucleosis — Infectious mononucleosis (IM) is the best known acute clinical manifestation of Epstein-Barr virus infection. IM
often begins with malaise, headache, and low-grade fever before development of the more specific signs of tonsillitis and/or pharyngitis, cervical
lymph node enlargement and tenderness, and moderate to high fever. Affected patients usually have peripheral blood lymphocytosis, composed
in large measure of atypical lymphocytes.
The lymphadenopathy characteristically is symmetric and involves the posterior cervical chain more than the anterior chain. Tonsillar exudate is
a frequent component of the pharyngitis; the exudate can have a white, gray-green, or necrotic appearance. Obstruction of the upper airway due
to massive tonsillar enlargement and mucosal edema is an uncommon but potentially fatal complication of infectious mononucleosis [1]. (See
"Clinical manifestations and treatment of Epstein-Barr virus infection".)
Epiglottitis — Although much less common in the post-conjugate vaccine era, epiglottitis (supraglottitis) is a life-threatening bacterial
infection characterized by rapidly progressive inflammation of and around the epiglottis. Common symptoms of upper airway compromise
include acute respiratory distress with the child preferring an upright posture with the head in a sniffing position (picture 2), dysphagia, muffled
voice, and difficulty handling oral secretions. In children, risk factors include incomplete or lack of immunization to Haemophilus influenzae, type
b or immune deficiency. (See "Epiglottitis (supraglottitis): Clinical features and diagnosis".)
A rapid overview provides key clinical findings and immediate management for patients with epiglottitis (table 2). An algorithm provides the
diagnostic approach to epiglottitis (algorithm 1) and specific steps in acute airway management (algorithm 2). (See "Epiglottitis (supraglottitis):
Management".)
Foreign body — Small children often choke on food or small objects and usually clear the obstruction spontaneously with coughing and
choking. In a retrospective report, the majority of prehospital calls for airway obstruction in children less than 5 years of age were caused by a
foreign object [2]. Symptoms resolved in more than half of children prior to the arrival of paramedics. An intervention was required in 2 percent of
cases.
Clinical manifestations vary by the location of the FB:
● Airway FB – Most aspirated objects lodge in the bronchi and are not immediately life-threatening. Although rare, FBs in the larynx or
trachea can cause significant complete or partial airway obstruction that requires immediate treatment. These patients may have a history of
choking and present with signs of severe airway obstruction (marked suprasternal retractions, stridor, and anxious appearance) typically
without fever. (See "Airway foreign bodies in children", section on 'Signs and symptoms'.)
If a child presents with complete airway obstruction (ie, is unable to speak or cough), dislodgement using back blows and chest
compressions in infants, and the Heimlich maneuver in older children, should be attempted (algorithm 3). By contrast, these interventions
should be avoided in children who are able to speak or cough since they may convert a partial to a complete obstruction. For the same
reason "blind" sweeping of the mouth and oropharynx should not be performed. (See "Airway foreign bodies in children", section on
'Management'.)
For patients with suspected FB aspiration who are symptomatic but stable, the first step in the evaluation is to perform plain radiography of
the chest (algorithm 4). Ideally, both inspiratory and expiratory radiographs (eg. lateral decubitus films) should be obtained, if this is possible,
because this may increase the sensitivity for detecting a radiolucent FB. Subsequent steps depend on the degree of clinical suspicion for
FBs, and may include CT or bronchoscopy. Normal radiographic studies do not exclude the presence of an aspirated FB. (See "Airway
foreign bodies in children", section on 'Evaluation' and "Airway foreign bodies in children", section on 'Management'.)
● Esophageal FB – FBs lodged in the esophagus in the area of the cricoid cartilage or the tracheal bifurcation can compress the airway
causing partial airway obstruction (figure 1). It is also possible that an esophageal FB will become dislodged into the upper airway. Eliciting a
history of choking in a child with characteristic findings of dysphagia, drooling, and respiratory distress are the keystones in diagnosing an
esophageal FB and to the prevention of its complications. Imaging can be used to confirm the findings and to localize the site of the FB
(image 5). The diagnostic steps and treatment depend on the patient's symptoms, the shape and location of the FB, whether it is radio-
opaque, or whether it has magnetic properties (algorithm 5 and algorithm 6). (See "Foreign bodies of the esophagus and gastrointestinal
tract in children".)
Trauma
Blunt or penetrating airway injury — Serious airway trauma is rare in children and requires rapid assessment and management of the
airway similar to the approach in adults (algorithm 7). (See "Emergency airway management in the adult with direct airway trauma", section on
'Airway assessment' and "Emergency airway management in the adult with direct airway trauma", section on 'Management'.)
Blunt or penetrating injury to various anatomic structures may result in upper airway obstruction:
● Traumatic injury to the face or neck may cause soft tissue swelling or hemorrhage, leading to airway compromise.
● Blunt or penetrating trauma directly to the larynx or subglottic trachea may result in dyspnea, altered phonation, bruising and swelling of the
neck, and/or subcutaneous emphysema [3]. Other signs of significant airway trauma include hemoptysis, dysphagia, and cough.
● Injury to the epiglottis (eg, aggressive blind finger sweeps for an FB) can cause swelling and upper airway obstruction with a clinical
presentation indistinguishable from infectious epiglottitis [4].
Injuries sustained from direct trauma to the airway are often dynamic and conditions can deteriorate quickly. Because of the higher likelihood that
bronchoscopic intubation or emergency tracheostomy may be necessary, emergency consultation with an otolaryngologist and anesthesiologist
should occur [3]. It is best to secure the airway early whenever signs of active or impending obstruction are identified or there is doubt about the
extent of the injuries or their likely course.
Upper airway burns (thermal and chemical) — A history of exposure to high heat in a closed space, facial burns, or singed facial hairs
should alert the practitioner to the possibility of thermal injuries to the upper airway. Although there may be no initial airway compromise, edema
can rapidly progress. Thus, timely endotracheal intubation before the development of edema is advisable. (See "Moderate and severe thermal
burns in children: Emergency management", section on 'Initial management decisions'.)
Thermal injury to the epiglottitis, usually from hot beverages, has been reported [4]. Thermal injury below the vocal cords is unlikely due to the
cooling efficiency of the upper airways [5]. Burns following ingestion of caustic liquids or solids have also been associated with chemical burns of
the epiglottis. (See "Caustic esophageal injury in children", section on 'Airway injury'.)
The airway management of thermal or caustic epiglottitis is the same as for infectious epiglottitis and requires prompt airway management (table
2 and algorithm 1). (See "Epiglottitis (supraglottitis): Management", section on 'Approach to airway management'.)
Anaphylaxis — Anaphylactic reactions may be severe and life-threatening when edema involves the retropharynx and/or larynx. Onset of
symptoms is usually sudden, and there may be associated signs such as urticaria and facial swelling. Emergency treatment requires timely
administration of intramuscular epinephrine and can be life-saving (table 3).
Patients whose symptoms do not improve or worsen despite treatment with epinephrine require definitive airway management (algorithm 8).
Hereditary angioedema — Laryngeal edema with or without swelling of the lips, tongue, uvula, and soft palate occurs in approximately one-half
of all patients with hereditary angioedema at some point during their lifetime. Many patients present in childhood or adolescence. Tooth
extraction and oral surgery are common triggers for laryngeal attacks which present with progressive airway obstruction that is often associated
with lip and oral swelling. (See "Hereditary angioedema: Epidemiology, clinical manifestations, exacerbating factors, and prognosis".)
Hereditary angioedema should be suspected in patients with progressive upper airway edema that is not responsive to intramuscular
epinephrine. Assessment and protection of the upper airway is the first and most important management issue in the patient with an acute attack
involving any part of the airway, because none of the available therapies (table 4), including first-line agents, can be considered universally
effective in all cases. In addition, these agents take time to work and the patient's airway must be protected in the interim. (See "Hereditary
angioedema: Acute treatment of angioedema attacks", section on 'Laryngeal attacks'.)
Laryngospasm — Laryngospasm is an acute manifestation of vocal cord dysfunction that is usually precipitated by irritation of the vocal cords
(eg, aspiration during sedation). The vocal cords become tightly opposed and cause complete upper airway obstruction. Hypocalcemic tetany is
also a rare cause of laryngospasm. (See "Clinical manifestations of hypocalcemia", section on 'Tetany'.)
Management of laryngospasm should start with application of continuous positive pressure (CPAP) using a bag valve mask. Rapid sequence
intubation should be performed if the laryngospasm does not rapidly resolve with CPAP. (See "Anesthesia for the child with a recent upper
respiratory infection", section on 'Treatment'.)
Decreased oropharyngeal muscle tone — The tongue can fall back into the pharynx and obstruct the airway in children with decreased
oropharyngeal muscle tone as can occur with depressed levels of consciousness or neuromuscular disease (eg, cerebral palsy, congenital
myopathies, or cranial neuropathy). Simply repositioning the airway may relieve the obstruction. Persistent obstruction may be treated with a
nasopharyngeal airway in the conscious or semiconscious patient. (See "Basic airway management in children".)
Airway secretions or bleeding — Oropharyngeal or nasopharyngeal bleeding and secretions can cause significant upper airway obstruction in
children. Superficial suctioning of the naso- and oropharynx and, as needed, control of bleeding resolves the obstruction. However, the physician
should be careful to not perform orotracheal suction children with underlying conditions (eg, epiglottitis or an upper airway FB) where excessive
oro- or nasopharyngeal stimulation may cause abrupt and complete airway obstruction.
Examples of conditions where suctioning is indicated include:
● Infants younger than six months of age who are obligate nasal breathers and who are at particular risk for significant airway obstruction
caused by nasal secretions secondary to a viral process (eg, viral upper respiratory infection [URI]).
● Patients with a chronic upper airway obstruction exacerbated by excessive airway secretions due to a viral URI. (See 'Acute on chronic
conditions' below.)
● Children exposed to organophosphates or other cholinergic agents. In these patients, suctioning should be augmented by atropine
administration. The recognition and management of organophosphate poisoning is discussed separately. (See "Organophosphate and
carbamate poisoning", section on 'Clinical features' and "Organophosphate and carbamate poisoning", section on 'Cholinergic toxicity'.)
● Children with posterior arterial epistaxis (rare) or oropharyngeal trauma with bleeding; management consists of suctioning and rapid
hemorrhage control. Posterior epistaxis requires advanced techniques to tamponade bleeding in the posterior nasopharynx. (See
"Management of epistaxis in children", section on 'Advanced techniques'.)
Vocal cord dysfunction — Vocal cord dysfunction (VCD) may be caused by injury to the recurrent laryngeal nerve (eg, after thoracotomy),
brainstem abnormality or injury, or paradoxical vocal fold movement. The anatomy and physiology of vocal cord function are discussed
extensively elsewhere. (See "Hoarseness in children: Evaluation".)
The symptoms of VCD are usually chronic. The acute onset or worsening of stridor in patients with VCD can be alarming and may be a clue to a
more serious and possibly progressive problem. This is particularly true when the VCD is due to a lesion in the brainstem. As an example, VCD
can occur in children with Chiari II malformations and may warrant neurosurgical intervention.
Involuntary vocal cord adduction during inspiration has been described in children and adolescents and is called paradoxical vocal fold
movement. Significant findings of upper airway obstruction may occur. However, endotracheal intubation, cricothyrotomy, or tracheostomy is not
an appropriate treatment for this condition. (See "Inducible laryngeal obstruction (paradoxical vocal fold motion)", section on 'Acute
management'.)
Acute on chronic conditions — Children who have chronic narrowing of the upper airway, either congenital (table 5) or acquired, can develop
critical obstruction with an acute illness (eg, croup) or injury that affects the upper airway. As an example, a child with mild stridor as the result of
a laryngeal web may develop severe obstruction with a URI. Similarly, mild upper airway obstruction as the result of extrinsic compression of the
trachea from a neoplasm can become acutely life-threatening if bleeding into the tumor causes it to suddenly expand.
Most children with chronic causes of upper airway obstruction (eg, tracheomalacia) become symptomatic gradually, usually in early infancy.
Some conditions, such as lymphatic malformations, may become evident at an older age, in association with infection or, occasionally, trauma
[6]. Severe, recurrent croup may be an indicator of an underlying airway abnormality that warrants diagnostic investigation. Congenital
anomalies affecting the airway are discussed in detail elsewhere. (See "Congenital anomalies of the jaw, mouth, oral cavity, and pharynx" and
"Congenital anomalies of the larynx" and "Congenital anomalies of the intrathoracic airways and tracheoesophageal fistula".)
EMERGENCY AIRWAY ASSESSMENT AND MANAGEMENT
Rapid assessment of the airway and breathing — The initial evaluation of children with acute upper airway obstruction begins with a rapid
assessment of airway patency and respiratory status to identify those who need emergency airway management [7]. Throughout this evaluation,
every reasonable effort must be made to keep the child calm and comfortable because anxiety and crying can substantially increase airway
obstruction and the work of breathing in young children [7].
The clinician should focus upon signs of airway obstruction and respiratory failure:
● Upper airway obstruction – The degree of obstruction can be estimated based upon physical findings:
• Mild – Mild obstruction presents with the following findings:
- Ability to speak (voice may be hoarse) or hoarse cry

- Good air entry
- Inspiratory stridor (may only be heard with crying, agitation, excitement, or tachypnea) or occasional snoring (stertor)
- Minimal or no suprasternal retractions and no flaring or grunting
• Moderate to severe – Moderate obstruction is characterized by:
- Tachypnea
- Audible inspiratory stridor (and possibly expiratory stridor) with every breath
- Prolonged inspiratory time with signs of significant effort (suprasternal retractions, nasal flaring, or grunting)
- Decreased air entry
Hypoxemia (pulse oximetry <91 percent or poor color), the presence of "sniffing" (picture 2) or "tripod" (picture 3) positions taken to
maintain an open airway, and/or decreased mental status suggest that the obstruction is severe and that emergency airway
management is needed.
• Complete – With severe or complete upper airway obstruction, there is markedly reduced or no effective air movement; the child is
struggling to breathe with signs of severe respiratory distress (nasal flaring, grunting, and/or marked suprasternal or supraclavicular
retractions), and may be silently gagging or coughing in an attempt to clear the airway. If the obstruction is not relieved, the child's
condition can rapidly deteriorate, with loss of consciousness. (See 'Severe or complete obstruction' below.)
● Respiratory failure – Children with respiratory failure caused by upper airway obstruction have developed inadequate oxygenation,
inadequate ventilation, or both. The following clinical features indicate respiratory failure [7]:
• Poor color (ashen or centrally cyanotic)

• Obtunded mental status
• Decreased chest wall movement, with or without signs of respiratory distress
• Bradypnea or marked tachypnea
As respiratory failure progresses, the child's respiratory rate often decreases and the pattern of respirations becomes irregular. Without
intervention, respiratory arrest quickly develops.
It is often impractical to initially measure pulse oximetry in an anxious child with respiratory distress. Poor color and decreased mental status
are indications of hypoxemia in this situation.
Emergency airway management
Severe or complete obstruction — With severe or complete upper airway obstruction, there is markedly reduced or no effective air
movement; the child is struggling to breathe with signs of severe respiratory distress (nasal flaring, grunting, and/or marked suprasternal or
supraclavicular retractions), and may be silently gagging or coughing in an attempt to clear the airway. If the obstruction is not relieved, the
child's condition can rapidly deteriorate, with loss of consciousness.
These patients require emergency airway management by the most experienced physician available. Whenever possible, an anesthesiologist
and otolaryngologist should be emergently called to assist with securing the airway.
Suspected foreign body — The management of a child with severe or complete obstruction due to a suspected foreign body (FB) is
provided in the algorithm (algorithm 3).
An obstructing upper airway FB may be suspected based upon the history of a witnessed ingestion, history of a sudden onset of symptoms in a
previously well child without signs of an allergic reaction, or visualization of the FB in the oropharynx or on plain radiographs although many FBs
are not radiopaque.
Basic life-saving maneuvers for FB airway obstruction should be initiated based upon cadaver studies and extensive experience and as
recommended by the American Heart Association [7,8].
The approach varies by degree of responsiveness:
● Responsive patients:
• Infants younger than 1 year of age – Five back slaps are delivered with the infant held in a head down position, followed by five chest
thrusts. Abdominal thrusts are not recommended for infants less than 1 year of age because they may cause damage to the liver,
which is relatively large and unprotected in this age group.
• Children ≥1 year of age – Five abdominal thrusts (Heimlich maneuver) should be performed.
After each round of back slaps and chest thrusts or abdominal thrusts, check to see if the airway obstruction is relieved.
● Unresponsive patients: Initiate cardiopulmonary resuscitation (CPR) beginning with compressions (algorithm 9 and algorithm 10). (See
"Pediatric basic life support for health care providers", section on 'Basic life support algorithms'.)
Prior to each attempt at ventilation, open the airway and look for and remove any obstructing airway. Do not perform a blind finger sweep.
If the obstruction is relieved and the child resumes adequate breathing, the physician should ensure that the FB is completely removed and
observe the patient for signs of postobstructive pulmonary edema (eg, hypoxemia by pulse oximetry, tachypnea, rales, and/or pulmonary
edema on chest radiograph).
If the obstruction is relieved but the child does not resume adequate breathing, initiate bag-mask ventilation and prepare for endotracheal
intubation by rapid sequence intubation (table 6). (See "Rapid sequence intubation (RSI) outside the operating room in children: Approach",
section on 'Approach' and "Emergency endotracheal intubation in children".)
If the obstruction is not relieved within 1 minute, then direct laryngoscopy should be performed to determine if the FB can be visualized and
removed by Magill forceps or suction. If successful, proceed with airway management according to whether the child recovers with adequate
breathing or not as described above.
If the airway obstruction remains, further care is determined by the location of the FB:
● Obstructing FB above the vocal cords – When an FB causing complete airway obstruction above the vocal cords cannot be removed, the
patient should undergo cricothyrotomy; either needle cricothyrotomy (table 7 and figure 2 and figure 3) for patients younger than 12 years of
age (see "Needle cricothyroidotomy with percutaneous transtracheal ventilation", section on 'Needle cricothyroidotomy') or surgical
cricothyrotomy in patients 12 years of age or older. (See "Emergency cricothyrotomy (cricothyroidotomy)", section on 'Methods'.)
Once the cricothyrotomy is in place, percutaneous transtracheal ventilation is used to bypass the obstruction and oxygenate the patient.
(See "Needle cricothyroidotomy with percutaneous transtracheal ventilation", section on 'Performing transtracheal ventilation'.)
Patients should then be immediately transferred to the operating room (OR) for establishment of a definitive airway and FB removal.
● Obstructing FB below the vocal cords – An FB that is lodged below the vocal cords may completely obstruct the subglottic trachea. This
obstruction cannot be removed with direct laryngoscopy. In this situation, the trachea should be intubated and the endotracheal tube
advanced into the right mainstem bronchus. This maneuver is an attempt to relieve the tracheal obstruction by pushing it into the right
mainstem bronchus. At this point, the endotracheal tube should be withdrawn to a position above the carina and ventilation with the right
side down performed to maximize ventilation of the left lung.
The child will now have a bronchial FB but may receive adequate ventilation and oxygenation while preparations are being made to remove
it in the OR. Anecdotal experience supports the effectiveness of this approach in the setting of complete subglottic airway obstruction from a
FB. Case reports of patients requiring one lung ventilation for surgical procedures and studies in dogs have also demonstrated effective
oxygenation and ventilation [9,10].
No foreign body suspected — The acute airway management for patients with severe or complete upper airway obstruction but no FB is
provided in the algorithm (algorithm 8).
Patients with severe upper airway obstruction in patients without signs of a FB should undergo bag-mask ventilation. If bag-mask ventilation
achieves adequate oxygenation (pulse oximetry in the high 80s or better and steadily improving), then the patient should emergently undergo
controlled intubation in the OR.
If bag-mask ventilation does not rapidly establish adequate oxygenation, then the most experienced physician present should make one attempt
at endotracheal intubation using rapid sequence intubation (algorithm 11 and table 6). If endotracheal intubation is accomplished, then further
care directed at the underlying cause should be provided and the patient admitted to a pediatric intensive care unit.
If endotracheal intubation is unsuccessful and the obstruction is due to tongue swelling, then placement of a supraglottic device (eg, laryngeal
mask airway [LMA]) (figure 4) may be attempted. The size of the LMA is chosen based upon weight (table 8). If oxygenation is maintained by the
supraglottic airway, then the patient should undergo controlled intubation in the OR. If oxygenation is not maintained, then proceed with
cricothyrotomy as described below for patients with distortion of airway anatomy.
If the airway obstruction is caused by distortion of the airway anatomy (eg, laryngeo-tracheal trauma or epiglottic swelling due to burns, trauma,
or infection) then a supraglottic airway is contraindicated and the patient should undergo cricothyrotomy; either needle cricothyrotomy (table 7
and figure 2 and figure 3) for patients younger than 12 years of age (see "Needle cricothyroidotomy with percutaneous transtracheal ventilation",
section on 'Needle cricothyroidotomy') or surgical cricothyrotomy in patients 12 years of age or older. (See "Emergency cricothyrotomy
(cricothyroidotomy)", section on 'Methods'.)
Once the cricothyrotomy is in place, percutaneous transtracheal ventilation is used to bypass the obstruction and oxygenate the patient. (See
"Needle cricothyroidotomy with percutaneous transtracheal ventilation", section on 'Performing transtracheal ventilation'.)
Patients should then be immediately transferred to the OR for establishment of a definitive airway.
Conditions with progressive upper airway obstruction — Patients with the following conditions may initially have mild to moderate
symptoms of upper airway obstruction but warrant rapid sequence intubation to avoid the risk of sudden decompensation and increased difficulty
with securing the airway due to rapidly progressive upper airway swelling:
● Upper airway burns caused by smoke inhalation or caustic ingestion

● Upper airway angioedema that does not rapidly respond to administration of intramuscular epinephrine
● Significant trauma to the airway (algorithm 7)
● Epiglottitis (infectious, thermal, or chemical) (algorithm 2) (see "Epiglottitis (supraglottitis): Clinical features and diagnosis", section on
'Clinical features')
Whenever difficulty with endotracheal intubation is anticipated, the physician should emergently call for an anesthesiologist, pediatric intensivist,
and/or otolaryngologist to assist with airway management.
Furthermore, all stable patients with suspected FBs of the upper airway warrant emergency consultation with an otolaryngologist to perform
airway visualization and removal of the FB in the OR.
EVALUATION
History — Historical findings that are particularly helpful in determining initial management priorities include the following:
● Acute onset of symptoms – The sudden onset of choking, gagging, or stridor in the absence of trauma or fever suggests a foreign body
(FB) or an allergic reaction. In general, symptoms that have been rapidly progressive indicate severe disease.
By comparison, the gradual development of hoarseness then worsening to stridor suggests less severe involvement, as in viral croup.
● Trauma – Stridor in the setting of acute trauma (eg, clothesline injury, hanging, motor vehicle collision, thermal burns, or caustic ingestion)
points to a high likelihood of a critical airway injury that requires immediate action. Smoke inhalation can result in chemical or thermal injury
to the airway. Ingestion of a caustic liquid can cause chemical epiglottitis. (See 'Emergency airway assessment and management' above.)
● Fever – A history of fever suggests an infectious etiology. Rapid onset of symptoms in a febrile child is more likely in a bacterial process
such as epiglottitis, bacterial tracheitis, retropharyngeal abscess, or peritonsillar abscess (PTA).
● Change in voice – Most children with acute upper airway pathology will have a change in voice. A muffled voice can be seen in supraglottic
processes such as infection (epiglottitis or PTA) or injury. Hoarseness or stridor occurs with laryngeal or subglottic inflammation, as with
croup.
● Exposures – An allergic reaction may be the cause of upper airway obstruction when symptoms are related to exposure to a known
allergen (eg, bee sting) or new food or medication.
● Underlying medical conditions – More severe symptoms are frequently observed in children with congenital anomalies and/or previous
airway surgery who develop inflammation of the upper airway from any cause. Similarly, children with underlying poor tone or
neuromuscular disease (Down syndrome, cerebral palsy, muscular dystrophy, or quadriplegia) are at increased risk of more severe
symptoms.
Physical examination — For the child with severe respiratory distress, the initial physical examination may consist solely of a rapid respiratory
assessment. (See 'Emergency airway assessment and management' above.)
Vital signs, including weight, should be obtained as the child's respiratory status permits. A careful examination of the pharynx and lungs can be
performed as soon as the child's condition is stabilized.
Signs of airway obstruction — The following findings suggest upper airway obstruction:
● Tachypnea
● Inspiratory stridor, wheezing, or stertor
● Suprasternal or supraclavicular retractions
● Prolonged inspiratory phase
● Drooling
● Dysphagia
● Positions of comfort to help maintain airway patency in patients with severe obstruction:
• "Sniffing" position (picture 2) (neck is mildly flexed and head is mildly extended)
• Tripod position (picture 3) (leaning forward while bracing on the arms with neck hyperextended and chin thrust forward)
In addition, children may have general signs of respiratory distress including tachypnea, nasal flaring, and grunting.
Based upon physical findings, the physician should rapidly identify patients who warrant emergency airway intervention. (See 'Rapid assessment
of the airway and breathing' above.)
Associated findings — The following findings may suggest a particular diagnosis:
● High fever, toxic appearance, and significant respiratory distress suggest bacterial tracheitis or, rarely, epiglottitis. (See "Bacterial tracheitis
in children: Clinical features and diagnosis", section on 'No artificial airway' and "Epiglottitis (supraglottitis): Clinical features and diagnosis",
section on 'Children'.)
● Abrupt onset of choking, gagging, or difficulty swallowing without other associated findings (eg, fever, allergen exposure, or trauma) suggest
the presence of upper airway FB; inspection of the posterior pharynx frequently does not permit visualization of the object.
● Acute upper airway symptoms with stridor in association with any of the following: swollen lips, tongue, or uvula; generalized urticaria or
flushing, or pruritus especially in the setting of allergen exposure (known food allergy or exposure to a new food or medication) supports the
diagnosis of anaphylaxis. (See "Anaphylaxis: Acute diagnosis", section on 'Criterion 1'.)
● Altered phonation, bruising and swelling of the neck, and/or subcutaneous emphysema suggest laryngeo-tracheal injury caused by blunt or
penetrating trauma.
● The child with burns or singed hair who has hoarseness, drooling, or respiratory distress may have a burn injury to the upper airway. (See
"Moderate and severe thermal burns in children: Emergency management", section on 'General examination'.)
● An infant or toddler who is irritable, not moving the neck, and who will not swallow may have a retropharyngeal abscess. (See
"Retropharyngeal infections in children", section on 'Clinical manifestations'.)
● PTA can present in the older child as a muffled (eg, hot potato) voice and trismus. Palatal cellulitis and a bulging mass are apparent on
examination of the pharynx. (See "Peritonsillar cellulitis and abscess", section on 'Typical presentation'.)
Ancillary studies — Securing a definitive airway takes priority over the diagnostic evaluation in a child with acute upper airway obstruction.
Many causes are readily apparent based upon clinical findings supplemented by direct visualization of the airway, as needed. Imaging and
laboratory studies supplement this clinical impression in selected patients. (See 'Determining the cause of upper airway obstruction' below.)
Imaging — Plain radiographs may be useful in identifying the location and nature of the airway obstruction but should never interfere with the
stabilization of a child with a critical obstruction:
● Soft tissue radiographs of the neck can be helpful in diagnosing epiglottitis (image 6), retropharyngeal abscess (image 4), and croup (image
7) [11].
● In patients with signs of acute airway obstruction, AP and lateral neck and chest films may demonstrate the presence of an FB (image 5),
but most FBs are radiolucent. Other imaging studies (eg, barium swallow or computed tomography are more definitive but cannot be safely
performed in unstable patients. (See "Airway foreign bodies in children", section on 'Conventional radiography'.)
Laboratory studies — Laboratory studies generally are not necessary for establishing the cause of upper airway obstruction.
In the child with a bacteriologic etiology such as epiglottitis, PTA, infectious mononucleosis, or a retropharyngeal abscess, a throat culture, blood
culture, and/or serologies for Epstein-Barr virus may provide important information for antimicrobial treatment once the airway is secured. (See
"Evaluation of sore throat in children", section on 'Ancillary studies' and "Epiglottitis (supraglottitis): Clinical features and diagnosis", section on
'Laboratory features'.)
Direct visualization — Direct visualization of the posterior oropharynx in the anxious child with significant partial airway obstruction may risk
causing abrupt complete obstruction. Thus, it should only be performed in an emergency department, intensive care unit, or operating room with
necessary specialized airway equipment and, whenever available, pediatric airway specialists (ie, anesthesiologist and otolaryngologist)
immediately available.
Direct visualization during laryngoscopy for severe airway obstruction can identify structural abnormalities of the epiglottis (eg, epiglottitis,
epiglottic burns, or angioedema) and supraglottic FBs.
Nasopharyngeal endoscopy is also useful for airway decisions in patients with partial obstruction and is the diagnostic method of choice for vocal
cord dysfunction during an acute episode.
The approach to direct visualization of the airway in children with epiglottitis is discussed in detail separately. (See "Epiglottitis (supraglottitis):
Clinical features and diagnosis", section on 'Examining children'.)
Determining the cause of upper airway obstruction — Airway management precedes the diagnostic evaluation in children with upper airway
obstruction and severe respiratory distress (algorithm 8 and algorithm 3) [12]. (See 'Emergency airway management' above.)
Clinical findings, supplemented as needed with direct visualization of the airway, usually identify the underlying etiology (algorithm 12) [13]. (See
'Evaluation' above.)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See
"Society guideline links: Airway foreign bodies in children" and "Society guideline links: Airway management in children".)
SUMMARY
● Any condition that causes upper airway obstruction can be life-threatening (table 1). Patients with an upper airway foreign body (FB), smoke
inhalation, laryngotracheal injury, and epiglottitis (infectious, thermal, or chemical) are at particular risk for sudden decompensation and also
frequently require emergency airway intervention. (See 'Causes' above.)
● The initial evaluation of children with acute upper airway obstruction begins with a rapid assessment of airway patency and respiratory to
identify those who need emergency airway management (see 'Rapid assessment of the airway and breathing' above):
• Mild – Mild obstruction presents with the following findings:
- Ability to speak (voice may be hoarse) or hoarse cry

- Good air entry
- Inspiratory stridor (may only be heard with crying, agitation, excitement, or tachypnea) or occasional snoring (stertor)
- Minimal or no suprasternal retractions and no flaring or grunting
• Moderate to severe – Moderate obstruction is characterized by:
- Tachypnea
- Audible inspiratory (and possibly expiratory) stridor with every breath
- Prolonged inspiratory time with signs of significant effort (suprasternal retractions, nasal flaring, or grunting)
- Decreased air entry
Hypoxemia (pulse oximetry <91 percent or poor color), the presence of "sniffing" (picture 2) or "tripod" (picture 3) positions taken to
maintain an open airway, and/or decreased mental status suggest that the obstruction is severe and that emergency airway
management is needed.
• Complete – The child is struggling to breathe with signs of severe respiratory distress (nasal flaring, grunting, and/or marked
suprasternal or supraclavicular retractions), and may be silently gagging or coughing in an attempt to clear the airway. If the obstruction
is not relieved, the child's condition can rapidly deteriorate, with loss of consciousness. Such patients require immediate interventions to
secure the airway.
• Respiratory failure – Children with respiratory failure caused by upper airway obstruction display one or more of the following findings:
- Poor color (ashen or centrally cyanotic)

- Obtunded mental status
- Decreased chest wall excursion, with or without signs of respiratory distress
- Bradypnea or marked tachypnea
● Whenever managing a child with severe or complete upper airway obstruction or respiratory failure arising from obstruction, the physician
should emergently call for an anesthesiologist, pediatric intensivist, and/or otolaryngologist to assist with definitive management. (See
'Suspected foreign body' above and 'No foreign body suspected' above.)
● The management of a child with severe or complete upper airway obstruction depends on whether obstruction is due to a suspected FB
(algorithm 3) or due to other conditions (algorithm 8) as shown in the algorithms.
● Airway management precedes the diagnostic evaluation in children with upper airway obstruction and severe respiratory distress. Clinical
findings, supplemented, as needed, with direct visualization of the airway, provides the underlying etiology in most patients (algorithm 12).
Imaging or ancillary studies may be helpful in selected patients. (See 'Evaluation' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Chan SC, Dawes PJ. The management of severe infectious mononucleosis tonsillitis and upper airway obstruction. J Laryngol Otol 2001;
115:973.
2. Vilke GM, Smith AM, Ray LU, et al. Airway obstruction in children aged less than 5 years: the prehospital experience. Prehosp Emerg Care
2004; 8:196.
3. Chatterjee D, Agarwal R, Bajaj L, et al. Airway management in laryngotracheal injuries from blunt neck trauma in children. Paediatr
Anaesth 2016; 26:132.
4. Yen K, Flanary V, Estel C, et al. Traumatic epiglottitis. Pediatr Emerg Care 2003; 19:27.
https://www.uptodate.com/contents/emergency-evaluation-of-acute-upper-airway-obstruction-in-children/print?search=epiglottitis&source=search_re… 10/48
5. Fein A, Leff A, Hopewell PC. Pathophysiology and management of the complications resulting from fire and the inhaled products of
combustion: review of the literature. Crit Care Med 1980; 8:94.
6. Rahbar R, Rowley H, Perez-Atayde AR, et al. Delayed presentation of lymphatic malformation of the cervicofacial region: role of trauma.
Ann Otol Rhinol Laryngol 2002; 111:828.
7. Recognition of respiratory distress and failure. Samson RA, Schexnayder SM, Hazinski MF, et al (Eds). Pediatric Advanced Life Support Pr
ovider Manual. American Heart Association, Dallas, 2016, p. 113.
8. Langhelle A, Sunde K, Wik L, Steen PA. Airway pressure with chest compressions versus Heimlich manoeuvre in recently dead adults with
complete airway obstruction. Resuscitation 2000; 44:105.
9. Pawar DK, Marraro GA. One lung ventilation in infants and children: experience with Marraro double lumen tube. Paediatr Anaesth 2005;
15:204.
10. Riquelme M, Monnet E, Kudnig ST, et al. Cardiopulmonary changes induced during one-lung ventilation in anesthetized dogs with a closed
thoracic cavity. Am J Vet Res 2005; 66:973.
11. Darras KE, Roston AT, Yewchuk LK. Imaging Acute Airway Obstruction in Infants and Children. Radiographics 2015; 35:2064.
12. Nagler J, Luten RC. The difficult pediatric airway. In: The Walls Manual of Emergency Airway Management, 5th ed, Brown CA (Ed), Wolter
s Kluwer, Philadelphia 2018.
13. Hoppa E, Perry H. Stridor. In: Fleisher and Ludwig's Textbook of Pediatric Emergency Medicine, 7th ed, Shaw KN, Bachur RG (Eds), Wolte
rs Kluwer, Philadelphia 2016. p.486.
Topic 6455 Version 16.0
GRAPHICS
Causes of acute upper airway obstruction that are potentially life-threatening
Infectious
Epiglottitis
Croup
Bacterial tracheitis
Retropharyngeal abscess (rare)
Peritonsillar abscess (rare)
Infectious mononucleosis
Foreign body
Trauma
Blunt or penetrating airway injury

Upper airway burns (thermal and chemical [eg, caustic ingestion])
Anaphylaxis
Decreased oropharyngeal muscle tone
Hereditary angioedema
Laryngospasm (vocal cord irritation or hypocalcemia)
Vocal cord dysfunction (eg, paradoxical vocal cord movement, brainstem abnormality [eg, Arnold Chiari malformation] or recurrent laryngeal nerve injury)
Acute on chronic conditions (eg, viral laryngotracheitis in a child with laryngomalacia, bleeding into adjacent tumor)
Graphic 62015 Version 5.0
Lateral neck radiograph of a child with croup
Lateral neck radiograph showing subglottic narrowing (arrow) and distended

hypopharynx (arrowheads) consistent with acute laryngotracheitis.
Courtesy of Joe Black, Diagnostic Imaging, Texas Children's Hospital.
Croup: Anteroposterior radiograph with "steeple sign"
The anteroposterior (AP) view demonstrates tapering of the upper trachea,

known as the "steeple sign" of croup. Note that the finding can be simulated by
differing phases of respiration even in normal children.
Courtesy of the Department of Diagnostic Imaging, Texas Children's Hospital.
Bacterial tracheitis: Lateral neck radiograph
Lateral neck radiograph showing intraluminal membranes and tracheal wall

irregularity consistent with bacterial tracheitis.
Courtesy of R Paul Guillerman, MD, Department of Radiology, Baylor College of

Medicine.
Retropharyngeal abscess
Lateral neck radiograph demonstrating widening of the retropharyngeal space

and reversal of the normal cervical spine curvature. The retropharyngeal space
normally measures one-half the width of the adjacent vertebral body and is
considered widened if it is greater than a full vertebral body at C2 or 3 when the
spine is properly extended in an infant or child younger than 5 years of age. The
epiglottis and subglottic area in this radiograph are normal.
Courtesy of Joe Black, Department of Diagnostic Imaging, Texas Children's Hospital.
Peritonsillar abscess
A large unilateral abscess is visible in the pharynx of a patient examined in the

emergency department. Prominent swelling of the anterior pillar and soft palate
is present.
Courtesy of Lawrence B Stack, MD.
Child with classic presentation of acute epiglottitis
This 4-year-old girl has epiglottitis caused by Haemophilus influenzae type b.

(A) She prefers to sit and appears anxious.
(B) The child assumes the characteristic sniffing position to maximize the
patency of her airway.
Reproduced with permission from: Fleisher GR, Ludwig W, Baskin MN. Atlas of
Pediatric Emergency Medicine, Lippincott Williams & Wilkins, Philadelphia 2004.
Copyright © 2004 Lippincott Williams & Wilkins.
Rapid overview: Epiglottitis (supraglottitis) in children
Clinical findings
Respiratory distress: stridor, tachypnea, anxiety, refusal to lie down, "sniffing" or "tripod" posture
Sore throat, dysphagia, drooling, anterior neck pain (at the level of the hyoid)
Muffled "hot potato" voice or aphonia
Marked retractions and labored breathing indicate impending respiratory failure
Verbal patients with pain out of proportion to oropharyngeal examination
Unimmunized or under-immunized patients
Immediate management
Defer attempts at visualizing the epiglottis (tongue blade or any other instrument) or invasive procedures (eg, IV placement, phlebotomy, or any other
painful or frightening intervention) until after airway assessment and management
Prepare to manage the airway and immediately involve airway specialists (anesthesiologist or critical care physician and otolaryngologist) whenever
available
Patient not able to maintain the airway: Attempt bag-valve mask ventilation
Unable to oxygenate (pulse oximetry lower than high 80s or falling): Attempt endotracheal intubation by rapid sequence intubation first but be prepared to establish
a surgical airway (eg, needle cricothyrotomy or surgical cricothyrotomy)*
Able to oxygenate (pulse oximetry high 80s and steady or improving): Endotracheal intubation by the most capable provider, preferably in the operating with an
otolaryngologist present ¶
Patient able to maintain the airway
Provide supplemental humidified oxygen and maintain the child in a position of comfort with the parent present (eg, sitting on the parent's lap on the stretcher)
Keep the patient in a setting where the airway can be rapidly managed if necessary with capable personnel and specialized airway equipment constantly available
Soft-tissue radiograph of the lateral neck (portable if possible) may be helpful but necessary personnel and equipment to manage an acute airway event must remain with the
patient at all times during the imaging process.
Do not image patients with severe respiratory distress in whom it will delay definitive airway management
Radiographic findings of epiglottitis: Enlarged epiglottis ("thumb" sign), loss of vallecular air space, thickened aryepiglottic folds, and/or distended hypopharynx
Attempts at direct visualization are only appropriate in patients with no stridor or stridor without significant distress, no increase in symptoms with agitation, and no cyanosisΔ
In children <6 years of age with confirmed epiglottitis or older children who are toxic-appearing or have >50 percent obstruction of the lumen by direct visualization, perform
endotracheal intubation in the operating room with an otolaryngologist present
Additional management
Laboratory studies: only obtain after the airway is assessed and managed
Epiglottal cultures after establishment of artificial airway
Blood cultures after the airway is secured
Antimicrobial therapy
Administer empiric antimicrobial therapy (ceftriaxone OR cefotaxime AND an antistaphylococcal agent [eg, vancomycin or clindamycin as determined by the local
prevalence of methicillin-resistant Staphylococcus aureus and, if prevalent, its local sensitivity profile])◊
* Needle cricothyroidotomy may be performed on children of any age. The age at which one can safely perform a surgical cricothyroidotomy on a child is not well established, and
recommendations vary from 5 to 12 years old. Surgical cricothyroidotomy is best performed in children in whom external landmarks of the neck (eg, the cricothyroid membrane) are
easily palapable. Refer to UpToDate topics on needle cricothyroidotomy with percutaneous transtracheal ventilation and emergent surgical cricothyroidotomy (cricothyrotomy).
¶ Refer to UpToDate topics on the management of epiglottitis, endotracheal intubation in the pediatric patient with a difficult airway and devices for difficult endotracheal intubation in
children.
Δ Refer to UpToDate topics on the diagnosis of epiglottitis for an approach to examining the oropharynx of children with epiglottitis.
◊For antibiotic regimens refer to UpToDate tables on intravenous antimicrobial treatment regimens for epiglottitis and UpToDate topics on the management of epiglottitis.
Approach to the child with suspected epiglottitis
* Epiglottitis is more likely in un- or under-immunized children and those with

drooling but no cough.
Reproduced with permission from: Harper MB, Fleisher GR. Infectious disease
emergencies. In: Textbook of Pediatric Emergency Medicine, Fleisher GR, Ludwig S
(Eds), 6th edition, Lippincott Williams & Wilkins, 2010. Copyright © 2010 Lippincott
Williams & Wilkins. www.lww.com.
Initial airway management for patients with epiglottitis
RSI: rapid sequence intubation.

* Until the airway is secured in young children (6 years of age or younger), avoid intravenous access, unnecessary physical
examination (oropharyngeal or laryngeal examination with a tongue blade or other instruments), and diagnostic tests (eg,
phlebotomy or epiglottic cultures) which may provoke anxiety or crying with abrupt airway obstruction.
¶ Supraglottic airway use is contraindicated in patients with severe hypopharyngeal pathology, such as epiglottitis. Refer to
UpToDate topics on rapid sequence intubation in children.
Δ Refer to UpToDate topics on needle and surgical cricothyrotomy.
◊ Children with epiglottitis should receive ongoing care in a pediatric intensive care unit.
Management of upper airway obstruction due to a foreign body in children*
FB: foreign body; CPR: cardiopulmonary resuscitation; RSI: rapid sequence intubation; ETT: endotracheal tube; OR: operating
room.
* The following findings suggest upper airway obstruction:
Inspiratory stridor, wheezing, or stertor
Suprasternal or supraclavicular retractions
Prolonged inspiratory phase
Oral mucosa or tongue swelling
Drooling
Dysphagia
Positions of comfort to help maintain airway patency in patients with severe obstruction:
"Sniffing" position (neck is mildly flexed and head is mildly extended)
Tripod position (leaning forward while bracing on the arms, with neck hyperextended and chin thrust forward)
¶ Refer to UpToDate algorithms and topics on pediatric basic life support for health care providers and FB obstruction.
Δ Refer to UpToDate topics on evaluation of upper airway obstruction in children.
◊ Surgical cricothyrotomy may be appropriate in selected patients younger than 12 years of age, as determined by cricothyroid
membrane size. Refer to UpToDate topics on needle and surgical cricothyroidotomy.
Algorithm for suspected foreign body aspiration in children
CT: computed tomography; FBA: foreign body aspiration.

* Refer to algorithm for complete airway obstruction in children.
¶ A moderate or high suspicion of FBA includes all children with a witnessed FBA (regardless of
symptoms) and those with suggestive respiratory symptoms or suspicious characteristics on imaging,
especially if there is a history of choking.
Δ For stable patients with a high clinical suspicion of aspiration, it is reasonable to proceed directly to
bronchoscopy, even if the plain radiographs are normal or inconclusive. Alternatively, CT can be
performed first to help clarify the diagnosis (dotted line), if the provider judges that negative imaging
would be sufficient to preclude bronchoscopy. Where low-dose CT protocols are available, early use of
this modality may be appropriate for many patients and may reduce the need for bronchoscopy.
◊ Rigid bronchoscopy is the procedure of choice to remove a foreign body. In cases where the
diagnosis or location of the foreign body is unclear, it is usually preferable to perform flexible
bronchoscopy first and then proceed to rigid bronchoscopy for foreign body removal.
Courtesy of Fadel Ruiz, MD.
Esophageal foreign body sites
Common sites of esophageal impaction of smooth foreign bodies.
Reproduced with permission from: Schunk JE, Dudley NC. Management of esophageal foreign
bodies. In: Textbook of Pediatric Emergency Procedures, 2nd ed, King C, Henretig FM (Eds),
Lippincott Williams & Wilkins, Philadelphia 2008. Copyright © 2008 Lippincott Williams & Wilkins.
www.lww.com.
Esophageal foreign body
The posteroanterior chest film demonstrates a coin in the esophagus. Deviation

of the trachea as a result is also noted.
Courtesy of Alan E Schlesinger, MD, Department of Radiology, Baylor College of

Medicine.
Overview of the management of suspected foreign body ingestion in children
CT: computed tomography.

* Refer to UpToDate content on the management of upper airway obstruction.
¶ In a child with negative conventional radiographs (no foreign body identified), a CT is not necessary if the child is asymptomatic and if suspected object is small (<2 cm) and blunt.
Δ In adults or older children, a long object is defined as one that is ≥5 cm; such objects should be removed from the stomach because they may not pass the duodenal sweep. There is
no guidance for defining long objects in younger children. We generally remove an object from the stomach of a child <5 years if the object is longer than 2.5 cm.
◊ High-powered magnets are also known as "rare earth" or neodymium magnets. Management depends on the number of magnets present. Refer to UpToDate content and algorithms
about magnet ingestion.
§ Guidelines vary for management of battery ingestion. Refer also to UpToDate topic on disc ("button") or cylindrical battery ingestion.
¥ Symptoms suggesting complications include vomiting, abdominal pain, fever, hematemesis, or melena.
‡ If an object remains in the stomach for more than 4 weeks, it should be removed because this means that the object is unlikely to pass beyond the pylorus. If the object is radiolucent
and in the stomach, it is reasonable to remove the object initially if endoscopic expertise is readily available, especially if the object is larger than 2 cm, in which case it may not easily
pass the pylorus. If observation is chosen, the parents should monitor stools until they determine that the object has passed and should notify the clinician if any symptoms develop.
† For objects beyond the duodenal bulb that are radiopaque, monitor with serial radiographs (weekly for blunt objects, daily for sharp or long objects). Surgery is reserved for patients
who develop complications (eg, obstruction, perforation) and for nonprogression of a foreign body (a blunt object that remains in the same location distal to the duodenum for more than
1 week or a sharp foreign body that does not advance radiographically for 3 consecutive days).
**If no object is identified, further evaluation depends on the patient's symptoms, type of object thought to be ingested, and likelihood that the ingestion occurred. If there is concern for
aspiration of the object or for ingestion of an object that could lead to complications (large, long, or sharp), the evaluation might include diagnostic endoscopy or bronchoscopy, further
imaging (eg, CT if not already done), and/or close observation.
Courtesy of Mark Gilger, MD.
Algorithm for management of single high-powered magnet ingestion
PEG 3350: polyethylene glycol 3350.

* If magnet might be or is known to be a high-powered type (neodymium, or "rare earth" type).
¶ Radiographs do not reliably distinguish between single and multiple magnets, since it is possible for magnets to
stick together or overlap on a single view and be misdiagnosed as a single magnet.
Δ The following "magnet precautions" should be for any child who has ingested 1 or more magnets: Remove any
magnetic objects nearby, avoid clothes with metallic buttons and belts with buckles, and ensure that no other metal
objects or magnets are in the child's environment that could be accidentally ingested. Maintain these precautions
until magnet has passed out of the gastrointestinal tract.
Modified with permission from: Hussain SZ, Bousvaros A, Gilger M, et al. Management of ingested magnets in
children. J Pediatr Gastroenterol Nutr 2012; 55:239. Copyright © 2012 Lippincott Williams & Wilkins.
Algorithm for acute management of traumatized airway
Double set-up refers to simultaneous preparation for both direct oral intubation and emergency
cricothyrotomy.
IV: intravenous catheter; RSI: rapid sequence intubation; SaO 2 : arterial oxygen saturation; Sns: clinical
signs; TTJV: transtracheal jet ventilation.
Rapid overview: Emergency management of anaphylaxis in infants and children*
Diagnosis is made clinically:

The most common signs and symptoms are cutaneous (eg, sudden onset of generalized urticaria, angioedema, flushing, pruritus). However, 10 to 20% of patients have no
skin findings.
Danger signs: Rapid progression of symptoms, evidence of respiratory distress (eg, stridor, wheezing, dyspnea, increased work of breathing, retractions,
persistent cough, cyanosis), signs of poor perfusion, abdominal pain, vomiting, dysrhythmia, hypotension, collapse.
Acute management:
The first and most important therapy in anaphylaxis is epinephrine. There are NO absolute contraindications to epinephrine in the setting of anaphylaxis.
Airway: Immediate intubation if evidence of impending airway obstruction from angioedema. Delay may lead to complete obstruction. Intubation can be difficult and should
be performed by the most experienced clinician available. Cricothyrotomy may be necessary.
IM epinephrine (1 mg/mL preparation): Epinephrine 0.01 mg/kg should be injected intramuscularly in the mid-outer thigh. For large children (>50 kg), the maximum is
0.5 mg per dose. If there is no response or the response is inadequate, the injection can be repeated in 5 to 15 minutes (or more frequently). If epinephrine is injected
promptly IM, patients respond to one, two, or at most, three injections. If signs of poor perfusion are present or symptoms are not responding to epinephrine injections,
prepare IV epinephrine for infusion (see below).
Place patient in recumbent position, if tolerated, and elevate lower extremities.
Oxygen: Give 8 to 10 L/minute via facemask or up to 100% oxygen, as needed.
Normal saline rapid bolus: Treat poor perfusion with rapid infusion of 20 mL/kg. Re-evaluate and repeat fluid boluses (20 mL/kg), as needed. Massive fluid shifts with
severe loss of intravascular volume can occur. Monitor urine output.
Albuterol: For bronchospasm resistant to IM epinephrine, give albuterol 0.15 mg/kg (minimum dose: 2.5 mg) in 3 mL saline inhaled via nebulizer. Repeat, as needed.
H1 antihistamine: Consider giving diphenhydramine 1 mg/kg (max 40 mg IV, over 5 minutes) or cetirizine (children aged 6 months to 5 years can receive 2.5 mg IV, those
6 to 11 years of age can receive 5 or 10 mg IV, over 2 minutes).
H2 antihistamine: Consider giving famotidine 0.25 mg/kg (max 20 mg) IV, over at least 2 minutes.
Glucocorticoid: Consider giving methylprednisolone 1 mg/kg (max 125 mg) IV.
Monitoring: Continuous noninvasive hemodynamic monitoring and pulse oximetry monitoring should be performed. Urine output should be monitored in patients receiving
IV fluid resuscitation for severe hypotension or shock.
Treatment of refractory symptoms:

Epinephrine infusion ¶: In patients with inadequate response to IM epinephrine and IV saline, give epinephrine continuous infusion at 0.1 to 1 mcg/kg/minute, titrated to
effect.
Vasopressors ¶: Patients may require large amounts of IV crystalloid to maintain blood pressure. Some patients may require a second vasopressor (in addition to
epinephrine). All vasopressors should be given by infusion pump, with the doses titrated continuously according to blood pressure and cardiac rate/function monitored
continuously and oxygenation monitored by pulse oximetry.
IM: intramuscular; IV: intravenous.

* A child is defined as a prepubertal patient weighing less than 40 kg.
¶ All patients receiving an infusion of epinephrine and/or another vasopressor require continuous noninvasive monitoring of blood pressure, heart rate and function, and oxygen
saturation. We suggest that pediatric centers provide instructions for preparation of standard concentrations and also provide charts for established infusion rate for epinephrine and
other vasopressors in infants and children.
Management of severe upper airway obstruction not due to

a foreign body in children*
RSI: rapid sequence intubation; ICU: intensive care unit; LMA: laryngeal mask airway;
OR: operating room.
Drooling
Dysphagia
Tripod position (leaning forward while bracing on the arms with neck hyperextended
and chin thrust forward)
¶ Refer to UpToDate topics on evaluation of upper airway obstruction in children.
Δ For description of the technique and performance of cricothyrotomy and transtracheal
ventilation, refer to UpToDate topics on needle and surgical cricothyrotomy.
Acute treatment of angioedema episodes of in adults and children with hereditary angioedema (HAE)
Medication Availability Dosing Precautions
C1 inhibitor concentrate (plasma-derived) Widely available. Berinert (all ages): 20 units per kg body Do not shake solution, because protein
(Berinert, Cinryze) In United states, Cinryze is not approved weight given intravenously over 10 will denature.
for acute treatment but is effective. minutes. Symptoms usually stabilize in 30
minutes. Second dose uncommonly
In Europe, Cinryze is approved for
needed but may be given 30 minutes to 2
children.
hours after first.
Despite the differences in product
Cinryze (children): 500 units for body
labeling, both products are effective
weight <25 kg and 1000 units ≥25 kg; a
for acute treatment of attacks.
second dose should be given if no
response.
Relapse of symptoms is reported in <1%
of episodes.
Recombinant C1 inhibitor Europe, United States, some other 50 units per kg body weight for patients Do not shake solution.
Conestat alfa (Ruconest, Rhucin) countries. <84 kg. 4200 units (2 vials) for those
≥84 kg. Relapse of symptoms in reported
in <3% of episodes.
Bradykinin B 2 -receptor antagonist United States and many other countries. Adults: 30 mg slow subcutaneous infusion Caution in patients with unstable angina.
Icatibant (Firazyr) Approved in the United States for (because of volume) in abdominal area. Mild injection site reactions are common.
individuals over the age of 18 years. Children: Dosing is weight-based:
Registered in the European Union for Administer 10 mg if weight is 12 to
children as young as 2 years of age. 25 kg
Administer 15 mg if weight is 26 to
40 kg
50 kg
65 kg
Administer 30 mg if weight is >65
kg
Second dose can be given 6 hours after
first if symptoms continue to worsen.
Relapse of symptoms is reported in up to
10% of episodes. Maximum of three
doses in 25 hours.
Kallikrein inhibitor United States only. 30 mg (3 doses of 10 mg each) given at Rare allergy reaction reported usually in
Ecallantide (Kalbitor) Approved in the United States for three separate sites subcutaneously in <1 hour. Should be administered by a
individuals over the age of 12 years. abdomen, upper arm, or thigh and away clinician or nurse in a medical setting
from site of angioedema. Relapse is equipped to treat anaphylaxis.
reported in <3% of episodes. May be
repeated in 1 hour.
Plasma Widely available as solvent detergent- 2 units initially. Can be repeated every 2 Monitor for volume overload in patients
treated plasma (preferred) or fresh frozen to 4 hours, if needed. with underlying conditions predisposing to
plasma. volume overload. Theoretical risk of
transmission of blood-borne pathogens.
Rare reports describe worsening of
angioedema after administration of
plasma.
Congenital anomalies associated with stridor
Malformation Characteristics
Nose* Nasal deformities Choanal atresia or agenesis, septum deformities, turbinate hypertrophy, vestibular atresia, or stenosis.
Pharynx* Craniofacial anomalies Anomalies causing facial retrusion are associated with upper airway obstruction, including Crouzon,
Pierre Robin, and Apert syndromes.
Tongue Macroglossia and glossoptosis.
Larynx Laryngomalacia Most common cause of chronic stridor in infants. Almost all patients present by 6 weeks of age.
Symptoms are more pronounced after upper respiratory infections.
Laryngeal webs 75% located in the glottic area. Complete webs cause respiratory distress at birth and partial webs
produce stridor, weak cry, and different degrees of respiratory distress. Associated anomalies are
common.
Laryngeal cysts If located in supraglottic area, may cause respiratory distress and stridor.
Laryngeal clefts Characterized by abnormal communication between the larynx and pharynx, sometimes extending
downward between the trachea and esophagus. Patients may present with aspiration, cough, swallowing
difficulties, respiratory distress, hoarse cry, or occasionally with stridor; often associated with other
congenital anomalies.
Subglottic hemangioma Presents as with stridor and respiratory distress, usually worsening during the first few months of life.
Often associated with cutaneous hemangiomas.
Subglottic stenosis May be congenital but more often acquired secondary to intubation. Usually located 2 to 3 mm below
the glottis.
Vocal cord paralysis Idiopathic or secondary to a neurologic disorder (including Chiari II malformation, hydrocephalus,
meningomyelocele, hypoxic cerebral palsy, and cerebral hemorrhage) [1,2].
Trachea ¶ Tracheal stenosis Usually presents with stridor or both stridor and wheezing. If stenosis is significant, respiratory distress
occurs.
Vascular rings or slings 74% of vascular rings are symptomatic. The airway compression usually is intrathoracic, causing
expiratory stridor. Associated anomalies are common.
Tracheomalacia Often associated with other congenital anomalies. May be secondary to a vascular ring or cysts.
Worsens with upper respiratory infections, crying, coughing, or feeding. May cause severe spells with
cyanosis.
Bronchi and distal airways ¶ Bronchogenic cyst May occur at any point throughout the tracheobronchial tree. Typically present during childhood with
recurrent coughing, wheezing, or pneumonia, but may become symptomatic during infancy or adulthood
or present as an incidental finding on chest radiographs.
* Noise generated from the nose or pharynx is typically low in pitch and is referred to as snoring or stertor.
¶ Noise generated from the trachea, bronchi, or distal airways is mostly wheezing.
References:
1. Nisa L, Holtz F, Sandu K. Paralyzed neonatal larynx in adduction. Case series, systematic review and analysis. Int J Pediatr Otorhinolaryngol 2013; 77:13.
2. Holinger LD, Holinger PC, Holinger PH. Etiology of bilateral abductor vocal cord paralysis: a review of 389 cases. Ann Otol Rhinol Laryngol 1976; 85:428.
Epiglottitis: Tripod posture
This child's "tripod" positioning (trunk leaning forward, neck hyperextended,

chin thrust forward) is caused by epiglottitis and represents the patient's
attempt to maximize the patency of a significantly obstructed upper airway.
Also, note the child's toxic appearance.
Tripod positioning may also be seen in other causes of respiratory distress, such
as severe asthma.
Reproduced with permission from: M Douglas Baker, MD.
Basic life support health care provider pediatric cardiac arrest algorithm for the single
rescuer: 2015 update
CPR: cardiopulmonary resuscitation; AED: automated external defibrillator; ALS: advanced life support.
Reference:
1. Web-based Integrated 2010 & 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care – Part 8: Post-Cardiac Arrest Care. Available at: https://eccguidelines.heart.org/circulation/cpr-ecc-
guidelines/part-8-post-cardiac-arrest-care/ (Accessed on October 10, 2019).
Reprinted with permission. Web-based Integrated 2010, 2015, & 2017 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care – Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality.
Copyright © 2015 American Heart Association, Inc.
Basic life support healthcare provider pediatric cardiac arrest algorithm for 2 or more
rescuers: 2015 update
AED: automated external defibrillator; CPR: cardiopulmonary resuscitation; ALS: advanced life support.
Reprinted with permission. Web-based Integrated 2010, 2015, & 2017 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care – Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation
Quality. Copyright © 2015 American Heart Association, Inc.
Rapid overview of rapid sequence intubation in children
Preparation: Utilize an active checklist to:

Begin preoxygenation as described below.
Identify conditions that will affect choice of medications (eg, increased intracranial pressure, septic shock, bronchospasm, status epilepticus, or, if succinylcholine use is
planned, absolute contraindications for its use as listed below).
Identify conditions that will predict difficult intubation or bag-mask ventilation (eg, small chin, inability to fully open the mouth, upper airway trauma, or infection).
Assemble equipment and check for function.
Develop contingency plan for failed intubation (refer to UpToDate topics on devices for difficult endotracheal intubation).
Preoxygenation
Begin preoxygenation as soon as rapid sequence intubation is potentially needed:
Spontaneously breathing: 100% FiO 2 (>7 L/min oxygen flow) by nonrebreather mask for 3 minutes
Apneic or inadequate breathing: Bag-mask ventilation with small tidal breaths using 100% FiO 2
During induction and paralysis, provide apneic oxygenation via nasal cannula at flow rate of 1 L/kg/min (maximum flow 15 L/min)
Administer oxygen at the highest concentration available.
Pretreatment (optional)
Atropine: Although not routinely recommended, many experts suggest atropine as pretreatment for:
Children ≤1 year
Children in shock
Children <5 years receiving succinylcholine
Older children receiving a second dose of succinylcholine
Dose: 0.02 mg/kg IV without a minimum dose (maximum single dose 1 mg; if no IV access, can be given IM).
Fentanyl: Optional for increased intracranial pressure in patients with normal or elevated blood pressure. Dose: 1 to 3 mcg/kg given over 30 to 60 seconds to avoid
respiratory depression and chest wall rigidity. Give 3 minutes before induction agent is administered.
Sedation
Etomidate:
Safe with hemodynamic instability, neuroprotective, transient adrenal cortico-suppression. Do not use routinely in patients with septic shock.
Dose: 0.3 mg/kg IV.
Ketamine:
Safe with hemodynamic instability if patient is not catecholamine depleted. Use in patients with bronchospasm and septic shock. Use with caution in hypertensive
patients with increased intracranial pressure.
Dose: 1 to 2 mg/kg IV (if no IV access, can be given IM dose: 3 to 7 mg/kg).
Propofol:
Causes hypotension. May use in hemodynamically stable patients with status epilepticus.
Dose 1 to 1.5 mg/kg IV.
Midazolam:
May use in hemodynamically stable patients with status epilepticus. Time to clinical effect is longer; inconsistently induces unconsciousness. May cause hemodynamic
instability at doses required for sedation.
Dose: 0.2 to 0.3 mg/kg IV (maximum dose 10 mg; onset of effect requires 2 to 3 minutes).
Fentanyl:
Optional for cardiogenic shock or catecholamine-depleted shock (eg, persistent hypotension despite vasopressor therapy). Limited evidence in children.
Dose 1 to 5 mcg/kg titrated to effect. Start at lower end of range in hypotensive patients. Give over 30 to 60 seconds to avoid respiratory depression or chest wall rigidity.
Thiopental:
Neuroprotective. Do not use with hemodynamic instability.

Dose: 3 to 5 mg/kg IV.*
Paralytic
Rocuronium:
Use for children with contraindication for succinylcholine or as primary paralytic if sugammadex is immediately available.
Dose: 1 mg/kg IV. ¶
Succinycholine:
Do not use with extensive crush injury with rhabdomyolysis, chronic skeletal muscle disease (eg, Becker muscular dystrophy) or denervating neuromuscular disease (eg,
cerebral palsy with paralysis); 48 to 72 hours after burn, multiple trauma, or denervating injury; patients with history or malignant hyperthermia; or pre-existing
hyperkalemia.
Dose: Infants and children ≤2 years: 2 mg/kg IV, older children and adolescents: 1 to 1.5 mg/kg IV (if IV access unobtainable, can be given IM, dose: 4 mg/kg). Δ
Protection and positioning

Maintain manual cervical spine immobilization during intubation in the trauma patient.
If cervical spine injury is not potentially present, put the patient in the "sniffing position" (ie, head forward so that the external auditory canal is anterior to the shoulder and
the nose and mouth point to the ceiling).
Utilize external laryngeal manipulation or, in infants, gentle cricoid pressure to optimize the view of the glottis during direct laryngoscopy if the initial view is suboptimal or
inadequate despite correct laryngoscope blade positioning. ◊
Positioning, with placement

Confirm tracheal tube placement with end-tidal CO 2 detection and auscultation.
Postintubation management
Obtain a chest radiograph to confirm the depth of tracheal tube insertion.
Provide ongoing sedation (eg, midazolam), analgesia (eg, fentanyl 1 mcg/kg), and, if indicated, paralysis. §
If IV access is not rapidly obtained, intraosseous administration of drugs is an acceptable alternative.
IM: intramuscularly; IV: intravenously; CO 2 : carbon dioxide; FiO 2 : fraction of inspired oxygen.
* Not available in many countries, including the United States and Canada.
¶ Sugammadex in a dose of 16 mg/kg can provide immediate reversal of paralysis when given approximately 3 minutes after a single dose of rocuronium or vecuronium. Vecuronium
may be used in children with contraindications to succinylcholine and when rocuronium is not available. Suggested dose for rapid sequence intubation: vecuronium 0.15 to 0.2
mg/kg. Patients may experience prolonged and unpredictable duration of paralysis at this dose.
Δ Defasciculating agents (eg, rocuronium or vecuronium at one-tenth of the paralyzing dose) are not routinely recommended for children receiving succinylcholine. Onset of paralysis
is slower by the IM route; the clinician must ensure full pre-oxygenation prior to administration, whenever possible, and be prepared to perform bag-mask ventilation if desaturation
occurs before the patient is fully paralyzed for endotracheal intubation.
◊ Bimanual laryngoscopy, also called external laryngeal manipulation (ELM), entails manipulating the thyroid cartilage or hyoid bone with the right hand during laryngoscopy in order
to improve the view of the glottis. For a description of how to perform ELM, refer to topics on emergency endotracheal intubation in children and rapid sequence intubation in
children.
§ If decompensation occurs after successful intubation, use the DOPE mnemonic to find the cause:
D: Dislodgement of the tube (right mainstem or esophageal)
O: Obstruction of tube
P: Pneumothorax
E: Equipment failure (ventilator malfunction, oxygen disconnected or not on)
Needle cricothyroidotomy with percutaneous transtracheal ventilation (PTV): Procedure summary and clinical tips
Procedure summary table:

1. Locate the cricothyroid membrane, bound by cricoid cartilage inferiorly and thyroid cartilage superiorly.
2. Use universal precautions and sterile technique. Cleanse the puncture site with povidone-iodine solution.
3. Attach a 3- to 10-mL syringe with a few mL of saline to a 13 to 18 gauge IV catheter. (AVOID needleless catheters that will not attach to a syringe.)
4. Hold the trachea in place and provide skin tension with the thumb and middle finger of the non-dominant hand on either side of the trachea while palpating the
cricothyroid membrane with the index finger.
5. Enter the cricothyroid membrane in its inferior-central part, directing the needle caudally (toward the feet) at an angle of 30 to 45 degrees.
6. Puncture the skin and subcutaneous tissue. Advance the needle while continuously applying negative pressure on the syringe, until air bubbles are seen, confirming
intratracheal placement.
7. Advance the catheter forward off the needle until its hub rests at the skin surface. Remove the syringe and the needle.
8. Reattach the syringe to the catheter and again aspirate for air to confirm that the catheter remains in the trachea.
9. Hold the catheter firmly in place at all times or delegate an assistant to do so.
10. Connect the high pressure tubing (connected to a valve and a source of 100 percent oxygen) to the catheter.
11. Give a few ventilations by delivering short bursts of gas to reconfirm placement and ensure that the equipment is functioning properly.
12. Secure the transtracheal catheter with suture or a tracheostomy tie while ventilation continues.
13. Begin regular ventilation with I:E ratio 1:4 and respiratory rate 10 to 12 breaths/min in the patient without complete upper airway obstruction; adjust in patients with
complete airway obstruction: I:E ratio 1:8 to 1:10 respiratory rate 5 to 6 breaths/min).
14. Monitor the patient carefully.
15. Initiate establishment of a more definitive airway (endotracheal tube or tracheostomy) which may require consultation with anesthesiology and/or otolaryngology.
Procedure tips table:

1. In older children, feel the laryngeal cartilage and then go caudad to identify cricothyroid membrane.
2. In infants and younger children, follow the tracheal rings superiorly to locate the prominence of the cricoid cartilage. The cricothyroid membrane, even if not felt clearly, is
just superior to the cricoid cartilage.
3. If the cricothyroid membrane cannot be located with certainty in an infant or a young child, the catheter can be introduced between tracheal cartilages.
4. The cricothyroid membrane should be punctured below its central part to avoid blood vessels.
5. One person should be assigned to hold the hub of the IV catheter in place over the neck at all times.
6. A pre-assembled system including all the necessary components for needle cricothyrotomy and PTV should be readily available in all resuscitation areas.
7. The system should be used in regular mock codes to improve familiarity of the medical, nursing, and respiratory therapy staff.
IV: intravenous.
Anatomic landmarks for needle cricothyroidotomy
(A) Cartilaginous skeleton of the extrathoracic airway. With older children and adolescents,
the laryngeal prominence at the superior border of the thyroid cartilage can usually be
palpated. The thyroid cartilage is followed inferiorly to locate the cricothyroid membrane.
(B) With infants and younger children, the laryngeal prominence is not developed. The rings
of the tracheal cartilage are followed superiorly to locate the prominence of the cricoid
cartilage. The cricothyroid membrane is just superior to the cricoid cartilage.
(C) A midline approach will avoid the normal position of the cricothyroid artery.
Reproduced with permission from: Mittal MK, Baren JM. Percutaneous Transtracheal Ventilation.
In: Textbook of Pediatric Emergency Procedures, 2nd ed, King C, Henretig FM (Eds), Lippincott
Williams & Wilkins, Philadelphia 2008. Copyright © 2008 Lippincott Williams & Wilkins.
www.lww.com.
Needle cricothyroidotomy
Performing needle cricothyroidotomy:

(A) The needle is angled caudally at 30 to 45 degrees and inserted through the cricothyroid
membrane until bubbles are seen in the fluid-filled syringe, indicating puncture of the
trachea.
(B) The catheter is advanced to the hub as the needle and syringe are removed.
(C) The catheter is secured in place and connected to the oxygen delivery system.
Reproduced with permission from: Mittal MK, Baren JM. Percutaneous Transtracheal Ventilation. In:
Textbook of Pediatric Emergency Procedures, 2nd ed, King C, Henretig FM (Eds), Lippincott Williams
& Wilkins, Philadelphia 2008. Copyright © 2008 Lippincott Williams & Wilkins. www.lww.com.
Difficult airway management outside the operating room
OR: operating room; RSI: rapid sequence intubation; SpO 2 : oxygen saturation; PIM:
post-intubation management; BMV: bag-mask ventilation; EGA: extraglottic airway
device; ILMA: intubating laryngeal mask.
* A failed airway exists when the clinician cannot oxygenate or ventilate a patient.
Clinically, this occurs when a patient cannot be intubated and ventilation with a bag
and mask or extraglottic device fails to maintain oxyhemoglobin saturations above
90%. Refer to the topic and algorithm discussing management of the failed airway.
¶ During RSI, physiologic derangements such as hypotension and hypoxemia place
the patient at great risk of cardiovascular collapse during the peri-intubation period.
Possible interventions to prevent such collapse include an intravenous bolus of
isotonic fluid and press-dose vasopressor in the hypotensive patient, and flush-rate
administration of oxygen and apneic oxygenation in the hypoxic patient. Please refer
to UpToDate topics on RSI for further detail.
Reproduced with permission from: The Difficult Airway Course®: Emergency and
Brown III CA, Walls RM. The Emergency Airway Algorithms. In: The Walls Manual of
Emergency Airway Management, 5th ed, Brown III CA, Sakles JC, Mick NW (Eds),
Wolters Kluwer, Philadelphia 2018. Copyright © 2018 Wolters Kluwer.
Laryngeal mask insertion by standard technique
(A) The LMA is held in the operator's dominant hand like a pen or pencil, with
the index finger at the cuff as shown.
(B) The patient's mouth is opened, and the LMA is pressed against the patient's
hard palate. The wrist of the operator should remain flexed. If neck movement
is not prohibited, placement of the operator's nondominant hand as shown can
increase leverage and facilitate placement.
(C) The LMA mask is pressed inward by extension of the index finger. Contact
with the palate is maintained.
(D) The index finger is pressed toward the nondominant hand to exert
counterpressure.
(E) The LMA cuff is advanced into the hypopharynx until resistance is felt. The
operator maintains gentle downward pressure on the tube while removing the
index finger from the patient's mouth.
LMA: laryngeal mask airway.
Image courtesy of LMA North America, Inc. Originally published in: King BR, Hagberg
CA. Management of the difficult airway. In: Textbook of Pediatric Emergency Medicine
Procedures, 2nd edition, King C, Henretig FM (Eds), Lippincott Williams & Wilkins,
Philadelphia 2008. Copyright © 2008.
http://www.lww.com
Weight based laryngeal mask airway (LMA) sizing
LMA size Patient weight (kg)
1 up to 5
1.5 5 to 10
2 10 to 20
2.5 20 to 30
3 30 to 50
4 50 to 70
Epiglottitis: Lateral neck radiograph
(A) A normal epiglottis on a lateral neck radiograph, with the structures illustrated in
panel B. Epiglottitis is similarly depicted radiographically (C, D).
Reproduced with permission from: Fleisher GR, Ludwig W, Baskin MN. Atlas of Pediatric
Emergency Medicine. Philadelphia: Lippincott Williams & Wilkins, 2004. Copyright © 2004
Lippincott Williams & Wilkins.
Epiglottitis: Lateral radiograph
Lateral neck radiograph demonstrating swollen epiglottis (arrow) and

aryepiglottic folds (asterisks) in a child with epiglottitis due to Haemophilus
influenzae type b. The swollen epiglottis is often called a "thumb sign."
Courtesy of Evelyn Y Anthony, MD, Wake Forest University School of Medicine.
Diagnostic approach to upper airway obstruction in children

Oral mucosa or tongue swelling
Drooling
Dysphagia
Tripod position (leaning forward while bracing on the arms with neck hyperextended and chin thrust forward)
¶ Given the risk of sudden decompensation, patients with significant laryngotracheal injury, thermal or chemical epiglottitis, or symptomatic upper airway obstruction
warrant emergency consultation with an anesthesiologist or pediatric intensivist and an otolaryngologist to help secure the airway.
Contributor Disclosures
Laura L Loftis, MD Nothing to disclose Stephen J Teach, MD, MPH Nothing to disclose Adrienne G Randolph, MD, MSc Equity Ownership/Stock Options:
Abbvie. Grant/Research/Clinical Trial Support: Genentech [Influenza critical illness]. Consultant/Advisory Boards: La Jolla Pharmaceuticals [Pediatric refractory
shock]. James F Wiley, II, MD, MPH Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review
process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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23/9/2020 Emergency evaluation of acute upper airway obstruction in children - UpToDate

Official reprint from UpToDate®

Clinical manifestations vary by the location of the FB:

Examples of conditions where suctioning is indicated include:

EMERGENCY AIRWAY ASSESSMENT AND MANAGEMENT

• Mild – Mild obstruction presents with the following findings:

- Ability to speak (voice may be hoarse) or hoarse cry

• Moderate to severe – Moderate obstruction is characterized by:

• Poor color (ashen or centrally cyanotic)

Emergency airway management

The approach varies by degree of responsiveness:

● Upper airway burns caused by smoke inhalation or caustic ingestion

Associated findings — The following findings may suggest a particular diagnosis:

SOCIETY GUIDELINE LINKS

• Mild – Mild obstruction presents with the following findings:

- Ability to speak (voice may be hoarse) or hoarse cry

• Moderate to severe – Moderate obstruction is characterized by:

- Poor color (ashen or centrally cyanotic)

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 6455 Version 16.0

Causes of acute upper airway obstruction that are potentially life-threatening

Blunt or penetrating airway injury

Decreased oropharyngeal muscle tone

Laryngospasm (vocal cord irritation or hypocalcemia)

Graphic 62015 Version 5.0

Lateral neck radiograph of a child with croup

Lateral neck radiograph showing subglottic narrowing (arrow) and distended

Courtesy of Joe Black, Diagnostic Imaging, Texas Children's Hospital.

Graphic 64727 Version 4.0

Croup: Anteroposterior radiograph with "steeple sign"

The anteroposterior (AP) view demonstrates tapering of the upper trachea,

Courtesy of the Department of Diagnostic Imaging, Texas Children's Hospital.

Graphic 52418 Version 2.0

Bacterial tracheitis: Lateral neck radiograph

Lateral neck radiograph showing intraluminal membranes and tracheal wall

Courtesy of R Paul Guillerman, MD, Department of Radiology, Baylor College of

Graphic 80331 Version 6.0

Lateral neck radiograph demonstrating widening of the retropharyngeal space

Courtesy of Joe Black, Department of Diagnostic Imaging, Texas Children's Hospital.

Graphic 63233 Version 4.0

A large unilateral abscess is visible in the pharynx of a patient examined in the

Courtesy of Lawrence B Stack, MD.

Graphic 69943 Version 3.0

Child with classic presentation of acute epiglottitis

This 4-year-old girl has epiglottitis caused by Haemophilus influenzae type b.

Graphic 76538 Version 6.0

Rapid overview: Epiglottitis (supraglottitis) in children

Muffled "hot potato" voice or aphonia

Marked retractions and labored breathing indicate impending respiratory failure

Verbal patients with pain out of proportion to oropharyngeal examination

Unimmunized or under-immunized patients

Patient able to maintain the airway

Epiglottal cultures after establishment of artificial airway

Blood cultures after the airway is secured

Graphic 80169 Version 11.0

Approach to the child with suspected epiglottitis

* Epiglottitis is more likely in un- or under-immunized children and those with

Graphic 90183 Version 6.0