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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

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Oct 2016. | This topic last updated: Dec 09, 2013.

INTRODUCTION — Acute upper airway obstruction from any cause can be a life-threatening emergency. Complete obstruction will result in respiratory failure followed by cardiac arrest in a matter of minutes. This situation requires an immediate, aggressive response.

In contrast, a child with a partial obstruction may initially have an adequate airway. However, this condition can deteriorate rapidly. Under these circumstances, providing supportive care and mobilizing resources for definitive airway management may be the most appropriate intervention.

Compared with adults, infants and young children have small airways and can quickly develop clinically significant upper airway obstruction. The increased work of breathing that results can rapidly progress to respiratory failure because these young patients have less respiratory reserve. Therefore, prompt recognition of airway compromise and the institution of appropriate therapy are necessary to prevent progressive deterioration in respiratory function and improve outcomes.

This topic will review an emergency diagnostic and therapeutic approach to acute severe upper airway obstruction in children. The emergent evaluation of children with acute respiratory distress and issues related to stridor, chronic upper airway problems, and airway management techniques for the difficult pediatric airway are discussed separately.

●(See "Emergency evaluation and immediate management of acute respiratory distress in children".)

●(See "Assessment of stridor in children".)

●(See "Hoarseness in children: Evaluation".)

●(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). However, most children have an identifiable etiology and respond well with prompt recognition and appropriate intervention. The most common cause of upper airway obstruction in children is croup [1]. (See 'Croup' below.) Choking on a foreign body also occurs frequently, resulting in 17,000 emergency department visits for children less than 14 years of age in 2000 [2].

The discussion here will emphasize causes that can result in severe, rapidly progressive symptoms. The causes of mild upper airway obstruction and the assessment of stridor are discussed elsewhere. (See"Assessment of stridor in children".)

Decreased 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. Simply repositioning the airway may relieve the obstruction. (See "Basic airway management in children".)

Infectious etiologies — 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.

Epiglottitis — Epiglottitis (supraglottitis) is a life-threatening infection characterized by rapidly progressive inflammation of and around the epiglottis. Common symptoms of upper airway compromise include dysphagia, muffled voice, and difficulty handling oral secretions. The incidence of epiglottitis has declined dramatically since routine infant vaccination with Haemophilus influenzae type b (Hib) protein-polysaccharide conjugate vaccines began in 1991. An algorithm provides the diagnostic approach to epiglottitis (algorithm 1). A rapid overview provides evaluation and management (table 2). (See "Epiglottitis (supraglottitis): Clinical features and diagnosis".)

Croup — Laryngitis, laryngotracheitis, and laryngotracheobronchitis are synonyms for a viral infection involving the larynx and trachea. Spasmodic croup causes symptoms that are the same as those of laryngotracheitis, but without fever. There may be an allergic component to spasmodic croup.

All of these processes 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. Croup, frequently a mild illness, is the most common infectious cause of upper airway obstruction in children 6 to 36 months of age. It is discussed in detail elsewhere (image 1 and image 2 and image 3). (See "Croup: Clinical features, evaluation, and diagnosis", section on 'Clinical presentation' and "Croup: Approach to management".)

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. (See "Bacterial tracheitis in children: Clinical features and diagnosis".)

Retropharyngeal abscess — A retropharyngeal abscess may extrinsically compress structures in the upper airway. Prominent presenting complaints are usually neck pain, fever, and sore throat rather than acute, severe airway obstruction. A detailed discussion of retropharyngeal abscess may be found separately (image 4). (See "Retropharyngeal infections in children".)

Peritonsillar abscess — Peritonsillar abscess generally occurs in later childhood and adolescence. The sudden onset of severe respiratory distress is rare. Peritonsillar abscess is discussed in detail elsewhere. (See"Peritonsillar cellulitis and abscess".)

Infectious mononucleosis — Obstruction of the upper airway due to massive tonsillar enlargement and mucosal edema is an uncommon and potentially fatal complication of infectious mononucleosis [3]. (See"Clinical manifestations and treatment of Epstein-Barr virus infection".)

Foreign bodies — 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 five years of age were caused by a foreign object [4]. Symptoms resolved in more than half of children prior to the arrival of paramedics. An intervention was required in 2 percent of cases.

Airway foreign body — Most aspirated objects lodge in the bronchi and are not immediately life-threatening [5]. Although rare, foreign bodies in the larynx or trachea can cause significant complete or partial airway obstruction that requires immediate treatment. An approach to upper airway foreign bodies is discussed below. (See 'Algorithmic approach' below.) The presentation, evaluation, and management of lower airway foreign bodies are discussed in detail elsewhere. (See "Airway foreign bodies in children".)

Esophageal foreign body — Foreign bodies lodged in the esophagus in the area of the cricoid cartilage or the tracheal bifurcation can compress the airway causing partial airway obstruction. It is also possible that an esophageal foreign body will become dislodged into the upper airway. The presentation, evaluation, and management of esophageal foreign bodies is discussed in detail elsewhere (image 5). (See "Foreign bodies of the esophagus and gastrointestinal tract in children".)

Trauma

Blunt and penetrating injury — Blunt or penetrating injury to various anatomic structures may result in upper airway obstruction:

●Traumatic injury to the face may cause soft tissue swelling or hemorrhage, leading to airway compromise.

●Blunt or penetrating trauma to the larynx or subglottic trachea may result in dyspnea, altered phonation,and/or subcutaneous emphysema [6].

●Injury to the epiglottis can cause swelling and upper airway obstruction with a clinical presentation indistinguishable from infectious epiglottitis [7].

Burn injuries — The presence of 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.

Thermal injury to the epiglottitis, usually from hot beverages, has been reported [7]. Thermal injury below the vocal cords is unlikely due to the cooling efficiency of the upper airways [8].

Anaphylaxis — Anaphylaxis and anaphylactoid 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 can be life-saving (table 3). (See 'Severe upper airway obstruction' below.)

Hereditary angioedema — Laryngeal edema occurs in approximately one-half of all patients with hereditary angioedema at some point during their lifetime. Tooth extraction and oral surgery are common triggers for laryngeal attacks. (See "Hereditary angioedema: Epidemiology, clinical manifestations, exacerbating factors, and prognosis".)

Vocal cord dysfunction — Laryngospasm is an acute manifestation of vocal cord dysfunction that is usually precipitated by irritation of the vocal cords, as can occur with aspiration. Hypocalcemic tetany is a rare cause of laryngospasm. (See "Clinical manifestations of hypocalcemia", section on 'Tetany'.)

The symptoms of vocal cord dysfunction (VCD) are usually chronic. The acute onset or worsening of stridor from 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, vocal cord dysfunction can occur in children with Chiari II malformations. (See "Pathophysiology and clinical manifestations of myelomeningocele (spina bifida)", section on 'Chiari II malformation'.)

The anatomy and physiology of vocal cord function are discussed extensively elsewhere. (See "Hoarseness in children: Evaluation".)

Involuntary vocal cord adduction during inspiration has been described in children and adolescents. Severe symptoms of upper airway obstruction may occur. (See "Paradoxical vocal fold motion".)

Acute on chronic conditions — Children who have chronic narrowing of the upper airway from any cause can develop critical obstruction with an acute illness or injury that affects the upper airway (table 4A-B). As an example, a child with mild stridor as the result of a laryngeal web may develop severe obstruction with an 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 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 [9]. 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".)

EVALUATION

Initial rapid assessment — The initial evaluation of children with signs and symptoms of acute upper airway obstruction must begin with a rapid assessment of respiratory status to identify those who need resuscitation [10]. Conditions that require immediate intervention include the following:

●Complete upper airway obstruction

●Rapidly progressing partial airway obstruction

●Respiratory failure

To rapidly identify the presence of these conditions, the clinician should focus upon signs of upper airway patency, the degree of respiratory effort, and the effectiveness of respiratory function. Throughout this evaluation, every reasonable effort must be made to keep the child calm and comfortable, since anxiety and crying can substantially increase airway obstruction and the work of breathing in young children [10].

Upper airway patency — There is no effective air movement in children with complete upper airway obstruction. Consequently, there is no audible speech or cough, although the child may be gagging or choking in an attempt to clear the airway.

Audible phonation or breath sounds indicates that the airway is patent, although it may be partially obstructed. With partial extrathoracic upper airway obstruction, respirations are usually noisy in inspiration (stridor).

A child with worsening obstruction may have an airway that is patent but inadequate because complete obstruction is imminent. Worsening respiratory distress (retractions, nasal flaring) with diminished air movementand/or worsening hypoxemia (poor color and decreased mental status) suggest that the obstruction is rapidly progressive.

Respiratory failure — Children with respiratory failure have developed inadequate oxygenation, inadequate ventilation, or both. The following clinical features indicate respiratory failure [10]:

●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.

History — Two historical variables that are particularly helpful in determining initial management priorities are onset of symptoms and presence of fever.

Onset of symptoms — The sudden onset of choking, gagging, or stridor suggests a foreign body 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.

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.

Other useful historical information includes:

●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 peritonsillar abscess) 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 or new food or medication. Smoke inhalation can result in chemical or thermal injury to the airway.

●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, 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 'Initial rapid assessment' 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 — In addition to the signs of airway obstruction previously mentioned (see'Upper airway patency' above), upper airway obstruction is also indicated by the following:

●Children with significant obstruction may prefer to sit up and lean forward in a "sniffing" position (neck is mildly flexed and head is mildly extended). This position tends to improve the patency of the upper airway.

●There can be some degree of drooling when the patient is unable to swallow.

●Retractions (suprasternal and supraclavicular) and nasal flaring may be noted.

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

●High fever, toxic appearance, and moderate respiratory distress in a school age child suggest bacterial tracheitis or, rarely, epiglottitis.

●Signs such as choking, gagging, or difficulty swallowing are more sensitive for the presence of upper airway foreign body than inspection of the posterior pharynx.

●The acute onset of upper airway symptoms with facial swelling and wheezing are consistent with an allergic reaction.

●Bleeding, bruising, or subcutaneous air suggest blunt or penetrating trauma.

●The child with burns or singed hair who has hoarseness or respiratory distress may have a burn injury to the upper airway.

●An infant or toddler who is irritable, not moving the neck, and who will not swallow may have a retropharyngeal abscess.

●Peritonsillar abscess 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.

Ancillary studies — The diagnostic evaluation must proceed in conjunction with treatment. (See 'Algorithmic approach' below.)

Imaging — Imaging 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 and croup (image 6). AP and lateral neck and chest films may demonstrate the presence of a foreign body, but many foreign bodies are radiolucent.

Microbiology — The role of the laboratory in establishing the diagnosis is limited. In the child with a bacteriologic etiology such as epiglottitis or a retropharyngeal abscess, a throat culture or blood culture may provide important information for ongoing antibiotic therapy.

Direct laryngoscopy — Laryngoscopy for diagnostic purposes alone is rarely necessary in children with acute upper airway obstruction. It is the diagnostic method of choice for vocal cord dysfunction during an acute episode.

ALGORITHMIC APPROACH — The child who has a complete airway obstruction must be identified immediately and life-saving maneuvers initiated. Although the etiology of the obstruction must be considered, the response to therapeutic interventions directs initial management (algorithm 2A) [11].

The strategy is somewhat different in the child with severe but partial upper airway obstruction. In this setting, clinical features suggest the diagnosis and guide therapeutic interventions (algorithm 2B) [12].

No airway, complete obstruction — With complete upper airway obstruction, there is no effective air movement. Initially, the child is anxious, struggling to breathe, and may be silently gagging or coughing in an attempt to clear the airway. The child's condition will rapidly deteriorate, with loss of consciousness, if the obstruction is not relieved. Treatment must be initiated immediately. The most expert physician available, who may be from anesthesia or otorhinolaryngology rather than emergency medicine or pediatrics, should manage the airway (algorithm 2A).

Suspected foreign body — Sudden onset of symptoms in a previously well child suggests the possibility that a foreign body may be obstructing the airway. Basic life saving (BLS) maneuvers for foreign body airway obstruction should be initiated [13].

Studies in cadavers have demonstrated that chest compressions and abdominal thrusts are each effective in generating sufficient pressure to expel a supraglottic foreign body [14]. Based upon this limited evidence and extensive clinical experience, the American Heart Association recommends chest compressions or abdominal thrusts as follows [13]:

●For infants less than one year of age, five back blows are delivered, followed by five chest thrusts. Abdominal thrusts are not recommended for infants less than one year of age because they may cause damage to the liver, which is relatively large and unprotected in this age group.

●For children one year of age or older, five abdominal thrusts (Heimlich maneuver) should be performed.

If the obstruction is relieved and the child resumes breathing adequately, he or she should at least be observed to confirm the diagnosis of relieved foreign body airway obstruction and that recovery has been complete.

Direct laryngoscopy should be performed when complete upper airway obstruction has not been relieved with BLS maneuvers. In some cases, foreign material can be removed with Magill forceps and/or suction. The child who begins to breathe adequately should receive supportive care, including supplemental oxygen, and be admitted to the hospital for observation. Bag-mask ventilation should be provided to patients who do not resume breathing spontaneously. Those who can be adequately ventilated and oxygenated should receive ongoing airway support and may require endotracheal intubation. (See "Emergency endotracheal intubation in children" and "Devices for difficult endotracheal intubation in children".)

Complete airway obstruction that is unremovable with direct laryngoscopy may occur with a foreign body that is lodged above or below the vocal cords:

●When a foreign body causing complete airway obstruction above the vocal cords cannot be removed, we recommend needle cricothyroidotomy with percutaneous transtracheal jet ventilation to bypass the obstruction, providing oxygenation. Case reports and studies in dogs have documented adequate oxygenation, despite poor ventilation, using this technique [15,16]. Patients should then be immediately transferred to the operating room for definitive removal of the obstruction. (See "Needle cricothyroidotomy with percutaneous transtracheal ventilation".)

●A foreign body that is lodged below the vocal cords may completely obstruct the subglottic trachea. This obstruction cannot be removed with direct laryngoscopy. In this situation, we recommend that the trachea 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. The left lung can then be ventilated. The child will now have a bronchial foreign body, but may receive adequate ventilation and oxygenation while preparations are being made to remove it in the operating room. There is no evidence to support the effectiveness of this approach in the setting of complete subglottic airway obstruction from a foreign body. However, case reports of patients requiring one lung ventilation for surgical procedures and studies in dogs have demonstrated effective oxygenation and ventilation [17,18].

No foreign body suspected — Complete upper airway obstruction may develop as the result of many processes other than a foreign body. (See 'Causes' above.) When this occurs, bag-mask ventilation should be initiated (algorithm 2C). (See "Basic airway management in children".) If this results in successful ventilation and oxygenation, preparations can be made for controlled intubation. Evaluation and treatment of the condition causing airway obstruction can also be initiated.

When bag-mask ventilation is not rapidly successful, endotracheal intubation should be performed (algorithm 2C and table 5). If this is accomplished and ventilation and oxygenation are adequate, medical management of the underlying condition can continue. Admission to a pediatric intensive care unit should be arranged.

When endotracheal intubation cannot be performed, use of a laryngeal mask airway (LMA) should be considered (algorithm 2D and table 6). Although evidence suggesting efficacy in children is lacking, successful oxygenation and ventilation with an LMA have been described in adults with upper airway obstruction from supraglottic edema [19]. (See "Emergency rescue devices for difficult pediatric airway management", section on 'Laryngeal mask airway (LMA)'.)

Needle cricothyroidotomy and transtracheal jet ventilation may also bypass the obstruction and provide some ventilation and oxygenation while preparations are being made to take the child to the operating room (figure 1and figure 2 and table 7). (See "Needle cricothyroidotomy with percutaneous transtracheal ventilation".)

Severe upper airway obstruction — Early, appropriate treatment of many causes of upper airway obstruction frequently stabilizes the child's respiratory function and prevents decompensation. However, it is important to realize that aggressive airway intervention in some clinical settings may result in dramatic deterioration [11]. Therefore, the initial approach to the child with severe symptoms includes a rapid assessment of respiratory function and identification of key clinical features (such as history of injury, fever, and onset of symptoms) that suggest the diagnosis and guide therapeutic interventions (algorithm 2B). (See'Causes' above.)

Imminent decompensation — Patients with burns around the face, a caustic ingestion, or another injury that has resulted in airway symptoms may suddenly develop worsening airway swelling and obstruction. Children without an injury who are deteriorating rapidly also require a secure airway. In both of these situations, patients require emergency controlled intubation. Consideration should be given to mobilizing subspecialty support, including anesthesia or otorhinolaryngology (algorithm 2C). (See "The difficult pediatric airway", section on 'Airway management'.)

Fever — The presence of fever suggests an infectious cause of upper airway obstruction.

●Croup/tracheitis – The gradual onset of hoarseness and cough, with other upper respiratory tract symptoms is consistent with croup or tracheitis. As with all children who have severe upper airway obstruction, the patient must be approached cautiously. The caregiver should be instructed to comfort the child and administer humidified oxygen, whenever possible. Nebulized epinephrine should be quickly added. Also, children with croup require treatment with corticosteroids. (See "Croup: Approach to management".)

Patients who have responded to nebulized epinephrine must be observed for three to four hours. Those with croup who continue to do well may be discharged with close follow-up. Children with tracheitis are usually more toxic and should be admitted to the hospital. In retrospective reports describing hospitalized children with severe upper airway infections, more children with bacterial tracheitis required admission to intensive care units and intubation than did those with viral croup [20-22].

●Epiglottitis, retropharyngeal, or peritonsillar abscess – Children who rapidly develop high fever, a toxic appearance, and severe upper airway obstruction may have a bacterial illness such as epiglottitis. Patients often have a muffled voice and difficulty swallowing. Cough is typically absent. (See "Epiglottitis (supraglottitis): Clinical features and diagnosis", section on 'Clinical features'.)

Symptoms of a retropharyngeal abscess include fever, neck pain, and sore throat. They may not progress as quickly as those of epiglottitis. (See "Deep neck space infections", section on 'General clinical manifestations'.)

Older children with a peritonsillar abscess may rarely have symptoms of severe upper airway obstruction. On examination, palatal cellulitis, with a bulging mass, is noted. (See "Peritonsillar cellulitis and abscess", section on 'Evaluation and diagnosis'.)

Patients with epiglottitis, retropharyngeal, or peritonsillar abscesses should receive appropriate antibiotics. Those with retropharyngeal abscesses may require radiographic evaluation to define the extent of infection. Consultation with an otorhinolaryngologist and hospital admission are also indicated for patients with severe upper airway obstruction secondary to retropharyngeal abscesses. Emergent incision and drainage of a peritonsillar abscess by the emergency physician or an otorhinolaryngologist, followed by hospital admission, is recommended. (See "Peritonsillar cellulitis and abscess".)

●Indications for definitive airway management – Children with epiglottitis and those with other infectious etiologies whose condition is deteriorating require immediate airway management by the most skilled physician available. Time permitting, emergency subspecialty (otorhinolaryngology and anesthesia) consultation should be obtained and the patient taken to the operating room for definitive airway management. (See "Epiglottitis (supraglottitis): Treatment and prevention", section on 'Airway management'.)

No fever — Symptoms of severe upper airway obstruction that develop suddenly in children without fever may be the result of trauma, a foreign body lodged in the upper airway, or acute swelling of the airway secondary to anaphylaxis or spasmodic croup.

●Trauma, foreign body – A history of trauma or choking on a foreign body requires evaluation for a laryngotracheal injury or removal of a subglottic foreign body. Emergent subspecialty consultation should be obtained, with definitive management in the operating room whenever possible.

●Anaphylaxis – The sudden onset of symptoms without associated trauma or choking in a child with urticaria, facial swelling, or wheezing suggests anaphylaxis. In this situation, patients should immediately receive intramuscular epinephrine, followed promptly by diphenhydramine intramuscularly or intravenously. The addition of corticosteroids should be considered (table 3). Patients who have had severe upper airway obstruction secondary to an allergic reaction should be admitted to the hospital for observation.

●Spasmodic croup – Children with the sudden onset of acute upper airway obstruction without associated allergic symptoms may have spasmodic croup. Treatment with nebulized epinephrine and steroids should be initiated. Those who respond to these interventions must be observed for three to four hours and admitted if symptoms recur. (See "Croup: Approach to management".)

●Indications for definitive airway management – Children with a laryngeal injury or upper airway foreign body require emergency subspecialty consultation, with definitive management in the operating room whenever possible. Those with anaphylaxis or spasmodic croup generally improve with medical therapy. However, prompt definitive airway management, which may include intubation, is required for those with persistent or worsening severe upper airway obstruction.

Infants with the gradual onset of severe upper airway obstruction may have laryngomalacia (also called congenital laryngeal stridor) or another congenital anomaly. Admission to the hospital for further evaluation and supportive care should be considered. Older children may have a neoplasm or tonsillar hypertrophy. Symptoms of severe upper airway obstruction can only be attributed to psychogenic causes after a thorough evaluation and period of observation. (See "Congenital anomalies of the larynx", section on 'Laryngomalacia'.)

SUMMARY AND RECOMMENDATIONS

●Acute upper airway obstruction can be a life-threatening emergency. There are many causes, including infections, aspirated foreign body, trauma, allergic reactions, and congenital anomalies (table 4A and table 4B). (See 'Causes' above.)

●Prompt recognition of the child who requires resuscitation and therapeutic intervention is essential (table 1). (See 'Initial rapid assessment' above.)

●Factors that influence choice of treatment options include degree of airway compromise, presence of fever, sudden onset of symptoms, history of injury, and age. (See 'Evaluation' above.)

●The algorithms provide an approach to evaluation and treatment of the child with acute severe upper airway obstruction or complete airway obstruction and the approach to the management of the difficult or failed airway (algorithm 2A-D). (See 'No airway, complete obstruction' above and 'Severe upper airway obstruction' above.)

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