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PALS Provider Course: Respiratory Emergencies

MANAGEMENT OF UPPER AIRWAY OBSTRUCTION

 

Upper airway obstruction prevents air from reaching the lungs, leading to severe respiratory distress and potential respiratory failure if not treated promptly. Unlike lower airway conditions (asthma, bronchiolitis), upper airway obstruction primarily affects inspiration and can rapidly progress to hypoxia and cardiac arrest.

🚨 Key Goals of Management:
✅ Identify the cause and provide immediate intervention.
✅ Secure the airway and ensure adequate oxygenation.
✅ Prevent progression to respiratory failure.

 

1️⃣ CROUP (Laryngotracheobronchitis) MANAGEMENT

Croup is a viral infection (most commonly parainfluenza virus) that causes inflammation and swelling of the larynx, trachea, and bronchi, leading to airway narrowing and stridor.

🔍 Signs of Upper Airway Obstruction in Croup:

  • Barking cough (“seal-like”)
  • Inspiratory stridor (worse with agitation)
  • Hoarseness
  • Low-grade fever, runny nose (viral symptoms)
  • Retractions and tachypnea in severe cases

🔹 Treatment Approach for Croup:

Mild Croup (No Stridor at Rest)

✅ Dexamethasone (0.6 mg/kg PO, max 16 mg) – Reduces airway inflammation.
✅ Supportive care (hydration, humidified air).

Moderate to Severe Croup (Stridor at Rest, Increased Work of Breathing) 🚨

✅ Nebulized Epinephrine (5 mL of 1:1000 solution, or 0.5 mL/kg of 1:1000 diluted in saline):

  • Provides rapid airway swelling reduction.
  • Monitor for rebound symptoms after 2 hours.
    ✅ Dexamethasone 0.6 mg/kg IV/IM/PO (alternative: Budesonide neb 2 mg).
    ✅ Oxygen therapy (if hypoxic, SpO₂ < 90%).

Severe Croup (Impending Respiratory Failure) 🚨

✅ Consider Heliox (helium-oxygen mixture) to reduce airway resistance.
✅ Prepare for intubation if stridor worsens despite treatment.
✅ AVOID intubation if possible – swelling can make extubation difficult.

🚨 When to Intubate?

  • Severe respiratory distress, cyanosis, altered mental status.
  • Failure to respond to nebulized epinephrine and steroids.

🛠️ Key Clinical Pearls:
✅ Nebulized epinephrine is first-line therapy for severe croup.
✅ Corticosteroids are essential to reduce inflammation.
✅ Avoid distressing the child—crying worsens stridor.

2️⃣ ANAPHYLAXIS MANAGEMENT

Anaphylaxis is a life-threatening allergic reaction causing airway swelling, bronchospasm, and cardiovascular collapse. It requires immediate administration of epinephrine to reverse symptoms.

🔍 Signs of Upper Airway Obstruction in Anaphylaxis:

  • Stridor, hoarseness, difficulty breathing (due to laryngeal edema).
  • Swelling of the lips, tongue, or throat.
  • Urticaria (hives), flushing, or angioedema.
  • Hypotension, dizziness, or shock (late sign).

🔹 Treatment Approach for Anaphylaxis:

Immediate Life-Saving Treatment 🚨

✅ IM Epinephrine (0.01 mg/kg, max 0.3 mg per dose) – Repeat every 5-15 minutes as needed.
✅ Oxygen therapy (high-flow O₂ if respiratory distress).
✅ IV Fluids (NS or LR 20 mL/kg) for hypotension.

Adjunctive Therapies (AFTER Epinephrine)

✅ Antihistamines (H1 blocker – Diphenhydramine 1 mg/kg IV/PO, max 50 mg).
✅ H2 Blocker (Ranitidine or Famotidine) to reduce histamine effects.
✅ Corticosteroids (Methylprednisolone 1-2 mg/kg IV) – Prevents delayed reactions.
✅ Albuterol nebulizer for bronchospasm (wheezing).

🚨 When to Intubate?

  • Severe airway swelling, persistent stridor despite treatment.
  • Respiratory distress with hypoxia or altered mental status.

🛠️ Key Clinical Pearls:
✅ Epinephrine is the ONLY life-saving treatment—give it immediately!
✅ Antihistamines and steroids are secondary and do NOT replace epinephrine.
✅ Monitor for biphasic reactions (recurrence of symptoms hours later).

 

3️⃣ FOREIGN BODY ASPIRATION MANAGEMENT

Foreign body aspiration (FBA) is a leading cause of sudden upper airway obstruction in young children, especially ages 1-3 years. It is most commonly caused by food, toys, or small objects lodging in the airway.

🔍 Signs of Foreign Body Aspiration:

  • Sudden onset of choking or coughing.
  • Inspiratory stridor (if in upper airway).
  • Wheezing (if lodged in lower airway).
  • Severe cases: Cyanosis, inability to speak or cry, respiratory failure.

🔹 Treatment Approach for Foreign Body Aspiration:

Immediate Response for Complete Airway Obstruction 🚨

✅ Infants (<1 year old):

  • 5 Back Blows + 5 Chest Thrusts (Repeat as Needed).
    ✅ Children (>1 year old):
  • Abdominal Thrusts (Heimlich maneuver).
    ✅ If the child becomes unresponsive:
  • Start CPR immediately.
  • Attempt to remove the object only if visible in the mouth.

Management of Partial Airway Obstruction (Mild Cases)

✅ Encourage coughing if the child is still breathing.
✅ Avoid blind finger sweeps—this may push the object deeper.
✅ Prepare for definitive removal via bronchoscopy.

🚨 When to Intubate?

  • Severe obstruction that does not resolve with BLS maneuvers.
  • Persistent respiratory distress with declining oxygen levels.

🛠️ Key Clinical Pearls:
✅ Back blows & chest thrusts for infants, abdominal thrusts for older children.
✅ If the child is breathing but has persistent stridor, prepare for bronchoscopy.
✅ High suspicion in any child with sudden-onset respiratory distress.

 

4️⃣ SUMMARY: KEY MANAGEMENT STRATEGIES FOR UPPER AIRWAY OBSTRUCTION


ConditionFirst-Line TreatmentEscalation Therapies
CroupDexamethasone, nebulized epinephrineIntubation for impending failure
AnaphylaxisIM epinephrine, oxygen, IV fluidsIntubation for severe swelling
Foreign Body AspirationBack blows, chest thrusts, HeimlichBronchoscopy for unresolved cases

✅ Croup = Viral inflammation → Steroids + Nebulized epinephrine.
✅ Anaphylaxis = Airway swelling + shock → IM Epinephrine IMMEDIATELY.
✅ Foreign Body = Mechanical obstruction → BLS maneuvers first, bronchoscopy if needed.
✅ Early intervention is critical to prevent respiratory failure.

🚑 Takeaway: Upper airway obstruction is a life-threatening emergency. Rapid recognition and targeted treatment can mean the difference between life and death.