The document discusses various causes of upper airway obstruction in children, including decreased muscle tone, infections like epiglottitis and croup, and diphtheria. Epiglottitis causes sudden life-threatening obstruction and requires intubation. Croup is usually mild but can progress to respiratory failure. It is commonly caused by viruses and treated with racemic epinephrine, steroids, and supportive care. Spasmodic croup involves acute attacks relieved by steam or epinephrine. Diphtheria must be considered but is now rare with immunization. Prompt recognition and treatment are important to prevent airway obstruction.

2.  The extrathoracic airways narrow during inspiration
and widen during expiration.
 Obstruction of the extrathoracic airway causes
intraluminal pressure distal to the obstruction to fall
during inspiration, which adds to the obstruction.

3. CF
 Inspiratory stridor,:
 Stridor is a harsh, high-pitched, musical sound
produced by turbulent airflow through a partially
obstructed airway.)

4.  hoarseness,
 and both suprasternal and intercostal retractions are
signs of a partial obstruction of the larynx and
extrathoracic trachea.
 If the obstruction is severe, then agitation, cyanosis,
acidosis, and respiratory failure occur

5.  Although acute stridor usually is caused by acute
airway infections, other disorders may be present and
should be considered when symptoms are severe,
prolonged, or recurrent.
 In these patients, imaging studies and endoscopy may
be necessary.

6.  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 have an
adequate airway initially.
 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.

7.  Compared to 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 is necessary
to prevent progressive deterioration in respiratory
function and improve outcomes

8.  Any condition that causes upper airway obstruction
can be life-threatening (show 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 .
 Choking on a foreign body also occurs frequently .

9.  The discussion here will emphasize causes that can
result in severe, rapidly progressive symptoms.

10. CAUSES

11. Decreased muscle tone
 The tongue can fall back into the pharynx and
obstruct the airway in children with decreased
oropharyngeal muscle tone:
 ●depressed levels of consciousness or
 ● neuromuscular disease.
 Simply repositioning the airway may relieve the
obstruction

12. 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

13. 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
influenza type b (Hib) protein-polysaccharide
conjugate vaccines began in 1991

14.  Acute epiglottitis is an infection of the epiglotis, with
rapid swelling of the epiglottis and increasing
inspiratory difficulty.
 It usually is caused by H. influenzae type b and
requires early and aggressive treatment.
 The widespread use of Hemophilus b vaccine has
reduced the incidence of this disease, but it still must
be considered in any child with acute, croup-like
symptoms.

15.  The child with acute epiglottitis usually is older than 3
years of age.
 Onset is acute, with inspiratory stridor, drooling, and
increasing agitation.
 The disease progresses over 4 to 12 hours to almost
total airway obstruction.

16.  There usually are fever and other signs of systemic
toxicity.
 In contrast to a child with viral
laryngotracheobronchitis, there is rarely any history of
an antecedent upper respiratory infection,
 and there is absence of spontaneous cough

17.  When obstruction is severe, breath sounds are
diminished over the lung fields.
 The child tends to remain in a sitting position with
chin extended and may complain of pain in his or her
throat on swallowing.
 Secretions are not swallowed.
 As the obstruction progresses, stridor may decrease as
breathing becomes shallow and rapid.

18.  In patients with good air exchange, a cautious
examination of the posterior pharynx (being careful
not to touch the wall of the pharynx with the tongue
blade) will reveal a grossly edematous epiglottis.
 This swollen epiglottis has been described as
resembling a bright red raspberry.
 Once the tip of the swollen epiglottis is visualized,
examination of the pharynx should stop—any further
manipulation of the inflamed epiglottis may cause
complete laryngeal obstruction.

20.  . It is essential that appropriate equipment and
personnel who are trained to perform endotracheal
intubation or tracheostomy be present when a child
with possible epiglottitis is examined.
 The examination should be performed only in an
emergency room, intensive care unit, operating room,
or similar setting, where a surgical airway can be
established if necessary.
 The diagnosis of epiglottitis also may be suggested by
identifying a plump, swollen epiglottis on a lateral
neck radiograph.

21.  A child with confirmed epiglottitis should be intubated. A
tube that is 0.5 to 1.0 mm smaller than usually is
appropriate for the child's size should be selected.
 Endotracheal intubation may be difficult; tracheotomy
may be necessary. The average duration of endotracheal
intubation after starting antibiotics is 2 to 4 days.
 The incidence of postintubation complications is low.
 Pulmonary edema can complicate both acute epiglottitis
and viral croup, and it may cause hypoxemia and
pulmonary infiltrates that are seen on chest radiographs

22.  After blood for culture is obtained (which are often
positive with epiglottitis), immediate treatment with
intravenous cefuroxime, 75 mg/kg/d, should begin.
 The child should be monitored in an intensive care
unit.

24. 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.

25.  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.

26.  Acute laryngotracheitis is the most common cause of
acute stridor that is encountered in pediatric practice.
 It usually occurs in the late fall and winter months,
when viral respiratory infections reach their peak
incidence.
 It is more common in boys than in girls, and occurs
more often in children between 6 months and 6 years
of age who have had an upper respiratory infection for
2 to 3 days before inspiratory stridor develops.

27.  Many children have a barking seal cough and
wheezing.
 Fever usually is present, but the child generally does
not appear to be very ill.
 On cautious examination of the posterior pharynx, the
epiglottis may be slightly red and mildly edematous,
which is quite different from the gross swelling of
acute epiglottitis

28.  The obstruction in acute laryngotracheobronchitis is
primarily subglottic in location
 and produces the so-called steeple sign on
posteroanterior neck radiographs because the airway
appears to taper gradually to a very narrow segment.
 Parainfluenza type 1 viruses are the most common
cause of viral croups accounting for up to 65% of the
incidents

29.  and parainfluenza type 3,
 influenza A and B viruses,
 adenoviruses,
 respiratory syncytial virus, and echovirus cause most
of the rest.
 Mycoplasma pneumoniae also can produce croup
symptoms in older children.

30.  Most children with croup do not require
hospitalization.
 Treatment at home consists of air humidification,
 avoidance of agitation,
 and reduction of fever.
 An oral electrolyte solution may be offered to mildly
affected infants, but those with respiratory distress or
cough-induced vomiting should be fed with caution

31.  . Oropharyngeal suctioning should be avoided because
stimulating the posterior pharynx may cause reflex
laryngeal and bronchial constriction.
 If signs of severe obstruction develop, treatment with
an aerosol of racemic epinephrine (2.25%), nebulized
with 100% oxygen, frequently provides relief.
 Frequent aerosol treatments may be needed for the
first few hours

32.  . A single parenteral dose of dexamethasone, 0.6
mg/kg, is effective in decreasing the length and
severity of respiratory symptoms that are associated
with viral croup.
 Inhaled corticosteroid therapy has also been used
with some success, but parenteral dexamethasone is
somewhat easier.
 Intubation or tracheostomy rarely is necessary.

33.  Sedation should be either avoided or used in a
monitored environment.
 Arterial pH and blood gas measurements may help in
guiding treatment, but they are not a substitute for
good clinical judgment.
 Arterial blood gas values may not be representative of
the child's overall condition, and arterial puncture may
cause further agitation

34.  . Heliox has been used successfully to maintain gas
exchange in critically ill patients who might otherwise
have required intubation.
 Estimation of arterial saturation by pulse oximetry
can be used to monitor oxygenation. Intubation rarely
is necessary, but if required, the presence of an
underlying congenital lesion such as subglottic
stenosis or a vascular ring should be considered.

35.  The differential diagnosis of viral croup includes epiglottitis,
foreign body, and angioneurotic edema. Careful history taking
usually can distinguish viral croup from these other disorders.
 Some children have recurrent croup, usually as a result of
recurrent infection with viruses that are known to cause the
disease.
 In these patients, however, other congenital and acquired causes
of stridor should be considered, especially with infants.
 In patients with frequent episodes or the inability to sustain
long symptom-free intervals, barium esophagram and
bronchoscopy should be performed to exclude structural
disorders

38.  Westley croup score — The elements of the Westley
croup score describe key features of the physical
examination .
 Each element is assigned a score, as illustrated below:
 Level of consciousness: Normal, including sleep = 0;
disoriented = 5
 Cyanosis: None = 0; with agitation = 4; at rest = 5
 Stridor: None = 0; with agitation = 1; at rest = 2

39.  Air entry: Normal = 0; decreased = 1; markedly
decreased = 2
 Retractions: None = 0; mild = 1; moderate = 2; severe =
3

40.  The total score ranges from 0 to 17. Mild croup is
defined by a Westley croup score of ≤ 2.
 Typically these children have a barking cough, hoarse
cry, but no stridor at rest.
 Children with mild croup may have stridor when
upset or crying (ie, agitated) and either none, or only
mild chest wall/subcostal retractions .
 Moderate croup is defined by a Westley croup score of
3 to 7

41.  Children with moderate croup have stridor at rest, at least
mild retractions, and may have other symptoms or signs of
respiratory distress, but little or no agitation .
 Severe croup is defined by a Westley croup score of ≥ 8.
 Children with severe croup have significant stridor at rest,
although stridor may decrease with worsening upper
airway obstruction and decreased air entry .
 Retractions are severe (including indrawing of the
sternum) and the child may appear anxious, agitated, or
fatigued.
 Prompt recognition and treatment of children with severe
croup are paramount.

42.  Respiratory failure — Croup occasionally results in
significant upper airway obstruction with impending
respiratory failure, heralded by the following signs :
 Fatigue and listlessness
 Marked retractions (although retractions may decrease
with increased obstruction and decreased air entry)
 Decreased or absent breath sounds
 Depressed level of consciousness
 Tachycardia out of proportion to fever
 Cyanosis or pallor

43.  MILD CROUP
 Home treatment
 Outpatient treatment

44.  MODERATE TO SEVERE CROUP
 Supportive care
 Monitoring
 Fluids
 Intubation
 Pharmacotherapy
 Observation
 Discharge to home
 Hospitalization
 Indications
 Interventions
 Infection control
 Discharge criteria

45. SPASMODIC CROUP
 Spasmodic croup (ie, acute spasmodic laryngitis) is
characterized:
 by acute attacks of inspiratory stridor that tend to occur
suddenly during the evening or at night,
 last several hours, and then subside, only to recur during
the next several days.
 It usually is seen in children between 6 months and 3
years of age.
 Its etiology is uncertain, but it may represent recurrent
viral laryngotracheitis.
 The child with spasmodic croup usually awakens with a
barking, metallic cough and marked inspiratory stridor.

46.  The degree of inspiratory obstruction can be striking,
with retractions of the supraclavicular and substernal
areas.
 Fever is absent, and although the child may have had
a mild upper respiratory infection preceding the
attack,
 examination of the posterior pharynx reveals only
minimal, if any, signs of inflammation.
 Acute adductor spasm of the vocal cords also may be a
cause, possibly triggered by a mild viral illness or
allergy.

47.  Placing the child in a closed bathroom in which a hot
shower is running may bring relief in a few minutes.
 Paradoxically, exposure to the cool night air while en route
to a hospital frequently breaks the attack before the
hospital is reached.
 Aerosol treatment with racemic epinephrine usually
terminates the attack. If symptoms are atypical or frequent,
structural causes of recurrent stridor should be considered.
 Occurrence in later childhood and adolescence suggests
psychogenic illness, especially if symptoms do not occur
during sleep

48. DIPHTHERITIC CROUP
 Diphtheria must be considered in the differential
diagnosis with acute infectious croup;
 a history of completed immunizations for diphtheria
makes the diagnosis very unlikely.
 Typically, a child with diphtheritic croup has been ill
for 1 to 2 days, looks sick, and has a serous or
serosanguineous nasal discharge.
 Cutaneous lesions and cervical lymphadenopathy also
may be present.

49.  Examination of the posterior pharynx may reveal a
gray-white membrane over the tonsils, with possible
extension to the uvula.
 Occasionally, this membrane is limited to the larynx,
making it difficult to visualize and the diagnosis
difficult to make.
 Treatment requires immediate administration of
diphtheria equine antitoxin and either penicillin or
erythromycin .

50. BACTERIAL TRACHEITIS
(PSEUDOMEMBRANOUS CROUP
 Bacterial tracheitis is a rare but important cause of
severe upper airway obstruction and should be
considered in older patients with stridor or in infants
who do not respond to racemic epinephrine
inhalation.
 Children with this condition initially have symptoms
that are similar to epiglottitis or severe viral
laryngotracheitis

51.  Lateral neck radiographs show subglottic narrowing and
foreign material in the tracheal lumen.
 Endoscopy reveals extensive sloughing of the respiratory
epithelium and large amounts of mucopurulent secretions
and debris blocking the trachea.
 These secretions may be difficult to remove and
progressively occlude the airway.
 Staphylococcus aureus is the most common organism that
is associated with this condition;
 nontypable H. influenzae, Branhamella catarrhalis, and
Streptococcus pneumoniae are less often the cause

52.  Treatment includes culture of secretions,
 appropriate intravenous antibiotics,
 oxygen,
 avoidance of fluid overload,
 and endotracheal intubation if there are signs of
progressive respiratory failure.

53.  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

55. 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.

56.  Abscess formation in the retropharyngeal space rarely
follows a viral infection of the nasopharynx or a
penetrating pharyngeal injury.
 In this age of frequent antibiotics use, this is a rare but
urgent problem.
 These abscesses form in children who are under 5 years
of age and who present with sudden onset of fever,
dysphagia, drooling, neck rigidity, and noisy and
labored breathing.

57.  Examination of the pharynx can reveal bulging of the
posterior wall.
 Widening of the retropharynx is easily seen on a
lateral neck radiograph.
 Surgical drainage and broad-spectrum parenteral
antibiotics are required.
 Group A Streptococcus is the most common cause,
but anaerobes (eg, Bacteroides sp.) also can cause this
infection.
 Intubation may be needed to protect the airway
during the acute phase of the illness.

59. Peritonsillar abscess
■ Peritonsillar abscess generally occurs in later
childhood and adolescence.
■The sudden onset of severe respiratory distress is
rare.

60.  Abscess of the peritonsillar space generally occurs in
older children, who present with severe throat pain
and a muffled voice.
 Examination of the pharynx reveals medial
displacement of the soft palate, tonsil, and uvula.
 The abscess must be drained surgically with an
endotracheal tube in place to protect the airway.
 Antibiotics are given as for a retropharyngeal abscess

61. OTHERS

62. Laryngeal papillomatosis
 are benign, warty growths that are difficult to treat
and
 are the most common laryngeal neoplasm in children.
 Human papillomaviruses 6, 11, and 16 have been
implicated as causative agents.
 A substantial percentage of mothers of patients with
laryngeal papillomas have a history of genital
condylomas at the time of delivery, so the virus may be
acquired during passage through an infected birth
canal

63.  The age at onset is usually 2–4 years, but juvenile-onset
recurrent respiratory papillomatosis is well documented.
 A younger age of onset may be a worse prognostic
indicator.
 Patients usually develop hoarseness, voice changes, croupy
cough, or stridor that can lead to life-threatening airway
obstruction.
 Diagnosis is by direct laryngoscopy.
 The larynx was involved at the time of diagnosis in over
95% of patients, most of whom had only one site involved

64.  Treatment is directed toward relieving airway
obstruction, usually by surgical removal of the lesions.
 Tracheostomy is necessary when life-threatening
obstruction or respiratory arrest occurs.
 Various surgical procedures (laser, cup forceps, or
cryosurgery) have been used to remove papillomas,
but recurrences are the rule, and frequent reoperation
may be needed.


65.  The lesions occasionally spread down the trachea and
bronchi, making surgical removal more difficult.
 The use of interferon therapy remains controversial.
 Fortunately, spontaneous remissions do occur, usually
by puberty, so that the goal of therapy is to maintain
an adequate airway until remission occurs.

66.  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

67.  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 .
 Symptoms resolved in more than half of children
prior to the arrival of paramedics.
 An intervention was required in 2 percent of cases.

68.  Airway foreign body — Most aspirated objects lodge in
the bronchi and are not immediately life-threatening .
 Although rare, foreign bodies in the larynx or trachea
can cause significant complete or partial airway
obstruction that requires immediate treatment.

69.  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.

71.  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 orsubglottic trachea may
result in dyspnea, altered phonation, and/or subcutaneous emphysema
.
 Injury to the epiglottis can cause swelling and upper airway obstruction
with a clinical presentation indistinguishable from infectious
epiglottitis [

72.  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 .
 Thermal injury below the vocal cords is unlikely due to the
cooling efficiency of the upper airways

73.  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.
Emergent treatment can be life-saving

74.  Angioedema — Laryngeal edema occurs in
approximately one-half of all patients with inherited
angioedema at some point during their lifetime.
 Tooth extraction and oral surgery are common triggers
for laryngeal attacks.

75.  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.

76.  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

77.  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 .
 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.

78.  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 .