PALS Provider: Course

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.

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

  • Dexamethasone (0.6 mg/kg PO, max 16 mg)
  • Supportive care (hydration, humidified air)

Moderate to Severe Croup

  • Nebulized Epinephrine (5 mL of 1:1000 or 0.5 mL/kg diluted in saline)
  • Dexamethasone 0.6 mg/kg IV/IM/PO or Budesonide neb 2 mg
  • Oxygen therapy if SpO₂ < 90%

Severe Croup (Impending Respiratory Failure)

  • Consider Heliox to reduce airway resistance
  • Prepare for intubation if stridor worsens despite treatment
  • Avoid intubation if possible—swelling complicates extubation

When to Intubate: Severe distress, cyanosis, altered mental status, failure to respond to epinephrine and steroids.

Key Clinical Pearls:

  • Nebulized epinephrine is first-line for severe croup
  • Corticosteroids reduce inflammation and prevent worsening
  • Avoid distressing the child—crying worsens stridor

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
  • Swelling of lips, tongue, or throat
  • Urticaria, 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) – repeat every 5–15 minutes as needed
  • High-flow oxygen
  • IV Fluids (NS or LR 20 mL/kg) for hypotension

Adjunctive Therapies (After Epinephrine)

  • H1 Blocker – Diphenhydramine 1 mg/kg IV/PO (max 50 mg)
  • H2 Blocker – Ranitidine or Famotidine
  • Corticosteroids – Methylprednisolone 1–2 mg/kg IV
  • Albuterol nebulizer for bronchospasm

When to Intubate: Severe swelling, persistent stridor, respiratory distress with hypoxia or AMS.

Key Clinical Pearls:

  • Epinephrine is the only life-saving treatment—give it immediately
  • Antihistamines and steroids are adjuncts, not replacements
  • Watch for biphasic reactions

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.

Signs of Foreign Body Aspiration:

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

Treatment Approach for FBA:

Complete Obstruction

  • Infants: 5 Back Blows + 5 Chest Thrusts
  • Children: Abdominal Thrusts (Heimlich)
  • If unresponsive: Start CPR, remove visible object only if seen

Partial Obstruction

  • Encourage coughing if child is still breathing
  • Do not perform blind finger sweeps
  • Prepare for bronchoscopy if unresolved

When to Intubate: Severe obstruction unrelieved by BLS, persistent respiratory distress, or declining oxygenation.

Key Clinical Pearls:

  • Use age-appropriate maneuvers: back blows/chest thrusts vs. Heimlich
  • Persistent stridor = suspect lodged object → bronchoscopy
  • High suspicion in sudden-onset unexplained respiratory distress

Summary: Key Management Strategies for Upper Airway Obstruction

Condition First-Line Treatment Escalation Therapies
Croup Dexamethasone, nebulized epinephrine Intubation for impending failure
Anaphylaxis IM epinephrine, oxygen, IV fluids Intubation for severe swelling
Foreign Body Aspiration Back blows, chest thrusts, Heimlich Bronchoscopy 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.