10.2 Upper Airway Emergencies (Epiglottitis, Foreign Body)

Acute Upper Airway Obstruction in Children

Acute stridor and airway obstruction are high-stakes presentations because a misstep — such as examining the throat of a child with suspected epiglottitis — can convert a partially obstructed airway into a completely obstructed one. The Arab Board Part 1 exam expects candidates to differentiate the major causes rapidly and to know exactly what NOT to do.

Croup, Epiglottitis, and Bacterial Tracheitis at a Glance

Croup — Diagnosis and Management

Croup (viral laryngotracheobronchitis) is the most common cause of acute stridor in children aged 6 months to 3 years. Parainfluenza virus is the leading pathogen, though other respiratory viruses (RSV, influenza, adenovirus, SARS-CoV-2) can produce the same picture. Diagnosis is clinical: a prodrome of rhinorrhea and low-grade fever followed by a barking, seal-like cough, hoarse voice, and inspiratory stridor that worsens at night. The child is typically non-toxic, alert, and comfortable at rest between coughing paroxysms — a key contrast with epiglottitis and bacterial tracheitis.

Severity is graded at the bedside using the Westley Croup Score (0–17), which combines stridor, retractions, air entry, cyanosis, and level of consciousness. Mild croup (score 0–2) has occasional barking cough without stridor at rest; moderate (3–7) has stridor at rest with mild-to-moderate retractions; severe (8–11) has marked retractions, agitation, and decreased air entry; impending respiratory failure (≥12) includes lethargy, pallor, or cyanosis.

Treatment for all severities includes a single dose of dexamethasone (0.15–0.6 mg/kg orally, intramuscularly, or intravenously — even mild croup benefits from corticosteroids, which reduce return visits and hospitalization). For moderate-to-severe croup (stridor at rest, significant retractions, or hypoxia), add nebulized racemic epinephrine (or L-epinephrine 1:1000, 5 mL) and observe for 2–3 hours after the last dose because of the risk of rebound worsening once the epinephrine effect wears off. Humidified air has not been shown to improve outcomes and is not recommended as primary therapy. Hospitalize children who require repeated epinephrine doses, have hypoxia, dehydration, or a history of severe croup or airway anomaly.

Exam pearl: A non-toxic child with a barking cough and hoarse voice who improves with nebulized epinephrine has croup — not epiglottitis. Epiglottitis children are toxic, drool, and have no cough.

Acute Epiglottitis — The Do-Not-Miss Diagnosis

Acute epiglottitis is inflammation and swelling of the epiglottis and surrounding supraglottic structures that can obstruct the airway within hours. Since routine Haemophilus influenzae type b (Hib) vaccination, incidence has fallen dramatically, but it still occurs in unvaccinated or under-vaccinated children and, increasingly, is caused by Streptococcus and Staphylococcus species.

Classic presentation: abrupt onset of high fever, sore throat, and rapidly worsening respiratory distress in a toxic-appearing child who sits upright in the tripod position (leaning forward on outstretched arms, neck extended, chin thrust forward — the "sniffing" posture) to maximize airway patency, drools because swallowing is too painful, and speaks with a muffled "hot potato" voice. Cough is characteristically absent, which is a key discriminator from croup.

Critical exam rule: Never examine the oropharynx or attempt to visualize the epiglottis with a tongue depressor, and never attempt IV access, lay the child supine, or otherwise agitate the child if epiglottitis is suspected. Any of these can precipitate complete laryngospasm and airway obstruction in a child whose airway is already critically narrowed. Keep the child calm, upright, and with a caregiver; arrange for the airway to be secured under controlled conditions in the operating room by the most experienced available anesthesiologist or ENT surgeon, with intubation (or a surgical airway as backup). Only after the airway is secured should blood cultures, epiglottic cultures, and IV antibiotics (a third-generation cephalosporin such as ceftriaxone or cefotaxime, covering H. influenzae) be pursued.

Bacterial Tracheitis — The Modern Bacterial Airway Emergency

With Hib vaccination reducing epiglottitis, bacterial tracheitis (pseudomembranous croup) is now the more common life-threatening bacterial upper-airway infection in vaccinated populations. Classically it is biphasic: a child has a typical viral croup-like prodrome, then suddenly develops high fever and rapid clinical deterioration with a toxic appearance, a harsh brassy cough, and thick purulent tracheal secretions or membranes. Unlike croup, it responds poorly or not at all to nebulized epinephrine. It is most often caused by Staphylococcus aureus (including MRSA) superinfecting the trachea after a viral illness. Diagnosis is often confirmed by direct laryngoscopy or bronchoscopy (thick membranes, purulent secretions), and many children require intubation and intensive care plus IV antibiotics covering staphylococci (for example, vancomycin or clindamycin) with additional gram-negative coverage.

Foreign Body Airway Obstruction

Foreign body aspiration typically presents with sudden-onset coughing, gagging, or choking, often during eating (nuts, seeds, hot dogs, grapes) or while playing with small objects, sometimes witnessed by a caregiver.

Management depends on whether the cough is effective:

• Effective cough (child can cry, speak, or cough forcefully): do not intervene physically. Encourage continued coughing and observe closely — physical maneuvers can convert a partial obstruction into a complete one.
• Ineffective cough or signs of complete obstruction (silent cough, cyanosis, inability to cry or breathe, or the universal choking sign of hands clutched at the throat):
  • Infant (under 1 year): alternate 5 back blows (infant prone along the rescuer's forearm, head lower than the chest, blows delivered between the shoulder blades) with 5 chest thrusts (infant supine, two-finger technique at the same landmark used for CPR compressions). Abdominal thrusts are never used in infants — the risk of liver and spleen injury is unacceptably high given the infant's anatomy.
  • Child (over 1 year): abdominal thrusts (Heimlich maneuver) — a rescuer standing behind the child delivers inward-and-upward subdiaphragmatic thrusts, repeated until the object is expelled or the child becomes unresponsive.
  • If the child becomes unresponsive: start cardiopulmonary resuscitation (CPR) with chest compressions; before each set of rescue breaths, open the airway and look inside the mouth, removing an object only if it is directly visualized — blind finger sweeps are never performed, since they risk pushing the object further into the airway.

Exam Pearls

• Absent cough plus drooling plus tripod position plus toxic appearance means think epiglottitis, and keep hands off the airway.
• A viral prodrome followed by sudden high fever and poor response to nebulized epinephrine means think bacterial tracheitis.
• Back blows plus chest thrusts for infants; abdominal thrusts for children over 1 year; never abdominal thrusts in infants.
• Never perform a blind finger sweep — only remove a foreign body that can be seen.