5.1 Acute Upper Airway Obstruction: Croup, Epiglottitis, Bacterial Tracheitis & Foreign Body Aspiration

Acute Upper Airway Obstruction

Keep the child with their caregiver and allow a position that eases breathing. Observe air movement, retractions, voice or cry, handling of secretions and alertness before touching the child. Quiet stridor with worsening air entry, fatigue or altered mental status can signal impending obstruction. Call experienced pediatric airway support early when obstruction is severe or progressing. Defer nonessential tests and procedures until the airway is secure. Pediatric upper airway obstruction guideline

Pediatric airway anatomy and resistance

Craniofacial obstruction. A neonate with a small lower jaw, a posteriorly displaced tongue and upper-airway obstruction has the pattern of Robin sequence. A cleft palate may coexist. For example, retractions or desaturation during sleep or feeds despite a quiet awake exam warrant monitored assessment and early pediatric airway and craniofacial consultation. If breathing is compromised, support oxygenation and ventilation and mobilize an experienced difficult-airway team before nonurgent testing. Once stable, assess feeding safety and let the team determine whether sleep testing or airway endoscopy will help. Positioning or a nasopharyngeal airway may relieve tongue-base obstruction in selected monitored infants. The team should establish the home sleep plan after weighing airway and sleep-related risks. Robin sequence consensus · Infant airway cohort · AAP infant sleep guidance

In the idealized Poiseuille model, laminar flow through a rigid cylindrical tube has resistance proportional to the inverse fourth power of its radius.

$R = \frac{8\eta l}{\pi r^4}$

Here $\eta$ is fluid viscosity, $l$ is tube length and $r$ is internal radius. A 1 mm layer of circumferential edema in an airway initially 4 mm in diameter leaves a 2 mm diameter. The radius falls from 2 to 1 mm, the area falls to one quarter, and modeled resistance increases by $(2/1)^4=16$. In an 8 mm airway, the same edema leaves a 6 mm diameter and increases modeled resistance by $(4/3)^4\approx3.16$. Variable geometry and turbulent flow limit the model's bedside precision. Assess actual air entry, effort and alertness.

Croup

Viral croup causes hoarseness, barky cough and inspiratory stridor, often after an upper respiratory prodrome and typically between 6 months and 3 years. Parainfluenza is a common cause. Clinical assessment guides treatment; imaging is unnecessary in typical croup. A frontal neck film may show subglottic tapering if imaging is obtained for an atypical, stable presentation. Consider another cause when there is prominent drooling, toxicity, sudden choking, atypical age or a poor response to treatment. CPS croup practice point, updated 2026 · CHOP croup pathway, revised 2026

The Westley score describes severity using five domains. Use the child's trajectory to make escalation decisions, including when a tiring child becomes quieter.

The maximum is 17. A child with stridor at rest (2), moderate retractions (2), decreased air entry (1), normal consciousness (0) and no cyanosis (0) scores 5. Resting stridor and retractions warrant prompt treatment and reassessment even when oxygen saturation is preserved. Original Westley trial · Queensland Westley scoring guide

• Dexamethasone: Give a single dose for symptomatic croup presenting to the ED. Oral treatment is preferred if tolerated. A common regimen is 0.6 mg/kg, with dose caps and lower-dose protocols varying. A large ED trial found 0.15 mg/kg noninferior in its study population, which had mainly mild croup. Follow the local regimen in severe disease. Dexamethasone dose trial · CPS practice point
• Nebulized epinephrine: Use for moderate to severe obstruction. Examples are 0.5 mL of 2.25% racemic epinephrine prepared per local protocol or 5 mL of L-epinephrine 1 mg/mL. Improvement can begin within 10–30 minutes and the effect wanes by about two hours. Symptoms may return as the temporary effect wanes. Evidence does not establish worsening beyond pretreatment severity as a drug-induced rebound. Original epinephrine comparison · CPS practice point
• Disposition: Observe after the last epinephrine dose using the local protocol. The CPS practice point supports reassessment over 2–4 hours. Consider discharge after sustained improvement with no resting stridor, minimal work of breathing, adequate intake, and a caregiver able to return for deterioration. Persistent or recurrent resting stridor, repeat treatment, poor intake, hypoxemia or fatigue warrants extended observation or admission according to the trajectory. Activate the airway team for impending respiratory failure. Prospective discharge study · CHOP croup pathway

Epiglottitis and bacterial tracheitis

If imaging is indicated and safe, lateral neck radiography can show an enlarged epiglottis (thumbprint sign). Tracheal irregularity can occur in bacterial tracheitis. Avoid delaying airway care to obtain these clues. Pediatric imaging examples

Once the epiglottitis airway is stabilized, obtain indicated cultures when feasible and treat promptly, often with a third-generation cephalosporin such as ceftriaxone. Add MRSA coverage according to severity, local resistance and specialist guidance. For bacterial tracheitis, select initial IV coverage for S. aureus and common respiratory pathogens; include MRSA coverage when the clinical or local risk warrants it. Narrow therapy to culture results. With an artificial airway, humidify and suction according to secretion burden and clinical response. Avoid routine saline instillation during suctioning. Extubation depends on clinical improvement, airway patency and the airway team's readiness assessment. Pediatric epiglottitis pathway · CDC Hib surveillance · Epiglottitis and croup diagnostic study · Pediatric bacterial tracheitis cohort · AARC suction guideline

Foreign body aspiration

Suspect aspiration with sudden choking, cough, unilateral wheeze or asymmetric air entry. A witnessed event may be absent. Persistent focal findings or recurrent pneumonia in the same region can be delayed presentations. Aspirated objects may lodge in either bronchial tree. Partial one-way obstruction can cause distal air trapping, while complete obstruction can cause atelectasis. Pediatric aspiration cohort · Age and location cohort

For severe choking in a responsive infant, the 2025 AHA/AAP algorithm alternates five back blows and five chest thrusts. In a responsive child beyond infancy, alternate five back blows and five abdominal thrusts. If the patient becomes unresponsive, start CPR beginning with compressions. Remove an object only if it is visible when opening the airway. 2025 AHA/AAP pediatric BLS

In a stable child, initial radiographs can identify a radiopaque object or indirect changes such as air trapping. Many aspirated objects are radiolucent. A normal film leaves aspiration possible. If radiographs are negative and further imaging is appropriate, ACR favors noncontrast chest CT and generally discourages decubitus films. High clinical suspicion or a threatened airway calls for urgent specialist management without waiting for more imaging. ACR pediatric foreign body imaging criteria

Rigid bronchoscopy gives the team ventilation control and access for retrieval instruments and is generally preferred when findings strongly suggest aspiration or direct airway control is needed. In selected stable children, flexible bronchoscopy can clarify an equivocal presentation or retrieve a suitable object through a secured airway with rigid bronchoscopy immediately available. ERS interventional bronchoscopy statement