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Acute upper airway obstruction can be caused by foreign body aspiration, viral or bacterial infections (croup, epiglottitis, tracheitis), anaphylaxis, burns or trauma. Clinical signs of the severity of obstruction:
Obstruction Signs Danger signs Complete Yes Imminent complete Severe Moderate No Mild
Initially stable and partial obstruction may worsen and develop into a life-threatening emergency, especially in young children.Clinical features
Management in all cases
- Examine children in the position in which they are the most comfortable.
- Evaluate the severity of the obstruction according to the table above.
- Monitor SpO2, except in mild obstruction.
- Administer oxygen continuously:
- to maintain the SpO2 between 94 and 98% if it is ≤ 90% or if the patient has cyanosis or respiratory distress;
- if pulse oxymeter is not available: at least 5 litres/minute or to relieve the hypoxia and improve respiration.
- Hospitalize (except if obstruction is mild), in intensive care if danger signs.
- Monitor mental status, heart and respiratory rate, SpO2 and severity of obstruction.
- Maintain adequate hydration by mouth if possible, by IV if patient unable to drink.
Management of foreign body aspiration
Acute airway obstruction (the foreign body either completely obstructs the pharynx or acts as a valve on the laryngeal inlet), no warning signs, most frequently in a child 6 months-5 years playing with a small object or eating. Conscience is initially maintained.
Perform maneuvers to relieve obstruction only if the patient cannot speak or cough or emit any sound:
- Children over 1 year and adults:
Heimlich manoeuvre: stand behind the patient. Place a closed fist in the pit of the stomach, above the navel and below the ribs. Place the other hand over fist and press hard into the abdomen with a quick, upward thrust. Perform one to five abdominal thrusts in order to compress the lungs from the below and dislodge the foreign body.
Place the infant face down across the forearm (resting the forearm on the leg) and support the infant’s head with the hand. With the heel of the other hand, perform one to five slaps on the back, between shoulder plates.
If unsuccessful, turn the infant on their back. Perform five forceful sternal compressions as in cardiopulmonary resuscitation: use 2 or 3 fingers in the center of the chest just below the nipples. Press down approximately one-third the depth of the chest (about 3 to 4 cm).
Repeat until the foreign body is expelled and the patient resumes spontaneous breathing (coughing, crying, talking). If the patient loses consciousness ventilate and perform cardiopulmonary rescucitation. Tracheostomy if unable to ventilate.
Differential diagnosis and management of airway obstructions of infectious origin
| Viral croup | Stridor, cough and moderate respiratory difficulty | Prefers to sit | Progressive |
| Epiglottitis | Stridor, high fever and severe respiratory distress | Prefers to sit, drooling (cannot swallow their own saliva) | Rapid |
| Bacterial tracheitis | Stridor, fever, purulent secretions and severe respiratory distress | Prefers to lie flat | Progressive |
| Retropharyngeal or tonsillar abscess | Fever, sore throat and painful swallowing, earache, trismus and hot potato voice | Prefers to sit, drooling | Progressive |
Management of other causes
- Anaphylactic reaction (angioedema): see Anaphylactic shock (Chapter 1)
- Burns to the face or neck, smoke inhalation with airway oedema: see Burns (Chapter 10).
Airway obstructions are common and may even be underreported. The prevalence and type of airway obstruction varies with age. Children younger than four, for example, are more vulnerable to choking-related upper airway obstructions, and adults commonly experience airway obstruction caused by complications from smoking. First responders will inevitably encounter a wide variety of airway obstructions and must be prepared to promptly respond to each with appropriate medical care. Here are the most common causes of upper airway obstruction.
Tongue-Related Airway Obstruction
A relaxed tongue is the most common cause of upper airway obstruction in patients who are unconscious or who have suffered spinal cord or other neurological injuries. The tongue may relax into the airway, causing an obstruction. In some cases, other injuries complicate this phenomenon. For example, a patient who is unconscious following a blow to the head may also have suffered upper airway trauma, causing both the tongue and the trauma to block the airway.
Foreign Body/Choking
The most common cause of airway obstruction in children is a foreign body lodged in the airway. Choking can fully or completely obstruct the airway. Small toys, round foods such as berries and grapes, rocks, pebbles, and other enticing objects are common culprits. Eighty-eight percent of airway obstruction deaths occur in children younger than four.
Swelling
Swelling can obstruct the airway in a matter of seconds. Though infections can cause severe upper airway swelling, the most common cause is anaphylaxis. Anyone with an allergy can have an anaphylactic reaction, even if they have been previously exposed to the allergen without such an extreme reaction. More than 32 million Americans have food allergies, putting millions at risk of swelling-related airway obstructions. Moreover, the prevalence of food allergies is increasing. There’s been a 21% increase in peanut allergies in children since 2010.
Asthma may also cause upper airway swelling. In most cases, asthma is well-managed with a rescue inhaler, but severe asthmatic reactions can be fatal. About 26 million Americans have asthma. Worldwide, about 180,000 people each year die from asthma, but prompt medical care and diligent airway management has greatly reduced mortality in the U.S.
Infection
Infections such as pneumonia, RSV, and even colds may obstruct the upper airway. Children are more vulnerable because of their smaller airways. In newborns, upper airway obstructions, even partial ones, are particularly dangerous because newborns breathe through the nose. People with chronic respiratory diseases such as COPD also face a higher risk of infectious upper airway obstructions.
Trauma
Traumatic injuries can directly obstruct the airway, such as when a gunshot or knife wound collapses portions of the airway. Trauma can also cause continuous bleeding or vomiting that obstructs the airway, making airway management difficult and increasing the risk of aspiration pneumonia. In the latter scenario, continuous suction via the SALAD technique can clear the airway and lower mortality risk.
Traumatic brain and spinal cord injuries may also lead to upper airway obstruction. If a patient cannot clear their own airway, they may require suctioning. In some cases, brain and spinal cord injuries inhibit the brain’s ability to control breathing, coughing, and other important respiratory functions.
Proper management of upper airway obstruction is key to stabilizing the patient for transport and potentially saving their life. Portable suction ensures you can immediately attend to the patient. In the case of unstable patients for whom movement may be risky, such as spinal cord injury survivors, this can improve outcomes. For help selecting the right portable emergency suction device for your agency, download our free guide, The Ultimate Guide to Purchasing a Portable Emergency Suction Device.
Editor's Note: This blog was originally published in July 2019. It has been re-published with additional up-to-date content.