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Paediatric Upper Airway Obstruction 279

a bronchial FB, usually in the right main bronchus in older weight, intravensously (IV), 6-hourly), antibiotics, and intubation or
children, but in either bronchus in infants. Vegetable FBs (such tracheostomy are required.
as peanuts) are more dangerous than inert objects because • Angioneurotic oedema is usually caused by ingestion or inhalation
vegetables contain oil that can cause a local pneumonitis and they of an allergen to which the child is sensitive. Common allergens
tend to crumble. Antibiotics are probably wise while waiting for are nuts, penicillin, and some foods. There may well be other
treatment. The situation is usually not desperate, and assessment signs of systemic shock that need appropriate management, but
and investigation can be carried out. airway obstruction from a grossly swollen tongue or larynx is an
Clinical examination may show the trachea deviated to either urgent problem, as is acute asthma. Early recognition of the prob-
side. If there is a valve effect, then air will go in but little will go lem can avoid emergency tracheostomy. Adrenaline (10 mgm/kg
out due to bronchospasm, in which case the affected lung will be body weight, intramuscular (IM)), nebulised adrenaline (5 ml of
hyperinflated and the trachea deviated away from the affected 1 in 1000 with 100% oxygen), and hydrocortisone (4 mg/kg body
side. If there is complete obstruction, then the lung will collapse weight, IV, over 15 minutes) is the first aid management and usu-
and the trachea will deviate towards the affected side. Percussion ally will avoid intubation or tracheostomy.
of the chest and a chest x-ray in inhalation and exhalation will
confirm the diagnosis. Acute infective upper airway obstruction
Treatment is rigid ventilation bronchoscopy by a skilled ear, The following infective causes need to be considered and a diagnosis
nose, and throat (ENT) surgeon and removal using appropriate rapidly made because, especially in the case of the epiglottitis, acute
forceps. Physiotherapy prior to bronchoscopy is not advised deterioration will lead to asphyxiation and death: laryngotracheobron-
because the FB might be impacted further, compounding the chitis (common “croup”), epiglottitis, bacterial tracheitis, tonsillitis
situation. Postoperative physiotherapy is essential to help the (rarely), glandular fever, retropharyngeal abscess, and diphtheria.
lung expand. Certain rules exist for the safe management of upper airway
• Burns: Inhalational burns are extremely dangerous. The cause may obstruction, the most important being not to frighten the child, which
be chemical—from ingestion of bleaches or other caustic chemicals will often make the stridor worse. The child’s temperature is taken,
often stored in inappropriate containers (e.g., soda bottles) or from preferably with an ear thermometer; if there is no fever, the diagnosis
inhalation of smoke and flame. Airway obstruction may not develop is not one of the infective causes discussed in this section. The mother
immediately and may be missed while dealing with burns to other can give a good relevant history, with the child staying on her knee
parts of the body. If there is airway obstruction, intensive care unit without any interference such as blood tests or throat examination,
(ICU) admission, large doses of hydrocortisone (4mg/kg body especially if the stridor has come on rapidly, suggesting epiglottitis.

Table 42.1: Various symptoms of acute infective causes of upper airway obstruction.

Laryngotracheobronchitis Retropharyngeal Glandular fever/
Symptoms Epiglottitis Diphtheria
(LTB) abscess tonsillitis

Speed of onset Days Hours Days Days Days

Age 18 months 2–5 years Any Any Any

Preceding upper
respiratory tract Yes No Yes Yes Yes
infection (URTI)

Voice Hoarse Muffled/”hot potato” Normal Normal Normal

Position Lying down Sitting up and leaning Sitting up Any Any
forward

Copious drooling and
Drooling/swallowing No drooling/can swallow Some Some Some
unable to swallow

Stridor Noisy Quiet Often none or stertor Variable Often nil or stertor

Appearance Pale lips and struggling Pale lips and Toxic Toxic Variable
frightened

Need for alternative Less than 5% 90% Surgical drainage If antibiotics and Rareluy
usually relieves
airway antitoxins fail
obstruction