What is the initial approach to managing acute upper airway disorders, both infectious and non-infectious?

Management of Acute Upper Airway Disorders: Infectious and Non-Infectious

The initial approach to managing acute upper airway disorders requires rapid assessment of airway patency, identification of the specific etiology, and prompt intervention with appropriate medical or surgical treatment to prevent life-threatening complications.

Initial Assessment and Stabilization

Airway Assessment

• Evaluate for signs of impending airway obstruction:
  • Stridor (inspiratory, expiratory, or biphasic)
  • Suprasternal/intercostal retractions
  • Change in voice quality
  • Difficulty handling secretions
  • Tripod positioning
  • Drooling

Immediate Interventions

• Maintain patent airway using positioning techniques:
  • Head tilt-chin lift for unconscious patients without trauma
  • Jaw thrust for patients with suspected cervical spine injury 1
• Administer humidified oxygen
• Prepare for potential airway intervention:
  • Have appropriate equipment ready for intubation
  • Involve the smallest necessary number of experienced staff 2
• Wear appropriate personal protective equipment (PPE), especially for infectious cases 2

Infectious Upper Airway Disorders

Viral Croup (Laryngotracheobronchitis)

• First-line treatment:
  • Dexamethasone 0.6 mg/kg IV/IM (single dose) for moderate to severe cases 3, 4
  • Nebulized budesonide for mild cases 4
  • Nebulized epinephrine (5 mL of 1:1000 solution) for severe cases with respiratory distress 4
• Supportive care:
  • Humidified oxygen
  • Maintain hydration
  • Monitor for clinical improvement

Epiglottitis

• Considered a medical emergency requiring:
  • Immediate airway management in a controlled setting
  • Avoid agitating the patient or examining the throat with a tongue depressor
  • Prepare for intubation or surgical airway if needed 5
• Antibiotic therapy:
  • IV ceftriaxone or similar broad-spectrum antibiotic 4
  • Coverage for Haemophilus influenzae, Streptococcus, and Staphylococcus

Bacterial Tracheitis

• Now more common than epiglottitis as a life-threatening infection 6
• Management includes:
  • Early airway intervention (83% require intubation) 6
  • Broad-spectrum antibiotics (cloxacillin, amikacin, and clindamycin) 4
  • ICU admission for close monitoring

Retropharyngeal Abscess

• Treatment approach:
  • Early administration of IV antibiotics (cloxacillin, amikacin, clindamycin) 4
  • Surgical drainage by ENT specialist
  • Airway management as needed

Upper Airway Cough Syndrome (Post-nasal Drip)

• For allergic etiology:
  • Nasal corticosteroids, antihistamines, and/or cromolyn 2
• For non-allergic/post-viral etiology:
  • First-generation antihistamine/decongestant combinations (e.g., dexbrompheniramine maleate plus pseudoephedrine) 2, 3
  • Newer generation antihistamines are less effective for non-allergic causes 2

Non-Infectious Upper Airway Disorders

Angioedema

• Immediate management:
  • Subcutaneous epinephrine (1:1000,0.01 mL/kg)
  • IV hydrocortisone (10 mg/kg)
  • Antihistamines 4
  • Discontinue potential causative medications (e.g., ACE inhibitors) 3

Foreign Body Aspiration

• Management approach:
  • Abdominal or chest compressions for complete obstruction
  • Direct visualization and removal with appropriate instruments
  • Surgical airway if other measures fail 1

Trauma-Related Obstruction

• Immediate interventions:
  • Maintain cervical spine immobilization if trauma suspected
  • Clear blood/secretions
  • Consider early intubation for expanding hematomas or severe facial trauma 1

Advanced Airway Management

Indications for Intubation

• Progressive respiratory distress despite medical therapy
• Inability to maintain oxygen saturation
• Exhaustion
• Altered mental status
• Impending complete airway obstruction 2

Intubation Approach

• Use videolaryngoscopy when available 2
• Consider awake fiberoptic intubation for difficult airways
• Have surgical airway equipment ready (cricothyroidotomy kit)
• Use a team-based approach with clear communication 2

When Intubation Fails

• Perform cricothyroidotomy or tracheostomy
• In children, needle cricothyroidotomy with jet ventilation may be preferred until definitive airway established 1

Special Considerations

COVID-19 Patients

• Additional precautions:
  • Full airborne PPE with N95/FFP3 mask
  • Minimize aerosol-generating procedures
  • Most experienced airway manager should perform intubation
  • Consider rapid sequence induction to avoid bag-mask ventilation 2

Pediatric Patients

• Anatomical differences require specialized approach:
  • Smaller equipment sizes
  • Higher risk of rapid desaturation
  • Consider age-appropriate interventions
  • Lower threshold for specialist consultation 4

Disposition and Follow-up

• ICU admission criteria:

  • Need for airway intervention
  • Severe respiratory distress
  • Potential for airway deterioration
  • Need for close monitoring 6

• Discharge criteria:

  • Resolution of respiratory distress
  • Adequate oral intake
  • Appropriate follow-up arranged
  • Patient/caregiver education on warning signs

Common Pitfalls to Avoid

1. Delaying airway intervention when signs of impending obstruction are present
2. Failing to recognize bacterial tracheitis, which has eclipsed epiglottitis as a common life-threatening infection 6
3. Using newer generation antihistamines for non-allergic upper airway cough syndrome 2
4. Attempting to visualize the throat in suspected epiglottitis before airway equipment is ready
5. Underestimating the severity of post-viral cough syndromes that may persist for weeks 3