What treatment should be given for upper airway wheezing?

Treatment for Upper Airway Wheezing

For upper airway wheezing, nebulized epinephrine (adrenaline) at a dose of 0.5 ml/kg of 1:1000 solution is the recommended first-line treatment, especially in cases of croup or stridor. 1

First-Line Treatments Based on Suspected Cause

For Croup/Stridor (Upper Airway Obstruction):

• Nebulized epinephrine (adrenaline) 0.5 ml/kg of 1:1000 solution provides rapid but short-lived relief (1-2 hours) and is used to avoid intubation or stabilize patients prior to transfer to intensive care 1
• Nebulized steroids (e.g., 500 μg budesonide) may also reduce symptoms in croup in the first two hours 1
• These treatments should NOT be used in children who are shortly to be discharged or on an outpatient basis due to their short duration of action 1

For Asthma/COPD-Related Wheezing:

• For moderate to severe cases, nebulized β-agonist (salbutamol 2.5-5 mg or terbutaline 5-10 mg) should be administered 1
• In more severe cases, consider combined nebulized treatment with β-agonist plus ipratropium bromide (250-500 μg) 1, 2
• DuoNeb (ipratropium bromide and albuterol combination) is particularly effective for moderate to severe exacerbations 2

Treatment Algorithm Based on Severity

Mild Upper Airway Wheezing:

• Hand-held inhaler with β-agonist: salbutamol 200-400 μg or terbutaline 500-1000 μg 1
• Consider first-generation antihistamine plus decongestant if related to upper airway cough syndrome 1

Moderate Upper Airway Wheezing:

• Nebulized β-agonist: salbutamol 2.5-5 mg or terbutaline 5-10 mg every 4-6 hours 1
• If stridor is present, consider nebulized epinephrine (adrenaline) 0.5 ml/kg of 1:1000 solution 1
• For croup, add nebulized steroids (budesonide 500 μg) 1

Severe Upper Airway Wheezing:

• Nebulized epinephrine (adrenaline) for stridor/croup 1
• Combined nebulized treatment: β-agonist (salbutamol 2.5-10 mg) with ipratropium bromide (250-500 μg) every 4-6 hours 1, 2
• If carbon dioxide retention and acidosis are present, the nebulizer should be driven by air (not high-flow oxygen) 1
• Consider Larson's maneuver for laryngospasm: place middle fingers between posterior border of mandible and mastoid process while displacing mandible forward 1

Special Considerations

For Laryngospasm:

• Apply continuous positive airway pressure with 100% oxygen using reservoir bag and facemask 1
• If laryngospasm persists or oxygen saturation falls, administer propofol (1-2 mg/kg IV) 1
• For severe cases unresponsive to propofol, suxamethonium 1 mg/kg IV may be required 1

For Upper Airway Cough Syndrome (Previously Postnasal Drip):

• First-generation antihistamine plus decongestant combinations are effective for non-allergic causes 1
• For allergic rhinitis, nasal corticosteroids, antihistamines, and/or cromolyn are usually the initial drug choices 1

Important Caveats and Pitfalls

• Not all wheezing is asthma or bronchiolitis - consider upper airway causes including croup, laryngospasm, foreign body, or structural abnormalities 3
• Nebulized epinephrine should not be used in children who are shortly to be discharged due to its short duration of action (1-2 hours) and potential for rebound symptoms 1
• When treating with nebulized medications, a mouthpiece rather than face mask should be used except for infants or young children who won't tolerate a mouthpiece 1
• For patients with glaucoma, using a mouthpiece rather than face mask with ipratropium is recommended to prevent worsening of glaucoma 1
• After acute episodes resolve, treatment should be changed from nebulizer to hand-held inhaler before discharge from hospital 1, 2