What is the management of upper airway obstruction in a child?

Management of Upper Airway Obstruction in a Child

Immediate Assessment and Initial Actions

The management of upper airway obstruction in a child depends critically on the cause: for foreign body aspiration, immediately deliver five back blows followed by five chest thrusts (infants) or abdominal thrusts (children >1 year); for other causes, optimize head positioning, administer high-flow oxygen, and prepare for escalating airway interventions based on the child's response. 1

Safety, Stimulation, and Call for Help

• Approach safely, gently stimulate the child, and immediately shout for help 1
• Summon the best available assistance early—institutions should have pre-planned emergency response protocols 1
• In hospital settings, activate the resuscitation team (2222); outside hospital, call emergency services (999) 1

Initial Airway Assessment

• Position the head appropriately for age: neutral position with chin lift for children <2 years (consider shoulder roll); "sniffing the morning air" position for older children 1
• Apply high-flow oxygen to both the face AND tracheostomy site if the child has a tracheostomy (requires two oxygen sources) 1
• Assess for spontaneous breathing by looking, listening, and feeling at both the mouth/nose and any tracheostomy site 1
• Look for signs of respiratory distress: stridor, accessory muscle use, tracheal tug, sternal/intercostal recession, agitation, or restlessness 1

Foreign Body Aspiration (Choking)

If upper airway obstruction from foreign body aspiration is witnessed or strongly suspected, never perform blind finger sweeps—these can impact the foreign body into the larynx. 1

For Infants

1. Deliver five smart back blows to the middle of the back with the infant in prone position, head lower than chest (hold along forearm or across thighs) 1
2. Deliver five chest thrusts with infant supine, head lower than chest, using technique similar to chest compressions but sharper and more vigorous (approximately 20 per minute) 1
3. Check mouth after each cycle and remove any visible foreign bodies 1
4. Reposition airway with head tilt/chin lift or jaw thrust 1
5. Attempt rescue breathing if no effective spontaneous respiration 1
6. Repeat cycle until airway is cleared 1

For Children Over 1 Year

1. Deliver five back blows (same technique as infants, adapted for size) 1
2. After the second round of back blows, substitute five abdominal thrusts for chest thrusts 1
3. Upright Heimlich maneuver if child is conscious; if unconscious, place supine with heel of one hand in middle of upper abdomen, directing five sharp thrusts upward toward diaphragm 1
4. Alternate back blows with chest thrusts or abdominal thrusts in subsequent cycles 1
5. Continue protocol until foreign body is cleared 1

Critical pitfall: Abdominal thrusts are NOT recommended in infants because they may rupture abdominal viscera 1

Non-Foreign Body Upper Airway Obstruction

First-Line Interventions

• Optimize head position with jaw thrust maneuver 1
• Ensure adequate depth of anesthesia if obstruction occurs during anesthesia 1
• Apply CPAP to help maintain airway patency 1
• Insert oropharyngeal or nasopharyngeal airway if simple maneuvers fail 1
• Upper airway obstruction during deep anesthesia typically resolves quickly with jaw thrust or oropharyngeal airway insertion 1

Rescue Breathing

• Deliver five rescue breaths if the child is not breathing or spontaneous ventilation is inadequate (evidenced by cyanosis, low oxygen saturations, bradycardia, respiratory distress, or unresponsiveness) 1
• Use high-flow oxygen where possible, though mouth-to-mouth or mouth-to-tracheostomy ventilation is acceptable 1
• If upper airway is patent: deliver rescue breaths via facemask 1
• If upper airway is obstructed: deliver rescue breaths via tracheostomy stoma (if present), occluding the stoma when ventilating via upper airway 1

Escalating Airway Management

If mask ventilation fails, use a supraglottic airway device (SAD) to ensure oxygenation—this is strongly recommended and can prevent or correct hypoxemia quickly. 1

Supraglottic Airway Device Insertion

• Limit insertion attempts to 2-3 maximum 1
• Second-generation SADs are preferred as they allow more effective ventilation at lower pressures and reduce aspiration risk 1
• Occlude the tracheostomy stoma (if present) with gloved finger or surgical gauze to prevent air escape 1
• If ventilating via stoma, apply pediatric facemask or SAD over the stoma and close the upper airway 1
• SAD can serve as conduit for fiberoptic intubation by trained practitioners 1

If SAD Fails

• Return to optimized mask ventilation with two-person technique 1
• Consider gastric decompression to improve ventilation 1
• Proceed to "cannot intubate, cannot oxygenate" (CICO) algorithm if oxygenation remains inadequate (SpO2 <90%) 1
• Antagonize neuromuscular blockade if used 1

Advanced Airway Management

• Direct laryngoscopy: maximum 2 attempts by senior clinician 1
• Use stylet, bougie, or videolaryngoscope if difficult glottic visualization 1
• Straight-bladed laryngoscope is easier in infants and young children; curved blade for older children 1
• Plain plastic tracheal tubes cause less local edema in children 1

Tracheostomy-Specific Emergencies

Essential Preparation

• Bedhead signs must communicate essential airway details and should be mandated as part of theatre sign-out 1
• Essential airway equipment must be immediately available and accompany the patient at all times 1
• Healthcare professionals, families, and carers should receive regular training using high- and low-fidelity simulation 1

Tracheostomy Tube Assessment

• Assess tube patency through suction and clinical evaluation 1
• Use waveform capnography where possible—this is a key intervention to improve airway management safety 1
• If tube is visibly displaced, proceed immediately to emergency tube change 1

Emergency Tube Change

• Do not attempt more than three insertion attempts 1
• After three failed attempts, pursue alternative oxygenation strategies 1
• Be aware that attempting to ventilate through a displaced tracheostomy can cause subcutaneous emphysema and complicate management 1

Special Considerations

Upper Respiratory Tract Infection

• Facemask ventilation is associated with fewer perioperative respiratory adverse events compared to endotracheal intubation or laryngeal mask airway in children with URI 1
• Consider preoperative inhaled salbutamol in children <6 years with URI (approximately 50% reduction in cough and bronchospasm) 1

Complications to Anticipate

• Pulmonary edema can occur in 12% of children requiring intubation for upper airway obstruction, usually following intubation 2
• PaO2 below 50 mmHg occurs in 38% and pneumothorax in 24% of severe cases 2
• Manage with supplemental oxygen, positive end-expiratory pressure, mechanical ventilation, and chest tube drainage as needed 2

Cardiopulmonary Arrest

• If no signs of breathing or life, assess for pulse and initiate CPR following Advanced Paediatric Life Support guidelines 1
• Continue airway management strategies during resuscitation, as blocked or displaced airway may have caused the arrest 1

Critical principle: The child's clinical appearance is the most reliable indicator of severity; measurable signs are of less value. If respiratory failure is imminent, airway protection may have priority over any other diagnostic procedure. 3