Upper Airway Obstruction in Children

Abstract

Children with upper airway obstruction are both unique and variable in their presentation and management, often posing a challenge to the pediatrician. Several anatomical and physiologic peculiarities make a child vulnerable to develop an obstruction of upper airways. The characteristic finding in upper airway obstruction is stridor-inspiratory, biphasic or expiratory. The etiologies vary widely throughout the age groups and according to the mode of presentation. The approach starts with suspicion, mandates careful clinical evaluation of the degree of obstruction and many a times emergency measures precede any investigation or even precise diagnosis. Maintaining an open and stable airway is of the utmost importance, often requiring a team approach of emergency physician, pediatrician, otorhinolaryngologist and pediatric pulmonologist. The commonest condition presenting with upper airway obstruction in pediatric population is viral croup. Croup is a clinical diagnosis in a febrile child, with barking cough and stridor preceded by upper respiratory infection. It is treated with systemic or inhaled steroids and nebulized epinephrine. Epiglottitis and bacterial tracheitis are acute bacterial infections of upper airways, presenting as true airway emergencies. Though the mainstay of therapy is IV antibiotics, the prime concern is maintenance of airway, which frequently requires endotracheal intubation. Rigid bronchoscopy is the procedure of choice for airway foreign bodies, a common cause of upper airway obstruction in children below 3 y of age. Airway malacias are the commonest cause of chronic stridor and are mostly managed conservatively.

Stridor in the Pediatric Patient

“…There are several anatomical differences unique to the pediatric airway that make children, especially infants under 1 year of age, more susceptible to airway obstruction. 5,6 The pediatric larynx is more anterior and superior and less fibrous than adults, thereby more compliant. 6,7 The pediatric epiglottis is longer, omega-shaped, and softer, and the tongue is larger in comparison to the size of the oral cavity, resulting in obstructed airflow.…”

“…5,6 The pediatric larynx is more anterior and superior and less fibrous than adults, thereby more compliant. 6,7 The pediatric epiglottis is longer, omega-shaped, and softer, and the tongue is larger in comparison to the size of the oral cavity, resulting in obstructed airflow. 6,7 Children also have a larger and more prominent occiput, causing mechanical obstruction by flexion of the neck when supine.…”

“…6,7 The pediatric epiglottis is longer, omega-shaped, and softer, and the tongue is larger in comparison to the size of the oral cavity, resulting in obstructed airflow. 6,7 Children also have a larger and more prominent occiput, causing mechanical obstruction by flexion of the neck when supine. 6 While the cricoid cartilage was previously believed to be the narrowest portion of the airway, more recent measurement techniques have challenged this and shown that the glottic and subglottic areas may be narrower in children.…”

“…6,7 Children also have a larger and more prominent occiput, causing mechanical obstruction by flexion of the neck when supine. 6 While the cricoid cartilage was previously believed to be the narrowest portion of the airway, more recent measurement techniques have challenged this and shown that the glottic and subglottic areas may be narrower in children. 7,8 Worsening obstruction resulting in a decreased airway radius leads to increased turbulence to air flow, which is explained by Poiseuille's law.…”

Editorial: Advances in Pediatric Pulmonology

“…Some of these illnesses present as an acute emergency and need immediate intervention, while other conditions are chronic and mandate long term management. In this issue Mandal et al [4] describe various causes of airway obstruction, their diagnosis and treatment, which should assist all dealing with these conditions. Acute lower respiratory tract infection or pneumonia is the leading cause of mortality in under five year old children.…”