This document outlines the approach to managing acute upper airway obstruction, focusing on its causes, clinical assessment, and treatment strategies. It emphasizes the differences in airway obstruction across age groups and details various conditions leading to obstruction, especially in children. The importance of immediate intervention and detailed history and physical examination for effective management is also highlighted.

1. Approach to a patient with acute upper
airway obstruction
Prepared by GIRM ABDISSA (C-1)
& AHEMD KITAW (C-1)
Moderator: Dr. Anwar M. (MD, Assistant Professor of
Surgery)
Yekatit 12 Hospital Medical College
Department of surgery
Seminar

2. Outlines
• Objectives
• Introduction
• Etiology
• Classification
• History and Physical examination
• Investigations
• Management Principles
2

3. Objectives
• Understand the causes of acute upper airway obstruction
• Describe the clinical manifestations, assessment
approaches, diagnostic methods and its principle of
management.
3

4. Introduction
• Acute upper airway obstruction is a life-threatening emergency
requiring immediate assessment and intervention B/c it can leads
do to
respiratory failure
 hypoxia, and brain damage
4

5. Incidence and Prevalence
Children:
 UAO is notably prevalent in paediatric populations,
accounting for up to 15% of emergency department visits due
to respiratory distress.
The most common cause croup, with an annual incidence of
approximately 18 per 1,000 children in the USA. The peak
incidence occurs in children aged 1 to 2 years
5

6. Infants
A study highlighted that 58% of cases of UAO in infants occur
between 1 to 6 months of age.
 laryngomalacia (70%)
 subglottic stenosis (18%)
Adults
most frequent cause of chronic UAO is obstructive sleep
apnea (OSA),
26% of the adult population in the U.S.
Other include inflammation, infection, and trauma.
6

7. Surgical Anatomy
• The upper airway extends from the nose/mouth down to the
larynx, including the nasal cavity, oral cavity, and pharynx
(naso-, oro-, and laryngopharynx), and ends at the glottis in the
larynx.
• Key physiological narrowing points in the upper airway:
Nostrils
Velopharyngeal valve (between nasopharynx and oropharynx)
Glottis
7

8. Respiratory Airway Anatomy
8

9. FIGURE 510-1. Differences between the adult (left) and pediatric (right) upper airway.
(Finucane BT: Principles of Airway Management. Philadelphia, FA Davis, 1988.)
9

10. Types of Airway Obstruction
• Upper airway obstruction (UAO): Blockage from the mouth to
the trachea, including the nasopharynx and larynx. CAO and UAO
can coexist in certain conditions.
• Central airway obstruction (CAO): Blockage in the trachea and
main stem bronchi.
• Lower airway obstruction: Blockage in smaller bronchi from
chronic diseases like asthma or COPD, usually unrelated to CAO or
UAO.
10

11. Upper Vs Lower Airway Obstruction
• Ventilation-perfusion mismatch, Hypercarbia, Hypoxemia
is rare unless upper airway obstruction is severe
• Upper airway obstruction does not improve with
bronchodilators, unlike asthma or COPD.
• Upper airway obstruction present as inspiratory stridor
• Lower airway obstructive processes present as expiratory
wheezing.
11

12. • Normal loop: The expiratory curve rises quickly to the peak,
then falls linearly. The inspiratory curve is symmetrical and
saddle-shaped.
• Extrathoracic obstruction: Inspiratory limb shows flow
limitation and flattening.
• Intrathoracic obstruction: Expiratory limb shows flow
limitation and flattening.
• Fixed upper airway obstruction: Both inspiratory and
expiratory limbs show flow limitation and flattening.
• Lower airway obstruction: Expiratory limb appears concave
upward, with a "scooped-out" pattern.
Distinguish the site of airway narrowing.
12

13. 13
FIGURE 285-4 Flow-volume loops. A. Normal. B. Airflow obstruction. C. Fixed central airway obstruction
(either above or below the thoracic inlet). D. Variable upper airway obstruction (above the thoracic inlet) E.
Variable lower airway obstruction (below the thoracic inlet). RV, residual volume; TLC, total lung capacity.

14. Classification of upper airway obstruction
Based on
Anatomical based Classification
Age-based based Classification
Functional based Classification
Clinical presentation based Classification
Etiological Based classification
14

15. 15

16. Anatomical Classification 16
• Nasal Cavity/Nasopharynx: foreign bodies, structural
anomalies like choanal atresia, or growths such as nasal polyps
and adenoid hypertrophy.
• Oropharynx: Enlarged tonsils, peritonsillar abscesses, and
retropharyngeal abscesses c
• Larynx: Inflammation (laryngitis), swelling (edema), vocal
cord paralysis, and tumors
• Trachea: Narrowing due to stenosis or malacia, tumors, and
foreign bodies

17. Age-based Classification
17
• Pediatric: Common conditions include croup, epiglottitis,
foreign bodies, and congenital anomalies.
• Adult: Tumors, vocal cord paralysis, anaphylaxis, and
infectious causes are prevalent.
• Elderly: Laryngeal tumors, aspiration, and neurological
causes are typical concerns.

18. Functional Classification 18
• Obstructive: Physical blockages such as foreign bodies,
tumors, and swelling can obstruct the airway.
• Restrictive: Conditions that limit airway expansion, like
tracheal stenosis and neck trauma, fall under this category.
• Central: Issues related to central control, such as CNS
depression and brainstem injuries, can affect breathing.

19. Clinical presentation-based blassification 19
● Gradual Onset: Conditions such as tumors, chronic
infections, and subglottic stenosis develop slowly over
time.
● Sudden Onset: Rapidly occurring conditions include
anaphylaxis, foreign body aspiration, acute infections, and
trauma.

20. Etiological classification
20
• Foreign Bodies/Inflammatory/Edematous: Inhaled objects, food
particles, allergic reactions, and inflammatory edema.
• Infectious: epiglottitis and croup
• Traumatic: Neck trauma and post-surgical edema
• Allergic/Immunological: Anaphylaxis and angioedema.
• Neoplastic: laryngeal carcinoma and thyroid tumors.
• Congenital: laryngomalacia and tracheoesophageal fistula.
• Neurological: vocal cord paralysis and CNS injuries

21. Foreign Body Aspiration
• Sudden choking, violent coughing, inspiratory stridor, no
fever
• Occurs after playing with food or small objects
• Common in toddlers (1 to 3 years)
• History of choking episode, localized wheezing or stridor
21

22. Foreign Body Aspiration... Cont’d
• Typically identified from patient’s history.
Neurological disorders
Trauma with loss of consciousness
Sedative or alcohol use
Poor dentition
Advanced age
•Falling back tongue
Head-Tilt, Chin-Lift Maneuver
Jaw-Thrust Maneuver
22

23. Heimlich maneuver (abdominal thrust)
23

24. Back slap and abdominal thrust 24

25. Deep cervical space infections
• life-threatening upper airway obstruction.
• Symptoms: sore throat, odynophagia, neck swelling, pain,
fever, dyspnea.
• Severe cases show stridor and profound respiratory difficulty.
• Common sites: parapharyngeal, peritonsillar, submandibular,
and retropharyngeal abscesses.
25

26. Treatment of deep cervical infections
• Maintenance of oxygenation and ventilation by securing an
adequate airway,
• administration of appropriate antibiotics,
• when indicated, use of surgical drainage.
26

27. Ludwig’s angina
• Ludwig’s angina an infection of the submandibular space and
the floor of the mouth is potentially lethal and is commonly
associated with significant upper airway obstruction.
• A cellulitic process and can affect the submandibular spaces
bilaterally.
• 75 percent of the cases with true Ludwig’s angina required
tracheostomy.
27

28. Ludwig’s angina 28

29. Lemierre’s syndrome
• Starts from nasopharyngitis or peritonsillar abscess.
• Leads to internal jugular vein thrombophlebitis, septicemia, and
metastatic abscesses.
• Fusobacterium necrophorum is the main causative agent.
• Symptoms: sore throat, fever, neck swelling, tender lymph
nodes, dysphagia, trismus, and airway obstruction.
• Treatment: early antibiotics (penicillin with metronidazole or
clindamycin) to prevent high mortality.
29

30. Epiglottitis
• Caused by various organisms in adults,
including Haemophilus influenzae,
pneumococci, and group A streptococci.
• Initial treatment: third-generation
cephalosporin or extended-spectrum
penicillin.
• Corticosteroids
• Close observation and readiness for
airway management (intubation or
surgery) are essential.
30

31. Epiglottitis
in a 5-year-old male with
respiratory distress and
drooling. A lateral soft tissue
neck radiograph shows a
markedly thickened epiglottis
(white arrow), which is referred
to as the “thumb” sign.
The aryepiglottic folds (black
arrow) also are thickened.
(From Laya BF,
Lee EY. Upper airway disease. In Coley BD,
ed. Caffey’s Pediatric Diag_x0002_nostic
Imaging, 13th ed. Philadelphia: Elsevier;
2019: Fig. 51.2, p. 477.)
31

32. Laryngotracheobronchitis
• Croup is an acute viral illness in children, causing
subglottic narrowing, stridor, barking cough, and
hoarseness.
• Rare in adults,
32

33. Fig. 433.1 Croup. A, Frontal soft
tissue neck radiograph
demon_x0002_strates a
“Steeple” appearance of the
subglottic trachea (arrows). B,
Lateral soft tissue neck radiograph
in another patient shows a dilated
hypopharynx (asterisk), along with
haziness and narrowing of the
sub_x0002_glottic region (arrows).
(From Laya BF, Lee EY. Upper
airway disease. In
Coley BD, ed. Caffey’s Pediatric
Diagnostic Imaging, 13th ed.
Philadel_x0002_phia: Elsevier;
2019: Fig. 51.8, p. 481.)
33

34. Facial Trauma
• Emergency airway access is needed in up to 6% of facial
trauma cases.
• If intubation is difficult, consider cricothyroidotomy or
tracheostomy.
• Common signs: stridor, wheezing, dysphonia, hemoptysis,
neurological deficits, cervical crepitus, subcutaneous
emphysema, ecchymoses, hematomas,
pneumomediastinum, pneumothorax.
34

35. Facial Trauma... Cont’d
• Diagnostic tools: flexible fiberoptic laryngoscopy,
bronchoscopy, CT imaging.
• Management: secure airway promptly, avoid blind intubation,
consider tracheostomy, use awake fiberoptic intubation.
• High mortality rate (20-40%).
35

36. Inhalation Injuries
• Serious airway obstruction from thermal/chemical injuries.
• Signs: cough, dyspnea, hoarseness, singed nasal hairs,
carbonaceous sputum, facial burns.
• Early fiberoptic bronchoscopy for assessment and management.
• Trans-laryngeal intubation standard; early tracheostomy
possible.
• Tracheal stenosis risk.
36

37. Neuromuscular Disorders
• Myasthenia gravis and motor neuron disease affect bulbar muscles,
increasing airway resistance.
• Inspiratory flow plateau and "saw tooth pattern" in flow-volume loops are
seen, indicating extrathoracic obstruction.
• Extrapyramidal disorders cause vocal cord tremors, leading to flow
oscillations.
• Muscle denervation in motor neuron diseases results in upper airway
muscle tremor and irregular airflow.
37

38. Vocal Cord Dysfunction
• Vocal cord dysfunction causes paradoxical vocal cord
closure during inspiration, mimicking asthma and leading to
wheezing and stridor.
• Often misdiagnosed as asthma, it may have psychogenic
causes and is linked to psychiatric disorders or past trauma.
• Speech therapy or psychotherapy is recommended for
management.
38

39. Allergic Reaction (Anaphylaxis)
• Stridor, swelling of lips, tongue, face (angioedema), hives,
wheezing
• Rapid onset after allergen exposure, systemic reaction
(rash, hypotension)
• Affects any age group
• Recent allergen exposure (e.g., food, insect sting), history
of allergies or asthma
39

40. • Laryngotracheal Trauma
 Hoarseness, painful swallowing, stridor, hemoptysis
 Neck swelling or bruising
 Any age
 Recent neck trauma or intubation
• Retropharyngeal Abscess
 Difficulty swallowing, muffled voice, high fever, neck stiffness
 Unilateral neck swelling
 Mostly children < 5 years
 Recent bacterial throat infection
40

41. Peri tonsillar Abscess
 Severe sore throat,
 uvula deviation
 Adolescents and adults
 Recent fever,
 throat infection
41

42. Angioedema
• Causes swelling of the face, lips, tongue, and throat,
risking fatal airway obstruction.
• Triggers include drugs, NSAIDs, and ACE inhibitors;
most are non-allergic.
• Hereditary angioedema involves C1 esterase inhibitor
deficiency, leading to painless swelling.
• Treatment: secure airway, corticosteroids, antihistamines,
and epinephrine.
42

43. History and Physical Examination
• After rapid assessment of the airways and breathing and
emergency airway management(ABC, O2 saturation by pulse
oxymeter, IV line )
• History
Pt may unable to give HX (distressed, child)
Common Chief Complaints
Difficulty breathing or shortness of breath
Noisy breathing (stridor)
Coughing or choking episodes
Hoarseness or change in voice
43

44. • Onset and Duration
Sudden vs. gradual onset of symptoms
Duration of symptoms: acute, subacute, or chronic
• Course and Precipitating Events
Recent respiratory infections (e.g., croup, epiglottitis)
History of trauma (e.g., burns, injury to the neck)
Allergic reactions or exposure to irritants
Inhalation of a foreign body
44

45. • Aggravating and Relieving Factors
Worsening with lying down (e.g., supine position in
croup)
Temporary relief with sitting or forward-leaning position
(e.g., in epiglottitis)
• Associated Symptoms:
Choking, violent coughing, or gagging
Agitation or anxiety
Difficulty swallowing (dysphagia)
Altered mental status (confusion, lethargy)
Change in color (cyanosis, bluish skin)
Fever (indicates infection)
45

46. Physical Examination
•General Appearance
Cyanosis (bluish discoloration of the skin)
Agitation or lethargy
Use of accessory muscles for breathing
•Positioning
Tripod position (sitting, leaning forward with
neck extended)
Inability to lie flat (seen in epiglottitis)
46

47. • Respiratory Rate
Tachypnea (rapid
breathing)
Bradypnea (late sign of
severe obstruction)
• Chest and Abdomen
Movement
Asymmetrical chest rise
Poor chest expansion
Paradoxical breathing
(abdomen moves inward
with inspiration)
• Stridor
Inspiratory stridor
(obstruction above vocal
cords, e.g., croup, epiglottitis)
Biphasic stridor (subglottic or
tracheal obstruction, e.g.,
foreign body)
Expiratory stridor
(obstruction in the lower
trachea or bronchi)
47

48. • Voice/ Cry
Hoarseness (laryngeal or
vocal cord involvement)
Muffled voice (suggests
retropharyngeal or
peritonsillar abscess)
Weak cry in infants (sign of
severe obstruction)
• Skin Color
Pallor (early hypoxia)
Cyanosis (advanced
hypoxia)
Sweating (sign of distress)
• Nasal Flaring
Widening of nostrils during
breathing (indicates respiratory
effort)
• Retractions
Intercostal retractions (between ribs)
Subcostal retractions (below ribs)
Suprasternal or supraclavicular
retractions (above sternum or
collarbone)
• Capillary Refill Time
Prolonged (> 3 seconds, indicates
poor perfusion)
48

49. Neck Examination
Swelling (e.g., angioedema,
retropharyngeal abscess)
Tracheal deviation (mass
effect or tension
pneumothorax)
• Oropharyngeal Examination
Edema of the uvula or soft
tissues
Erythema (redness)
Visible foreign body
(careful with oropharyngeal
examination in epiglottitis)
Auscultation
Decreased or absent breath sounds
Localized wheezing (suggests foreign
body aspiration)
Absent breath sounds (sign of
significant obstruction)
• Oxygen Saturation
Low oxygen saturation (< 90%)
• Heart Rate
Tachycardia (response to hypoxia)
• Palpation of Neck and Chest
Crepitus (subcutaneous emphysema,
suggests air leakage)
49

50. Severity signs of upper airway obstruction
• Tachypnea
• Change in Voice or Cry
• Barking Cough
• Hoarseness
• Inspiratory Stridor
• Poor Chest Rise on Inspiration
• Nasal Flaring: Widening of the nostrils.
Recognizing these signs promptly is crucial for managing upper airway
obstruction
50

51. Severity based on Clinical Features
1. Mild: Stridor only with activity, mild cough,
normal oxygenation.
2. Moderate: Stridor at rest, moderate
retractions, oxygen saturation 90-95%, nasal
flaring.
3. Severe: Continuous stridor, severe
retractions, cyanosis, oxygen saturation <
90%, altered mental status.
51

52. Investigation
• CT Scans are preferred for detailed imaging of the airway, superior to X-
rays.
• Flexible and Rigid Laryngoscopy visualization and intervention
capabilities.
• Bronchoscopy assesses the tracheobronchial tree and aids in foreign body
removal.
• Ultrasound is useful for evaluating soft tissue swelling, especially in
children.
• Blood Tests help identify systemic conditions that may contribute to
obstruction.
• Pulmonary Function Tests
• Allergy Testing identifies potential allergic triggers for chronic issues.
• Throat culture
52

53. Emergency Management Principles
• Immediate rapid Assessment with simultanous Airway
Managment Before History taking and P/E
Rapid Airway Assessment: Quickly evaluate airway
patency and breathing.
Assess for Signs of Severe Obstruction: Look for stridor,
cyanosis, use of accessory muscles, and altered
consciousness.
Check Consciousness Level: Determine if the patient is
alert, lethargic, or unresponsive.
53

54. Emergency Airway Management
Ensure Airway Patency:
Head-Tilt, Chin-Lift: If the
patient is unconscious or unable
to maintain their airway.
Jaw-Thrust Maneuver:
Alternative if cervical spine
injury is suspected.
Positioning:
Supine: For patients with
suspected croup or tracheitis.
Sitting Forward: For suspected
epiglottitis to optimize airway
position.
Comfortable Position: For
children, hold in a parent's lap if
possible.
54

55. Positioning
Supine: For patients with suspected croup or tracheitis.
Sitting Forward: For suspected epiglottitis to optimize
airway position.
Comfortable Position: For children, hold in a parent's lap if
possible.
55

56. Provide Supplemental Oxygen:
Hand Position: The little,
ring, and index fingers are
spread over the mandible from
the angle of the jaw forward
towards the chin in the shape
of an "E".
●Jaw Lift: The jaw is lifted,
pulling the face into the mask.
●Mask Seal: The thumb and
forefinger are placed over the
mask in the shape of a "C",
forming a seal between the
mask and the skin.

57. Advanced Airway Interventions
• Suctioning: Clear visible obstructions or
secretions.
• Endotracheal Intubation: Prepare for intubation
if the airway is compromised and other
measures are insufficient.
• Tracheostomy: Consider if intubation fails or is
not possible, especially in severe cases.
57

58. Tracheostomy Airway Interventions
• Relieve upper airway obstruction
• Prolonged intubation
• Reduce anatomical dead space
• Toilet of the airway
58

59. Pharmacological Interventions
• Administer Epinephrine: For suspected anaphylaxis or severe
croup.
• Steroids: For reducing inflammation in cases like croup or
epiglottitis.
• Antibiotics: Administer if bacterial infection (e.g., epiglottitis)
is suspected.
59

60. References
1. Schwartz's Principles of Surgery (11th Edition, McGraw-Hill
Education)
2. Bailey & Love's Short Practice of Surgery (28th Edition, CRC Press)
3. Nelson Textbook of Pediatrics (21st Edition, Elsevier)
4. Rosen's Emergency Medicine: Concepts and Clinical Practice (9th
Edition, Elsevier Saunders)
5. Up-to-date
60

61. 61
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