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  1. What is Respiratory Distress - Upper Airway?

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In this lesson, we're going to cover upper airway respiratory distress, including causes, signs and symptoms, treatment options in general, and some information on the best courses of treatment for a few specific causes of respiratory distress in pediatric patients.

Respiratory distress is an important subject to cover, and it's important to note that upper airways obstructions can present mild to severe symptoms and include the large airway anatomy – such as the nose, pharynx, and larynx.

Because children and infants have much smaller airways than adults, they are more susceptible to these types of obstructions. Remember, a child's trachea is roughly the size of their pinky finger.

Pro Tip #1: Also, in children and infants with a decreased level of consciousness, the tongue itself can cause the obstruction, because when the muscles relax, the tongue can fall to the back of the throat and obstruct the oral pharynx part of the airway.

Common Causes of Upper Airway Respiratory Distress

There are several common causes of upper airway respiratory distress in pediatric patients, and these include:

  • Food or other small foreign body objects
  • Infections, such as epiglottitis or croup
  • Thick secretions in the nasal passages
  • Swelling of the airway due to conditions like anaphylaxis or epiglottitis

And less common causes include:

  • Mass-like abscesses
  • Congenital conditions affecting the airway
  • Trauma that causes a narrowing of the airway

Signs and Symptoms

The signs and symptoms of upper airway obstructions are different than those for lower airway obstructions, as they occur mostly during inspiration and include:

  • Inspiratory retractions
  • The use of accessory muscles
  • Nasal flaring
  • Hoarseness
  • Snoring
  • Drooling
  • Changes in voice or cry sounds
  • Barking seal-like cough
  • Stridor-like sounds

Usually, as upper airway obstructions worsen, breathing will become more labored and faster.

Pro Tip #2: However, it's important to note that in the later stages with severe hypoxia, breathing becomes slower and will eventually stop altogether if left untreated.

Early recognition, identification, and treatment of respiratory distress in infants and children is vital to achieve a good outcome and also for their survival, as respiratory distress can quickly progress into respiratory failure and cardiac arrest.

Identifying and Treating Upper Airway Obstructions

Treatments for specific causes will often vary, however there are some general methods used to treat a child in respiratory distress, and these include:

  • Proper positioning – put the patient into a comfortable position that keeps the airway open to help support their breathing efforts, such as:
    • Sitting the child upright so their head is above their heart
    • Leaning the child forward if they're really distressed
    • Helping the child remain calm, perhaps by holding a toy or stuffed animal
  • Check the patient's lung sounds and apply an oxygen saturation monitor while the child is still on room air, which will help establish a good baseline for their SpO2 levels
  • Administer high flow oxygen immediately for respiratory arrest and remember the goal – keep the patient's oxygen saturation above 94 percent
  • Consider suctioning as needed after oxygen therapy is established
  • Assess the patient's blood pressure, pulse and respiratory rates, temperature, and ECG

It's also important to identify and treat specific types or causes of upper airway obstruction based on the patient's signs and symptoms.

Identifying and Treating Croup

Croup is most commonly identified by:

  • That seal-like barking cough
  • Stridor lung sounds
  • Retractions, in severe cases

For treating croup, administer nebulized epinephrine at 5ml of 1:1000 as indicated. And after initial airway treatment has been initiated, establish IV or IO access to administer corticosteroids if required.

A commonly recommended corticosteroid for croup is dexamethasone at .6mg/kg delivered via IV or IO.

Pro Tip #3: It's important to reassess the patient's vitals after the initial treatment and continue to monitor them closely. You should also be prepared to intubate if respiratory failure occurs.

Treating Anaphylaxis

For pediatric patients with anaphylaxis, treat with intramuscular epinephrine, as this is considered the first course of treatment for this condition.

Depending on the patient's specific signs and symptoms, you should also consider:

  • Corticosteroids
  • Albuterol
  • Antihistamines

Treating for Foreign Body Obstructions

If the patient has a foreign body obstruction, where they cannot cough or breathe, that obstruction must be removed immediately with proper basic life support.

Techniques you can use to remove an obstruction are:

  • Abdominal thrusts
  • Back slaps
  • Chest thrusts

For mild cases of foreign body obstructions, you'll recognize this as the child will still be able to make sounds, like coughing forcefully.

Pro Tip #4: Do not try to physically remove the obstruction in these cases. Instead, call for expert consultation, if time allows. And if the patient's status remains stable, you should still see if surgical intervention or deep suctioning is required.

Always remember to allow the infant or child to remain in the most comfortable position possible and always monitor them closely for deteriorating symptoms. And if they do deteriorate, treat them accordingly.