Upper airway obstruction: recognition and first steps
- Emergency
A blocked upper airway can kill in minutes; noisy breathing, drooling and a muffled voice are warnings to get expert airway help at once.
What it is
Upper airway obstruction is narrowing or blockage of the air passage above the carina, most often in the pharynx, larynx or upper trachea. Causes include foreign bodies, infections (epiglottitis, croup, deep neck abscess, Ludwig angina), angioedema and anaphylaxis, trauma, burns and tumours. The first job is not to find the cause but to keep the patient oxygenated, avoid making things worse and bring the most experienced airway team early.
How to recognise it
- Partial obstruction: stridor, hoarseness, cough, the patient can still speak or cry.
- Complete obstruction: no voice, no effective cough, the hands go to the throat, cyanosis, then loss of consciousness.
- Speed of onset helps: seconds suggest a foreign body; hours suggest epiglottitis or angioedema; days suggest an abscess or croup.
- Fever, toxic look and drooling suggest infection; urticaria, wheeze and hypotension suggest anaphylaxis.
Structure
- Supraglottic: epiglottitis, angioedema, deep neck infection, Ludwig angina, peritonsillar abscess, tumours.
- Glottic: foreign body, bilateral vocal cord paralysis, laryngeal tumour, laryngeal trauma.
- Subglottic and tracheal: croup, subglottic stenosis (for example after intubation), tracheostomy problems, tracheal compression.
Step-by-step management
- Call for help early: the most experienced airway operator (anaesthesia, ENT) and the difficult airway kit.
- Give high-flow oxygen and let the patient sit in the position of comfort; do not force them to lie down.
- Keep the patient (especially a child) calm; avoid painful procedures and throat examination until the airway is safe.
- Treat the cause you can: back blows and thrusts for choking, intramuscular adrenaline for anaphylaxis, steroids and nebulised adrenaline for croup.
- Plan the definitive airway in theatre when possible (awake fibreoptic intubation or awake tracheostomy), with a surgeon ready.
- If intubation fails and oxygenation fails, proceed to emergency front-of-neck access without delay.
- Once the airway is safe, investigate the cause (nasendoscopy, CT neck) and give targeted treatment (for example antibiotics).
Common causes of acute upper airway obstruction and their clues
| Cause | Typical patient | Clues |
|---|---|---|
| Foreign body | Toddler; older adult eating | Sudden choking while eating or playing |
| Croup | Child under about 6 years | Barking cough, hoarseness, worse at night, mild fever |
| Epiglottitis | Unvaccinated child or adult | Fast onset, high fever, drooling, no barking cough |
| Angioedema or anaphylaxis | Any age; ACE inhibitor users | Lip and tongue swelling, urticaria, hypotension |
| Deep neck infection or Ludwig angina | Dental infection, diabetes | Neck swelling, trismus, raised floor of mouth |
Red flags
- Stridor at rest, drooling, inability to swallow saliva or to lie flat.
- Cyanosis, falling saturation, drowsiness or a silent chest.
- Rapid progression over minutes to hours.
- Swelling of the tongue, lips or floor of the mouth.
- Neck trauma with voice change, subcutaneous emphysema or haemoptysis.
Next step / Initial management
- Do not send an unstable patient to radiology; imaging (lateral neck X-ray, CT) only once the airway is secure or the patient is stable and accompanied.
- Flexible nasendoscopy by ENT, with airway support ready, shows the site and degree of narrowing.
- First-line treatment by cause: adrenaline for anaphylaxis, corticosteroids (dexamethasone) for croup, intravenous antibiotics (a third-generation cephalosporin) for epiglottitis.
- Refer as an emergency, the same moment: any stridor at rest or drooling needs the ENT and anaesthesia team at the bedside, not an outpatient referral.
Test yourself
Think of the answer, then tap the question to see it.
A 4-year-old unvaccinated child has high fever, drooling and sits leaning forward with soft inspiratory stridor. What should you avoid and what is the next step?
Avoid examining the throat with a tongue depressor, lying the child flat or painful procedures. Keep the child calm with a parent and call anaesthesia and ENT to secure the airway in theatre.
Which type of stridor suggests obstruction above the vocal cords?
Inspiratory stridor. Biphasic stridor suggests a glottic or subglottic lesion; expiratory noise suggests the intrathoracic airway.
What is the rescue when a patient can be neither intubated nor oxygenated?
Emergency front-of-neck access, usually a surgical cricothyroidotomy (needle technique in young children).
Connections
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Foreign Body Airway Obstruction (StatPearls) (StatPearls Publishing, NCBI Bookshelf, 2026); Epiglottitis (StatPearls) (StatPearls Publishing, NCBI Bookshelf, 2026); Deep Neck Infections (StatPearls) (StatPearls Publishing, NCBI Bookshelf, 2026).
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Representative model, for educational purposes only.