Management of life-threatening causes of acute respiratory compromise in children

Condition	Maneuver	Comments
Foreign body with acute airway obstruction¶	Back blows/chest thrusts (<1 year of age)	Maneuvers should only be used for patients who are unable to phonate.
	Abdominal thrusts (≥1 year of age)	Maneuvers should only be used for patients who are unable to phonate.
	Manual removal with finger sweep	Perform this maneuver only when a foreign body is visible in the oropharynx.
	Laryngoscopy and removal with Magill forceps
	Needle cricothyrotomy	For patients with complete obstruction not rapidly relieved by the above actions and who have a supraglottic foreign body, this procedure is a temporizing measure that can provide oxygenation but not ventilation.
Laryngospasm^Δ	Positive pressure with a ventilation bag and tight-fitting mask	Additional measures such as rapid sequence intubation or needle cricothyrotomy may be necessary if laryngospasm persists despite bag-mask ventilation.
Soft tissue upper airway obstruction^Δ	Head tilt/chin lift	Avoid in patients who may have cervical spine injury.
	Jaw thrust	Use for patients who may have cervical spine injury.
	Nasopharyngeal airway	Use for conscious or unconscious patient.
	Oropharyngeal airway	Use only in an unconscious patient.
Respiratory failure^Δ	Bag-mask ventilation	Suspect upper airway obstruction if unable to ventilate with proper size equipment and technique.
	High-flow nasal cannula^◊	Use for spontaneously breathing patients with hypoxemic respiratory failure without hypercarbia.
	Noninvasive ventilation^§	Use for spontaneously breathing patients with hypoxemic or hypercarbic respiratory failure. Contraindicated in children with upper airway disease, high risk for aspiration, or hemodynamic instability.
	Endotracheal intubation^¥	Use for patient in respiratory failure requiring more than a few minutes of bag-mask ventilation, those with impending airway compromise (eg, thermal burns, severe epiglottitis, or airway trauma), and/or those who are unconscious or have altered mental status with an absent gag reflex. In a patient with an airway that is manageable with bag-mask or noninvasive ventilation, chest compressions and vascular access should be prioritized over intubation.
Tension pneumothorax	Needle thoracentesis	Patients will require chest tube or pigtail placement following emergency decompression.
Cardiac tamponade	Pericardiocentesis^‡	Use ultrasound guidance whenever available.

CPAP: continuous positive airway pressure; Bi-PAP: bi-level noninvasive positive airway pressure.
* Refer to UpToDate content on needle cricothyroidotomy with percutaneous transtracheal ventilation.
¶ Refer to UpToDate content on emergency evaluation of acute upper airway obstruction in children, section on suspected foreign body.
Δ Refer to UpToDate content on basic airway management in children.
◊ Refer to UpToDate content on high-flow nasal cannula.
§ Refer to UpToDate content on noninvasive ventilation in children.
¥ Refer to UpToDate content on emergency endotracheal intubation in children.
‡ Refer to UpToDate content on emergency pericardiocentesis.

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Management of life-threatening causes of acute respiratory compromise in children