Acute upper airway obstruction

Also known as Upper airway obstruction (UAO) · Acute epiglottitis · Supraglottitis · Ludwig's angina · Retropharyngeal abscess · Peritonsillar abscess (quinsy) · Angioedema (hereditary, ACEi-induced, allergic) · Foreign body airway obstruction · Post-extubation stridor · Bilateral vocal cord paralysis · Inhalational thermal injury · Can't intubate, can't oxygenate (CICO) · Heliox · Awake fibre-optic intubation (AFOI)

Acute upper airway obstruction in the ICU and ED — NAP4 (61% of ICU airway events caused death or neurological injury; missing capnography in 74%), the DAS critically-ill and awake-intubation guidelines, scalpel-bougie-tube front-of-neck access, adult epiglottitis (airway intervention 15.6%, failed intubation 4.2%), deep neck infection, bradykinin angioedema (HAE: C1-INH or icatibant; icatibant no better than placebo in ACE-inhibitor angioedema), croup, heliox, and steroid prophylaxis of post-extubation stridor.

medium18 referencesUpdated 2 Oct 20268 min readSource-verified · Oct 2026

Checked against its sources on 2 Oct 2026

Practise this topic

8 MCQs

The one-line answer

Acute upper airway obstruction is a threatened airway that must be secured without being lost. NAP4 found that 61 per cent of major airway events in ICU led to death or persistent neurological injury, and the DAS critically-ill guideline answers with a comprehensive strategy: early videolaryngoscopy, second-generation supraglottic rescue, and a scalpel-bougie-tube front-of-neck airway. Awake tracheal intubation has a high success rate and favourable safety profile but is underused in anticipated difficult airways. Treat the cause alongside the airway — antibiotics for epiglottitis and deep neck infection, bradykinin-targeted therapy for hereditary angioedema (where adrenaline, antihistamines and steroids tend to be ineffective), and steroids before extubation to prevent post-extubation stridor.^[3]^[2]^[19]^[18]^[7]

Meet the patient

A 52-year-old with three days of worsening sore throat now has severe dysphagia, drooling and a muffled voice; he prefers to sit forward. A junior reaches for a tongue depressor. In adults, epiglottitis presents most commonly with severe dysphagia in a subacute manner, with drooling, muffled voice and dyspnoea — and visualisation of the epiglottis is the key to diagnosis.^[10]

The question that decides the next hour: how do I secure this airway without losing it? In adult epiglottitis the inflammation spreads to the surrounding supraglottic structures and disease progression is often unpredictable.^[16]

References18Show

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