Children with unstable airways deserve the utmost attention because most cardiac arrests in children are the result of respiratory failure, frequently in conjunction with some sort of upper dren who are in respiratory distress or failure as a result of upper airway obstruction and should institute the preventive and interventional procedures to maintain and secure the airway to guarantee appropriate delivery of oxygen and gas exchange.

The four common sites where stenotic lesions of the airway are found are as follows: the nose; the nasopharynx; the larynx in the supraglottic, glottic, or subglottic areas; and the tracheobronchial tree. Supraglottic and subglottic airway obstructions are the simplest way to classify the anatomic nature of the obstruction. The subglottic region of the larynx is the narrowest point of the pediatric airway and is the most common site of life-threatening upper airway obstruction.

The origin of subglottic obstruction is stenosis caused by congenital, acquired, or idiopathic lesions. Congenital subglottic stenosis is defined as subglottic stenosis present at birth, in the absence of a history of intubation, extrinsic compression (e.g., double aortic arch), or laryngeal trauma. A congenital lesion should be high in the differential diagnosis. Acquired subglottic stenosis is caused by laryngeal trauma, intubation, previous airway surgery, foreign body, infection, neoplasia, or chemical irritation (thermal or caustic).

Other causes of life-threatening acquired laryngeal abnormalities obstruction are autoimmunity, infection (epiglottitis, diphtheria, and laryngotracheobronchitis), gastroesophageal reflux, inflammatory diseases, laryngeal papillomatosis, neoplasms, and inhaled foreign body.

Generally, the approach to the differential diagnosis of upper airway obstruction is limited to three areas: (a) Is the airway maintainable with or without an endotracheal tube? (b) Is the disorder supraglottic or subglottic? (c) Is the insertion of an endotracheal tube urgent and possible outside the operating room? Table 254.1 illustrates the clinical features that differentiate supraglottic from subglottic upper airway obstruction.