Upper airway obstruction and aspiration

• The upper airway is the corridor from the nose and mouth to the carina; partial narrowing produces stridor (a harsh inspiratory sound), while complete or near-complete obstruction kills within minutes because oxygen stores are small.
• Foreign body aspiration is a time-critical event in young children and a diagnostic trap in adults; epiglottitis is now mainly an adult disease; vocal cord dysfunction (inducible laryngeal obstruction) is often mistaken for asthma.
• Aspiration events split into three different problems: a foreign body in the airway, aspiration pneumonitis (chemical injury from gastric contents), and aspiration pneumonia (infection from oropharyngeal bacteria).
• The first question is always the same: is the airway safe now? Recognition (stridor, dysphonia, dysphagia, drooling, tachypnoea, hypoxaemia) comes before diagnosis.
• Early corticosteroid and antibiotic therapy were independently associated with lower intubation risk in a large adult epiglottitis cohort, and speech and language therapy is first-line for inducible laryngeal obstruction.

By the end of this page you should be able to:

1. Explain why stridor localises to the extrathoracic airway and list the main causes by anatomical level.
2. Manage a suspected foreign body aspiration in a child and in an adult, including when to bronchoscope.
3. Recognise adult epiglottitis, outline its changing epidemiology, and state the evidence on early steroids and antibiotics.
4. Diagnose and treat inducible laryngeal obstruction, and tell it from asthma.
5. Distinguish aspiration pneumonitis from aspiration pneumonia and describe immediate treatment.
6. Use an algorithm for the acutely obstructed upper airway, including when measures have failed.

This page covers acute and subacute upper airway obstruction (UAO) and the aspiration syndromes that threaten it. Upper airway obstruction means partial or complete blockage of airflow at or above the carina (nose, pharynx, larynx, or trachea outside the thorax). It is a presentation, not a single disease, so the causes range from a toy piece in a toddler’s bronchus to swollen epiglottic tissue in an adult to paradoxical vocal fold closure in an anxious adolescent.

Aspiration means entry of material from the mouth or upper gastrointestinal tract into the larynx or lower respiratory tract. Three patterns matter and are managed differently: foreign body aspiration, aspiration pneumonitis, and aspiration pneumonia. ^[1] An obstructed airway and an aspiration event often overlap (a food piece can block, or gastric contents can inflame), so this page treats them together.

• Foreign body aspiration (FBA) in children: a leading cause of accidental death in children under three, and perhaps the most time-sensitive emergency in paediatrics. ^[4] In the United States an estimated 1908 children with FBA were hospitalised each year (2009 to 2011), with healthcare costs over 50 million US dollars a year. ^[4] A systematic review of 14 studies of 748 children in sub-Saharan Africa found 61% were male (95% confidence interval 58 to 64%) and most were under five years of age. ^[4]
• Anaesthetic aspiration: clinically important gastric aspiration occurs in roughly one in two to three thousand anaesthetised patients, although observed aspiration occurs in about 3 in 10,000. ^[1]
• Aspiration pneumonia: accounts for 5 to 15% of community-acquired pneumonia. ^[1]
• Mortality of aspiration pneumonitis: up to 70% when a large volume is aspirated with a low pH in already ill patients. ^[1]
• Adult epiglottitis: in a 10-year US network study the incidence rose from 0.002% of adult emergency department visits in 2014 to 0.005% in 2024 (about a 9% increase per year). ^[2] Adults now make up most cases in high-income countries, a shift linked to widespread Haemophilus influenzae type b vaccination in children. ^[2]
• Paediatric FBA case fatality: 0.5 to 3% in hospitalised children in high-income settings, but approximately 1 to 8% in resource-limited settings. ^[4]

Causes of acute stridor and obstruction by level (selected):

• Supraglottic: epiglottitis/supraglottitis, peritonsillar or deep neck infection, anaphylaxis and angioedema of the tongue, laryngeal oedema after intubation, thermal or caustic injury, trauma or haematoma.
• Glottic: foreign body, vocal cord paralysis, inducible laryngeal obstruction (vocal cord dysfunction), epiglottic cyst, tumour.
• Subglottic/tracheal: croup (viral laryngotracheobronchitis), bacterial tracheitis, subglottic stenosis, tracheomalacia, compression from thyroid or mediastinal mass.
• Bronchial: foreign body, mucus plug, aspiration with lobe collapse.

Foreign body aspiration (FBA): in children, anatomical reasons (immature swallowing, incomplete dentition, narrow airway) combine with behaviour (exploring objects orally, eating while playing or laughing). ^[4] In adults, risk factors predominate: swallowing problems, altered mental status, neuromuscular disease, intoxication, dementia, poor dentition or dental appliances, and iatrogenic events during dentistry or intubation. ^[1]

Epiglottitis/supraglottitis: infection spreads through pharyngeal tissues and reaches the epiglottis and adjacent supraglottic structures. The usual cause is bacterial infection, but viral and non-infectious inflammation also occur, and widespread Haemophilus influenzae type b vaccination in children has shifted epidemiology toward adults. ^[2][3]

Inducible laryngeal obstruction (ILO, “vocal cord dysfunction”): inappropriate glottic or supraglottic closure, usually on inspiration, causing intermittent airflow obstruction. ^[6] Triggers include strong scents, temperature change and airborne irritants. ^[6] It presents as stridor, wheeze, chest tightness or breathlessness and mimics asthma. ^[6] It occurs most often in female patients and is frequently accompanied by dysfunctional breathing; comorbid asthma is common. ^[6]

Aspiration risk factors (large-volume aspiration): altered consciousness (sedation, brain injury, seizure, intoxication), gastrointestinal disorders (reflux, gastroparesis, ileus, achalasia, stricture), compromised gag reflex (intubation, enteral feeding, bulbar palsy), dysphagia (stroke, dementia, Parkinson disease, chronic obstructive pulmonary disease), obesity, and labour. ^[1]

Why partial obstruction sounds like stridor. Stridor is produced by turbulent flow through a narrowed airway. Because the extrathoracic trachea is exposed to atmospheric pressure during inspiration, inspiratory stridor localises obstruction above (or at) the thoracic inlet; expiratory stridor points to an intrathoracic (expiratory) narrowing; biphasic (inspiratory and expiratory) stridor means a fixed (often subglottic) obstruction. A wheeze, in contrast, is usually expiratory and lower pitched. As the lumen narrows, the work of breathing rises, and eventually alveolar ventilation falls; the extrathoracic airway can swing shut when the intraluminal pressure falls during inspiration.

Why complete obstruction is so fast. The tracheal lumen at rest is small. Once ventilation stops, oxygen is taken up from the functional residual capacity and the result is hypoxaemia within minutes. In a completely blocked trachea, brain and heart ischaemia become irreversible within about 3 to 5 minutes. ^[1] Oxygen stores in the lungs help only for a short time; hence pre-oxygenation before anaesthesia extends the safe apnoea time to about 8 minutes in healthy adults. ^[5]

Aspiration pneumonitis. Macroaspiration of gastric contents causes a chemical burn of the tracheal, bronchial and alveolar mucosa from low pH and particulate matter. ^[1] Two phases are described: phase one begins immediately, with cough or bronchospasm from capsaicin-sensitive neuron stimulation and direct epithelial caustic action; phase two develops over the next 4 to 6 hours, when neutrophil-driven inflammation, surfactant inactivation and increased capillary permeability cause oedema and hypoxaemia. ^[1] The stomach is usually sterile, but colonised gastric content can seed infection and convert pneumonitis into pneumonia. ^[1]

Aspiration pneumonia. Here oropharyngeal secretions carrying pathogenic bacteria are inhaled and invade lung tissue. ^[1] Which organisms appear depends on whether it is community-acquired, hospital-acquired or ventilator-associated pneumonia; the anaerobic dominance once assumed is now less clear. ^[1]

Foreign body. Food or objects (commonly seeds, nuts and plastics in children) impact in the lumen and cause obstruction, local inflammation, post-obstructive pneumonia, abscess or bronchiectasis if they are retained. ^[4] Organic objects swell and cause more inflammation and granulation, making extraction harder; inorganic objects may have sharp edges. ^[4]

Aspiration pneumonitis is an acute (chemical) lung injury rather than an infection at first; histology shows airway and alveolar epithelial damage, neutrophil influx, surfactant dysfunction and protein-rich oedema. ^[1] Epiglottitis is characterised by acute inflammatory oedema of the supraglottic tissues (epiglottis, aryepiglottic folds, vallecular region). ^[2][3] Foreign bodies produce mechanical obstruction and a secondary inflammatory reaction or granulation tissue, especially with organic material. ^[4]

• Stridor itself: a noisy, high-pitched breathing sound, usually worse on inspiration; the patient may say “I can’t breathe in”. Ask about voice change (hoarse, muffled or “hot potato” speech), swallowing difficulty, and whether the episode began while eating or running.
• Foreign body: sudden coughing or choking while eating or playing, followed by persistent cough, wheeze, dyspnoea, or, if the event was not witnessed, delayed presentation with chronic cough, recurrent pneumonia, or wheeze unresponsive to treatment. ^[1][4]
• Epiglottitis: rapid onset of severe sore throat, pain on swallowing, fever, hoarse or muffled voice, drooling (inability to swallow saliva), and anxiety; symptoms develop over hours. ^[2][3]
• ILO/vocal cord dysfunction: recurrent, abrupt episodes of throat tightness, inspiratory difficulty, wheeze or stridor triggered by scents, cold air or exercise; often “I think I am choking”. The classic triad of choking, coughing and wheeze is present in only a minority of foreign body cases. ^[6][4]
• Aspiration event: choking or coughing during eating, drinking, vomiting or tube feeding; after macroaspiration, abrupt dyspnoea, hypoxaemia, fever and sometimes purulent sputum. ^[1]

Look, listen and only then act:

• Airway patency and severity: stridor at rest, tripod posture, drooling, intercostal and supraclavicular recession, silent chest, cyanosis, altered consciousness, and resting tachypnoea. A patient with stridor at rest, drooling or voice change needs an active airway plan now.
• Key findings by cause:
  • Foreign body: unilateral decreased breath sounds, localised wheeze, persistent cough. ^[4]
  • Epiglottitis: forward-leaning posture, drooling, muffled voice, tender larynx; the larynx should not be palpated aggressively and the gag reflex should not be tested unnecessarily. ^[2][3]
  • ILO: often a normal examination between episodes; paradoxical inspiratory stridor; speech may be unaffected.
  • Aspiration pneumonia: crackles or bronchial breathing, often in dependent lobes (right lower lobe in ambulant, upper lobes in bed-bound patients). ^[1]
• Stridor prevalence in paediatric FBA: stridor was recorded in 15 to 26% of children in studies that documented it. ^[4]
• Predictors of airway intervention in epiglottitis: stridor occurred in 70% of patients who required intervention compared with 2% of those who did not; dyspnoea and supraglottic extension of oedema were also strongly predictive. ^[3]

The table separates the causes most likely to produce acute stridor or sudden aspiration-related distress. In practice, several may coexist.

First-line, at the bedside

• Observation and oxygenation: pulse oximetry and, if trained, flexible nasolaryngoscopy to inspect the supraglottis. ^[3] Keep the patient calm and in the position they choose (often sitting upright and leaning forward).
• Imaging for suspected foreign body: chest X-ray first. It is poor for radiolucent objects (only 2 to 6% visible) but may show hyperinflation, atelectasis or post-obstructive changes. ^[4] If suspicion remains, proceed to bronchoscopy rather than waiting for CT, which was not used in any study in the African meta-analysis. ^[4]
• Imaging for infection: contrast-enhanced CT of the neck and chest to define the anatomical extent of deep neck infection or mediastinal spread; it is essential when abscess or multispace infection is suspected. ^[3]
• Bloods: full blood count and inflammatory markers when infection is suspected; they do not diagnose foreign body aspiration.

Confirmatory

• Foreign body: bronchoscopy (rigid or flexible) is both the gold standard of diagnosis and the treatment. ^[4] Rigid bronchoscopy under general anaesthesia remains the traditional choice for children and offers excellent airway control. ^[4]
• Epiglottitis: diagnosis is clinical, confirmed by direct or video laryngoscopy (or nasolaryngoscopy). ^[3] Routine X-ray of the neck is not required and can delay care.
• ILO: diagnosis requires laryngoscopy during a symptomatic episode, showing inappropriate glottic or supraglottic closure; it should be paired with a full assessment for asthma and other airway disease. ^[6]
• Aspiration pneumonia vs pneumonitis: history plus dependent lobe infiltrates on chest X-ray; procalcitonin may help distinguish bacterial infection from chemical inflammation, and bronchoalveolar lavage with culture can guide antibiotics. ^[1]

What each result means: a normal chest X-ray does not exclude foreign body aspiration, because radiolucent objects are common and the signs can be subtle or absent. ^[4] New dependent-lobe infiltrates after a witnessed aspiration are consistent with either pneumonitis or pneumonia and should be interpreted with the clinical course. ^[1]

There is no single severity score for “upper airway obstruction” as a whole; severity is judged clinically (stridor at rest, voice change, drooling, cyanosis, falling saturation, rising PaCO2, altered consciousness). Selected disease-specific measures:

• Epiglottitis: older age, diabetes, heart failure, chronic kidney disease, alcohol use disorder, plus lower blood pressure, tachypnoea and hypoxaemia, were independent predictors of intubation or ICU admission. ^[2]
• FBA in children: time from aspiration to presentation often exceeds five days; delayed extraction is associated with pneumonia, atelectasis, lung abscess and bronchiectasis. ^[4]
• Aspiration pneumonitis: poor outcomes are more likely with low gastric pH and large aspirated volume; up to one-third develop a severe, protracted course leading to acute respiratory distress syndrome (ARDS). ^[1]

1. Call for help early (anaesthesia, ear-nose-throat, senior emergency clinician). Keep the patient upright and calm; avoid unnecessary instrumentation in suspected epiglottitis.
2. Foreign body:
   • Choking, unable to speak or breathe: use back blows and abdominal thrusts (Heimlich manoeuvre) in accordance with local first-aid guidance. ^[1]
   • Once past the immediate crisis, bronchoscopy is needed; rigid bronchoscope is standard in children and either rigid or flexible devices are used in adults depending on the object and operator experience. ^[1][4]
   • Time matters: a complete tracheal blockage leaves only about 3 to 5 minutes before irreversible brain, heart and organ injury. ^[1]
3. Epiglottitis/supraglottitis:
   • Airway first; most adults can be managed without intubation but with close observation. ^[3]
   • Start systemic corticosteroids and broad-spectrum parenteral antibiotics within 24 hours: early steroid therapy was associated with a lower risk of intubation (risk ratio 0.48, 95% CI 0.26 to 0.88) and ICU admission (0.71, 0.55 to 0.92); early antibiotics with intubation risk ratio 0.54 (0.34 to 0.85) and ICU admission 0.72 (0.60 to 0.86) in matched cohorts. ^[2]
   • Typical early agents used were hydrocortisone, prednisone, methylprednisolone, dexamethasone or prednisolone for steroids and ceftriaxone, ampicillin-sulbactam, piperacillin-tazobactam or levofloxacin for antibiotics. ^[2]
   • Deep neck infection predictors of needing tracheostomy included age 65 years or older, involvement of three or more deep neck spaces and mediastinitis. ^[3]
4. Aspiration event:
   • Position the patient to reduce further aspiration, suction the pharynx and oral cavity, raise the bed (head 45 degrees if safe) and intubate according to hypoxaemia, neurological status and haemodynamic stability. ^[1]
   • Nebulised bronchodilators for bronchospasm; protect the lung with standard lung-protective ventilation if intubated. ^[1]
   • Bronchoscopy helps when a large volume is aspirated or there is particulate (central) obstruction; routine bronchoscopy with lavage rarely helps for liquid. ^[1]
5. Inducible laryngeal obstruction: acute attack is managed by reassurance, slowing the breath, nasal inspiration and relaxed expiration; most attacks settle without intervention. ^[6]

When intubation is difficult or impossible (Difficult Airway Society 2015 principles): ^[5]

• Limit the number of attempts and focus on oxygenation.
• If intubation fails, use a supraglottic airway device to oxygenate and then decide whether to wake the patient or proceed.
• If both intubation and supraglottic device fail, wake the patient when possible; if mask oxygenation is impossible with muscle relaxation, perform cricothyroidotomy immediately (scalpel cricothyroidotomy is recommended). ^[5]
• Pre-oxygenation matters: healthy adults desaturate within about 1 to 2 minutes breathing air but can extend apnoea to about 8 minutes with pre-oxygenation. ^[5]

• Foreign body: extraction at bronchoscopy is definitive. Most adult patients have an underlying risk factor, so swallowing and neurological assessment (and dental work) matters after the event. ^[1]
• Epiglottitis: after the airway is secure (or judged safe), continue IV antibiotics and complete a course as clinically indicated; early therapy data support the combination of steroids plus antibiotics but not one without the other. ^[2]
• ILO: a multidisciplinary approach with a diagnosis confirmed by laryngoscopy, trigger management and breathing retraining. ^[6]
• Aspiration pneumonia: antibiotics directed at the likely pathogens and acquisition setting (community vs hospital vs ventilator-associated), de-escalating or stopping if cultures are negative; bronchoalveolar lavage helps guide therapy. ^[1]
• Aspiration pneumonitis: supportive care (oxygen, ventilation if needed); antibiotics are not indicated for pure pneumonitis unless bacterial infection develops. ^[1]

• Speech and language therapy (SLT) is the recommended first-line (mainstay) treatment for ILO, with breathing retraining, trigger management, laryngeal relaxation and biofeedback. ^[6]
• Dosing reported as effective: three to six sessions over about four months, with a longer first session and then roughly 30-minute sessions, combining in-person and remote delivery. ^[6]
• Position and nursing: for aspiration risk, confirm swallowing safety, offer thickened fluids in high-risk dysphagia, use a chin-down posture, encourage oral rather than enteral feed where appropriate and position the head turned to one side during swallowing. ^[1]
• Ventilator and airway care: minimise sedation, verify feeding-tube placement, and elevate the head of the bed 45 degrees in at-risk patients. ^[1]

This page does not prescribe drug doses beyond those supported by the cited sources:

• Epiglottitis: early systemic corticosteroid and broad-spectrum parenteral antibiotic within 24 hours (agents and examples above), monitored for intubation and ICU escalation. ^[2]
• Aspiration pneumonia: see the regimen table drawn from current practice: ampicillin-sulbactam 1.5 to 3 g IV every 6 hours; amoxicillin-clavulanate 875 mg twice daily orally; piperacillin-tazobactam 4.5 g IV every 8 hours or 3.375 g every 6 hours; ceftriaxone 1 to 2 g IV once daily; cefepime 2 g IV every 8 to 12 hours; ertapenem 1 g IV once daily; imipenem 500 mg every 6 hours or 1 g every 8 hours; meropenem 1 g every 8 hours; levofloxacin 750 mg IV or oral daily; moxifloxacin 400 mg IV or oral daily; clindamycin 450 mg orally 3 to 4 times daily or 600 mg IV every 8 hours; gentamicin or tobramycin 5 to 7 mg per kg IV daily; amikacin 15 mg per kg IV daily; colistin 9 million IU daily in divided doses (loading 6 to 9 million IU); vancomycin 15 mg per kg every 12 hours IV; linezolid 600 mg every 12 hours IV or oral (doses for patients with normal renal function, adjusted to trough targets). ^[1]
• What to avoid: systemic corticosteroids are not recommended for aspiration pneumonitis because they have shown no benefit and one study found a higher rate of Gram-negative pneumonia in steroid-treated patients. ^[1] Antibiotics should be withheld unless bacterial infection is suspected; prophylactic antibiotics were less effective than treatment of proven (or apparent) aspiration pneumonia. ^[1]
• Monitoring: oxygen saturation, respiratory rate, work of breathing, haemodynamics; in epiglottitis watch for stridor, drooling, dyspnoea and rising need for intubation. ^[2][3]

• Foreign body: rigid bronchoscopy (traditional in children) or flexible bronchoscopy; exceptionally thoracotomy for objects beyond bronchoscopic reach. ^[4]
• Deep neck infection with abscess, multispace involvement, or mediastinal extension: surgical drainage with airway secured (intubation 82% of surgically treated deep neck infection cases in one series; tracheostomy primary 17%, secondary 12%). ^[3]
• Cricothyroidotomy: rescue (scalpel technique preferred) when CICO (can’t intubate, can’t oxygenate) develops. ^[5]
• Tracheostomy: for selected patients with extensive multispace infection, distorted anatomy, failed intubation or anticipated prolonged airway support. ^[3]

• After foreign body removal, arrange swallowing and dental review in adults and home-safety counselling in children (especially in resource-poor regions where seeds, pins or pen caps are common). ^[1][4]
• After epiglottitis, arrange ear-nose-throat review for voice and swallowing, following local practice (no validated interval is specified in the cited sources).
• After ILO, arrange SLT sessions and reassess (many patients need three to six sessions). ^[6]

• Same day (emergency): acute epiglottitis/supraglottitis, complete or severe partial obstruction, foreign body with cyanosis, stridor at rest, voice change with drooling, bacterial tracheitis, deep neck infection, penetrating or thermal injury.
• Urgent (days): recurrent unexplained lower respiratory infections, retained foreign body, suspected ILO not confirmed, aspiration pneumonia with severe dysphagia.
• Specialist: anaesthesia/intensive care for difficult airway planning; speech and language therapy for ILO; ear-nose-throat for laryngeal or structural disease.

• Foreign body: post-obstructive pneumonia, atelectasis, lung abscess, bronchiectasis; procedural complications include laryngeal oedema, hypoxia, cardiac arrest, pneumothorax. ^[4]
• Epiglottitis: airway obstruction, ICU admission, anoxic brain injury, death. ^[3]
• Aspiration: acute respiratory distress syndrome (ARDS), secondary infection, lung abscess, exogenous (lipoid) pneumonia, and chronic interstitial fibrosis; mortality up to 70% in large-volume, low-pH aspiration. ^[1]
• ILO: unnecessary steroid courses, asthma mislabelling, loss of employment, social isolation and reduced quality of life. ^[6]

Foreign body aspiration in children has excellent outcomes once the object is removed; deaths cluster around severe hypoxia before removal and are higher in resource-limited settings. ^[4] Adult epiglottitis is usually curable with airway protection and antibiotics, with a 30-day mortality of about 1 to 2% in the cited cohort. ^[2] Aspiration pneumonitis resolves within 48 hours in milder cases but can progress to ARDS with 30% mortality; aspiration pneumonia has a mortality around 29.4% compared with 11.6% for other community-acquired pneumonia. ^[1] ILO improves with SLT but needs sustained practice. ^{[6] [3]}

• Foreign body: keep nuts, seeds and small objects away from children under three (especially in seed-consuming regions), supervise toddlers while eating, and teach school-aged children not to hold pens or small items in their mouths. ^[4]
• Aspiration: fasting before surgery (no food for at least 8 hours, clear fluids up to 2 hours before), rational use of sedatives in high-risk patients, swallowing assessment after stroke, speech therapy and thickened fluids in dysphagia, and semi-recumbent positioning of tube-fed patients. ^[1]
• Epiglottitis: Hib vaccination in children remains the major driver of the changed epidemiology. ^[2]
• Screening: no population screening exists; high-risk groups (recent stroke, dysphagia, dementia, tube feeding) should have swallowing assessment.

Children: FBA is predominantly a disease of children under five years (most serious in those under three); croup and bacterial tracheitis are common paediatric causes of stridor. ^[4] Epiglottitis is now rare in infants who have received Hib vaccine. ^[2] ILO can affect adolescents and young adults. ^[6]

Older adults: adult epiglottitis incidence is rising fastest in 60- to 74-year-olds, and older adults have more comorbidities and predictors of airway compromise. ^[2] Aspiration risk rises with dementia, stroke and dysphagia.

Pregnancy: some data come from surgical and anaesthetic practice (cricoid pressure, aspiration in labour); apply the same positioning and fasting rules; an individualised airway plan should be made before any anaesthetic. ^[1][5]

Immunocompromised: may present with atypical organisms and non-infectious causes of airway swelling; move to early specialist review.

• Paediatric FBA deaths are higher where presentation is delayed and bronchoscopy services are scarce (about 1 to 8%). ^[4] Chest X-ray misses most foreign bodies (only 2 to 6% visible), so an unwitnessed aspiration in a child with unilateral wheeze or recurrent pneumonia needs bronchoscopy based on clinical suspicion, not on imaging alone. ^[4]
• Rigid bronchoscopy is the main extraction method in the available data (14 studies); learning and equipment should be supported where case loads are high. ^[4]
• Seeds dominate East Africa and plastics/metals dominate southern Africa, so prevention messages should be region-specific rather than identical everywhere. ^[4]

• In resource-limited adult epiglottitis, early steroids and antibiotics within 24 hours are supported by observational data even where ICU and advanced airway rescue are limited; strict airway observation and a lowest-threshold plan for transfer are essential. ^[2]

• Stridor is a sign, not a diagnosis: it means turbulent airflow through a narrowed extrathoracic airway; inspiratory stridor localises obstruction above the chest.
• Complete tracheal obstruction can cause irreversible brain and heart injury in about 3 to 5 minutes. ^[1]
• FBA is a paediatric emergency in toddlers and a diagnostic trap in adults; only 2 to 6% of objects are visible on chest X-ray, so maintain a low threshold for bronchoscopy. ^[4]
• Epiglottitis is now mainly an adult disease with rising incidence; early corticosteroids and antibiotics within 24 hours were associated with roughly halving intubation risk. ^[2]
• Vocal cord dysfunction/inducible laryngeal obstruction mimics asthma; it needs laryngoscopy during an attack for diagnosis and speech and language therapy as first-line treatment. ^[6]
• Aspiration pneumonitis is a chemical injury first; give supportive care, and avoid steroids; aspiration pneumonia needs antibiotics guided by origin and cultures. ^[1]
• Anaesthetic aspiration occurs in about 1 in 2,000 to 3,000 cases (observed in 3 in 10,000); aspiration pneumonia is 5 to 15% of community-acquired pneumonia. ^[1]
• Safety note: errors in upper airway presentations are usually errors of recognition and of delaying airway protection, not of drug choice.

• Asthma and chronic obstructive pulmonary disease (airway disease mimics and comorbidity).
• Pneumonia (community-acquired, hospital-acquired and ventilator-associated).
• Dysphagia and swallowing disorders.
• Difficult airway management in anaesthesia.
• Paediatric emergencies: croup, bacterial tracheitis, foreign body ingestion.