RCEM Syllabus Summaries - Acute Airway Obstruction (RP1), Choking (RC1), Stridor (RC2)

RCEM Syllabus Summaries: Resus - Acute Airway Obstruction in the Emergency Department (RP1), Choking (RC1), Stridor (RC2)

Executive Summary

Acute airway obstruction, designated under the Royal College of Emergency Medicine curriculum as clinical presentation RP1, remains one of the most significant challenges in the National Health Service Emergency Department environment. This presentation encompasses two distinct but often related issues: choking (RC1) and stridor (RC2). The management of these conditions requires a synthesis of rapid clinical gestalt, anatomical precision, and adherence to the latest Resuscitation Council UK and Difficult Airway Society guidelines. Choking, or foreign body airway obstruction, presents a high risk of morbidity and mortality, particularly at the extremes of age. In the United Kingdom, specific peaks in incidence are noted during mealtimes, and the elderly population remains particularly vulnerable due to factors such as poor dentition and neurological impairment.[1, 2, 3] Stridor, characterized by abnormal respiratory sounds, serves as a cardinal warning of critical upper airway narrowing. In paediatric populations, viral croup remains the most frequent cause, whereas in adults, the clinician must prioritize the exclusion of malignancy and acute supraglottitis.[4, 5]

The core of management across both presentations is the preservation of oxygenation and the anticipation of a "difficult airway" scenario. For choking, the shift from basic first aid to advanced life support occurs the moment a patient loses consciousness, necessitating immediate cardiorespiratory resuscitation with an emphasis on rescue breaths to potentially displace the obstruction.[6, 7] In stridor, pharmacological temporization using high-dose corticosteroids and nebulized adrenaline is standard practice, allowing time for senior anaesthetic and ear, nose, and throat specialist intervention.[8, 9] If non-invasive methods fail, the Emergency Department must be prepared for a surgical front-of-neck airway, with the scalpel-bougie cricothyroidotomy now established as the gold standard in the United Kingdom.[9] This briefing document provides an exhaustive framework for the assessment and management of these conditions, aligning with the specialty learning outcomes required of high-level emergency physicians.

Specialty Learning Outcomes and Curriculum Alignment

The management of acute airway obstruction is a fundamental competency that spans the breadth of the RCEM curriculum. Mastering these presentations allows the clinician to demonstrate capabilities across several Specialty Learning Outcomes (SLOs), ensuring safe and effective care in the high-pressure resuscitation environment.

SLO	Capability and Significance in RP1 Management
SLO 1	Care for stable patients presenting with complex comorbidities, such as those with chronic stridor secondary to laryngeal malignancy or neurological dysphagia.[10, 11]
SLO 2	Supporting the clinical team by providing expert guidance on airway stabilization and identifying the critical moment for specialist escalation to ENT or anaesthetics.[10, 12]
SLO 3	The identification and resuscitation of the critically ill patient. Airway obstruction is the 'A' in the ABCDE approach, requiring immediate intervention to prevent cardiac arrest.[10, 11]
SLO 4	Managing airway compromise in the context of trauma, such as laryngeal fractures or expanding neck haematomas requiring urgent stabilization.[10, 12]
SLO 5	Paediatric emergency care, specifically the management of croup, epiglottitis, and foreign body inhalation using age-appropriate techniques and pharmacotherapy.[10, 11]
SLO 6	Delivery of key procedural skills, including basic airway manoeuvres, foreign body removal, and emergency front-of-neck airway (FONA) procedures.[11, 12]
SLO 7	Dealing with the complex and challenging human factors inherent in a "cannot intubate, cannot oxygenate" (CICO) situation.[11, 12]
SLO 8	Leading the Emergency Department shift and coordinating the multidisciplinary response to a critical airway emergency.[11, 12]

The mastery of these SLOs ensures that the emergency physician operates not merely as a technician but as a clinical leader capable of synthesizing anatomical knowledge with rapid procedural execution and team management.[11, 13]

Clinically Relevant Anatomy and Physiology

A profound understanding of the anatomical differences between the adult and paediatric airway is critical for the emergency physician. These differences dictate the choice of equipment, the likelihood of certain pathologies, and the speed of physiological decompensation.

Developmental Anatomy: The Paediatric vs. Adult Airway

The paediatric airway is not simply a smaller version of the adult airway; it undergoes significant structural and positional changes from infancy through adolescence.

Feature	Paediatric Larynx (Infant/Toddler)	Adult Larynx
Laryngeal Position	Higher and more anterior (level of C3–C4).[14, 15]	Lower in the neck (level of C5–C6).[14, 15]
Laryngeal Shape	Funnel-shaped or conical.[14, 15]	Cylindrical.[14, 15]
Epiglottis	Long, floppy, U-shaped or Omega-shaped.[15, 16]	Shorter, firmer, and flatter.[15]
Narrowest Point	Subglottic region at the cricoid cartilage.[14, 15]	Glottis (vocal cords).[14, 15]
Cartilage Consistency	Soft, compliant, and prone to collapse.[15, 16]	Firm and calcified.[14, 16]
Tongue Size	Proportionally larger relative to oral cavity.[14, 17]	Proportionally smaller.[14]

The high, anterior position of the paediatric larynx can make visualization during direct laryngoscopy more difficult, often necessitating the use of a straight blade (e.g., Miller) to directly lift the floppy epiglottis.[16] Furthermore, because the cricoid ring is the narrowest point in children under eight to ten years old, subglottic edema (as seen in croup) has a disproportionate effect on airway resistance.[14, 17]

The Physics of Airflow: Poiseuille’s Law and Resistance

The clinical urgency associated with airway narrowing is explained by the physics of fluid dynamics. Airway resistance ($R$) is governed by Poiseuille’s Law, which states that resistance is inversely proportional to the fourth power of the radius ($r$):

$$R\propto \frac{8\eta L}{\pi r^4}$$

In a neonatal or infant airway with a small diameter, a single millimetre of mucosal edema can reduce the radius by half. This results in a $16$-fold increase in airway resistance ($1/0.5^4=16$), leading to a massive increase in the work of breathing and rapid respiratory muscle fatigue.[14, 17] In contrast, the same millimetre of edema in an adult airway has a much smaller percentage impact on the radius and therefore a less dramatic effect on resistance.[14, 17]

Dynamic Obstruction and Cartilaginous Support

The cartilaginous structures of the airway (thyroid, cricoid, and tracheal rings) provide the scaffold necessary to keep the airway patent during the negative pressures generated by inspiration. In children, these structures are soft and compliant. During respiratory distress, the high negative inspiratory pressures can cause dynamic collapse of these soft structures, further narrowing the lumen—a phenomenon often seen in laryngomalacia or tracheomalacia.[14, 16] In adults, these cartilages are firmer and eventually ossify, providing more stable support but also making procedures like cricothyroidotomy more physically demanding.[15, 16]

RC1: Choking (Foreign Body Airway Obstruction)

Definition and Classification

Choking, or Foreign Body Airway Obstruction (FBAO), is the sudden, mechanical impairment of airflow caused by an inhaled or ingested object lodged in the respiratory tract.[1] It is categorized into two clinical stages:

1. Mild Obstruction: The victim is able to speak, cry, and cough effectively. They are usually able to take a breath between coughs.[1]
2. Severe Obstruction: The victim is unable to breathe or speak. Coughing is quiet, weak, or absent. Cyanosis may be present, and the conscious level will rapidly deteriorate without intervention.[1]

Epidemiology and Aetiology

The incidence of choking within the United Kingdom exhibits a bimodal distribution, primarily affecting young children and the elderly. The Office for National Statistics (ONS) recorded $289$ deaths in $2016$ due to choking, with $91\%$ of these occurring in adults over $45$ years.[2]

Paediatric Incidence and Risk Factors

Choking is a leading cause of accidental death in children under three years old, with $80\%$ of cases occurring in the $1$ to $2$-year age group.[1] Children in this developmental stage engage in oral exploration and lack the molar teeth necessary to grind food effectively. Common aetiological agents include:

• Food Items: Grapes, hotdogs, candy, nuts, and seeds. Round, slippery foods are particularly dangerous as they can form a perfect seal in the paediatric airway.[1, 18]
• Non-Food Items: Coins, marbles, small toy parts, and latex balloons. Latex balloons are the leading cause of fatal non-food choking in children because they can conform to the shape of the airway.[1, 18]

Adult Incidence and Risk Factors

In adults, choking is frequently associated with mealtimes. Data from the London Ambulance Service (LAS) in $2016$ showed an average of $5.2$ choking calls per day, with significant spikes at lunch ($12:00$–$14:00$) and dinner ($16:00$–$20:00$), particularly on Sundays at $13:00$, likely related to the traditional Sunday roast.[3] Predisposing factors in adults include:

• Neurological Impairment: Stroke, Parkinson’s disease, and dementia, which impair the swallowing reflex (dysphagia).[2, 18]
• Poor Dentition: The absence of teeth (agomphiasis) or ill-fitting dentures prevents adequate chewing.[1, 2]
• Substance Use: Alcohol consumption and the use of sedative medications significantly increase the risk of aspiration.[1, 3]
• Psychiatric Factors: Patients with developmental disabilities or pica are at high risk.[2, 19]

Pathophysiology and Macroscopic Changes

The primary pathological consequence of FBAO is asphyxia. As the airway is occluded, gas exchange ceases, leading to rapid hypoxaemia and hypercapnia. The brain is the organ most sensitive to this lack of oxygen, with cellular death beginning within four to six minutes and irreversible damage occurring after ten minutes.[7, 20] Macroscopically, the airway mucosa may show immediate reactive edema, particularly if the object is sharp or chemically irritating. In cases of partial obstruction that become chronic (e.g., in children where the choking event was not witnessed), the clinician may find granulation tissue, localized pneumonia, or atelectasis on imaging.[21]

Clinical Assessment (ABCDE)

The assessment of a choking victim must be instantaneous. The "universal choking sign" (clutching the neck) is highly specific in conscious adults.[18]

Airway (A)

• Signs: Inability to speak, vocalize, or cry. In infants, look for "silent crying."
• Differentiating Features: If the patient can speak or cough forcefully, the obstruction is mild. If they are silent or making high-pitched "crowing" sounds, the obstruction is severe.[1, 22]

Breathing (B)

• Signs: Tachypnoea, use of accessory muscles, and supraclavicular/intercostal recession.
• Auscultation: May reveal unilateral wheeze if the object has passed into a main bronchus (usually the right due to its more vertical orientation).[1, 18]

Circulation (C)

• Signs: Tachycardia and hypertension are initial responses to distress and hypoxia.
• Cyanosis: A late and grave sign. Look for central cyanosis in the lips and tongue.[1, 22]
• Pre-terminal Signs: Bradycardia indicates imminent cardiac arrest.[23]

Disability (D)

• Signs: Rapid progression from agitation and anxiety to drowsiness and finally loss of consciousness.[1, 22]

Exposure (E)

• Signs: Examine the chest and abdomen for signs of trauma, particularly if bystander first aid has been attempted.[1]

Management and Summary of Evidence

The management of choking follows the Resuscitation Council UK 2021/2025 guidelines, which emphasize a sequence of manoeuvres based on the patient's age and conscious level.[6, 24]

The Conscious Choking Victim

If the patient has an effective cough, they should be encouraged to continue coughing and closely monitored. If the cough becomes ineffective:

• Back Blows: Deliver up to five sharp blows between the shoulder blades with the heel of the hand. The patient should be leaned forward to assist the movement of the object out of the airway.[6, 21]
• Abdominal Thrusts (Heimlich Maneuver): For adults and children over one year, deliver up to five abdominal thrusts. This increases intrathoracic pressure, acting as an "artificial cough".[6, 7]
• Chest Thrusts: For infants under one year, pregnant women, or the morbidly obese, alternate five back blows with five chest thrusts (using the same landmark as chest compressions but more sharp).[6, 7]

The Unconscious Choking Victim

If the victim becomes unresponsive, they must be gently lowered to the floor and emergency services (999 or 2222) called immediately.[6, 7]

• Commence CPR: Start with five rescue breaths. Healthcare professionals should use a bag-mask device if available.[6, 25]
• Mechanism: The aim of rescue breaths is not only to ventilate but also to potentially push the foreign body into a main bronchus, which, while not ideal, may allow for the ventilation of at least one lung.[7, 24]
• Airway Check: Before each set of breaths, check the mouth for the object. Only use a finger sweep if the object is clearly visible and easily reachable; blind finger sweeps are strictly prohibited as they may push the object deeper.[6]

Evidence on Effectiveness

A prospective observational study (the MOCHI registry) involving 407 patients demonstrated that bystander intervention with back blows or abdominal thrusts significantly improved neurological outcomes (38% vs. 16% in no intervention).[26] Back blows were specifically associated with a higher 30-day survival rate (HR 0.52).[26]

Complications and Their Management

The clinician must be aware that the treatments for choking can themselves cause significant injury.

Complication	Timeframe	Mechanism	Management
Visceral Rupture (Gastric/Splenic)	Immediate	Forceful abdominal thrusts causing internal organ damage.[1, 20]	All patients who receive abdominal thrusts require a formal abdominal assessment; consider CT if tender.[1]
Hypoxic Brain Injury	Immediate to Delayed	Prolonged period of asystole or severe hypoxia.[2, 7]	Neuroprotective intensive care, maintenance of normotension and normoglycaemia.[7]
Iatrogenic Airway Trauma	Immediate	Sharp edges of the foreign body or traumatic removal attempts.[2]	Dexamethasone to reduce edema; ENT review for mucosal lacerations.[2, 9]
Aspiration Pneumonia	Delayed (24–72h)	Inhalation of stomach contents or bacteria during the event.[21]	Broad-spectrum antibiotics and chest physiotherapy.[21]

RC2: Stridor (Acute Upper Airway Obstruction)

Definition and Classification

Stridor is a high-pitched, predominantly inspiratory sound caused by turbulent airflow through a narrowed upper airway. It is a symptom, not a diagnosis, and its presence indicates that the airway is narrowed to less than $50\%$ of its normal diameter.[4, 9]

Timing of Stridor	Likely Anatomical Level of Obstruction	Common Differentials
Inspiratory	Supraglottic or Glottic (above the cords).[4]	Croup, Epiglottitis, Peritonsillar Abscess, Vocal Cord Palsy.[4]
Expiratory	Tracheobronchial (below the cords).[4]	Tracheomalacia, Bronchial Foreign Body, Bronchospasm.[4]
Biphasic	Subglottic or Glottic (fixed obstruction).[4]	Subglottic Stenosis, Bacterial Tracheitis, Critical Laryngeal Cancer.[4]

Paediatric Stridor: Epidemiology and Aetiology

In children, stridor is most commonly due to infectious causes, although the emergency physician must always consider congenital anomalies and foreign body inhalation.

Viral Croup (Laryngotracheobronchitis)

Croup is the most frequent cause of acute stridor, affecting $3\%$ of children annually, typically between 6 months and 3 years.[4, 27]

• Aetiology: Primarily Parainfluenza virus (Types 1 and 3). Other causes include Influenza A and B, RSV, and Adenovirus.[4, 27, 28]
• Pathology: Viral invasion leads to mucosal edema and subglottic narrowing.[27, 29]

Acute Epiglottitis (Supraglottitis)

A life-threatening emergency characterized by rapid inflammation of the epiglottis and surrounding structures.

• Aetiology: Historically Haemophilus influenzae type b (Hib). Now rare in the UK due to vaccination, but can be caused by Streptococcus species or Staphylococcus aureus in older or unimmunized children.[30, 31]
• Pathology: Massive "cherry-red" swelling of the epiglottis that can act as a trapdoor, completely occluding the airway during inspiration.[32]

Bacterial Tracheitis

Often follows a viral respiratory infection. It is a severe bacterial infection of the tracheal mucosa, leading to thick, purulent secretions that can cause sudden airway plugging.[33, 34]

Adult Stridor: Epidemiology and Aetiology

In adults, stridor is less common than in children and frequently indicates a chronic process that has reached a critical threshold, or a severe, rapid-onset infection.

• Malignancy: Laryngeal, pharyngeal, or thyroid carcinoma. Stridor is often a late-stage sign of tumour growth.[5, 35]
• Acute Supraglottitis: The adult version of epiglottitis. It often presents with severe sore throat and dysphagia before stridor develops.[5]
• Trauma: Laryngeal fractures from blunt neck trauma (e.g., "clothesline" injuries).[4, 9]
• Angioedema: Rapid swelling of the tongue, lips, and posterior pharynx, often secondary to ACE inhibitors or anaphylaxis.[1, 36]

Clinical Assessment of Stridor

The cardinal rule in managing stridor, especially in children, is do not agitate the patient. Crying and anxiety increase inspiratory flow velocity, which increases turbulence and can lead to total airway collapse.[4, 8, 37]

Clinical Assessment (ABCDE)

• Airway: Assess for drooling (high specificity for epiglottitis, LR+ 13) and the barking cough (highly sensitive for croup, LR+ 40).[30, 31] Look for the "tripod" or "sniffing" position.[36, 37]
• Breathing: Monitor respiratory rate and saturation. Note that saturations are often normal until the airway is almost completely obstructed; hypoxia is a pre-terminal sign.[4, 8, 23]
• Circulation: Tachycardia is expected. Monitor for signs of shock if an abscess or epiglottitis is suspected.[4, 23]
• Disability: Agitation (hypoxia) vs. Drowsiness (hypercapnia/exhaustion).[8, 23]
• Exposure: Check for neck masses, surgical scars, or urticarial rashes.[5, 36]

Severity Scoring: The Westley Croup Score

Used to standardize the assessment and guide treatment in paediatric croup.[4, 23]

Parameter	0	1	2	3	4	5
Inspiratory Stridor	None	With agitation	At rest	-	-	-
Intercostal Recession	None	Mild	Moderate	Severe	-	-
Air Entry	Normal	Decreased	Markedly dec	-	-	-
Cyanosis	None	-	-	-	With agitation	At rest
Level of Consciousness	Normal	-	-	-	-	Altered

• Mild (≤2): Usually safe for discharge after a single dose of steroids.[4, 23]
• Moderate (3–5): Requires observation and steroids.[4, 23]
• Severe (≥6): Requires nebulized adrenaline and immediate senior/specialist review.[4, 23, 38]

Key Investigations

• Fibreoptic Nasendoscopy (FNE): In adults, this is the definitive diagnostic tool to visualize the site of obstruction. It should be performed by a specialist with equipment for emergency airway management immediately available.[9, 37, 39]
• Imaging: X-rays are rarely needed if the diagnosis is clear. The "Steeple Sign" (subglottic narrowing) and "Thumbprint Sign" (epiglottic swelling) are classic but should not delay treatment.[27, 34] CT is useful for deep neck space abscesses in stable patients.[35, 37]
• Blood Gases: Arterial or capillary blood gases are useful to monitor for rising $pC{O}_2$, which indicates respiratory failure.[9, 40]

Treatment and Evidence Summary

Management is focused on reducing airway edema and maintaining oxygenation while awaiting specialist intervention.

Pharmacotherapy

• Corticosteroids: A single dose of Dexamethasone (0.15 mg/kg orally in children, or 8 mg IV in adults) is the gold standard. It reduces the need for intubation and shortens hospital stay. Improvement typically begins within 2 hours.[4, 9, 41]
• Nebulized Adrenaline: Used for moderate to severe stridor. Dose: 0.5 mL/kg of 1:1,000 (up to 5 mL). It causes local vasoconstriction, reducing mucosal edema. Effect is rapid (30 mins) but temporary (2 hours); patients must be observed for "rebound" symptoms.[4, 8, 27]
• Heliox (Helium-Oxygen mixture): Because helium is significantly less dense than nitrogen, Heliox reduces the Reynolds number ($Re=\rho vd/\mu$), promoting laminar flow and reducing the work of breathing. It is most effective in severe, fixed obstructions.[9, 39]

Definitive Airway Management

If the patient fails to respond to medical therapy or shows signs of exhaustion:

• Intubation: Should be performed by the most senior anaesthetist available. In children, use an uncuffed endotracheal tube that is $0.5$ to $1$ size smaller than predicted for their age.[36, 38]
• Surgical Airway (FONA): In a "Cannot Intubate, Cannot Oxygenate" scenario, the UK standard is a scalpel-bougie cricothyroidotomy. A horizontal incision is made through the cricothyroid membrane, a bougie is inserted into the trachea, and a size 6.0 cuffed ETT is passed over the bougie.[9]

Complications and Clinical Pitfalls

Immediate vs. Delayed Complications

Scenario	Immediate Complications	Delayed Complications
Acute Stridor	Total airway collapse, hypoxia-induced cardiac arrest.[4, 20, 23]	Subglottic stenosis (if intubated), vocal cord granulomas.[14, 35]
Epiglottitis	Rapid CICO scenario if airway is examined with a tongue depressor.[4, 37]	Epiglottic abscess, septicaemia, meningitis.[30, 32]
Cricothyroidotomy	Haemorrhage, oesophageal perforation, pneumothorax.[9, 38, 40]	Tracheal stenosis, persistent stoma, subglottic scarring.[9]

Clinical Pitfalls to Avoid

1. Agitating the Child: Do not attempt IV access or throat examination in a child with suspected epiglottitis or severe croup until in a controlled theatre environment.[4, 37]
2. Relying on Pulse Oximetry: Saturations stay normal for a long time in upper airway obstruction. A "normal" $Sp{O}_2$ in a struggling patient is not reassuring.[4, 8, 23]
3. The "Silent Chest": Stridor may disappear because the patient is moving so little air, not because they are improving. This is a pre-terminal sign.[23, 37]
4. Premature Discharge: Patients who receive nebulized adrenaline must be observed for at least 3-4 hours to ensure no rebound stridor occurs.[8, 38]

Learning Aids and Bedside Mnemonics

Airway Assessment (The UK/US Integration)

• LEMON (Difficult Intubation): Look externally, Evaluate (3-3-2 rule), Mallampati, Obstruction (stridor), Neck mobility.[42, 43, 44]
• MOANS (Difficult BVM): Mask seal (beards), Obesity/Obstruction, Age (>55), No teeth, Stiff lungs.[42, 45, 46]
• SHORT (Surgical Airway): Surgery (previous), Haematoma, Obesity, Radiation, Tumour.[42, 43, 46]

The Impending Airway Disaster Triad

The emergency physician should be alerted to an imminent crisis by the presence of:

1. Rapid-onset aphagia or severe dysphagia (often with a severe sore throat).
2. Rapid-onset laryngeal voice change (hoarse, muffled, or "croaky").
3. Systemic illness (pyrexia, tachycardia, tachypnoea). .[9, 47]

The Seven S's of the Paediatric Larynx

To remember the paediatric anatomical differences: Size (smaller), Shape (funnel), Softness (compliant), Superior (higher C3-C4), Straighter (less oblique), Sensitivity (reactive mucosa), Subglottis (narrowest point).[15]

Electronic Health Record (EHR) Documentation (EPIC Structure)

A structured approach to documentation ensures that all critical safety parameters are captured and clinical reasoning is transparent.

EPIC SmartForm: Airway Obstruction / Stridor

Initial Clinical Gestalt

• [ ] Severe distress / Impending arrest
• [ ] Moderate distress / Compensating
• [ ] Mild distress / Stable

ABCDE Assessment

• Airway: [ ] Patent | [ ] Partially Obstructed | [ ] Complete Obstruction
  • Details: [ ] Stridor ( [ ] Insp | [ ] Exp | [ ] Biphasic) | [ ] Drooling | [ ] Voice change
• Breathing: RR: ____ | SpO2: ____% on ____ | [ ] Recession | [ ] Accessory muscle use
  • Auscultation: [ ] Normal | [ ] Unilateral dec. sounds | [ ] Stridor transmitted
• Circulation: HR: ____ | BP: ____ | CRT: ____s | [ ] Cyanosis
• Disability: GCS: ____/15 | [ ] Agitated | [ ] Lethargic | [ ] Responding only to pain
• Exposure: Temp: ____°C | [ ] Neck mass | [ ] Tracheal deviation | [ ] ACEi use

Medical Decision Making (MDM)

• Differential Diagnosis: [ ] Viral Croup | [ ] Epiglottitis | [ ] FBAO | [ ] Malignancy | [ ] Abscess
• Justification: Clinical findings of [barking cough/drooling/sudden onset] suggest. Absence of [fever/prodrome] makes less likely.
• Risk Stratification: Westley Score (if paeds): ____. Risk of deterioration: [High/Mod/Low].
• Escalation: [ ] Consultant EM aware | [ ] Anaesthetic Reg aware | [ ] ENT Reg aware
• Management Administered:
  • [ ] Dexamethasone (Dose: ____ mg | Route: ____)
  • [ ] Nebulized Adrenaline (Dose: ____ mg | Response: [Improved/No change])
  • [ ] Heliox started
• Procedures: [ ] BVM | [ ] Intubation attempted (Grade: ____) | [ ] FONA performed

Disposition and Safety Netting

• [ ] Admitted to
• [ ] Discharged after [4 hours] observation; stridor-free at rest.
• [ ] Safety netting provided (Patient leaflet / return if stridor recurs).

.[48, 49]

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1. Choking and Foreign Body Airway Obstruction (FBAO) - Patient.info, https://patient.info/doctor/history-examination/choking-and-foreign-body-airway-obstruction-fbao
2. Risk factors and prevention of choking - PMC - NIH, https://pmc.ncbi.nlm.nih.gov/articles/PMC10811631/
3. London ambulance source data on choking incidence for the calendar year 2016: an observational study - PMC, https://pmc.ncbi.nlm.nih.gov/articles/PMC5728301/
4. Acute Stridor - RCEMLearning, https://www.rcemlearning.co.uk/reference/croup/
5. Acute adult upper airway obstruction - Right Decisions - NHS Scotland, https://www.rightdecisions.scot.nhs.uk/nhs-borders-clinical-guidelines/ear-nose-and-throat/acute-adult-upper-airway-obstruction/
6. Paediatric Life Support (basic and advanced) | Resuscitation ..., https://www.resus.org.uk/professional-library/2025-resuscitation-guidelines/paediatric-basic-life-support-guidelines
7. Choking Definition, Symptoms, Causes, First Aid, Heimlich Maneuver - eMedicineHealth, https://www.emedicinehealth.com/choking/article_em.htm
8. Clinical Practice Guidelines : Croup (Laryngotracheobronchitis) - The Royal Children's Hospital, https://www.rch.org.au/clinicalguide/guideline_index/croup_laryngotracheobronchitis/
9. Stridor - entsho.com, https://entsho.com/stridor
10. RCEM SLOs Explained: The Key to Mastering Emergency Medicine, https://www.emlearningcentre.com/blog/rcem-slos-explained-the-key-to-mastering-emergency-medicine
11. (PDF) Royal College of Emergency Medicine Curriculum 2021 - ResearchGate, https://www.researchgate.net/publication/379862438_Royal_College_of_Emergency_Medicine_Curriculum_2021
12. Specialty Learning Outcomes (SLOs) - RCEMCurriculum, https://rcemcurriculum.co.uk/specialty-learning-outcomes-slos/
13. RCEM Curriculum 2021 - St.Emlyn's, https://www.stemlynsblog.org/rcem-curriculum-2021/
14. Pediatric vs Adult Airway: Key Differences Explained Clearly - Dental Sedation Education, https://dstareducation.com/pediatric-vs-adult-airway/
15. Adult vs Pediatric Larynx | ENT Notes & Lectures - The ENT Resident, https://www.theentresident.com/ent-notes-lectures/adult-vs-pediatric-larynx
16. Pediatric airway management - PMC - NIH, https://pmc.ncbi.nlm.nih.gov/articles/PMC3982373/
17. Significant Airway Anatomy Differences in Children, https://resources.time.leeds.ac.uk/rrapid/pRRAPID/03-airway-03.html
18. Foreign Body Airway Obstruction - StatPearls - NCBI Bookshelf, https://www.ncbi.nlm.nih.gov/books/NBK553186/
19. Clinical Practice Guidelines : Foreign body ingestion - The Royal Children's Hospital, https://www.rch.org.au/clinicalguide/guideline_index/Foreign_body_ingestion/
20. Effect of body position on relieve of foreign body from the airway - PMC, https://pmc.ncbi.nlm.nih.gov/articles/PMC6606524/
21. Choking - Wikipedia, https://en.wikipedia.org/wiki/Choking
22. Adult Foreign-Body Airway Obstruction - American Heart Association CPR and First Aid, https://cpr.heart.org/-/media/CPR-Files/CPR-Guidelines-Files/2025-Algorithms/Algorithm-BLS-Adult-FBAO-250630.pdf?sc_lang=en
23. 3.29 ACUTE STRIDOR AND CROUP - Sheffield Children's Hospital, https://www.sheffieldchildrens.nhs.uk/download/1720/medical-emergencies/64176/3-29-stridor-and-croup.pdf
24. Adult basic life support Guidelines | Resuscitation Council UK, https://www.resus.org.uk/professional-library/2025-resuscitation-guidelines/adult-basic-life-support-guidelines
25. Changes to the Resuscitation Council Guidelines 2021 Released! - Surrey First Aid, https://www.surreyfirstaid.com/news/232-changes-to-the-resuscitations-council-guidelines-2021.html
26. Efficacy of abdominal thrusts and back blows for patients with foreign body airway obstruction: MOCHI registry analysis - PMC, https://pmc.ncbi.nlm.nih.gov/articles/PMC12270737/
27. Croup for the USMLE Step 2 - ditki medical & biological sciences, https://ditki.com/course/usmle-comlex-step-2/glossary/pathophysiologic-disorder/croup-for-the-usmle-step-2
28. Laryngitis, epiglottitis and pharyngitis - PMC - NIH, https://pmc.ncbi.nlm.nih.gov/articles/PMC7152339/
29. Croup - Symptoms & causes - Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/croup/symptoms-causes/syc-20350348
30. Symptoms and signs differentiating croup and epiglottitis | Request PDF - ResearchGate, https://www.researchgate.net/publication/49622847_Symptoms_and_signs_differentiating_croup_and_epiglottitis
31. Croup: Rapid Evidence Review - American Academy of Family Physicians, https://www.aafp.org/pubs/afp/issues/2026/0300/croup.pdf
32. Croup & Epiglottitis | Overview, Causes & Differences - Study.com, https://study.com/academy/lesson/croup-vs-epiglottitis.html
33. Bacterial tracheitis in children: Approach to diagnosis and treatment - PMC - NIH, https://pmc.ncbi.nlm.nih.gov/articles/PMC2719512/
34. Comparison between Croup, Epiglottitis and Tracheitis - RCEMLearning, https://www.rcemlearning.co.uk/modules/acute-stridor/lessons/other-causes-of-acute-stridor-in-children/topic/comparison-between-croup-epiglottitis-and-tracheitis/
35. Malignant central airway obstruction - PMC - NIH, https://pmc.ncbi.nlm.nih.gov/articles/PMC5696549/
36. Clinical Practice Guidelines : Acute upper airway obstruction - The Royal Children's Hospital, https://www.rch.org.au/clinicalguide/guideline_index/acute_upper_airway_obstruction/
37. Stridor - Causes - Differential Diagnosis - TeachMeSurgery, https://teachmesurgery.com/ent/presentations/stridor/
38. Acute Upper Airway Obstruction, http://southwestpccodn.nhs.uk/wp-content/uploads/2024/08/Upper-Airway-obstruction-V1.2-07.02.2024-Publication.pdf
39. Management of Stridor - GGC Medicines, https://handbook.ggcmedicines.org.uk/guidelines/respiratory-system/management-of-stridor/
40. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults | Thorax, https://thorax.bmj.com/content/71/Suppl_2/ii1
41. Acute management of croup in the emergency department - PMC - NIH, https://pmc.ncbi.nlm.nih.gov/articles/PMC5804741/
42. Mnemonics for difficult airway predictors - Academic Life in Emergency Medicine, https://www.aliem.com/mnemonics-for-difficult-airway/
43. Airway Assessment - The US Approach - RCEMLearning, https://www.rcemlearning.co.uk/modules/difficult-airway-management/lessons/airway-assessment-the-us-approach/
44. Difficult Airway Management - RCEMLearning, https://www.rcemlearning.co.uk/reference/difficult-airway-management-2/
45. EMS Airway Clinic | Tag Archive | mnemonics, https://anaesthetics.ukzn.ac.za/Libraries/ab2/EMS_Airway_Clinic_Case_report_mnemonics.pdf
46. Airway Assessment – The US Approach - RCEMLearning EMFP, https://www.rcemlearning.org/modules/difficult-airway-management/lessons/airway-assessment-the-us-approach/
47. Stridor — entsho.com, https://www.entsho.com/stridor
48. What components are essential for an ER Medical Decision Making (MDM) template?, https://www.droracle.ai/articles/464609/what-components-are-essential-for-an-er-medical-decision
49. StatMacros, http://www.statmacros.com/uploads/2/0/9/5/20955098/statmacros-1544038580__1_.pdf

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