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Acute Upper Airway Obstruction

The management of acute upper airway obstruction has been modified to incorporate advances in our understanding of its pathophysiological features and causes. The traditional algorithm for management continues to call for high-flow oxygen and conservative measures, bag-mask ventilation, intubation, and, if needed, a surgical opening of the airway. Advances in anesthetic and surgical technologies appear to be improving practitioners’ ability to secure the airway in patients with acute airway obstruction.

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Articles of Interest

A Screwy Case of Pediatric Shortness of Breath

Airway foreign bodies (FB) are a common complaint in the pediatric population. Infants and toddlers explore the world around them by putting objects into their mouths, so it is unsurprising that children aged 6 months to 3 years are the most common age group to present with choking or a concern for FB aspiration. Younger children are at increased risk for significant airway obstruction because of their narrow airways. Their underdeveloped communication skills and unreliable histories further complicate clinical scenarios. Laryngotracheal FBs are most likely to present with acute respiratory distress, hoarseness, or stridor. Bronchial FBs are more likely to present with coughing, wheezing, diminished breath sounds, pain, shortness of breath, or infectious symptoms. Children frequently present with only mild symptoms

Airway Obstruction

Complete obstruction of the upper airway occurs when there is inability to talk, cough or breath. Apnea and cyanosis are present and paradoxical respiration may be noted. Incomplete obstruction occurs when there is partial upper airway obstruction and ability to breath is maintained. Inspiratory stridor and increased work of breathing are the hallmarks.

CritCases 6 – Airway Obstruction

The key to successful awake intubation is meticulous application of topical anesthetic. Get the patient to stick out their tongue and get an assistant to trap the tongue anteriorly with gauze. Get 5% lidocaine ointment and apply it gently to the posterior tongue, the most “gagogenic” region of the oropharynx. Use an atomizer (not a nebulizer) and administer 4% lidocaine to everything in sight. Bend the nozzle tip inferiorly to anaesthetize the glottis and trachea ideally during inspiration. They will cough and they can obstruct so always have your blade, bougie and ETT for an emergency FONA.

Deconstructing Obstructions Techniques for relieving airway obstructions when your advanced airway techniques are exhausted

In the field, few situations cause more anxiety than struggling to clear an obstructed airway. However, when a clinician is successful, it can also be one of the most rewarding experiences of their career. Routine training of advanced airway skills will prepare you to successfully manage most obstructed airway cases. But what happens when you run out of options? What do you do when repositioning and a finger sweep don’t fix the problem and there’s still no air passing into the lungs?

EM@3AM – Airway Obstruction

Unable to intubate (unable to perform airway rescue with supraglottic device) or unable to ventilate... Age > 10 years: cricothyrotomy: cricothyrotomy kit with #4 cuffed tracheal tube or scalpel with 6.0 cuffed ETT (or largest that will fit). Age < 10 years: temporization with transtracheal jet ventilation: placement of a 12 to 16 gauge angiocatheter and anesthesia consultation for definitive management.

Management of airway obstruction

There is no universal ‘best approach’ with experts often providing differing opinions on optimal management.

Management of the Obstructed Airway

In an emergency situation the nature of the obstruction may be unknown and the location, expertise and equipment may be lacking. Optimising the ability to oxygenate is fundamental to all airway stratgies.

Upper Airway Foreign Bodies: Emergency Department Presentation, Evaluation and Management

Although children account for most of foreign body aspiration cases, adults make up to 25% of these incidents. Developmentally delayed individuals are at a higher risk to aspirate foreign bodies.

Upper airway obstruction

Acute upper airway obstruction is a medical emergency and usually caused by aspiration, oedema (allergic, hereditary, and acquired angio-oedema, smoke inhalation), or infection (croup, epiglottitis, quinsy, retropharyngeal abscess). Non-acute causes of upper airway obstruction include malignancy, tracheal stenosis, tracheal compression, dynamic large airway collapse, and laryngeal dysfunction.

Upper Airway Obstruction in the Emergency Department

Face-to-face intubation, commonly referred to as tomahawk or axe intubation, is a difficult airway intervention utilized in pre-hospital, emergency department, inpatient, and operating room settings. Patients with pulmonary edema, significant spine pathology, obesity, etc. may not be able to tolerate laying supine. This technique is valuable as it allows glottic visualization without placing patients in a supine position. As these patients are commonly seen in the emergency department, tomahawk intubation is an extremely useful technique to consider when dealing with a difficult airway.

Upper Airway Obstruction Part 1

Consider BPAP, HFNC for preoxygenation if there is not a complete airway obstruction. Several studies/meta-analyses suggest these improve oxygenation.

Upper Airway Obstruction Part 2

Alternative method for intubation in patients with tenuous upper airway obstruction is face-to-face or seated oropharyngeal intubation, also known as the “tomahawk” method.

Resources

StatPearls

The outcomes for patients with airway obstruction depend on the cause. If the cause is a foreign body that has been removed, the outcomes are excellent. Airway obstruction caused by trauma, malignancy, or an infectious process may lead to delayed recovery and hypoxic brain damage