Acute airway obstruction

Theory

This is the most serious of all emergency situations and needs immediate assessment and management.

If a patient has no patent airway they will arrest and die rapidly.

Establishing a patent airway is the first step in the management of any patient, especially in the emergency or trauma situation.

Patients on the ward are susceptible to acute airway obstruction, especially if they have an altered conscious state due to opiate analgesia, confusion or the residual effects of anaesthetic agents.

This is the most common cause of acute airway obstruction in hospital patients and is managed by simple airway manoeuvres – chin lift, jaw thrust and head tilt.

Management focuses on relieving the obstruction and establishing a patent airway.

Immediate intern management

Attend patient and make rapid assessment.

If patient unconscious/severe respiratory distress/respiratory arrest

Tell nursing staff to call Code Blue then move to head end of bed.
Perform triple manoeuvre – chin lift, jaw thrust, head tilt.
Clear mouth – suction secretions, sweep out foreign body from pharynx.

If it is an acute obstruction and the above fail, then a definitive airway is required.

If mechanically obstructed

Surgical airway

Cricothyroidotomy
Tracheostomy

If acute neck haematoma

Open neck wound down to and including the deep fascial sutures.

If still obstructed and trachea on view attempt to incise and insert endotracheal tube.

If not mechanical

Bag and mask patient with oxygen using Guedel airway.

These manoeuvres can maintain an airway until help arrives.

Once more experienced staff are available the patient requires intubation and insertion of an Endotracheal tube.

If unable to intubate, can try to insert laryngeal mask but if this does not secure airway:

Surgical airway

Cricothyroidotomy
Tracheostomy

Clinical features (obtain rapidly)

History

Basic information about patient
Events resulting in obstruction
Recent drug administration/operation

Examination

Patient in extremis
Stridor
Respiratory distress
Cyanosis
Drooling
Swelling face/tongue

Causes

Acute mechanical obstruction
Sputum plug
Altered conscious state
Laryngospasm
Angio-oedema
Disruption ETT/tracheostomy
Neck haematoma post neck surgery
Trauma
Burns
Tumours

Investigations

No Investigation should delay treatment.

ABG
Basic blood tests
CXR
ECG

Cricothyroidotomy

Feel for the prominence of the thyroid cartilage
Incise horizontally in space inferior to thyroid cartilage, (this is cricothyroid membrane)
Insert handle of scalpel into incision and twist to open incision and allow insertion of endotracheal tube

Points for consideration – call for help early

An airway is required by any means possible
Choice depends on the cause as illustrated in ‘immediate intern management’
Suction and simple airway manoeuvres may be enough to establish an airway especially in a patient with secretions or a tracheostomy
Ideally intubation and advanced airway management should be performed by highly experienced staff
If simple airway measures are unsuccessful then a definitive airway is required
Intubation can be attempted but in mechanical obstruction is unlikely to be successful
A surgical airway is definitive
First line is cricothyroidotomy
A tracheostomy may be performed if there is sufficient time and adequate staff are readily available
Don’t confuse stridor (fixed airway noise on inspiration) with wheeze (fixed airway noise on expiration)

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