1.Acute Airway Obstruction

 

The airway may get obstructed due to a foreign body, tumor, inflammation or a neurological cause. In an upper airway obstruction patient would usually, but not always, present with stridor or stertor. He may be agitated and restless, semiconscious, or even cyanotic and unconscious. A short history, when available, is invaluable.

It should be remembered that while working to establish the airway, breathing and circulation needs to be simultaneously assessed and dealt with. Get help. You can’t do it alone.

Also, remember that definitive airway is either an endotracheal tube or a tracheostomy. Contrary to the popular belief, tracheostomy is not a suitable procedure in an emergency, especially in inexperienced hands. In a total obstruction, irreversible brain damage occurs in 3-5 minutes. Practically, a tracheostomy always takes longer than that unless the obstruction happens in the operating theatre itself. Therefore, even if a tracheostomy has been decided upon, other measures may be necessary to buy time.

Following is a list of actions that can be used to alleviate hypoxia, temporarily relieve an obstruction or establish a definitive airway in the case of upper airway obstruction.

  1. Oxygen – if the patient is breathing, high concentration oxygen through a facial mask will be helpful to counter hypoxia and to alleviate patient anxiety and agitation.

  2. Oropharyngeal airway – available in the ward, OPD/PCU, and theatre. Would be helpful in infective and inflammatory swellings (e.g. Ludwig’s angina) and tongue falling back. If the history suggests a foreign body in the throat, this carries the risk of pushing it further in.

  3. Nasopharyngeal airway – these are unavailable in the Sri Lankan setup. However, in an inflammatory swelling with trismus, where oropharyngeal airway cannot be inserted, these are quite helpful.

  4. An alternative is an endotracheal tube inserted through the nostril and advanced beyond the tongue base to function as a nasopharyngeal airway. This can be converted into an endotracheal tube by ‘railroading’ with the help of a flexible bronchoscope inserted through the tube. An experienced anesthetist might be able to do blind nasal intubation.

  5. Cricothyroid puncture – this is a helpful procedure that can be performed with minimal facilities to save a life.

  6. Cricoid is the first ‘hard stop’ you will feel when you palpate the trachea from the suprasternal notch upwards. Once this is identified, jab a wide bore IV needle attached to a syringe along its upper border. Placement is confirmed by aspirating air into the syringe. If that is successful, insert a few more needles. You could connect high flow O2 to one needle with the help of a 3cc syringe with plunger removed. Although a patient cannot be ventilated through a cricothyroid puncture, mass movement of gasses will help maintain the alveolar ventilation.

  7. Cricothyroidotomy – when positive pressure ventilation is needed in an emergency, this can be performed. A cricothyroid puncture is performed to confirm the airway, and a stab incision is made with a scalpel along the upper border of the cricoid. Once incised, the scalpel is turned to admit an artery forceps or a tracheal dilator, and later a small endotracheal tube. Care should be taken when stabbing into the trachea to avoid injuring the posterior tracheal wall and the esophagus. Commercial cricothyrodotomy kits are still not available in Sri Lanka.

  8. Emergency tracheostomy – approach is through a vertical incision from the cricoid to the suprasternal notch. Will be difficult in goiters.

© 2019 Dr. Chandra Jayasuriya
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