Airway obstruction: Clinical sciences

An airway obstruction is defined as the inability to move air, or ventilate, from a direct occlusion or anatomic narrowing. It requires an immediate assessment and swift intervention, since it can be fatal if left untreated. There are many causes that can lead to airway obstruction, including trauma, tracheal narrowing, foreign body aspiration, mucus plugging, malignancy, and deep neck infection. Keep in mind that all of these causes have the potential to cause hemodynamic instability due to respiratory failure, especially trauma and foreign body aspiration.

When assessing a patient with signs and symptoms suggestive of airway obstruction, you should first perform an ABCDE assessment to determine if the patient is unstable or stable. Be sure to look for red flags of impending airway compromise like stridor, tachypnea, accessory muscle use like gasping or nostril flaring, as well as bleeding in the nasopharynx or the oropharynx, large or expanding neck hematoma, crepitus in the neck or upper chest, and tracheal deviation.

If the patient is unstable with red flags, you must initiate acute management right away to stabilize their airway, breathing, and circulation. The goal here is to maintain oxygenation above 90% initially with a high-flow nasal cannula or non-rebreather. However, if the patient desaturates or cannot protect their airway, proceed with rapid sequence intubation. This involves administering an induction agent like etomidate; and a paralytic agent like succinylcholine or rocuronium. Once medications start working, you can intubate the patient.

Here’s a clinical pearl! If airway obstruction is anticipated, make sure to have multiple sizes of small endotracheal tubes available. Keep in mind that, although securing the airway is the top priority, the workup will likely require laryngoscopy and bronchoscopy.

Now, if intubation is unsuccessful after 3 attempts or you cannot maintain oxygenation above 90%, consider cricothyroidotomy to create an emergency surgical airway. Once you’re done securing the airway, make sure to establish IV access and administer fluids before continuing with your assessment.