Airway Obstruction Management

Airway obstruction is a critical medical emergency that can lead to hypoxia, brain damage, and death if not promptly and effectively managed. This lesson outlines the causes, recognition, and management of airway obstruction.

I. Causes of Airway Obstruction

Airway obstruction can occur at any level of the respiratory tract, from the nose and mouth to the trachea and bronchi. The causes of airway obstruction can be broadly classified as:

• Foreign body aspiration: This is a common cause of airway obstruction, particularly in children, but can also occur in adults. Examples include food, small objects, and vomit.
• Infections: Infections of the upper airway, such as croup, epiglottitis, and tonsillitis, can cause swelling and obstruction.
  • Croup: Primarily affects young children, causing inflammation of the larynx and trachea, leading to a “barking” cough, stridor, and respiratory distress.
  • Epiglottitis: A life-threatening infection of the epiglottis (the flap that covers the trachea), causing severe throat pain, difficulty swallowing, and rapid airway obstruction.
  • Tonsillitis/Peritonsillar abscess: Severe inflammation or infection of the tonsils or the area around the tonsils can cause swelling and obstruct the airway.
• Allergic reactions: Anaphylaxis can cause rapid swelling of the tongue and throat, leading to severe airway obstruction.
• Trauma: Trauma to the face, neck, or chest can result in airway obstruction due to bleeding, swelling, or displacement of structures.
  • Facial fractures: Fractures of the mandible, maxilla, or nasal bones can lead to swelling and displacement of tissues, obstructing the airway.
  • Neck trauma: Injuries to the larynx or trachea can cause direct obstruction or swelling that compromises the airway.
  • Chest trauma: While primarily affecting breathing, severe chest injuries can indirectly lead to airway obstruction due to decreased consciousness or the need for intubation.
• Tumors: Tumors in the airway or surrounding structures can compress the airway and cause obstruction.
• Laryngospasm: Involuntary contraction of the vocal cords, which can be triggered by irritation, intubation, or certain medications.
• Aspiration: Inhalation of gastric contents or other fluids into the lungs, which can cause both obstruction and inflammation.
• Underlying medical conditions: Conditions such as asthma, COPD, and subglottic stenosis can predispose individuals to airway obstruction.
  • Asthma: Bronchospasm, inflammation, and mucus production can cause airway obstruction during an asthma exacerbation.
  • COPD: Chronic inflammation and narrowing of the airways, along with mucus plugging, can lead to airflow obstruction.
  • Subglottic stenosis: Narrowing of the airway below the vocal cords, which can be congenital or acquired (e.g., after prolonged intubation).
• Obstructive sleep apnea: Relaxation of throat muscles during sleep can cause airway obstruction.

II. Recognition of Airway Obstruction

Prompt recognition of airway obstruction is crucial for effective management. The signs and symptoms of airway obstruction vary depending on the severity and location of the obstruction.

• Mild to moderate obstruction:
  • Coughing (may be forceful initially, then become ineffective)
  • Wheezing (suggests lower airway involvement)
  • Stridor (a high-pitched, noisy sound during inspiration, suggests upper airway obstruction)
  • Difficulty speaking (hoarseness or inability to complete sentences)
  • Increased respiratory effort (e.g., rapid breathing, use of accessory muscles)
• Severe obstruction:
  • Inability to speak or cry
  • Gasping or choking (ineffective or absent cough)
  • Cyanosis (bluish discoloration of the skin, lips, and nail beds – a late sign)
  • Loss of consciousness
  • Respiratory distress (marked tachypnea, retractions)
  • Use of accessory muscles of respiration (e.g., sternocleidomastoid, scalene, intercostal muscles)
  • Paradoxical chest movements (the chest moves inward during inspiration and outward during expiration)
• The universal choking sign: Clutching the neck with both hands is a universal sign of choking and indicates severe airway obstruction.

III. Management of Airway Obstruction

The management of airway obstruction depends on the severity of the obstruction and the underlying cause.

• Mild to moderate obstruction:
  • Encourage coughing: If the patient is able to cough, encourage them to continue coughing forcefully to try to dislodge the obstruction.
  • Positioning: Help the patient find a comfortable position that maximizes their ability to breathe. This is usually upright.
  • Supplemental oxygen: Administer supplemental oxygen if the patient is hypoxic or in respiratory distress.
  • Monitor closely: Closely monitor the patient’s condition for any signs of worsening obstruction.
  • Further evaluation: If symptoms persist, investigate the cause with imaging (X-ray, CT scan) or direct visualization (laryngoscopy, bronchoscopy).
• Severe obstruction (Conscious patient):
  • Heimlich maneuver:
    • Stand behind the patient and wrap your arms around their waist.
    • Make a fist with one hand and place it just above the patient’s navel.
    • Grasp your fist with your other hand and give quick, upward thrusts into the abdomen.
    • Continue thrusts until the obstruction is dislodged or the patient becomes unconscious.
  • Chest thrusts (for pregnant women or obese patients):
    • Place your arms under the patient’s armpits and around their chest.
    • Make a fist and place the thumb side of your fist on the middle of the patient’s breastbone.
    • Grasp your fist with your other hand and give quick, backward thrusts.
  • Back blows:
    • If the Heimlich maneuver is not effective, deliver five back blows between the patient’s shoulder blades using the heel of your hand.
    • Alternate between back blows and abdominal thrusts.
  • Direct laryngoscopy: If trained personnel are available, direct laryngoscopy may be used to visualize and remove the foreign body.
• Severe obstruction (Unconscious patient):
  • Activate emergency medical services (EMS): Call for immediate medical assistance.
  • Position the patient: Place the patient on their back.
  • Open the airway: Use the head-tilt/chin-lift maneuver to open the airway. If a foreign body is visible, attempt to remove it with a finger sweep (but only if you can see it).
  • Begin chest compressions: If the patient is not breathing, begin chest compressions as in CPR. The chest compressions may help to dislodge the obstruction.
  • Look for foreign object: Open the patient’s mouth and look for a foreign object. If you see an object, try to remove it.
  • Ventilate: Attempt to deliver breaths. If the first breath does not go in, reposition the head and try again. If breaths still do not go in, continue chest compressions.
  • Continue CPR: Continue CPR until the obstruction is dislodged, the patient begins to breathe, or EMS arrives.
• Advanced airway management:
  • Supraglottic airway devices: Devices such as the laryngeal mask airway (LMA) or oropharyngeal airway can be used to establish a temporary airway.
    • Oropharyngeal airway (OPA): A curved plastic device inserted into the mouth to keep the tongue from blocking the airway.
    • Nasopharyngeal airway (NPA): A flexible tube inserted through the nose to maintain airway patency.
    • Laryngeal mask airway (LMA): A device with an inflatable cuff that seals around the laryngeal inlet.
  • Endotracheal intubation: Insertion of a tube into the trachea to secure the airway.
  • Cricothyrotomy or tracheostomy: Surgical procedures to create an opening in the neck and trachea to bypass the obstruction. These are typically performed in emergency situations when other measures have failed.
    • Cricothyrotomy: An incision is made through the cricothyroid membrane to establish an airway.
    • Tracheostomy: A surgical opening is created in the trachea below the larynx.
  • Bronchoscopy: A flexible tube with a camera can be inserted into the airway to visualize and remove foreign bodies or other obstructions.