Airway Obstruction

Ann Kakabadze

Triangles of the neck

Fascial Layers of the Neck

1. F.Colli Superficialis
2. Lamina Superficialis fasciae colli propriae
3. Lamina profunda fasciae colli propriae
4. Fasciae Interna
5. Fasciae Prevertebralis

An airway obstruction is a blockage in the

airway. It may partially or totally prevent air from
getting into your lungs. Some airway obstructions
are life-threatening emergencies. They require
immediate medical attention to prevent death.

Types of Airway Obstructions:

Types of Airway Obstructions:

Upper airway obstructions occur in the area from your nose and lips to
your larynx.
Lower airway obstructions occur between your larynx and the narrow
passageways of your lungs.
Partial airway obstructions allow some air to pass. You can still breath
with a partial airway obstruction, but it will be difficult.
Complete airway obstructions do not allow any air to pass. You cannot
breath if you have a complete airway obstruction.
Acute airway obstructions are blockages that occur quickly. An example
of an acute airway obstruction is choking on a foreign object.
Chronic airway obstructions can occur in one of two ways. These can
be blockages that take a long time to develop. They may also be
blockages that last for a long time. For example, emphysema can cause
a chronic airway obstruction.

What Causes an Airway Obstruction?

The classic image of an airway obstruction is someone choking on a
piece of food. However, thats only one of many things that can cause
an airway obstruction. Other causes include:

inhaling or swallowing a foreign object

a small object becoming lodged in the nose or
mouth
allergic reactions
trauma to the airway from an accident
vocal cord problems
breathing in a large amount of smoke from a
fire
viral infections
bacterial infections
croup - a respiratory illness that causes upper
airway inflammation
swelling of the tongue or epiglottis
abscesses in the throat or tonsils
a collapse of the tracheal wall, known as
tracheomalacia
asthma
chronic bronchitis
Emphysemacystic fibrosis
chronic obstructive pulmonary disease
(COPD)

What Are the Symptoms of an Airway Obstruction?

The symptoms of an airway obstruction depend on the cause. They also
depend on the location of the obstruction. Symptoms you may experience
include:

Agitation
Cyanosis (bluish-colored skin)
Confusion
Difficulty breathing
Gasping for air
Panic
Breathing noises such as wheezing
Unconsciousness

How Is an Airway Obstruction Diagnosed?

Airway obstructions are diagnosed by evaluating your symptoms. Doctors
look for signs that include:

Slowed breathing
Rapid breathing
Decreased breath sounds in your
lungs
No breathing
Bluish skin color
Unconsciousness

Certain tests may also be used

to determine the cause of your
airway obstruction. These may
include:
Bronchoscopy a device called
a bronchoscope is used to look
into your lungs
Laryngoscopy your larynx is
examined using a scope
An X-ray can also be used to look
for obstructions.

How is an Airway Obstruction Treated?

Treatment for an airway obstruction depends on the cause of
the obstruction.
The Heimlich maneuver is an emergency technique that may help a person is
choking. It uses abdominal thrusts to dislodge a foreign object.

An endotracheal or nasotracheal tube may be inserted into the airway. This can
help get oxygen through swollen airways.

Tracheostomy and cricothyrotomy are openings made in the airway to bypass an

obstruction.

Epinephrine can be used to treat airway swelling due to an allergic reaction.

Some people with severe allergies carry EpiPens. These are simple injectors
containing epinephrine.

Cardiopulmonary resuscitation (CPR) can be used to help you if you are not
breathing.

Reduce your risk by doing the following:

o Avoid drinking a lot of alcohol before eating.
o Eat small bites of food.
o Eat slowly.
o Supervise small children when eating.
o Chew thoroughly before swallowing.
o Make sure your dentures fit properly.
o Keep small objects away from children.
o Do not smoke.
o Visit your doctor regularly if you have a condition that
can cause a chronic airway obstruction.

Heimlich
HeimlichManeuver
Maneuver

Endotracheal Intubation

Endotracheal intubation - Endotracheal intubation is

a medical procedure in which a tube is placed into the
windpipe (trachea), through the mouth or the nose. In most
emergency situations it is placed through the mouth.

Indications:

Cardiac or respiratory arrest

Failure to protect the airway

Inadequate oxygenation or ventilation

Impending or existing airway

obstruction

Care of critically ill pations with multisystem disease or injuries

Control of the airway during surgical

procedures requiring general anesthesia

Contra-indications:
Relative contra-indications:
Neck immobility or increased risk of neck trauma (eg, rheumatoid
arthritis or suspected cervical spine injury) - this is not a true
contra-indication, it just makes intubation more difficult. Consider
fibre-optic intubation if available.
Anticipated "difficult" airway - unsuccessful intubation may lead
to further difficulties, especially if anaesthetic drugs have been
given. In this scenarios it is best to continue bag and mask
ventilation (if possible) and get immediate senior help, or use of
other airway adjuncts or consider awake intubation

Absolute contra-indications (will necessitate a

surgical airway or nasal intubation):
Total upper airway obstruction.
Total loss of facial/oropharyngeal landmarks.
Inability to open the mouth (eg, scleroderma or surgical wiring).

Equipments:
Gloves
Face shield
Suction system
Laryngoscope and blade
Endotracheal tube with stylet
10 ml syrings
Bag-valve mask and oxygen
Oral and nasal airway
Endotracheal tube holder or tape

Guidelines in Choosing an Endotracheal

Tube:
Choosing an endotracheal tube needs to be done prior to inducing
anesthesia.
Diameter - The most reliable method to judge the diameter of the
endotracheal tube to be chosen is to gently palpate the trachea.
It is recommended to select three sizes for each patient, the most
closely matching the trachea size, one size smaller and one size
larger. This will ensure that there are two additional tubes ready
should your initial estimation be off.
Body weight (see chart below) can help in estimating your choice
of endotracheal tube. But this method can be misleading especially
for brachycephalic breeds or overweight patients.
Another subjective method involves using the width of the nose
between the nares as an approximation of tracheal diameter

Species
(Internal Diameter)
Feline

Canine

Body Weight (kg)

Tube Size

2
4
8

3
3 - 3.5
3.5 - 4

10
15
20
25
30
35
40
45
60
80

6
6-7
6-7
6-8
7-8
7-8
8-10
8-10
11-12
12-14

Length - The distal end should not extend past the point of
the shoulder, and the proximal end should not extend past the
incisor teeth. Once in place, the tip of the tube should be
located midway between the larynx and the thoracic inlet.

Keep in mind mechanical dead space gas can be the result of an

excessively long endotracheal tube. You can eliminate this by
trimming the proximal part of the endotracheal tube to a short length.

Macintosh blades

To begin the procedure, an anesthesiologist opens the patient's mouth by

separating the lips and pulling on the upper jaw with the index finger. Holding a
laryngoscope in the left hand, he or she inserts it into the mouth of the patient
with the blade directed to the right tonsil. Once the right tonsil is reached, the
laryngoscope is swept to the midline, keeping the tongue on the left to bring the
epiglottis into view. The laryngoscope blade is then advanced until it reaches the
angle between the base of the tongue and the epiglottis. Next, the laryngoscope
is lifted upwards towards the chest and away from the nose to bring the vocal
cords into view. Often an assistant has to press on the trachea to provide a
direct view of the larynx. The anesthesiologist then takes the endotracheal tube,
made of flexible plastic, in the right hand and starts inserting it through the
mouth opening. The tube is inserted through the cords to the point that the cuff
rests just below the cords. Finally, the cuff is inflated to provide a minimal leak
when the bag is squeezed. Using a stethoscope , the anesthesiologist listens for
breathing sounds to ensure correct placement of the tube.
The anesthesiologist should evaluate and follow the patient for potential
complications that may include edema; bleeding; tracheal and esophageal
perforation; pneumothorax (collapsed lung); and aspiration. The patient
should be advised of the potential signs and symptoms associated with lifethreatening complications of airway problems. These signs and symptoms
include but are not limited to sore throat, pain or swelling of the face and
neck, chest pain, subcutaneous emphysema, and difficulty swallowing.

TrtTracheostomy

A tracheotomy or a tracheostomy is an opening

surgically created through the neck into the trachea
(windpipe) to allow direct access to the breathing tube
and is commonly done in an operating room under
general anesthesia

Indications for a tracheostomy:

Obstruction of the upper airway, eg foreign body, trauma,
infection, laryngeal tumour, facial fractures.
Impaired respiratory function, eg head trauma leading to
unconsciousness, bulbar poliomyelitis.
To assist weaning from ventilatory support in patients on
intensive care.
To help clear secretions in the upper airway.

Tracheostomy Tubes

A commonly used tracheostomy tube consists of three parts: outer cannula with flange (neck plate),
inner cannula, and an obturator The outer cannula is the outer tube that holds the tracheostomy open. A
neck plate extends from the sides of the outer tube and has holes to attach cloth ties or velcro strap
around the neck. The inner cannula fits inside the outer cannula. It has a lock to keep it from being
coughed out, and it is removed for cleaning. The obturator is used to insert a tracheostomy tube. It fits
inside the tube to provide a smooth surface that guides the tracheostomy tube when it is being inserted

Types of tracheostomy tubes

Plastic or silver - silver tubes do not have an inner tube and
need to be changed every 5-7 days (compared with every 30
days with some plastic types).
Cuffed or uncuffed - cuffed tubes protect the airway and
tend to be used in ventilated patients.
Fenestrated or unfenestrated - these tubes may or may not
be cuffed. They have a hole in the outer cannula which
means that air can pass from the lungs and up to the vocal
cords and also the mouth and nose. Patients can thus
breathe normally, cough secretions out of the mouth and it
helps voicing. Fenestrated tubes tend not to be used in
children.[3]
Double or single cannula - double cannulae have an inner
and an outer tube. The inner tube reduces the lumen of the
outer tube meaning that respiratory effort is increased, but
the outer tube means that the stoma stays open.

Types of
tracheostomy:
1- Upper tracheostomy;
In the 1st and 2nd tracheal rings above
the isthmus of the thyroid gland
2- Middle tracheostorny;
In the 3rd and 4th trachea rings behind
the isthmus (operation of choice).

3- Inferior tracheostomy
in the 5th and 6th rings below the
isthmus.

1
2
3

4
5
6

Tracheostomy

Procedures of the operation:

1Anaesthesia:
a) No anaesthesia in cyanosed
patients and urgent cases.
b) Local: Infiltration with 1%
Novocain.
c) General: When there is no
emergency (pre-operarive).
2Position:
Neck is extended and a sandbag
is

Tracheostomy
Procedures of the operation:

3- Incision:
a) Midline incision from the lower
border of
the thyroid to the manubrium sterni
b) Cut the skin, superficial fascia,
platysma
and the deep fascia connecting the
pretracheal muscles (sternohyoid and
sternothyroid) of the two sides.
c) Separate the pretracheal muscles of

Tracheostomy
Procedures of the operation:

4- The thyroid isthmus is

divided between
2 kochers, transfixed by catgut
to prevent bleeding and leak of
thyroxin and then retracted.
5- Expose the trachea and inject
1/2 c.c surface anaesthetic
(pantrocaine 1%) in the trachea
to diminish the cough reflex

Tracheostomy
Procedures of the operation:

6- Fix the trachea and elevate it by a

cricoid hook.
7- Open the trachea by an incision or
by removal of a circular part of the
3rd and 4th rings.
8- Insert a suitable tracheostomy
tube
9- Close the wound after ligating the
bleeding

Compliations wich can cause

tracheostomy tube
Proper size
in position

Long curve
causing
injury of both
oesophagus
& trachea.

Long tube
causing
Injury of
esophagus

Small tube
causing
slipping out
&
surgical
emphysema
of neck.

Complications of
Tracheostomy
Intraopertaive

Early

Bleeding and
injury to big
vessels
Injury to
tracheoesophage
al wall
Pneumothorex

Bleeding
Tracheostomy
tube obstruction
Tracheostomy
tube
displacement
Infection

Late
Tracheal
Stenosis
Granulation
tissue
Tracheocutaneus
fistula
Tracheo inominate fistula

The risks associated with

tracheotomies are higher in the
following groups of patients
Children, especially newborns and infants
Smokers
Alcoholics
Obese adults
Persons over 60
Persons with chronic diseases or
respiratory infections
Persons taking muscle relaxants , sleeping
medications, tranquilizers, or cortisone

Aftercare
Postoperative care

Home care

A chest x ray is often

taken

patient and his or her

family members will
learn how clearing it
Warm compresses can
be used to relieve pain
at the incision site
The patient is advised
to keep the area dry
It is recommended that
the patient wear a loose
scarf over the opening
when going outside

prescribe antibiotics to
reduce the risk of
infection