The Obstructed Airway

Dr David Pritchard
23rd October 2009
 Important?

• All resus algorithms begin with A

• Key part of anaesthetic management
• They will call YOU
• Potential to make a bad situation worse
 Assessment
• Know what you are getting into
• Key is in the history
• Prev. Examinations or GA helpful but things
may have changed
• Xrays and CT may decide management
• Symptoms depend on level of obstruction,
severity and time-course
 Acute upper airway obstruction
Coughing, gagging choking
Failure to manage secretions
Stridor
Aphonia
Respiratory distress
Tripod positioning
Sternal tug, recession
See-sawing movements
 Acute lower airway
• Cough
• Wheeze + prolonged expiration
• May have stridor if tracheal
• Hypoxia/cyanosis
• Signs of distal infection or lung collapse
 Chronic upper airway
• Voice change
• Stridor
• Hypoxia/exertional dyspnoea
• Dysphagia
• May be asymptomatic
 Management
• Depends on level of obstruction, severity ,
time-course and cause
• Is it immediately life-threatening?
• Easily treatable cause?
• Is it rapidly progressing?
• What will happen on induction?
• Will I be able to get a tube/device past the
obstruction?
• Early surgical airway??
What’s the cause?
 Commonly...
• Tumour- inc. Goitre, haematoma
• Infection-abscesses/croup/epiglottitis
• Trauma-Direct/burns/chronic stenosis
• Inhaled foreign body
 Buying time
• Oxygen
• (Nebulised) adrenaline
• Steroids
• Patient positioning
• Heliox
 Heliox
• 21% O2 79% He
• Reduces density of inspired gas
• This increases the amount of laminar flow in
the airway and so reduces resistance
• Reduction in work of breathing, therefore less
O2 required and less CO2 produced
• Main downside is reduction in FiO2, lower
concentrations of He do not produce required effect
 IV induction?
• Simplest way
• Reduction of airway tone may lead to
complete airway obstruction
• May produce catastrophe if airway critical
• Only suitable for mild degrees of partial
obstruction
 Gas induction?
• Patient maintains own airway (ideally)
• Auto feedback
• Allows a look-see if degree of obstruction
uncertain
• First choice for most cases
• Not perfect as airway tone still reduced
• May take much longer due to reduced Vt
• Role of Halothane??
 Adjuncts to think about...
• Smaller tubes
• Bougies/stylets/airway exchange catheters
• Different scopes inc. Glidescope
• Epidural needle for retrograde passage of
catheter
 Fibre-optic intubation?
• Appeals as can maneouvre past obstruction
• However ,may well not be possible
• “cork in bottle”
• Friable tumours may start bleeding and
compromise view
• Probably only suitable for proximal oral
obstructions
 Awake tracheostomy
• Pt maintains own airway
• Surgical airway without compromising airway
tone
• Percutaneous awake techniques small
diameter, not always definitive
• Generally needs patient supine
• May be very distressing
• If any problems or airway bleeding, no plan B
 Last resorts
• Sternotomy
• Cardiopulmonary bypass

• Do nothing