Presentation

Classic presentation

• Patients with upper airway emergencies may have variable initial presentations, from presenting calmly and without distress, to presenting with cyanosis and obtundation.
  
• Patients may complain of airway symptoms such as hoarseness, shortness of breath, or speech changes. Patients may also complain of systemic symptoms such as an allergic reaction or fever.
  
• The wide variety of presentations mandates a high index of suspicion for potential airway compromise.

Critical presentation

• There is often rapid progression from benign to life-threatening symptoms, and one of the key challenges is to anticipate a patient’s clinical course.
  
• Key warning signs of impending airway collapse include
  
  
  
  • Signs of upper airway obstruction: stridor, muffled “hot potato” voice
    
  • Difficulty managing secretions: drooling, tripod position, pooled secretions in posterior pharynx
    
  • Signs of respiratory failure: dyspnea, tachypnea, accessory muscle recruitment, hypoxia.
  
  
• Patients may not demonstrate hypoxemia until late in their presentation.

Diagnosis and evaluation

• The first step in the evaluation of the patient with suspected upper airway emergency is to determine the need for emergent intubation or surgical airway.
  
• If possible, a brief history should be obtained focusing on history of cancer, allergies, exposure to medications including ACE inhibitors, a family history of C1 esterase inhibitor deficiency, trauma, and recent surgery.
  
• A targeted physical examination should include assessment for stridor, hoarseness, urticaria, edema of skin, lips, mouth, and throat.
  
  
  
  • Burns to facial skin or mouth, singed nose hairs, soot in airway should be considered high-risk features in burn patients.
    
  • Trauma patients should be evaluated for blood in airway, facial injuries, penetrating neck injuries, and neck hematomas or ecchymosis.
  
  
• Laboratory testing should be guided by the suspected underlying etiology.
  
• Imaging studies:
  
  
  
  • Patients at risk for impending airway collapse should not be sent to radiology
    
  • Lateral neck radiographs may demonstrate prevertebral swelling.
    
  • CT scan of the neck may provide better anatomical detail and define the amount and location of swelling or mass.

Critical management

• Given the high-risk, time-sensitive nature of these presentations, all practitioners should be familiar with their local resources, algorithms, and airway management options prior to seeing patients.
  
• Risk stratification of the patient by expected clinical course
  
  
  
  • High-risk patients:
    
    
    
    • For patients with severe anaphylaxis/angioedema, upper airway burns and signs of upper airway obstruction, consider intubation preemptively.
      
    • For trauma patients with any signs of airway involvement or “hard signs” of penetrating trauma to the neck, consider immediate intubation.
      
    • Video laryngoscopy with simultaneous surgical airway setup is recommended.
      
    • The high risk of airway collapse and decompensation during sedation and neuromuscular blockade must be considered in these patients.
      
    • The endotracheal tube should be at the smaller end of the acceptable range. A back-up tube of 5.5 or smaller should be immediately available.
    
    
  • Moderate-risk patients:
    
    
    
    • Patients with deep space infections and upper airway tumors have lower risk for rapid evolution and acute decompensation. However, these patients may present late in their course with an impending airway obstruction.
  
  
• Awake visualization/intubation
  
  
  
  • In patients with a rapidly evolving upper airway obstruction, awake evaluation can provide invaluable information about potential complications before paralytics are administered. Paralytics should never be administered if a “cannot intubate, cannot ventilate” situation is anticipated.
    
  • Giving sedation carries the risk of airway collapse during most upper airway emergencies. Optimization of local anesthesia is recommended to minimize need for sedation and to preserve airway reflexes.
    
  • The nasal route is usually preferred for cases mandating immediate visualization only. When planning intubation, the nasal route allows a direct passage to the vocal cords and may be easier for an awake patient to tolerate. Downsides to the nasal route include the need for greatly reduced tube diameter and the increased risk of inadvertent extubation due to a longer pathway for the tube. Therefore, the nasal route is primarily used in cases of angioedema or when an oral mass hinders oral visualization.
    
  • If the patient requires immediate intubation, but not an immediate surgical airway, oral visualization/intubation is the preferred method. This may be accomplished with a flexible endoscope loaded with an endotracheal tube, or video/standard laryngoscope.
    
  • Adequate preparation, including preoxygenation, gathering appropriate staff, having desired medications drawn up, and having a detailed algorithm including back-up and surgical options is critical prior to initiating any airway manipulation unless the patient is rapidly deteriorating.
    
  • The major steps to awake visualization/intubation are
    
    
    
    • Pretreatment with glycopyrrolate, if time allows, to minimize secretions
      
    • Topical anesthesia with atomized 2–4% lidocaine
      
    • Sedation
      
    • Airway visualization
      
    • Intubation
      
    • Postintubation management.
  
  
• Cricothyrotomy
  
  
  
  • In many cases, cricothyrotomy is the definitive management technique for upper airway emergencies.
    
  • Patients with upper airway obstruction who are high risk for hypoxia should be prepared for cricothyrotomy while the endotracheal intubation is attempted (“double setup”).
  
  
• Medical therapy
  
  
  
  • Once the airway is secured, or for patients of moderate risk not immediately requiring airway intervention, medical therapy should target the underlying etiology.
    
  • For anaphylaxis and angioedema, treat with IM epinephrine, IV H₂-blockers, diphenhydramine, IV methylprednisolone, and albuterol. In cases of angioedema with a known or suspected C1 esterase inhibitor deficiency, consider treatment with fresh frozen plasma.
    
  • For infections, treat with IV antibiotics as indicated by the underlying infection and dexamethasone.

Sudden deterioration

• Sudden deterioration is the hallmark of upper airway pathology and should be expected.
  
• For this reason, it is generally inappropriate to transfer patients with risk of deterioration without a definitive airway in place. This recommendation includes interfacility transfers, as well as intrafacility transfers to radiology or the intensive care unit. The sole exception is transport to the OR for definitive airway management, when the ED attending deems that the benefits of management in the OR outweigh the risks of transport.

Special circumstances

• Foreign bodies in the airway represent a special class of high-risk patients.
  
  
  
  • Need to rapidly distinguish complete from incomplete obstruction.
    
  • Liquid and semiliquid obstructions (blood, vomit, etc.) may be cleared with suction.
    
  • Solid and poorly visualized obstructions are higher risk for poor outcomes.
  
  
• In patients with incomplete obstruction from solid material, the goal is to temporize the patient and move to the operating room for definitive management.
  
  
  
  • Patients should be provided supplemental oxygen to prevent hypoxemia, but bag mask ventilation should be avoided as this may worsen the obstruction.
    
  • If the OR is not an option, the practitioner should be aware that topical anesthesia and sedation may facilitate laryngoscopy but may also result in complete obstruction.
  
  
• Complete obstructions require immediate action to relieve the obstruction.
  
  
  
  • In this case, basic life support techniques should be used on the conscious patient to expel the foreign body.
    
  • Subdiaphragmatic thrusts may be applied to both the semi-upright and supine patient.
  
  
• If the patient loses consciousness or arrives unconscious:
  
  
  
  • Immediate direct laryngoscopy should be performed to attempt removal of the obstruction using forceps.
    
  • Cricothyrotomy is indicated if the obstruction is above the vocal cords and cannot be removed.
    
  • If no obstruction is visible, endotracheal intubation should be performed immediately.
    
  • Inability to ventilate the patient with subglottic obstruction indicates a tracheal obstruction. In this case:
    
    
    
    • Stop ventilation, deflate the cuff, replace the stylet, and advance the endotracheal tube as far as possible in an attempt to displace the obstruction into one of the mainstem bronchi.
      
    • Then retract the endotracheal tube to the proper position and ventilate utilizing the contralateral lung.
      
    • Failure to ventilate at this point indicates either bilateral mainstem bronchial obstruction (which is not survivable without immediate extracorporeal membrane oxygenation) or unilateral obstruction with a contralateral pneumothorax. Thus bilateral needle thoracostomies should be considered as the final salvage maneuver.

Vasopressor of choice: none.

References

Related posts:

Burns Airway management Hypertensive emergencies Pulmonary embolism Acute respiratory distress syndrome Severe pelvic trauma

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