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Airway Obstruction

GENERAL PRINCIPLES

 

  • If the patient is conscious, with adequate ventilations, do not attempt to intervene 1.

  • The primary goals for airway management are, in order, oxygenation, ventilation, and airway protection 2. 

  • Patients should be treated in the position they are found, unless the airway is obviously obstructed (e.g. fluid, vomitus, etc.) 3

  • Vomiting and regurgitation (passive reflux of stomach contents) should both be treated by turning the patient laterally and manually clearing the airway 3 1.

  • The ‘head-tilt, chin-lift’ position should initially be used to attempt to establish an airway in a patient with an airway obstruction 3.

  • In any patient that is unresponsive, establishment of a patent airway takes precedence over any injury, including potential spinal injuries 3.

 

CLASSIFICATION

  • Respiratory distress, stridor, and dysphagia/drooling with dyspnoea all suggest a possible airway obstruction.  Obstructions can be:

    • Luminal (e.g. foreign body, laryngospasm, epiglottitis, blood)

    • Intramural (e.g. Oedema [Infection, Burn], Anaphylaxis/Angioedema, Tumour, Neuromuscular diseases)

    • Extramural (e.g. thyroid mass, crush trauma)

  • Airway obstructions can effectively be classified as incomplete (still breathing) or complete (not breathing) 2.

 

TREATMENT

 

RESPONSIVE PATIENTS

  • Any responsive patient should be encouraged to clear their own airway by coughing 4 5.  Paramedics can assist by administering oxygen, assisting the patient with optimal positioning, utilizing back blows or chest thrusts if required, and providing rapid transport to definitive treatment if necessary 4 5 6.

  • Initial treatment of airway obstruction may include: basic airway manoeuvres, positioning, suctioning, oro- or naso-pharyngeal airways, and/or LMA.  Mild sedation (e.g. benzodiazepines) may be used to permit basic airway management as the clinical situation permits 2.

  • If the cause of obstruction is swelling or laryngospasm paramedics should consider the need for early advanced airway management (e.g. RSI). Intra-oral manipulation should be avoided, and the patient should not be unduly distressed 6.  In cases of suspected anaphylaxis adrenaline should be administered as per the anaphylaxis CPG 6.

 

 

UNRESPONSIVE PATIENTS

  • If the obstruction is complete, then the airway should be visualised laryngoscopically and cleared using Magill forceps if an obstructive foreign body is discovered 1 5 6.

  • If the patient does not spontaneously resume ventilation, gentle IPPV should be initiated 1.  If this is problematic IPPV should be attempted with 2 nasopharyngeal plus an oropharyngeal airway in place 7.

  • If the patient cannot be effectively ventilated by this method, then they should be intubated 1 5.  Intubate utilizing rapid sequence induction if required.

  • If the intubation attempt is successful, placement should be confirmed using visualisation, continuous waveform end-tidal CO2 monitoring and auscultation 5 8 9. Once confirmed, the patient should be immobilized with a cervical collar to avoid inadvertent extubation due to movement of the head 7.

  • If the initial attempt at intubation is unsuccessful then the patient should continue to receive positive pressure ventilation, preferably with 2 nasopharyngeal plus an oropharyngeal airway in place, while the initial attempt is reviewed for causes of possible complicating factors and a second effort is attempted 7.  The mnemonic DOPE can be used to remember common causes for being unable to ventilate subsequent to intubation: Displacement  (of the ETT), Obstruction (both in the ETI and in the lower airway, such as asthma), Pneumothorax, and Equipment failure (consider failure from the source of oxygen, to the tip of the ETT and then back again) 9.

  • No more than 2-3 efforts at intubation should be attempted 7 5.  In the challenging airway patient consideration should be given to attempting intubation with the patient in the ‘ramped’ position (achieving horizontal alignment between the middle of the ear and the sternal notch), especially in obese patients 10 11.

  • If unable to intubate the patient an LMA should be attempted, if this is unsuccessful after two attempts the patient is considered a “can’t intubate - can’t ventilate” (CICV) patient 5.

  • In the rare and desperate situation of a CICV patient a surgical airway should be established 1 5 7.

  • Based on the paramedics level of expertise in conjunction with the rate of patient deterioration it may be appropriate to omit some earlier steps in this pathway and move directly to more advanced techniques 8.

 

 

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References:

 

1.        St John Ambulance, N. Z. Clinical Procedures and Guidelines, 2019-2021. (2019).

2.        ACT Ambulance Service. CMG 3 – AIRWAY MANAGEMENT. https://esa.act.gov.au (2014). Available at: https://esa.act.gov.au/sites/default/files/wp-content/uploads/CMG-3-AIRWAY-MANAGEMENT-Jan-2014-top.pdf.

3.        ANZCOR. ANZCOR Guideline 4 – Airway. 1–7 (2016).

4.        Queensland Ambulance Service Clinical Quality and Patient Safety Unit. Clinical Practice Guidelines: Respiratory/Airway obstruction (foreign body). https://www.ambulance.qld.gov.au (2016). Available at: https://www.ambulance.qld.gov.au/docs/clinical/cpg/CPG_Airway obstruction_foreignbody.pdf.

5.        Rehn, M. et al. Scandinavian SSAI clinical practice guideline on pre-hospital airway management. Acta Anaesthesiol. Scand. 60, 852–864 (2016).

6.        ACT Ambulance Service. CMG 12 - UPPER AIRWAY OBSTRUCTION. https://esa.act.gov.au (2015). Available at: https://esa.act.gov.au/sites/default/files/wp-content/uploads/CMG-12-UPPER-AIRWAY-OBSTRUCTION-Aug-2015-1.pdf.

7.        ACT Ambulance Service. CMG 3b - INTUBATION ALGORITHM. https://esa.act.gov.au (2014). Available at: https://esa.act.gov.au/sites/default/files/wp-content/uploads/CMG-3b-INTUBATION-ALGORITHM-Jan-2014.pdf.

8.        Ambulance Victoria. Clinical Practice Guidelines for Ambulance and MICA Paramedics. https://www.ambulance.vic.gov.au (2018).

9.        St John Ambulance Australia (Western Australia) Inc. Clinical Practice Guidelines for Ambulance Care in Western Australia. Version 34.1. (2019).

10.      Collins, J. S., Lemmens, H. J. M., Brodsky, J. B., Brock-Utne, J. G. & Levitan, R. M. Laryngoscopy and morbid obesity: A comparison of the ‘sniff’ and ‘ramped’ positions. Obes. Surg. 14, 1171–1175 (2004).

11.      El-Orbany, M., Woehlck, H. & Salem, M. R. Head and neck position for direct laryngoscopy. Anesth. Analg. 113, 103–109 (2011).