There are several medical and traumatic situations where an airway may become partially/fully occluded or compromised. Signs of airway compromise may include a stridor, gurgling, hoarseness, visual distress of the patient, and being unable to cough/swallow/speak. Rectifying the airway issue will potentially reverse the patients’ life-threatening condition. In all cases of airway compromise, the goal is to manage the patients’ airway to allow air in and out of the lungs. Where you think this may be difficult to manage or airway issues will worsen (such as in burns), consider early advanced clinical support and early transport to hospital for further advanced care.
Foreign body airway obstruction –
Foreign Body Airway Obstructions (FBAO), commonly known as choking, is where a foreign body has entered the airway and is causing an occlusion. This can be a partial or full occlusion. Depending on the obstruction, the object, and the circumstances, a FBAO can be classed as:
Mild – where the patient is still able to speak, cough, and breathe
Severe – where the patient is unable to speak and breathe, attempts at coughing are silent, and the patient may be unconscious
On attending a FBAO consider early backup for advanced clinical airway assistance if available. For severe cases, treatment actions depend on the patients’ age. Adults and children over 1 years old require 5 back blows between the shoulder blades. If the back blows do not alleviate the airway, then give 5 abdominal thrusts. Again, if this fails, start alternating 5 back blows and 5 abdominal thrusts until the airway is relieved or the patient becomes unconscious.
For children under 1 years old the process is similar bar the action of chest thrusts instead of abdominal thrusts. Complete 5 back blows, if this doesn’t alleviate the airway then give 5 chest thrusts. Again, if this fails, start alternating 5 back blows and 5 chest thrusts until the airway is relieved or the patient becomes unconscious.
On the patient becoming unconscious, regardless of age, investigate the airway for any obstruction. Attempt to visualise the vocal cords with a laryngoscope. On visualising the obstruction, attempt to remove with forceps or suction. If this fails, then attempt a cricothyroidotomy, or needle cricothyroidotomy in children if the skill set allows. Chest compressions should also be started when the patient becomes unconscious as the compressions can force air to expel the obstruction, allowing its removal.
If after failing all manoeuvres, then basic or advanced life support (depending on the clinicians available) needs to be started with ongoing attempts at airway management. Specialist resources should have already been requested at this point, and early transport to hospital should be considered for further surgical airway intervention.
Swelling and occlusion of the airway due to Anaphylaxis requires urgent treatment and reversal of the allergic manifestation. If possible, remove the patient away from the source of the allergic reaction, e.g., removing an insect stinger. Following this, Adrenaline 1:1000 Intra Muscular (IM) is required to start reversing the allergic manifestation of anaphylaxis. Typical administration in ambulance services across the UK include IM 500 mcg doses every 5 minutes until the life-threatening properties of anaphylaxis are diminished. Please review your own local guidelines as they may vary depending on area. Other medications may be required in maintaining patient homeostasis such as fluid therapy for anaphylactic shock, and Oxygen for hypoxia.
Correct use of Adrenaline 1:1000 IM will be of great importance in attempting to diminish the life-threatening elements of anaphylaxis. While waiting for the effects of the drug to work, airway management/support will follow a stepwise approach, depending on the consciousness of the patient, the severity of anaphylaxis, and surrounding factors. If you can intubate within your scope of practice and the patient is unconscious, you can consider early intubation to protect the airway before swelling and oedema causes disruption.
If the anaphylaxis advances and you cannot secure an airway with ETI, then a cricothyroidotomy will be needed. This may be difficult to complete due to swelling and oedema masking the landmarks around the neck.
A patient who has potential airway burns is at risk of their airway swelling and occluding. Any patient who has evidence of potential airway burns (for example, soot around the mouth and nostrils, burns near their face and throat, pain and/or swelling in the mouth/throat) should be considered high risk. Early consideration for advanced clinical care should be sought as the patient could undergo Rapid Sequence Intubation (RSI), helping protect the patient from a swelling airway. If the patient is unconscious and there is concern for a swelling airway, then early consideration should be made for intubation to secure the airway.
If airway burns are significant and airway patency is compromised, then a cricothyroidotomy may be required to secure an airway.
Trauma can affect a patients’ airway in many ways depending on the MOI and where the injury occurred. When trauma is involved, it is important to remember considerations for C-spine care. Use the stepwise airway approach to evaluate the best management for the patient.
General airway difficulties –
There are a multitude of other ways a patient may occlude or compromise their own airway, from an intoxicated patient collapsing to a patient suffering from a stroke. In general, where there are airway difficulties, using the stepwise airway approach will help in managing a patients’ airway.