What is the management for acute tongue swelling causing airway obstruction that lasts 30 minutes?

Management of Acute Tongue Swelling Causing Airway Obstruction

Immediate airway management is the top priority for acute tongue swelling causing airway obstruction, with early intubation or surgical airway intervention required if oxygen saturation is falling or respiratory distress worsens despite initial measures.

Initial Assessment and Management

1. Call for help - Summon emergency assistance immediately 1

2. Oxygenation:

   • Apply 100% oxygen via face mask 1
   • Position patient upright if possible to maximize airway patency 1

3. Airway assessment:

   • Evaluate for signs of impending complete obstruction: stridor, dyspnea, desaturation 1
   • Assess tongue swelling severity and rate of progression

Immediate Interventions

For Partial Obstruction:

• Apply continuous positive airway pressure with 100% oxygen using reservoir bag and facemask 1
• Avoid unnecessary upper airway stimulation which may worsen swelling 1
• If angioedema is suspected (especially in patients on ACE inhibitors), administer:
  • Epinephrine 0.3-0.5mg IM (1:1000 solution) 2
  • IV corticosteroids
  • Antihistamines

For Worsening or Complete Obstruction:

• Secure the airway immediately if swelling involves floor of mouth, tongue, and supraglottic or glottic areas 3
• Options for securing the airway:

1. Endotracheal Intubation:

• Consider awake intubation with topical anesthesia if patient is stable and cooperative 1
• Video laryngoscopy increases intubation success with difficult airways 1
• Use an uncut tracheal tube to allow for subsequent facial swelling 1

2. If Intubation Fails:

• Do not attempt multiple intubations if oxygen saturation is falling 1
• Proceed immediately to surgical airway (FONA - Front of Neck Access) 1
• Scalpel technique with vertical incision is recommended for emergency surgical airway 1

Post-Stabilization Care

1. Monitoring:

   • Continuous monitoring of oxygen saturation, respiratory rate, heart rate, and blood pressure 1
   • Close observation for signs of deterioration or improvement

2. Definitive Management:

   • Identify and treat underlying cause (allergic reaction, angioedema, trauma, infection)
   • Continue corticosteroids if indicated
   • Observe in high-dependency area until swelling resolves 1

3. Duration of Intubation:

   • Angioedema is typically self-limiting with swelling resolving in 2-3 days 3
   • Extubation should be performed only after visible reduction in tongue swelling
   • Consider nasendoscopy to assess airway patency before extubation 1

Special Considerations

• In cases of post-obstructive pulmonary edema (a potential complication), provide positive pressure ventilation and continue respiratory support until resolved 1

• For patients with known difficult airways, early involvement of specialists (ENT, anesthesia) is crucial 1

• Tracheostomy may be necessary in severe cases but recognition of the self-limiting course of angioedema can prevent unnecessary tracheostomy 3

Pitfalls to Avoid

• Delaying definitive airway management when signs of respiratory distress are present
• Multiple failed intubation attempts causing further trauma and worsening edema
• Failure to recognize angioedema as a potential cause, especially in patients taking ACE inhibitors
• Premature extubation before adequate resolution of swelling

Remember that tongue swelling can progress rapidly, and early, decisive airway intervention is critical to prevent mortality from complete airway obstruction.