What are the immediate steps to take when a patient's airway is compromised?

Signs of Airway Compromise

The most critical signs of airway compromise are stridor, obstructed pattern of breathing, and agitation, which require immediate intervention to prevent respiratory failure and death. 1

Primary Clinical Signs of Airway Compromise

• Respiratory distress indicators:

  • Stridor (high-pitched sound during breathing)
  • Obstructed breathing pattern
  • Agitation or restlessness
  • Accessory muscle use
  • Tracheal tug
  • Sternal/subcostal recession 1, 2

• Patient complaints:

  • A patient who complains of difficulty breathing should never be ignored, even if objective signs are absent 1
  • Anxiety (which increases work of breathing)
  • Severe sore throat, deep cervical pain, chest pain
  • Dysphagia or painful swallowing 1

Monitoring Parameters

• Vital signs changes:

  • Increased respiratory rate
  • Tachycardia
  • Hypertension (initially) followed by hypotension
  • Decreasing oxygen saturation (late sign) 1, 3

• Advanced monitoring:

  • Capnography is essential for early detection of airway obstruction
  • Pulse oximetry alone is insufficient and can give false readings
  • Decreasing arterial hemoglobin oxygen saturation is a late sign of impending hypoxemia 1, 2, 3

Post-Surgical/Procedural Warning Signs

• Early problems:

  • Excessive drain losses
  • Compromised free flap perfusion
  • Airway bleeding
  • Haematoma formation
  • Airway swelling 1, 4

• Late problems:

  • Signs of mediastinitis (fever, crepitus)
  • Evidence of airway injury (pneumothorax, pneumomediastinum, surgical emphysema) 1

Immediate Steps When Airway Compromise Is Identified

1. Call for help immediately - ensure an anesthetist or airway expert is summoned 1, 2

2. Position the patient:

   • Upright position to maximize airway patency
   • Consider extending the neck with a pillow under the shoulders 1, 2

3. Administer oxygen:

   • High-flow humidified oxygen
   • If tracheostomy present, apply oxygen to both face and stoma 1, 2

4. Assess airway patency:

   • If tracheostomy present, assess tube patency with suction catheter
   • Remove tube immediately if blocked or displaced 2

5. Prepare for intervention:

   • Ensure difficult airway trolley is immediately available
   • Have capnography ready
   • Prepare for possible emergency surgical airway 1, 5

Pharmacological Management

• For inflammatory airway edema:

  • Nebulized adrenaline (1 mg) may reduce airway edema
  • Systemic corticosteroids (equivalent to 100 mg hydrocortisone every 6 hours)
  • Start steroids early and continue for at least 12 hours 1, 2

• For bronchospasm:

  • Inhaled short-acting β₂-agonists 2

• Medication cautions:

  • Avoid sedative analgesia or titrate cautiously
  • Midazolam and other sedatives can depress respiration and should only be used with extreme caution in patients with potential airway compromise 6

Common Pitfalls to Avoid

• Never ignore a patient who is agitated or complains of difficulty breathing, even if objective signs are absent 1

• Don't rely solely on pulse oximetry as it can give false readings and is a late indicator of airway compromise 1, 3

• Avoid sedative medications that can worsen respiratory depression 1, 6

• Don't delay removing a blocked or displaced tracheostomy tube when faced with a deteriorating patient 2

• Avoid multiple blind attempts at securing an airway as this can create false passages and worsen the situation 2

By recognizing these signs early and taking immediate action, healthcare providers can significantly reduce morbidity and mortality associated with airway compromise.