What is the immediate management for a patient presenting with acute airway obstruction?

Immediate Management of Acute Airway Obstruction

The immediate management of acute airway obstruction requires rapid assessment and intervention following a structured approach, with the most experienced clinician available taking the lead to secure the airway.

Initial Assessment and Interventions

• Call for help immediately and ensure the most experienced airway practitioner is present 1
• Position the patient upright (30-35° head-up) if conscious to maximize airway patency and reduce airway edema 1
• Administer high-flow humidified oxygen 1, 2
• Assess severity of obstruction by observing for:
  • Stridor (inspiratory suggests supraglottic obstruction, expiratory suggests tracheal obstruction, biphasic suggests glottic/subglottic lesion) 3, 2
  • Suprasternal/intercostal retractions 2
  • Voice changes 3
  • Ability to handle secretions 2
  • Oxygen saturation 2

Immediate Airway Management Algorithm

For Partial Obstruction with Adequate Oxygenation:

• Maintain patient in upright position 1
• Continue high-flow oxygen 2
• Consider nebulized adrenaline (epinephrine) 5 ml of 1:1000 solution (5 mg) for reducing airway edema 2
• Administer IV corticosteroids (dexamethasone 0.6 mg/kg) if inflammatory cause suspected 2
• Prepare for potential deterioration 4

For Severe Obstruction or Deteriorating Patient:

• Declare an airway emergency to the team 1
• Limit intubation attempts to maximum of three, with at least one attempt by the most experienced clinician 1
• Use videolaryngoscopy if available and operator is trained, as it allows the operator to stay further from the airway 1
• Consider second-generation supraglottic airway device if intubation fails 1
• If oxygenation cannot be maintained, proceed rapidly to front-of-neck airway access (FONA) using scalpel-bougie-tube technique 1

Special Considerations

• For infectious causes (epiglottitis, bacterial tracheitis):

  • Administer appropriate antibiotics (Cloxacillin, Amikacin, Clindamycin) 2
  • Avoid agitating the patient to prevent complete obstruction 4

• For angioneurotic edema:

  • Administer subcutaneous adrenaline (1:1000,0.01 ml/kg) 2
  • Give hydrocortisone 10 mg/kg IV and antihistamines 2

• For foreign body obstruction:

  • Attempt removal only if visible and accessible 2
  • Avoid blind finger sweeps which may worsen obstruction 2

Post-Intubation Management

• Confirm tracheal tube placement with continuous waveform capnography 1
• Inflate the cuff to 20-30 cmH2O immediately after intubation 1
• Secure the tube properly and document insertion depth 1
• Verify bilateral chest expansion (avoid auscultation if infectious cause suspected) 1
• Consider chest X-ray to confirm tube position and identify complications 1

Common Pitfalls to Avoid

• Delaying definitive airway management in progressive obstruction 4, 5
• Multiple intubation attempts increasing morbidity 6
• Failing to recognize that initially mild presentations can rapidly deteriorate 4
• Administering sedatives without airway security in partial obstruction 2
• Not having FONA equipment immediately available 1
• Waiting for complete obstruction before intervening 5

Remember that any patient with audible stridor at rest requires consideration for early definitive airway management, as this indicates significant airway narrowing that can rapidly progress to complete obstruction 2, 5.