How should I urgently assess and manage a patient with tonsillitis who is now experiencing dyspnea and possible airway obstruction?

Urgent Assessment and Management of Tonsillitis with Dyspnea

This patient requires immediate assessment for upper airway obstruction and preparation for emergency airway management, as tonsillar hypertrophy causing dyspnea represents a life-threatening emergency that may progress rapidly to complete airway obstruction. 1

Immediate Assessment Priorities

Recognize Airway Emergency

• Dyspnea with tonsillitis indicates potential upper airway obstruction and must be treated as a medical emergency. 2, 1
• Look specifically for: hoarseness, inability to swallow liquids or solids, drooling, stridor (inspiratory), dysphonia, and extreme difficulty breathing 3, 1
• Note that pulse oximetry is a poor indicator of airway compromise—a decreasing SpO2 is a late sign of impending hypoxemia 2
• Monophonic wheezing loudest over the central airway and inspiratory stridor are key clues to upper airway obstruction 3

Initial Actions (Simultaneous)

• Provide 100% oxygen immediately with a tightly fitting mask to optimize oxygen stores 2
• Get anesthesia/ENT help immediately—this is a priority before the airway deteriorates further 2
• Position patient upright (sitting or head-up 25-30 degrees) to optimize upper airway patency 3
• Establish monitoring: pulse oximetry, continuous waveform capnography if available, blood pressure, heart rate, ECG 3

Airway Management Strategy

Preparation Phase

• Assemble an airway team immediately: minimum of intubator, assistant, drug administrator, and runner outside the room 3
• Prepare equipment for both intubation AND emergency front-of-neck access (FONA) before any intervention 3
• Have a clear strategy with primary plan and rescue plans briefed to the entire team before starting 3
• Identify and mark the cricothyroid membrane using the "laryngeal handshake" technique or ultrasound 3

Definitive Airway Control

If severe obstruction with obvious airway compromise:

• Proceed directly to the operating suite for controlled intubation with tracheostomy standby 1
• Consider awake nasotracheal intubation in cooperative patients, though this requires stable patients with minimal airway compromise 3, 1
• Use videolaryngoscopy when available to increase first-pass success 3

Modified rapid sequence intubation approach:

• Position optimally: head-up, lower cervical spine flexed, upper cervical spine extended 3
• Use the most experienced intubator available for the first attempt 3
• Focus on first-pass success—multiple attempts increase risk to both patient and staff 3
• Have bougie immediately available as laryngeal view may be compromised 3

Rescue Plans if Intubation Fails

• Transition through rescue algorithms promptly—minimize attempts at each technique 3
• Consider second-generation supraglottic airway as bridge between attempts (may reduce aerosol generation with better seal) 3
• If cannot intubate/cannot oxygenate: proceed immediately to emergency front-of-neck access using scalpel-bougie-tube technique 3

Medical Management

Immediate Pharmacotherapy

• Initiate broad-spectrum antibiotics immediately given severe presentation with airway compromise 1
• Consider corticosteroids to reduce tonsillar edema (though evidence specific to this indication is limited)
• Provide adequate analgesia to reduce patient distress 3

Post-Intubation Care

• Maintain on mechanical ventilation until tonsillar swelling resolves 1
• Continue broad-spectrum antibiotics 1
• Monitor for complications: pulmonary edema, secondary infections 1
• Consider tracheostomy if prolonged intubation anticipated 1

Critical Pitfalls to Avoid

• Never delay definitive airway management in a deteriorating patient—waiting for "one more test" can be fatal 2
• Do not attempt intubation without immediate FONA capability and expertise available 3
• Do not rely on pulse oximetry alone—clinical signs of obstruction (stridor, inability to speak, drooling) are more important 2
• Avoid sedation without airway control—this can precipitate complete obstruction 3
• Do not perform spirometry or other uncomfortable tests in patients with obvious severe obstruction 3

Special Considerations

• While most tonsillitis is viral (70-95%), severe cases with airway obstruction require immediate intervention regardless of etiology 4, 5
• This presentation can occur even without Epstein-Barr virus (mononucleosis) 1
• Hospital course may be complicated by pulmonary edema, tracheitis, and difficulty weaning from ventilator 1