INVESTIGATIONS

WAIT UNTIL STABLE!!

• ABGs (hypoxia, hypercapnia)
• FBC (increased WCC in infection)
• Clotting screen (coagulopathy)
• Blood cultures and oropharyngeal swabs
• Imaging
  • neck X-ray (AP & lateral)
  • CXR
  • CT scan may be required
• Fibre-optic endoscopy or direct laryngoscopy
  • Although nasendoscopy will potentially allow a view of the airway and aid diagnosis, it requires skill to be done safely
  • Direct laryngoscopy should not be attempted unless the airway is already secured, or all preparations are in place to immediately secure the airway (see section on immediate management)

****Airway interventions in a patient with a partially obstruct- ed airway can provoke complete airway obstruction

DIFFERENTIALS

• Equipment failure (e.g. incorrectly assembled self-inflating ambu-bag)
• ETT or tracheostomy obstruction
• Conditions which result in noisy breathing
  • Bronchospasm
  • Hysterical stridor
• Conditions which result in difficulty breathing spontaneously or high airway pressures when ventilating patient
  • Bronchospasm
  • Tension pneumothorax
• Conditions which result in patients adopting a sitting or leaning for- ward position
  • SVC obstruction
  • Cardiac tamponade

EMERGENCY MANAGEMENT

• 100% O2, pulse oximetry
• Assess condition of patient and likely cause of airway obstruction
• Support ventilation with bag and mask if required

If patient has suffered cardiac/respiratory arrest:

• Follow BLS guidelines (Here)
• Support/open airway; use adjuncts (oropharyngeal or nasopharyngeal airways) and suction
• Remove obvious obstruction and commence CPR (ALS algorithm)

If patient is peri-arrest:

• Call for skilled help: anaesthetist, ENT surgeon, your other ITU colleagues
• Obstruction requires immediate laryngoscopy (direct with a laryngoscope!!)/tracheal intubation
• Surgical airway i.e. cricothyroidotomy or tracheostomy for total obstruction if the above fails

If airway obstruction is due to diminished consciousness:

• Call for skilled anaesthetic assistance
• If traumatic: assume c-spine injury and asses for other injuries
• Consider replacing hard-collar with manual in-line stabilization (often helpful when supporting airway, required prior to intubation)****Ensuring an adequate airway always overrides concerns about potential c-spine injuries

• Support/open airway; use adjuncts (oropharyngeal or nasopharyngeal airways) and suction
• Support ventilation with bag and mask if required
• Proceed to definitive airway, most commonly rapid sequence intubation 
• Cricothyroidotomy or tracheostomy is indicated in the event of failed intubation***If airway obstruction is due to airway swelling, infection or physical obstruction; call for senior help (anaesthetic and ENT)

• Formulate an airway management plan and arrange for equipment to be available (e.g. plan A: endotracheal intubation; plan B: laryngeal mask airway; plan C: temporary cricothyroidotomy); CICV drill
• Arrange equipment for inhalational induction (anaesthetic machine with anaesthetic gas sevoflurane or halothane)
• Consider transferring patient to operating theatre where above equipment is present if patient stable enough
• Temporary measures which may be used whilst arranging the above include: nebulised adrenaline (5mg / 5ml 1:1000 in a nebuliser) and/or humidified oxygen or heliox

***Early intubation should be considered to reduce the risk of sudden deterioration and airway obstruction

• Cricothyroidotomy or tracheostomy is indicated in the event of failed intubation and ventilation, or as initial management plan under local anaesthesia

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• In the event of airway bleeding:
  • Call for skilled help – senior anaesthetist and ENT
  • Assess degree of bleeding and extent of lung soiling
  • Fibre optic laryngoscopy or bronchoscopy to assess the source of haemorrhage
• If minor bleeding from tracheostomy site:
  • Apply direct pressure +/- suture to obvious bleeding point. If still bleeding consider soaking a haemostatic dressing (e.g. Kaltostat) in 1 in 80,000 adrenaline and pack bleeding site
• If major stoma bleeding:
  • Suction upper airway and tracheostomy to remove clots
  • Orally intubate, use uncut tube and ensure cuff is inflated below tracheostomy stoma
  • Achieve haemostasis of stoma using digital pressure, packing or sutures 

  • Arrange theatre for definitive haemostasis
  • Urgent endoscopy may be required to remove clots from airway and lungs 

• If major bleeding occurs late it may be due to erosion of right brachiocephalic artery (usually preceded by insignificant sentinel bleed):
  • Bleeding can by massive and life threatening
  • 100% oxygen, call for senior help 

  • Suction airway 

  • Inflate tracheostomy cuff with 50ml air to provide local tamponade 

  • Apply digital pressure to root of neck in sternal notch
  • Commence IV fluid resuscitation, cross-match blood
  • Arrange an emergency theatre team, may also require vascular & 
cardiothoracic surgeons

If ever in doubt, secure airway using endotracheal intubation. Once Airway and Breathing are stabilized, continue ABC approach 


• Check to ensure adequate ventilation, if poor consider the possibility of pneumothorax 

• Urgent endoscopy may be required to remove clots from airway and lungs 

• Fluid/colloid/blood to restore circulatory volume 

• Correct any coagulopathy if there is airway bleeding 


FURTHER MANAGEMENT

• If condition is stable and any severe airway obstruction has been relieved:
  • Continue ventilation in an ICU setting
• If obstruction only mild or after the airway is re-established using ETT:
  • Re-explore tracheostomy wound and re-insert tube, this can be difficult, particularly via recent (<7 days) percutaneous tracheostomy wounds, senior anaesthetic or ENT help may be required
  • Resiting over an endoscope may help to ensure correct positioning
• If the patient has airway soiling or cellulitis:
  • Send wound or tracheal aspirate samples to microbiology
  • Use appropriate antibiotics
  • Consider bronchodilators, chest physiotherapy and regular suction
• If the patient has airway bleeding:
  • Assessment by ENT surgeon and/or thoracic surgeon for more definitive management of bleeding
  • Circulatory support including inotropes may be required

!!NOTES AND NIGHTMARES!!

• Malpositioning may not be immediately obvious
• Capnography is mandatory
• Tracheostomy displacement often occurs during turns and transfers
• If patient is not hypoxic, or has undergone recent neck surgery, await 
senior help before removing tracheostomy