Acute Airway Obstruction

Question 1

You are asked to review a 63-year-old male patient in recovery for sudden difculty in breathing and neck swelling. He has a history of atrial fbrillation, ischaemic heart disease and type II diabetes mellitus. He has just undergone a prolonged laparotomy for small bowel obstruction, for which he had a central venous catheter placed.

What is your initial management of this patient?

Answer 1

• This is an anaesthetic emergency and needs to be dealt with immediately.
• The patient should be reviewed urgently in recovery. Senior anaesthetic help should be sought and the difficult airway trolley should be present at the bedside.
• Conduct a rapid airway assessment to determine the cause of the patient’s dyspnoea. Apply 100% high-flow oxygen via a non-rebreather mask and transfer the patient to a place of safety if possible (closest empty theatre).
• Escalate the case rapidly to the duty anaesthetic consultant or a senior registrar.
• Take a prompt medical and anaesthetic history from the anaesthetic chart:
• Note the history of atrial fibrillation: this patient may be on an anticoagulant.

Question 2

The neck swelling is rapidly expanding. What are the options for airway management in this patient?

Answer 2

Early ENT and vascular involvement ? expanding neck haematoma

Intubation:
* The first line plan for this patient should be to secure the airway with an endotracheal tube as he is in danger of imminent airway obstruction. He may need a smaller tube size than expected due to the expanding neck swelling. Options for intubation are:
- Intravenous induction with direct or videolaryngoscopy.
- Gas induction with direct or videolaryngoscopy.
- Asleep fibreoptic intubation.
- Awake fibreoptic intubation.

Tracheostomy/front of neck access:
* In a patient with a rapidly expanding neck haematoma, this would be extremely difficult and should only be done in an emergency as part of “plan D”, or by a specialist (ENT surgeon - needs to be scrubbed).

Question 3

What are the concerns with an awake fibreoptic intubation in this patient?

Answer 3

• Limited time/expertise: Given the urgent nature of the scenario, there may not be adequate time or expertise to ensure a safe and skilled approach, including the time required for satisfactory airway topicalisation.
• The airway anatomy may be distorted by the neck swelling, making the technique more challenging.
• The procedure is unlikely to be well tolerated by a patient in respiratory distress and may cause total airway obstruction.
• The use of sedation may increase the risk of complete loss of the airway.

Question 4

What different types of videolaryngoscopes are available for use?

Answer 4

• Standard blade: This is a conventional blade with a camera, so it can also be used for direct laryngoscopy.
• Angulated blade: This requires the use of a stylet as the blade is more curved.
• Channelled: This uses mirrors and lenses, so the user has to look through the scope directly rather than at a screen.

Question 5

What are the potential complications associated with endotracheal intubation?

Answer 5

Early
* Misplaced tube (oesophageal/endobronchial).
* Dental/oral damage.
* Laryngeal trauma.
* Haemorrhage.
* Vocal cord haematoma.
* Airway oedema.

Late
* Tracheal stenosis.
* Laryngeal nerve damage/palsy.