Airway Obstruction and Tracheostomy

Question 1

What is the difference between stertor and stridor?

Answer 1

• stertor → noise from oropharynx (snoring)
• stridor → noisy breathing occurs w/ airway obstruction

Question 2

Upper airway obstruction is likely to occur at sites of anatomical narrowing such as the hypopharynx, at the base of the tongue and the vocal folds.

What is the aetiology of upper airway obstruction?

Answer 2

• congenital → laryngeal webs/cysts, stenosis, choanal atresia, macroglossia, laryngomalacia
• physical obstruction → prolonged intubation, foreign body, trauma, burns, angio-oedema, smoke inhalation
• infection → epiglottitis, diptheria, croup, quinsy, tracheitis, retropharyngeal abscess
• malignancy → tongue, larynx, pharynx, thyroid
• bilateral laryngeal paralysis → post-thyroidectomy, bulbar palsy, post-oesophageal surgery

Question 3

What is the clinical presentation of partial upper airway obstruction?

Answer 3

• coughing, stridor, dysponia, dysphonia, choking, drooling, gagging
• progressive → dyspnoea, feeble cough, resp distress
• signs of hypercarbia → confusion + anxiety
• cyanosis

Question 4

What is the clinical presentation of total upper airway obstruction?

Answer 4

• unable to speak, breathe or cough
• extreme anxiety + agitation
• vigorous resp efforts w/ intercostal + supraclavicular retraction
• cyanosis
• inc HR + BP initially → bradycardia + hypotension
• diminishing resp effort, loss of consciousness
• cardiac arrest
• death occurs if unrelieved after 2-5 mins

Question 5

What is the management for upper airway obstruction?

Answer 5

• A → try simple manouevres initially (head tilt, chin lift), oropharyngeal airway + possibly endotracheal intubation, suctioning may be helpful
  
  • rarely tracheostomy required (3%)
  • if pt unconscious + apnoeic → direct laryngoscopy + tracheal intubation is preferable
• B → 100% Oxygen
• C → obtain IV access, HR, BP, ABG

Question 6

List medical and surgical interventions in upper airway obstruction

Answer 6

• MEDICAL
  
  • heimlich maneouvre (suspected foreign body aspiration)
  • oropharyngeal airways
  • endotracheal intubation (transnasally / orally)
  • racemic epinephrine
  • corticosteroids
  • helium-oxygen mixture
• SURGICAL/BRONCHOSCOPIC
  
  • fiberoptic intubation
  • cricothyroidotomy
  • tracheostomy
  • laser/electrocautery/balloon dilatation
  • airway stenting

Question 7

What are the indications for tracheostomy?

Answer 7

• facilitate prolonged mechanical ventilation + weaning
• by-pass life-threatening upper airway obstruction (eg. sleep apnoea, tumour, foreign body)
• maintain patent airway in severe head + neck injury or surgery
• airway abnormalities
• secretion removal
• recurrent aspiration

Question 8

What are complications of tracheostomy?

Answer 8

• immediate → haemorrhage, surgical trauma (oeseophagus, recurrent laryngeal), pneumothorax
• intermediate → tracheal erosion, tube displacement, surgical emphysema, aspiration
• late → persistent fistula, airway stenosis, tracheo-oeseophageal fistula, atelectasis, dysphagia, scarring

Question 9

What is the definitive way of securing the airway?

Answer 9

• “a cuffed tube secured in the trachea”
• endotracheal tube
• tracheostomy

Question 10

What is the non-definitive way of securing the airway?

Answer 10

• laryngeal mask airway (LMA)
• oropharyngeal (guedel) airway
• nasopharyngeal airway

Question 11

What is the difference between a cricothyroidotomy and tracheostomy?

Answer 11

In cricothyrotomy, the incision or puncture is made through the cricothyroid membrane in between the thyroid cartilage and the cricoid cartilage. … Cricothyrotomy is easier and quicker to perform than tracheotomy, does not require manipulation of the cervical spine, and is associated with fewer complications.