Emergency Management of Airway Obstruction

Introduction:

The airway is the passage from the nose to the lungs through which oxygen-rich air reaches the lungs. Gas exchange (oxygen and carbon dioxide exchange) occurs in the lungs. The oxygen absorbed enters the blood and is supplied to all body parts, organs and tissues. Therefore, the airway must always be clear to allow sufficient blood oxygenation. Any obstruction or block in the airway (partial or complete) prevents oxygen-rich air from reaching the lungs. As a result, the blood carries less oxygen, and the organs do not get sufficient oxygen to function normally and get damaged. It can be fatal when vital organs such as the heart and brain are oxygen deprived. Thus, airway obstructions require prompt assessment and immediate medical treatment. The airway is assessed and kept clear in all health emergencies using emergency interventions.

What Are the Airway Obstructions Types?

The airway can get obstructed in different ways. Based on the type of obstruction and the severity of the block, airway obstructions are classified as:

1. Upper Airway Obstruction: Block in the airway passage from the nose and mouth to the voice box (larynx) is an upper airway obstruction.

2. Lower Airway Obstruction: Block in the airway passage from the voice box (larynx) to the lungs (including the windpipe and its smaller branches in the lungs) is lower airway obstruction.

3. Partial Airway Obstruction: Partial blockage of the airway causes breathing difficulties. It allows some air to reach the lungs.

4. Complete Airway Obstruction: No air passes through if the airway is completely obstructed. The patient cannot breathe in such a case.

5. Acute Airway Obstruction: Quick, sudden airway blockage is known as acute airway obstruction. Choking on food or foreign objects is an example of acute airway obstruction requiring immediate action.

6. Chronic Airway Obstruction: Airway obstructions that last for an extended period or obstructions that develop over a long period are chronic airway obstructions. Tumors affecting the airway tissues and chronic obstructive pulmonary disease are examples of chronic airway obstruction.

What Are the Common Causes of Airway Obstructions?

The common causes of airway obstruction include the following:

1. Foreign Objects: Inhaling in or choking on foreign objects obstruct the airway. These can lead to unintentional death if the airway is not cleared immediately. Hot dogs, balloons, sausages, candy, fruits, and vegetables are some examples of foreign objects that can cause upper airway obstruction.

2. Anaphylaxis: Severe allergic reactions in which the body’s immune system overreacts to common substances such as nuts, fish, latex, and medications is known as anaphylaxis. These can be fatal without emergency medical care. The airway tissues, including the tongue, swell up (edema) in anaphylaxis and block the air from reaching the lungs.

3. Burns: Burns and inhalation injuries damage the patient’s airway. Fluid resuscitation may cause fluid accumulation and swelling (edema) in the passage from the nose to the lungs. In addition, sloughing, edema, debris, excess secretions, and inflammation can be seen in the upper and lower airway, including the windpipe and its smaller lung branches affected by prolonged exposure. These block the airflow and make breathing difficult.

4. Infections: Bacterial and viral infections can obstruct the airway. Croup (a common viral infection seen in children), abscesses in and around the tonsils, and infection of the trachea and bronchi (windpipe and its branches) are a few examples of infections that block the airway.

5. Asthma: Chronic diseases such as asthma cause swelling and increased secretions in the airway leading to airway obstruction.

6. Chronic Obstructive Pulmonary Disease: Long-standing inflammatory disease of the lungs, such as chronic obstructive pulmonary disease, obstructs the airway and makes breathing difficult.

7. Airway Obstruction During Health Emergencies: The tongue falls back and blocks air entry in unconscious patients in a medical emergency.

8. Neuromuscular Disorders: Diseases of nerves and muscles involved in swallowing can cause airway obstructions due to improper swallowing of food.

What Are the Common Symptoms of Airway Obstruction?

The most common symptoms in patients with airway obstruction (partial or complete) include the following:

1. Breathlessness or gasping for breath.

2. Bluish discoloration of skin, lips, nails, and mucous membranes.

3. Severe cough.

4. Signs of choking.

5. Gagging.

6. Wheezing.

7. Gurgling (due to blood or secretions in the airway).

8. Breathing pattern alterations (rapid or shallow breathing).

9. High-pitched noises during breathing.

10. Unconsciousness.

11. Agitation or panic.

What to Do in an Airway Obstruction Emergency?

The treatment of airway obstruction depends on the cause and severity of the block. Blocked airways due to inhaled foreign objects, choking, burns and inhalation injuries, and anaphylaxis are medical emergencies that require immediate medical attention. In case of an emergency, follow the following steps:

1. Call for emergency services and initiate first aid whenever possible.

2. The Heimlich maneuver (five back blows followed by five abdominal thrusts) is recommended in case of choking and must be repeated until the object is coughed up.

3. If the airway is obstructed due to anaphylaxis, administer the self-injectable emergency drug Epinephrine if trained (examples include Twinject and Epipen). The emergency drugs usually are carried by the patient at risk for anaphylaxis. The person providing first aid can use the prescribed auto-injector in case of severe anaphylaxis.

4. If the patient is unconscious or is not breathing, initiate cardiopulmonary resuscitation. It helps to keep the blood flowing till help arrives (if trained).

How Is an Airway Obstruction Emergency Managed?

Procedures to manage airways are life-saving and facilitate complex patient care. The patient’s airway, breathing, and circulation are assessed to initiate emergency interventions to clear the airway. The emergency management of airway obstruction includes the following:

1. Simple Maneuvers: The tongue falls back and blocks the airway in unconscious patients. Head tilt, jaw thrusts, and chin lift maneuvers are done immediately to improve airway patency and to enable air to flow through. The Heimlich maneuver is performed in case of choking.

2. Oxygen Administration: Oxygen is pumped through a bag attached to the mask (bag-mask ventilation)

3. Cardiopulmonary Resuscitation: If required, cardiopulmonary resuscitation and defibrillation are done to restart the heart and to keep the blow flowing to all body parts.

4. Artificial Airways: Emergency intubations (artificial insertion of tubes into the airway) are done for various medical emergencies, including critical illness and trauma. Artificial airways are devices that secure breathing and respiration when the patient cannot breathe or maintain a clear air passage. These devices are inserted to create a clear path for the oxygen-rich air to reach the lungs. The commonly used devices for artificial airways include:

   • Laryngeal Mask Airway: These devices are used to temporarily open and maintain the airway. They facilitate ventilation without a secure airway. These are used when we administer general anesthesia or as an emergency measure to save patients' lives with a failed airway.

   • Endotracheal Tube: These are the most preferred devices (tubes) to secure airways in medical emergencies, critical illness, trauma, and complex patient care, including out-of-hospital cardiac arrests.

   • Tracheostomy Tube: These are curved tubes used in case of emergencies when other devices cannot be used and during prolonged ventilation. These are inserted into the slits made in the neck and trachea (windpipe) to enable breathing.

5. Medications and Antibiotics: Emergency drugs are administered depending on the cause of the emergency.

6. Oxygen Therapy: In cases of respiratory failure, oxygen therapy interventions include:

   • Noninvasive Positive Pressure Ventilation (NPPV) - Mild air is blown into the airway to keep it open using tubes or masks.

   • Ventilator - A machine that helps to support breathing and provides oxygen to the lungs.

   • Tracheostomy - Oxygen is supplied through a hole (surgically made) in the windpipe.

   • Extracorporeal Membrane Oxygenation (ECMO) - Artificial lung that can be used for several days to weeks till the lung recovers.

7. Treatment of the Underlying Cause: The cause of the airway obstruction is evaluated using various methods, including laryngoscopy and imaging tests such as X-rays, computerized tomography, and magnetic resonance imaging. Once the cause is identified, definitive treatment is initiated to manage it.

8. Surgeries: Depending on the cause and severity of the obstruction, surgical interventions are performed to keep the airway clear.

Conclusion:

The airway or the passage from the nose to the lungs can be blocked by foreign objects, growth, tumors, severe allergic reactions, burns, secretions, debris, swelling, infections, and others. Airway obstructions are dangerous and life-threatening. However, with prompt medical interventions such as oxygen therapy, simple maneuvers, and artificial airway, these obstructions can be managed successfully.