Upper Airway Obstruction: Causes, Symptoms & Management | Respiratory Disorders Guide
Management of Respiratory Disorders
Upper Airway Obstruction
Upper airway obstruction is a medical emergency that requires rapid evaluation of the degree of obstruction and prompt management to ensure effective ventilation and oxygenation. This section discusses the common causes of upper airway obstruction, their management can see below:
Infectious Epiglottitis and Laryngitis
Infectious epiglottitis is one of the most serious forms of upper airway obstruction. It commonly occurs in children between 2 and 7 years of age and is traditionally caused by Haemophilus influenzae type B. However, in immunized populations the causes may include Streptococcus species, Staphylococcus aureus, and other organisms. In adults, epiglottitis is often caused by Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus. Occasionally, Candida species may be involved in immunocompromised patients.
The clinical presentation typically includes drooling, difficulty swallowing, fever, muffled voice, and respiratory distress. The patient may appear toxic and prefer to sit upright to maintain airway patency. Examination of the airway should be performed carefully, preferably in a controlled environment such as the operating room, as manipulation of the airway can precipitate sudden obstruction.
Management focuses on maintaining the airway and treating the infection. Broad-spectrum intravenous antibiotics are administered, often including a third-generation cephalosporin. Supportive care and close monitoring in an intensive care setting are essential.
Causes and Therapy of Upper Airway Obstruction
Upper airway obstruction may occur at several anatomical sites including the nasopharynx, oropharynx, and laryngopharynx. The causes vary depending on the location.
In the nasopharynx, obstruction may result from nasal polyps, nasopharyngeal tumors, nasal trauma, or nasal packing. Management may include nasal steroids, surgical intervention, radiotherapy, chemotherapy, or removal of obstructive material.
Obstruction in the oropharynx may occur due to Ludwig’s angina, odontogenic infections, peritonsillar abscess, retropharyngeal abscess, macroglossia, Stevens–Johnson syndrome, or tumors. Treatment often involves antibiotics, surgical drainage of abscesses, tonsillectomy in selected cases, and supportive care such as steroids and antihistamines.
In the laryngopharynx, causes include epiglottitis, laryngeal tumors, angioedema, trauma, inhalational burns, and vocal cord dysfunction. Management depends on the specific cause and may involve airway stabilization, corticosteroids, antibiotics, laser resection, chemotherapy, or radiation therapy.
Management of a Patient with Airway Obstruction:
Airway obstruction should be suspected based on clinical history and physical examination. Warning signs include inspiratory stridor, biphasic stridor, wheezing, impaired phonation, poor air entry, suprasternal retractions, universal choking sign, respiratory distress, tachycardia, agitation, angioedema, and neck swelling.
If the patient is awake and breathing, the clinician should attempt to identify the cause through history and examination. Assistance from personnel experienced in difficult airway management, such as anesthesiologists or ENT specialists, should be obtained. Intubation equipment and a tracheostomy tray should be prepared, and transfer to the operating room may be considered for optimal airway management. Indirect laryngoscopy or fiber-optic nasopharyngolaryngoscopy may be performed cautiously.
Management is then directed according to the diagnosis. In non-progressive conditions, heliox or BiPAP may be used while the patient is closely monitored.
If the patient is unconscious or showing signs of impending respiratory arrest, emergency airway management is required. This includes calling for specialized help, performing head tilt–chin lift or jaw thrust maneuvers if the cervical spine is stable, inserting an oral or nasal airway, and ventilating with a bag-valve mask. Direct laryngoscopy and endotracheal intubation should be attempted. If intubation is not possible, a surgical airway such as bedside tracheostomy or cricothyrotomy may be necessary. Needle cricothyrotomy may be performed if trained personnel are not available to perform a surgical airway immediately.
Endotracheal Intubation
Endotracheal intubation is performed to secure the airway and allow mechanical ventilation. During the procedure, a laryngoscope is used to visualize the vocal cords. The tongue is displaced, the epiglottis is lifted, and the endotracheal tube is passed through the vocal cords into the trachea. Correct placement ensures effective ventilation and prevents aspiration.
Cricothyrotomy
Cricothyrotomy is an emergency procedure used when conventional airway management fails. The cricothyroid membrane, located between the thyroid cartilage and the cricoid cartilage, serves as the entry point.
In a surgical cricothyrotomy, a horizontal incision is made through the cricothyroid membrane. Hemostats are used to maintain the opening, and a tracheal tube is inserted and secured in place to establish the airway.
Needle cricothyrotomy is a temporary alternative in emergency situations. A large-bore needle (12–14 gauge) is inserted through the cricothyroid membrane into the trachea. The catheter is then connected to a high-flow oxygen source to provide oxygenation until a definitive airway can be established.
Angioedema
Angioedema is characterized by painless swelling of the soft tissues of the face, lips, tongue, and airway. It may result from allergic reactions mediated by immunoglobulin E, medications such as angiotensin-converting enzyme inhibitors, or hereditary deficiency of C1 esterase inhibitor.
Treatment includes antihistamines, corticosteroids, and epinephrine, along with airway management as required. Patients with hereditary angioedema may respond to purified C1 inhibitor concentrate, fresh frozen plasma, or ecallantide, a kallikrein inhibitor.
Post-Extubation Stridor
Stridor occurs in up to 15% of patients following extubation. The most common cause is laryngeal edema, while laryngospasm and airway secretions are less frequent causes.
Immediate management includes nebulized epinephrine to produce local vasoconstriction and reduce edema. Many clinicians also administer short courses of intravenous corticosteroids, although evidence supporting this practice is limited. Patients should be closely monitored in the intensive care unit with airway precautions in place.
Prevention of post-extubation stridor may involve assessment techniques such as the cuff-leak test before extubation; however, failure of this test does not reliably predict the occurrence of stridor.