Airway Obstruction- Ear Nose And Throat (ENT), Pulmonary And Respiratory Medicine

An airway obstruction is when there is something blocking air from entering the lungs. Such an obstruction may be partial or total. A total obstruction can lead to death very quickly and is a medical emergency. Minor obstructions are not as dangerous, but medical attention should be sought if any obstruction is suspected.

Who treats airway obstruction?

A general physician may treat people with minor obstructions, but it may be necessary to consult a respiratory physician or Pulmonologist who specializes in the respiratory system. An emergency room physician may initially treat a person with airway obstruction.

Diagnosis for treatment

Airway obstruction is sometimes obvious by the actions of the individual. For instance, a choking person will often grab their throat and not be able to talk or cough. They may also begin to change color and have a red face or blue lips.

In other cases, tests are needed to diagnose where the problem is so that the correct treatment methods can be decided.

Diagnostic tests include the following:

• Spirometry
• Bronchoscopy
• Laryngoscopy
• CT scan
• X-ray

Treatment methods for airway obstruction

The treatment method used to clear the obstruction depends on where the problem is and what is causing the blockage.

Heimlich maneuver

This is a method used when a person is choking on food or some object and is still conscious. The procedure is as follows:

1. Wrap your arms around the person as you stand behind them
2. Make a fist just above the navel
3. Grabbing the fist with the other hand, make five upward movements
4. Repeat the process until the object moves out of the mouth

Clearing the airway of infants

A specific technique is used on infants younger than 1-year-old who are choking. It is essential that you contact emergency personnel and carefully follow their instructions. The basic steps are given below:

1. Position the baby so it is facedown over your forearm, with the head of the baby below the rest of the body
2. Thump the infant's back five times with the heel of your hand
3. If that fails, flip the infant over onto your forearm
4. Do five chest compressions using two fingers and pressing gently but firmly below the nipple line
5. Repeat the procedure until help arrives or until the baby is breathing on their own

Cardiopulmonary resuscitation (CPR)

CPR is necessary if a person stops breathing and their heart stops beating and is used on unconscious choking adults. The steps of CPR are as follows:

1. Position the heel of your hand in the middle of the person’s chest
2. Place your other hand over this hand and press down forcefully about 100 to 120 times a minute

Medication

Histamines can help with allergic reactions. However, epinephrine is the choice of medicine when a person has an airway obstruction resulting from an allergic reaction.

For people with severe allergies who suffer from anaphylaxis, an EpiPen is used. An EpiPen is a device you can use to inject yourself with epinephrine.

Inhalers

Fast-acting inhalers are portable devices that contain bronchodilator medication such as salbutamol and can help when airways are constricted. This is often used by people with COPD and asthma.

High-flow nasal oxygen

Giving oxygen through a nasal cannula helps when people are showing low oxygen levels but do not have a complete obstruction. The extra oxygen may help those who are ill and have inflamed airways.

Laryngeal Mask Airway (LMA)

An LMA consists of a tube with a cuff that can be inflated. It is positioned down the oropharynx. Medicine is often given to stop the gag reflex so the LMA can be placed down the throat.

An LMA is usually done as a temporary measure before endotracheal intubation because it can cause complications like tongue swelling.

Endotracheal intubation (EI)

A Plastic tube called an endotracheal tube is placed down the throat of a person whose airway needs to be protected or who is not breathing.

Nasotracheal intubation (NTI)

This type of intubation involves positioning a tube through the nose and down into the windpipe and lungs.

Awake fibreoptic intubation (AFOI)

This method is used in patients who have a lesion in the epiglottis or back part of the tongue. This is a high-risk method that is not always advisable or possible. 

Cricothyrotomy

This is when a tube is positioned through an opening that is made in the cricothyroid membrane just below the larynx.

There are certain conditions when a cricothyrotomy is needed. These are given below:

• When an EI or NTI is not possible
• Excess vomit is present

Tracheostomy

A tracheostomy is an opening created in the trachea surgically under anesthesia, with a tube inserted to help the patient breathe. If needed, the tube can be connected to an oxygen supply source to aid respiration, i.e., a ventilator.

The conditions when a tracheostomy is usually required are given below:

• Burnt airway
• Injured larynx

Mechanical ventilation

Mechanical ventilators are sometimes needed when the person is not getting enough air into their lungs. Sometimes a severe asthma attack, severe COPD, or severe illness affecting respiration requires ventilation.

There are different types of ventilators, and potential complications when using mechanical ventilators. Invasive mechanical ventilators come with many complications, including pneumonia.

Conditions that can lead to airway obstruction

• Choking
• Allergic reaction and anaphylaxis
• Traumatic injury
• Viral infections
• Bacterial infections
• Smoke inhalation
• Asthma
• Tonsillitis
• Epiglottitis
• COPD
• Tracheomalacia: Trachea collapse

References:

• Ahmed, R. A., & Boyer, T. J. (2019). Endotracheal tube.
• Chauhan, V., & Acharya, G. (2016). Nasal intubation: a comprehensive review. Indian Journal of Critical Care Medicine: Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine, 20(11), 662.
• Ernst, A., Feller-Kopman, D., Becker, H. D., & Mehta, A. C. (2004). Central airway obstruction. American journal of respiratory and critical care medicine, 169(12), 1278-1297.
• Heimlich, H. J., & Patrick, E. A. (1990). The Heimlich maneuver: best technique for saving any choking victim's life. Postgraduate Medicine, 87(6), 38-53.
• Lynch, J., & Crawley, S. M. (2018). Management of airway obstruction. BJA education, 18(2), 46.
• McKenna, P., Desai, N. M., & Morley, E. J. (2019). Cricothyrotomy.

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