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Upper airway obstruction

        Sign & symptoms 

           * They are fairly nonspecific -

n     Most common symtoms are cough , dyspnoea & voice change may be associated with local pain or dysphagia

n      dyspnoea is the most important & when its progressive indicate imminent upper airway obstruction .

n     Stridor

  -It’s a cardinal sign of  upper airways obstruction

  -noisy breathing resulting from narrowing of larynx or trachea.

  -High pitched (low pitched called stertor)

     Types:

       Its inspiratory , expiratory or biphasic

 1 -Inspiratory when obst above the glottic level

 2 -Exp. Obst wih intrathoracic airway

 3 -Biphasic  in tracheal lesions.

  4-Extrathoracic airway tend to collapse during

  & the oppsits for intrathoracic airway due to effect of inrta pleural     pressure.

  -Trachea is protected from these fluctuations during respiratory cycle by its cartilage rings

n     Hoarseness

  -Its abnormal vibration of vocal cords.

  -Impaired vibration as a result of v.c paralysis , oedema , mucosal tears , laryngeal disrubtions or reduced airflow through the glottis

  -The greater the degree of hoarseness the greater the risk of laryngeal damage

  -Aphonea may occure in severe injury.  

n     Suprasternal retraction

  -Accessory ms used to overcome obst like suprasternal retraction , intercostal recession & flaring of the nostrils.

n     Restlessness

    -May be the result of anxiety  or hypoxia

    -A patient showing restlessness & suprasternal recession requires urgent resp. support

n     Drooling & bleeding

   -Drooling the result of pain

   -Pain is indicative of trauma or infection

   -Bleeding is indicative of mucosal truama

n     Fractures & subcutaneous emphysema

  -# of trachea , larynx , maxilla & mandible sh be checked.

Assessment

n     Exclude any immediately reversible cause of obstruction

n     Resuscitation of breathing & circulation

n     Full assessment of other injures & medical conditions

n     If airway is stable but the underlying cause of obst. Is not obvious then further assessment may be warrented

n     Most useful investigation is F.O examenation to site & extent of obst.

n     Cervical x-ray in cervical injury

n     Other radiographs may be needed neck , chest , facial views & arteriography

n     Endoscopy in significant disrubtion of aerodigestive tract 

Treatment
principles

n     Below the lowest level of obstruction

n     Careful consideration to pre or coexisting medical conditions

n     Once airway adequately secured other medical conditions should be addressed

n     The most straightforward & least invasive methode must be treated of choice

Medical management & Non invasive procedures

n     The time to do tracheostomy is when you first think of it

n     In minor trauma (infection or tumour) that cause moderate obstruction

n     A period of close observation while supportive & therapeutic measures are started

n     Trained staff are available

n     The most appropriate place is ICU

MEDICAL  MANAGEMENT

n     Heimlich maneuver

    -Used in laryngeal obstruction by a food bolus

    -Uses the residual air in the lungs to expel the bolus from the glottis

    -If fail cricothyroidotomy sh be done

    -complications:- pneumomediastinum & pneumo pericardium , surgical emphysema & gastric rupture & a period of observation before discharge is recommended

n     Oxygen & heliox

    -humidified O2 via face mask or nasal cannulae will help to relieve hypoxia

     -helium has low density & high viscosity & so less prone to turbulent flow than air or O2

     -Heliox is a mixture of 80% helium & 20% O2

    -Heliox result in reduced airway resistent

n     Steroids

   -Have a significant rule in reduction of inflammatory , infective & traumatic oedema

   -the main problem is with their underdosing rather than overdosing

n     Antibiotics

    - Given in suspected acute infection & mucosal inj

   - High dose of penicillin i.v or cephalosporin

ULTERNATIVE AIRWAY

1-Oral airway 

   -Semi rigid used in loss of consciousness & nasal inj

   -normal airway beyond oral cavity & nasopharynx

   -It facilitates suction

   -Used in conjunction with face mask & ambubag

2-Nasopharyngeal airway 

  -used when the problem at the level oforopharynx

   -simple , easy to insert , soft & well tolerated

3-Endotracheal intubation 

  -When oral & nasopharyngeal airway is not appropriate or failed

  -Incase that necessitate assisted ventilation

  -In progressive obstruction

n     Relative contraindication

1.     Fracture of cervical spine(injury)

2.     Sever facial trauma :bleeding , swelling , trismus , mucosal injury & bony instability

3.     Laryngeal trauma  

n     When transoral felt transnasal attempted under endoscopic control

n     Tip of endoscope is passed into trachea & the tube is then passed