GENERAL Tutorial 336

Management of the
Obstructed Airway
Dr Helen Bryant
Anaesthetic Registrar, Queen Alexandra Hospital, Portsmouth, UK

Dr Bisanth Batuwitage
Consultant Anaesthetist, Queen Alexandra Hospital, Portsmouth, UK

Edited by:
Dr Nicola Whittle
Correspondence to [email protected] 16th Aug 2016

QUESTIONS
Before continuing, try to answer the following questions. The answers can be found at the end of the article, together
with an explanation. Please answer True or False:
1. A 69-year old woman presents to the emergency department with a 3-day history of worsening stridor. A
mobile lesion obstructing 70% of the glottis is seen on fibreoptic nasal endoscopy
a. Immediate medical management in the form of humidified oxygen, nebulised adrenaline and intravenous
steroids should be considered
b. Transfer of the patient to theatre does not require specialist staff or equipment
c. Induction in the anaesthetic room is ideal
d. Face mask ventilation is likely to be easy
e. Examination of the neck and identification of the cricothyroid membrane using ultrasound is advisable

2. The following statements are correct with regard to endotracheal intubation

a. Direct laryngoscopy is likely to be easy with a base of tongue tumour
b. Videolaryngoscopy may produce a good view of the glottis however intubation may still be difficult
c. Awake fibreoptic intubation may result in complete obstruction in a critical airway
d. Transnasal humidified rapid inspiratory ventilatory exchange (THRIVE) can be used in conjunction with direct
and indirect laryngoscopy
e. The United Kingdom National Audit project on Major Airway Complications recommended multiple attempts
at laryngoscopy in patients with head and neck pathology

3. Regarding induction of anaesthesia

a. Inhalational induction of anaesthesia using a spontaneously breathing technique is always the best option in
an obstructed airway
b. Elective narrow-bore needle cricothyroidotomy may be considered as an option prior to induction
c. Awake tracheostomy can be a difficult procedure in an obstructed airway
d. The introduction of Sugammadex means that all patient should have an intravenous induction
e. Knowledge of human factors in complex airway management is less important than technical expertise

Key Points INTRODUCTION

• It is important to identify the nature, level and speed
Obstruction of the airway at its most extreme is an
of onset of airway obstruction when planning a
anaesthetic emergency requiring immediate intervention. In
management strategy
advanced life support algorithms, it usually refers to loss of
• Fibreoptic nasendoscopy, CT, and MRI should be airway patency in the unconscious patient or blockage by a
considered where time allows to investigate the foreign body in the event of choking. In these cases, airway
extent of the obstructing lesion opening manoeuvres or back blows and abdominal thrusts to
• Management of airway obstruction requires a relieve an obstruction may be life-saving before hypoxia and
multidisciplinary approach, with senior anaesthetic cardiac arrest ensue. In the context of this article, we will be
and surgical input from an early stage discussing management of airway obstruction relating to
pathology of the head and neck.
• A key consideration in the management strategy is
whether the airway should be secured awake Airway obstruction may present acutely or chronically
• Anaesthetists should be familiar with and regularly depending on the site, degree of narrowing and cause. The
practice can’t intubate can’t oxygenate (CICO) drills anatomical level can broadly be categorised as supraglottic,
glottic (laryngeal) or subglottic (Figure 1). The obstruction
• Appreciation of human factors are instrumental to may be due to luminal pathology such as inflammation,
the successful management of a difficult airway   tumour or haematoma or it may result from external

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ATOTW 336 – Management of the obstructed airway (16 Aug 2016) Page 1 of 9
compression and distortion. Central airway compromise due to anterior mediastinal masses can pose difficulties by
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nature of the obstruction being sited distal to surgical airway rescue . Management of the obstructed airway is
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particularly challenging and accounted for 40% of all cases (72 out of 184 patients) reported to the 4 UK National audit
2
project of major airway complications (NAP 4) . Important recommendations arising from the review of these cases have
been instrumental in guiding the assessment, planning and management strategies of patients with an obstructed airway
to optimise their outcome.

LEVEL OF OBSTRUCTION PATHOLOGY

Supraglottic Oropharyngeal lesions, base of tongue tumours, epiglottitis, retropharyngeal
abscess, invasive high oesophageal tumours
Glottic Vocal cord paralysis, glottic tumours, polyps
Subglottic Tracheal stenosis, laryngomalacia, subglottic tumours
Distal tracheal Lymphoma, thyroid mass, mediastinal masses

Figure 1. Potential pathological causes of airway obstruction

PATIENT ASSESSMENT
Symptoms and signs

A thorough history should be taken if the urgency of the situation allows. There may be a history of previous airway
problems and / or previous radiotherapy to the head and neck. Anaesthetic records and any difficult airway alert forms
should be reviewed.

Symptoms and signs generally reflect the site, extent of narrowing and its speed of onset (Figure 2). In an acute
obstruction, for example due to trauma, epiglottitis or Ludwig’s angina (cellulitis of the floor of the mouth and
submandibular tissues), stridor and dyspnoea are commonly encountered. Stridor is a harsh, high-pitched noise
created by turbulent airflow through a partially obstructed airway. It implies a reduction in airway diameter of at least
3
50% . In the inspiratory phase, stridor points to obstruction at a supraglottic or glottic level, whereas biphasic inspiratory-
4
expiratory stridor implies subglottic compromise . Expiratory stridor or wheeze classically suggests tracheal or
tracheobronchial obstruction. Stertor is a term to describe heavy snoring respiration and is usually generated from
1
obstruction at a nasopharyngeal level whereas gurgling may suggest an oropharyngeal origin . Other pertinent
symptoms of airway obstruction include hoarseness, voice change, a preference for sitting up, nocturnal dyspnoea,
orthopnoea, worsening fatigue, dysphagia and drooling.

Signs of impending airway obstruction

• Dyspnoea
• Stridor
• Stertor
• Voice change/ Hoarseness/
• Dysphagia
• Drooling/ Unable to swallow secretions
• Unable to lie flat, sitting forward to maintain airway patency

Figure 2. Table showing signs of airway obstruction

Chronic obstruction may present insidiously as patients become gradually conditioned to progressive narrowing of the
airway. Adequate alveolar minute ventilation can be achieved at rest through an orifice as little as 3 millimetres when
1
respiratory muscles have become trained . A patient who appears uncompromised and asymptomatic in this situation is
falsely reassuring. Stridor and sudden deterioration may only occur as critical obstruction is reached. Slow-growing
tumours of the pharynx, base of tongue, vocal cords, those causing external compression such as from the thyroid and
mediastinum, and some neuromuscular diseases may evolve in this way.
In addition to the above symptoms, patients with a mediastinal obstruction may report chest pain or fullness, sweats,
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symptoms of superior vena cava obstruction, postural cough and syncope . Alternatively they may be asymptomatic with
incidental finding of a mass reported on imaging.

Examination

The posture adopted by the patient should be noted. They may be dyspnoeic, using accessory muscles of respiration
and require supplementary oxygen. Assessment of the airway should include mouth opening, dentition, tongue
protrusion, Mallampati classification, jaw subluxation and neck movement. The neck should also be examined for
masses, mobility of the trachea, airway distortion and any potential difficulties for front of neck access (e.g. previous
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radiotherapy) .

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ATOTW 336 – Management of the obstructed airway (16 Aug 2016) Page 2 of 9
Investigations

Fibreoptic nasendoscopy (Figure 3) should be performed where

possible; either in clinic, at the bedside or in theatre, depending on the
urgency of the situation. This is usually well tolerated by the patient.
Inspection of the larynx in this way can provide important information
about the nature, level and degree of obstruction, attachment to
surrounding structures and any movement of the lesion during
respiration. It may also enable anticipation of the effects of
traumatising the lesion if it appears vascular or friable. These findings
should be discussed with the surgical team to help formulate a
management strategy. It is important to anticipate that induction of
anaesthesia and postural change may worsen the degree of
obstruction seen.

Ultrasound examination of the neck may provide additional

information about the lesion and degree of airway distortion, especially
if no landmarks are palpable. It is also valuable for identifying and
marking the cricothyroid membrane and noting any overlying vascular
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structures if front-of-neck access is contemplated .

MR and CT imaging is recommended where time and the patient

conditions allow (lying flat may result in worsening of symptoms) to
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further investigate the extent of any lesion (Figure 4). Imaging is
particularly helpful in delineating a mediastinal mass. A CT will
demonstrate the position and extent of the airway obstruction.
Awake CT-guided needle biopsy may be an option to avoid
manipulation of the airway under anaesthesia. Patients with Figure 3. The authors undertaking fibreoptic
cardiovascular symptoms or signs should be investigated using nasendoscopy  
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echocardiography as this may be a feature of mediastinal masses .

Figure 4. CT image of a supraglottic lesion (black arrow) in an 82-year old man,

demonstrating the level and extent of airway obstruction

MULTIDISCIPLINARY TEAM, PLANNING AND HUMAN FACTORS

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Management of patients with an obstructed airway requires senior anaesthetic and surgical input from an early stage .
The case should be jointly assessed where possible to clarify the level, extent and likely cause of the obstruction. In
chronic cases, imaging should ideally be reviewed in a multidisciplinary team setting and chaired by radiologists with
head and neck expertise.

For patients requiring urgent intervention, theatre staff should be alerted to prepare specialist teams and equipment.
2
Plans should be made to secure the airway in theatre alongside the rest of the team rather than in the anaesthetic room .
Inter or intra hospital transfer of an unstable patient should be done by medical personnel with airway expertise.
Equipment must be immediately available for airway maintenance or attempt to secure the airway if necessary. In
extreme cases such as central airway obstruction, a patient may require transfer to a specialist centre capable of

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instituting cardiopulmonary bypass (CPB) before induction of anaesthesia. This decision should be made early by the
multidisciplinary team, as using CPB as a back-up plan in the event of complications is unlikely to yield successful
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outcome .

Careful consideration of the relative risks and benefits of the proposed airway strategy, preparation of equipment, and
contingency planning are key to the successful management of an anticipated difficult airway. Clear role assignment and
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briefing of the multidisciplinary team, and an appreciation of human factors are vital . The leader should be clearly
identified (usually the most senior anaesthetist present) and should ensure clear communication and good teamwork as
the clinical situation may rapidly change.

MANAGEMENT STRATEGIES
In an emergency situation the nature of the obstruction may be unknown and the location, expertise and equipment may
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be lacking. Optimising the ability to oxygenate is fundamental to all airway stratgies . Immediate medical management
should include high-flow humidified oxygen and consideration of intravenous corticosteroids. Nebulised adrenaline and
Heliox (79% helium / 21% oxygen mixture) may also be indicated although the latter does restrict the amount of oxygen
that can be given. Where it becomes necessary to secure the airway, assistance from an anaesthetist skilled in
advanced airway techniques should be urgently sought. The Difficult Airway Society (DAS) guidelines for the
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management of an unanticipated difficult intubation should be followed . Anaesthetists should be familiar with and
regularly practice “cant-intubate, can’t oxygenate” drills, including front of neck access.
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The Aintree Difficult Airway Management (ADAM) website is a useful aid to decision making. It identifies 10 devices
which can potentially facilitate management of the difficult airway, ranging from conventional direct laryngoscopy to
videolaryngoscopy, rigid and flexible fibreoptic laryngoscopy and needle or surgical cricothyroidotomy. A difficult airway
scenario can be selected from a drop down menu and a problem list is completed. The ADAM website then generates a
management matrix which rates the utility of each device as recommended by a panel of experts from 1 - 5 (1 - minimally
hazardous, 5 – extremely hazardous). The summary rating is the worst hazard rating for each device. It then allows for a
printable contingency plan to be generated with observed problems and steps to intubation with the device. This website
can be accessed free of charge by registered medical professionals who can request a login at
http://adam.liv.ac.uk/adam8/login.aspx (Figure 5 and 6).

Figure 5. This is an example of the ADAM difficult airway device

summary table that is generated for the scenario of a supraglottic
laryngeal tumour. The summary matrix gives the “worst score” for
the device (1 - minimal hazard, 2 - 4 increasing hazardous, 5 -
extremely hazardous). In this scenario all devices have some aspect
of their use that is hazardous, by clicking ‘select’ a contingency plan
is generated for that device, with problems that may be encountered Figure 6. Awake Nasal Fibreoptic
and steps on how to use the device (see figure 7). laryngoscopy has been selected which
gives a contingency plan. Blue text =
  sequence of steps required for a successful
intubation, green text = everyday problems
in using the device, red = observed
problems for this case and the ADAM rating
for them (NB only the start of the plan is
illustrated here).

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AIRWAY STRATEGIES

There are four main options to consider when planning an airway strategy (Figure 7):
1) Inhalational induction
2) Intravenous induction
3) Awake fibreoptic intubation
4) Awake tracheostomy

NAP-4 identified that the site of obstruction in particular has a great influence on the efficacy and suitability of a
2
technique . We will consider these four techniques in turn.

Inhalational induction of anaesthesia

Inhalational induction of anaesthesia has classically been described as the preferred route in a patient with upper airway
10 5
obstruction and specifically in patients with central airway obstruction . Theoretically, this technique preserves
spontaneous ventilation and should the patient completely obstruct due to airway collapse, the uptake of vapour would
cease and awakening would ensue. In practice with severe obstruction, the onset of induction is slow and may
1,3
precipitate laryngospasm or apnoea with subsequent hypoxia . NAP 4 emphasised the risks of inhalational induction
with reports of 23 out of 27 cases becoming significantly compromised. In some cases, this necessitated rescue front-of-
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neck access . Reports demonstrated that in the event of compromise, patients did not rapidly waken as suggested. It is
therefore vital to have a contingency plan in place when this technique is considered. This may involve administration of
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neuromuscular blockade and mask ventilation if possible pending intubation . The use of halothane to facilitate
instrumenting of the airway under deep inhalational anaesthesia has all but disappeared in the UK but is a technique
employed in many low to middle income countries due to its ready availability and the lack of advanced airway
equipment. Inhalational induction is still commonly used in difficult paediatric airways where there is less likely to be
airway collapse and it is possible to maintain airflow.

Intravenous induction of anaesthesia

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The choice between inhalational and intravenous induction can be difficult and both scenarios may fail . Carefully
planned back-up techniques are therefore paramount. There is physiological evidence to suggest that in the case of
extra-thoracic intraluminal laryngotracheal stenosis, positive-pressure ventilation after intravenous induction is preferable
11
to spontaneous ventilation . The advent of Sugammadex to potentially reverse deep neuromuscular blockade in the
event of failed intubation may enhance contingency planning. That said, awakening and effective spontaneous
ventilation cannot be guaranteed. The use of a muscle relaxant gives the best intubating conditions and also optimum
access to the neck if a “can’t intubate, can’t oxygenate” (CICO) situation develops. Careful consideration of the
intubation technique should be made prior to induction of anaesthesia and may involve direct intubation, the use of
videolaryngoscopy, flexible or rigid fibreoptic layngoscopy (see section on devices). Alternatively, the recently published
12 13
technique of Transnasal Humidified Rapid-Insufflation Ventilator Exchange (THRIVE) or NO-DESAT! where high flow
oxygen is delivered via nasal cannula may be considered in isolation or to complement oxygenation prior to intubation.
This technique has many benefits however its role in the acutely obstructed airway remains unclear and it may give the
clinician a false sense of security.

Awake fibreoptic intubation (AFOI)

Depending on operator expertise, equipment availability and the site and extent of airway obstruction, AFOI can be used
14
successfully . Its use should be considered carefully after discussion with the surgical team and following
nasendoscopy. It may not be the best option if there is a potential to cause complete airway obstruction; the so-called
3
“cork-in-bottle” situation , for example in glottic tumours where the aperture of the airway may be greatly reduced. It may
also be ill-advised if the anatomy is grossly distorted, there is a risk of bleeding, the patient would struggle to co-operate
or if there is a risk of airway compromise due to either over-sedation or local anaesthetic topicalisation. AFOI in patients
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with an obstructed airway therefore remains controversial . Indeed, NAP 4 reported failure of this technique in 14 of 23
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head and neck cases .

Awake tracheal access

The decision to perform an awake surgical tracheostomy under local anaesthetic depends on urgency, experience,
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location, and the ability to perform contingency plans . Indications may include severe stridor, a fixed hemi-larynx,
advanced tumours, gross anatomical distortion, a larynx not seen on fibreoptic nasendoscopy, or where surgical
1,3,15
intervention will render the post-operative calibre of the airway poor . Several cases reported to NAP 4 were
2
criticised for failing to perform tracheostomy prior to induction of anaesthesia . This technique may be technically very
challenging depending on the underlying pathology and the ability of the patient to tolerate lying supine. A recent study
described the outcome of 68 patients requiring emergent awake tracheostomy due to upper airway obstruction (85% of

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cases due to malignancy) . Although 19 cases were lost to follow-up, the procedure was considered to be safe and
effective in securing the airway in these patients, with long-term complications reported in only three cases (tracheitis
and granuloma).

Where awake tracheostomy is not deemed necessary, elective narrow-bore needle cricothyroidotomy may be
considered as an option prior to induction allowing a cannula to be left in situ. This may be used for jet ventilation in the
event of failure to secure an endotracheal tube and conversion via a Seldinger technique (for example, using the Melker
cricothyroidotomy set) to a wide-bore cricothyroidotomy if necessary. It is important to note the diameter of the cannula if
non-standardised equipment is being used to ensure compatibility with the Seldinger set. In the CICO situation, NAP-4
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warned of a significant failure rate with cannula cricothyroidotomy, and the new DAS guidelines recommend a surgical
approach when emergency front-of-neck access is required.

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Figure 7. A cognitive aid to planning an airway strategy in an obstructed airway

ENDOTRACHEAL INTUBATION DEVICES

Broadly speaking, endotracheal intubation devices can be divided into four main categories. Each device has
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advantages and disadvantages and no single device is ideal for every difficult airway scenario . The choice ultimately
relies on the site and nature of the obstruction, device availability and operator preference and expertise.

Direct Laryngoscopy
Macintosh blade direct laryngoscopy is a well-established technique which affords the operator a wide view of the larynx
and surrounding structures. A gently inserted bougie may be useful to aid intubation. Straight blade retromolar
laryngoscopes may be preferred to directly elevate the epiglottis. NAP-4 recommends that multiple attempts at direct
laryngoscopy in patients with head and neck pathology should be avoided as this may lead to complete airway
2
obstruction. Supraglottic pathology may make access to the vallecula and therefore laryngoscopy, difficult.

Indirect Videolaryngoscopy
There are a range of videolaryngoscopes currently available and comparison of devices is ongoing. They can be divided
into channeled (e.g Airtraq) and non-channelled (e.g Storz C-MAC, GlideScope). The image is transmitted from the tip of
the instrument providing an indirect view of the larynx. The advantages are that the view is magnified and depending on
the angulation of the blade allows an improved view. There is also the benefit that members of the operating team can
see the difficulties being encountered which improves communication and team work. The role of videolaryngoscopy in
the obstructing lesion is unclear as despite a good view of the larynx the operator may encounter difficulty advancing the

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 18
endotracheal tube through the cords . Indirect videolaryngoscopy has more recently been used in awake patients as the
19, 20
force of laryngosopy is reduced and this technique may become more popular as experience increases. .

Flexible Fibreoptic Laryngoscopy (nasal or via LMA)

Asleep fibreoptic laryngoscopy is an alternative strategy depending on the nature of the obstruction. It’s use via an LMA
9.
and passage of a pre-mounted Aintree Exchange catheter has been advocated in preference to the intubating LMA A
case report described successful airway rescue using this technique via a ProSeal LMA in a patient with severe
21
supraglottic swelling following carotid endarterectomy . This technique should be rehearsed in simulation if it is the
chosen plan A or back-up strategy to optimise chances of success.

Rigid Fibreoptic Laryngoscopy

Rigid optical stylets such as the Bonfils fibrescope can be advantageous when negotiating laryngeal pathology. It’s utility
9
lies in the ability to gently push obstructing lesions to one side to enter the trachea and deploy the pre-mounted tube .
This technique requires training and should be considered carefully if there is a risk of causing bleeding and worsening
obstruction.

EXTUBATION CONSIDERATIONS

NAP-4 identifies extubation and early recovery as a period of risk for patients with head and neck pathology. In these
cases it is important to appreciate that the obstruction may not be effectively relieved by surgery due to residual disease,
haematoma or swelling. Risk of bleeding remains a possibility and demands a high index of suspicion in the
postoperative period. The report recommends that the surgical team remain immediately available at extubation until the
2
patient is effectively managing their own airway . Staged extubation kits are available for consideration in some patients.
These contain a wire which can be placed via the endotracheal tube prior to extubation and an airway catheter which can
be passed over the wire in the event of airway compromise. Its use should be discussed with the surgical team since it
involves instrumentation of the airway and may risk disrupting surgical site haemostasis.

SUMMARY

Management of the obstructed airway requires careful assessment, planning and execution to optimise success.
Involvement of the multidisciplinary team at an early stage is recommended. The NAP-4 report has significantly
impacted our approach to safely managing these cases (Figure 8). In particular it identifies potential pitfalls to be wary of
and the need for detailed contingency planning with a multidisciplinary approach.

Key recommendations from NAP 4 for the management of the obstructed airway

• Senior anaesthetic and surgical staff should be involved

• Anaesthetists should gain useful information from CT, MR imaging and nasendoscopy whenever possible
• Airway investigations should be jointly reviewed by the surgeon and anaesthetist
• The level of the obstruction in the airway should be determined whenever possible
• If no additional investigations are available, consideration should be given to awake nasendoscopy in theatre to reassess the
situation prior to starting
• An agreed airway management strategy should be formulated by the anaesthetist, surgeon and theatre team prior to starting
• The anaesthetic management of any case in which surgical tracheostomy is a rescue option should start in the operating
room with the entire team assembled and ready
• Multiple attempts at direct laryngoscopy should be avoided
• If fibreoptic intubation is the primary plan, there are good reasons for undertaking this in the awake patient
• Inhalational induction may fail with loss of airway and failure to wake and a clear rescue plan should be ready
• Emergency needle or large bore cricothyrotomy cannot be assumed to be possible or successful
• The team managing the patient should not disperse after extubation until the airway is safe
• Patients in ICU (intubated or with tracheostomy) require a continuously-ready strategy for reintubation if the tube dislodges or
blocks

2
Figure 8. Summary table of recommendations from NAP 4

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ANSWERS TO QUESTIONS

1. A 69-year old woman presents to the emergency department with a 3-day history of worsening stridor. A
mobile lesion obstructing 70% of the glottis is seen on fibreoptic nasal endoscopy
a. True. Immediate medical management involves maximizing oxygenation of the spontaneously breathing
patients. Nebulised adrenaline may improve airflow by causing bronchodilation and IV steroids may reduce
oedema.
b. False. Transfer to theatre will need to be done with experienced staff who have advanced airway skills
along with appropriate equipment in case the patients deteriorates during the transfer.
c. False. Induction in patients with a compromised airway should ideally be done in theatre with all members
of the anaesthetic and surgical team present in case the patient deteriorates and needs front of neck
access. This was highlighted in NAP4.
d. False. In a patient with worsening stridor and a glottic lesion, face mask ventilation may be difficult as
following general anaesthesia loss of airway tone may result in the glottic lesion completely obstructing the
airway
e. True. This may be useful in case emergency front of neck access is necessary.

2. The following statements are correct with regard to endotracheal intubation

a. False. Access to the vallecula may be impossible with a base of tongue tumour making direct laryngoscopy
difficult.
b. True. Videolaryngoscopy may give an improved view of the glottis however tube advancement may still be
difficult as a good indirect view does not necessarily correspond with ease of intubation.
c. True. Awake fibreoptic intubation may result in the “cork in bottle’ effect where a partially obstructed airway
becomes completely obstructed.
d. True. THRIVE can be used to optimise apnoeic oxygenation when the airway is being instrumented.
e. False. NAP 4 found that repeated attempts at laryngoscopy and intubation often resulted in airway oedema
and deterioration from a difficult airway to a compromised airway

3. Regarding induction of anaesthesia

a. False. Inhalational induction, although still used in children, can result in complete obstruction of the airway
in adults as gas flow across the obstruction is limited. This results in less anaesthetic being delivered and
potentially suboptimal intubating conditions
b. True. Elective narrow-bore needle cricothyroidotomy may be considered prior to induction as a rescue
technique if intubation is difficult.
c. True. In a hypoxic patient who is struggling to maintain adequate gas exchange an awake tracheostomy
may be difficult due to compliance and difficulty in positioning
d. False. Although Sugammadex may mean that muscle relaxants can be reversed quickly an awake
technique may be the preferred option in the compromised airway.
e. False. Human factors are as important as technical expertise. NAP 4 found that there were numerous
examples where human factors contributed to a poor outcome.
 

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REFERENCES AND FURTHER READING
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4. Society for Head and Neck Anaesthesia. Round table discussion: the management of patients with the partially obstructed airway.
www.shanahq.com 2013, accessed November 2015.
5. Slinger P and Karsli C. Management of the patient with a large anterior mediastinal mass: recurring myths. Current opinion in
anaesthesiology 2007, 20 (1) 1-3
6. Dinsmore J, Heard AM and Green RJ. The use of ultrasound to guide time-critical cannula tracheotomy when anterior neck airway
anatomy is unidentifiable. Eur J Anaesthesiol. 2011 Jul;28(7):506-10
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intubation in adults. BJA 2015, 115 (6): 827-48
9. The Aintree Difficult Airway Management website. Available from http://adam.liv.ac.uk/adam8/login.aspx
10. Pinnock C, Lin T and Smith T. Fundementals of Anaesthesia, second edition 2003, Greenwich Medical Media Limited
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laryngotracheal stenosis. Br J Anaesth. 2008 Sep;101(3):419-23
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apnoea time in patients with difficult airways. Anaesthesia. 2015 Mar;70(3):323-9
13. Levitan R. NO-DESAT! (nasal oxygen during efforts securing a tube). epmonthly.com/article/nodesat. accessed February 2016
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16. Fang CH, Friedman R1, White PE et al. Emergent Awake tracheostomy--The five-year experience at an urban tertiary care center.
Laryngoscope. 2015; 125(11):2476-9
17. Bryant H, Frampton S, Dinsmore J, Turner M. A cognitive aid to planning an airway strategy in an obstructed airway. Portsmouth
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