NAP 4 project

Obstructed Airway
Dr Adrian Pearce
Guy’s and St Thomas’ Hospital
A patient with an advanced transglottic tumour required tracheostomy prior
to radiotherapy.

Anaesthesia was induced with total intravenous anaesthesia in the

anaesthetic room.

Intubation was attempted unsuccessfully by rigid videolaryngoscopy.

Rapid oxygen desaturation developed and both facemask ventilation and

needle cricothyroidotomy failed.

A late peri-arrest attempt at intubation was made by the surgeon.

The patient died in the anaesthetic room.

NAP 4 data for Head and Neck disease
72 reports (55 anaesthesia, 10 ICU/HDU, 7 ED forms)
More than one-third of all cases in the project
70% patients in this group had obstructed airway

Qualifying events:
Death or brain damage 13 Outcome at time of form completion:
Emergency surgical airway 50 Death 17
Unexpected ICU admission 27 Partial recovery 2
Full recovery 51
Not recorded 2
 Airway obstruction is the clinical situation in which a patient
develops signs or symptoms due to narrowing or ? distortion of
the airway

Airway obstruction is a blockage of the airway, resulting in reduced or

absent gas flow to and from the alveoli
Flavell EM, Stacey MR, Hall JE Clinical management of airway obstruction.
Current Anaesthesia and Critical Care 2009, 20: 102-112

Anaesthesia for diagnostic/resective surgery

NAP 4 data

~ 50 patients with Airway intervention to maintain airway

airway obstruction
Patients admitted via ED

Patients in ICU
 An ASA 3 elderly patient was scheduled for panendoscopy and biopsy
of a presumed airway tumour.

Preoperatively, the patient appeared comfortable, with mild stridor and

was able to lie flat without any distress.

No airway investigations had been undertaken and general anaesthesia

was induced.

The tumour obscured the larynx, intubation and mask ventilation were
impossible and the patient suffered a cardiac arrest from gross hypoxia.

The ENT surgeon performed an urgent surgical tracheostomy and the

patient was resuscitated.

The patient died several months later from inoperable disease.

 A middle aged, but not obese patient was scheduled for biopsy of a
suspected tumour of the base of tongue.

The patient had undergone radiotherapy to the head/neck following the

discovery of a malignant neck node four years previously and had continued
to smoke.

The consultant anaesthetist did not expect any particular problems.

However, after induction of general anaesthesia, on attempting laryngoscopy

no recognisable laryngeal structures could be seen and mask ventilation was
difficult.

Fibreoptic endoscopy showed an ‘inflamed and swollen epiglottis’ and

fibreoptic intubation was not successful.

The patient had an emergency surgical tracheostomy in the anaesthetic room

with satisfactory maintenance of oxygenation via facemask ventilation.
 Learning points
• Anaesthetists should be familiar with the tools of
assessment of the airway
• Stridor/respiratory distress at rest may not be
present in chronic obstruction
• Flexible nasendoscopy is very useful and was
the commonest additional airway investigation
• There is benefit in reviewing all
scans/endoscopy with the surgeon prior to
starting
 Learning point
• The anaesthetist should try to have a good idea
of the
- Degree of narrowing
- Site of narrowing
above the vocal cords
involving vocal cords
below vocal cords
- Type of narrowing
before starting
A middle aged ASA 3, slim patient presented for elective clearance of
infected tissue following pharyngeal surgery and radiotherapy.

Facemask ventilation, direct laryngoscopy, laryngeal mask placement

and direct tracheal access were all predicted to be difficult.

Facemask ventilation was optimal following induction of anaesthesia

and muscle relaxation but deteriorated after four attempts at direct
laryngoscopy with increasing bleeding, oedema and secretions.

Ventilation became impossible and a surgical tracheostomy was

performed.
An elderly, ASA 3 patient was known to have a grade 4 direct
laryngoscopy view due to oral carcinoma and radiotherapy.

Presented as an emergency with stridor.

Inhalational induction with halothane failed, ventilation was

impossible and the patient deteriorated to PEA cardiac arrest
requiring CPR.

Attempted fibreoptic intubation failed and the airway was

successfully rescued with a surgical airway.
An elderly, ASA 4 patient presented with stridor, due to invasive thyroid
carcinoma.

Inhalational induction and maintenance of spontaneous ventilation with

sevoflurane was planned.

Following induction, airway obstruction and laryngospasm occurred. No

muscle relaxant was administered.

Direct laryngoscopy revealed a grade 2 laryngeal view, attempted

intubation resulted in trauma and oedema with no ventilation.

A surgical airway was required.

A young fit and slim adult presented with a dental abscess
and facial swelling.

Inhalational induction and maintenance of spontaneous

ventilation with sevoflurane was planned.

Following induction airway obstruction and laryngospasm

occurred.

No muscle relaxant was administered, airway obstruction

persisted with desaturation.

Direct laryngoscopy and laryngeal mask ventilation failed.

Airway obstruction and inability to ventilate required a

surgical airway.
 Inhalational induction – what actually happened

A theme that emerged from the project data was the deterioration in
the airway following inhalational induction and subsequent inability
to maintain spontaneous ventilation.

Following induction of anaesthesia;

 No compromise to spontaneous ventilation in 4 patients

 Airway compromise with oxygen desaturation in 12 patients

 Failure of ventilation, either because the airway deteriorated

further or after direct laryngoscopy attempts were made in
11 patients
 Direct laryngoscopy – what actually happened

Another consistent theme to emerge from patients with head and neck
pathology was the deterioration in the airway following single or repeated
attempts at direct laryngoscopy.

Following induction of anaesthesia and attempts at direct laryngoscopy

the airway deteriorated with increasing difficulty in ventilation in 13
patients.

With repeated attempts the airway became impossible to ventilate in 15

patients. All these 15 patients subsequently required a surgical airway.
Flexible fibreoptic techniques - what actually happened
23 attempts to use flexible fibreoptic techniques
14 failed
9 successful

Of the 14 failures with this technique

4 awake and 10 asleep

Awake failure was due to an inability to either identify

the glottic inlet or an inability to pass either the
fibreoptic scope or tracheal tube.

Asleep fibreoptic failure in ten patients was as a result

of repeated attempts, inability to identify the glottic
inlet, inability to pass the fibreoptic scope or the
tracheal tube, bleeding and airway obstruction.

In those patients where fibreoptic techniques were

unsuccessful a surgical airway was usually required.
 Needle cricothyrotomy often fails

Of 27 uses of cannula cricothyroidotomy in head

and neck patients 12 were successful (by both
large and small bore devices) and 15 failed.

Failure of cannula cricothyroidotomy was due to

misplacement, inability to place, fracture, kinking,
blockage, dislodgement and barotrauma.

It is important to recognise that cannula

cricothyroidotomy has a significant failure rate in
CICV, and for head and neck patients a surgical
tracheostomy is often required.
We may love our anaesthetic rooms but ….

A patient bleeding after radical neck dissection returned to theatre in the

early hours of the morning. The patient was asymptomatic apart from a dull
ache and previous laryngoscopy was grade 2.

The anaesthetist undertook a RSI in the anaesthetic room.

 At laryngoscopy the tissues were completely oedematous
 Larynx was not visible.
 A blind attempt in placing a bougie failed.
 A prepared fibrescope was inserted but again no landmarks
 Ventilation via a SAD failed
 Large-cannula cricothyroidotomy was performed but unsuccessful

The patient was rushed into theatre for a surgical tracheostomy with an
intubating LMA in place but before intubation through this was started the
thiopentone and suxamethonium used at induction wore off enabling the
patient to awaken. A difficult awake tracheostomy was undertaken and the
patient made a full recovery.
 What can NAP4 tell us about the best approach to managing
the obstructed airway?

We must move away from talking about primary plans (I am going to do

an inhalational/IV/fibreoptic) to formulating logical, coherent strategies
There must be a strategy of primary and back-up plans with all the
equipment and personnel ready before starting
The outcome depends on the strategy adopted and not the initial or
primary approach to securing the airway
There is no obvious benefit in starting difficult cases in the anaesthetic
room when the back-up/rescue plan involves other members of the
theatre/surgical team
Needle cricothyrotomy has a high failure rate in practice – urgent
surgical tracheostomy appears to be a more successful back-up
 Limitations on NAP4 and the
obstructed airway
• Successful primary tracheostomy under LA or
GA was not reported to the project
• A rescue surgical airway may well be part of an
excellently planned and managed obstructed
airway
• ‘Successful’ airway management which did not
lead to a qualifying event was not reported
 Recommendations for management of the
obstructed airway 1
• 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 reviewed jointly
by the surgeon and anaesthetist
• The level of obstruction in the airway should be
determined whenever possible
 Recommendations for management of the
obstructed airway 2
• 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 theatre with
everyone assembled and ready
 Recommendations for management of the
obstructed airway 3
• Multiple attempts at direct laryngoscopy should
be avoided
• If FOI is the primary plan, there are good
reasons for undertaking this in the awake patient
and this should be considered
• 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
 Recommendations for management of the
obstructed airway 4
• 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
A patient with an advanced transglottic tumour required tracheostomy prior
to radiotherapy.

Anaesthesia was induced with total intravenous anaesthesia in the

anaesthetic room.

Intubation was attempted unsuccessfully by rigid videolaryngoscopy.

Rapid oxygen desaturation developed and both facemask ventilation and

needle cricothyroidotomy failed.

A late peri-arrest attempt at intubation was made by the surgeon.

The patient died in the anaesthetic room.

The report illustrating the largest number of learning points