Airway obstruction

Airway obstruction presents a major hazard in the comatose patient. The most common cause is the tongue, which slips backwards into the pharynx, blocking the airway. Characteristically, this produces noisy breathing or snoring. Laryngeal edema or tracheal obstruction is associated with inspiratory stridor. Although complete obstruction is silent, respiratory movements continue, often becoming more marked and labored, and characterized by a paradoxical 'seesaw' respiratory pattern in which the chest wall and suprasternal fossa are drawn inwards on inspiration.

Treatment of airway obstruction is by chin lift and elevation of the lower jaw, drawing the tongue out of the pharynx. In case of failure to relieve the obstruction or when injury to the cervical spine contraindicates neck extension, a jaw thrust technique is recommended. In this method the attendant pushes the lower jaw forward using pressure applied behind the angles of the mandible. If this is unsuccessful, insertion of an oral airway or a 6-mm nasopharyngeal tube may be needed.

When airway obstruction occurs at the level of the epiglottis, vocal cords, or trachea, intubation or a surgical airway is necessary. If intubation fails and oxygenation is threatened, catheter cricothyrotomy may be carried out using a 14G cannula introduced through the cricothyroid membrane. Once in place (air can be aspirated) and secured firmly, ventilation through the cannula can be carried out using a Sanders injector or high-frequency ventilator at rates of 40 to 50 breaths/min.There are other alternatives, such as connecting the male end of a 7.5-mm endotracheal tube adaptor to a plungerless 2-ml syringe which is then attached to the hub of the 14G

cannula. Connection to an anesthetic breathing circuit then allows ventilation by either bag compression or use of the oxygen flush valve ( Patel 1983) In these circumstances complete obstruction above the level of the cricothyrotomy may lead to barotrauma as expired gas cannot vent. This should be guarded against by insertion of another cannula or conversion to a wider-bore minitracheostomy or percutaneous tracheostomy as soon as control of oxygenation has been regained. While trying to overcome obstruction, it is essential that oxygen is presented to the airway at all times and that oxygen saturation and ECG monitoring are ongoing.

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