Specific measures

Recognized obstruction is best managed by experienced staff with adequate equipment. Although the operating room may be the optimal location for management, a suitably stocked emergency airway trolley is necessary for acute management in other locations (Table...?).

Table 2 Difficult airway management trolley: useful items to supplement the intubation trolley

The following procedures should be considered initially.

1. Release neck hematomas if postsurgical.

2. Perform the Heimlich maneuver if a foreign body is suspected.

3. Standby rigid bronchoscopy for removal of a foreign body.

If an airway cannot be maintained the following approaches are considered.

1. Laryngoscopy with elevation of laryngeal structures may provide tracheal support and reduce obstruction.

2. Perform awake intubation, bronchoscopically assisted, with a long thin endotracheal tube or catheter passed beyond obstruction. Small-diameter endotracheal tubes may not be long enough to bypass distal obstructions and adapted catheters may be required ( Syt.cli.ffe et. .al 1995).

3. Muscle relaxants decrease chest wall muscle tone and remove the expansile tracheal forces of spontaneous ventilation. Although not absolutely contraindicated, paralysis prior to control of airway may be associated with total loss of airway control.

4. In upper tracheal lesions, jet ventilation via a transtracheal catheter may be possible provided that expiration is unimpeded.

5. Femoral vein-femoral artery partial cardiopulmonary bypass has been used in this group of patients.

6. In the presence of massive hemoptysis from a bronchial site or intrabronchial rupture of a lung abscess, urgent placement of a double lumen endobronchial tube may 'isolate' the lungs and prevent contamination of the contralateral lung prior to definitive treatment.

Continuing hypoxia or hemodynamic compromise after successful bypassing of obstruction should lead to consideration of the emergence of another complication such as postobstructive pulmonary edema, pneumothorax, or aspiration pneumonitis. Although a small-size endotracheal catheter may allow acute crisis control, pending definitive treatment of obstruction the patient remains at risk from endotracheal tube kinking, luminal obstruction, suboptimal airway toilet, and difficulty in re-establishing spontaneous ventilation.

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