Acute upper airway obstruction In the last lecture we said that you might have complications; heart attack

, toxicity from LA , the pt. might comatose (enter in a coma) , when you have a comatose pt. the most important thing to check is the airway (ventilation) , as we said if we had airway obstruction we'll have low ventilation within 2-3 min. we'll have hypoxia another 3 min we'll have brain hypoxia which is irreversible and you'll lose the pt. So we are talking now about acute upper way obstruction . definition A blockage of the upper airway, which can be in the trachea, laryngeal (voice box), or pharyngeal (throat) areas. The blockage can be complete or partial ( caused by any obstruction of any part of the upper way

Upper way: from the nose to the mouth down to the naso-pharynx(the path of the pharynx behind the nose) and the oro-pharynx (the path of pharynx behind the mouth) then the larynx (voice box) then trachea and its divisions

Mild obstruction may result in air hunger in normal life when you're swallowing the glottis would be covering the airway allowing the food to go from mouth to esophagus , sometimes some of food particles enters the airway (especially when you are eating quickly) and might cause choke (partial airway obstruction) , this is what we call air hunger >> it's a protective mechanism thanks to GOD , even when you are sleeping it works. The patient with partial obstruction exhibits diminished tidal exchange (tidal volume which is about 500 ml) that is associated with retraction of the upper chest ; when you take a breath you'll have expansion of the chest , because you have negative intra-thoracic pressure you can suck air forcefully from outside and expand your lungs , but if you have partial obstruction >> we do the same mechanism but if you have something obstructing your airway you'll have retraction except for expansion (you can't expand your chest ,no air is coming to your chest) and accompanied by a snoring sound * snoring is because of obstruction , like in pt. he's obese and he has something obstructing ,sometimes when he's awake the breath will be compensated but while air way like sleeping everything in your body is relaxed so the tongue now is obstructing airway against oro-pharynx, so we have partial obstruction which leads to snoring , but if the obstruction is near the pharynx down and trachea its gonna be sth like stridor ( he tried to make the sound

of stridorm like the choke a little bit but seems stronger) >>> thats if the obstruction is nasopharyngeal complete obstruction its more tragedic , for partial obstruction the pt. waz still pinkish in color (because there is still oxygenation but not sufficient) but in complete obstruction we'll have cyanosis . we can have confusion >> no enough O2 in blood so no enough O2 in brain which will cause confusion or vasovagal attack ,it's a protective mechanism because when a pt. has a vasovagal attack he'll have vasodilatation in his body pouring the blood to the lower limps and decrease perfusion to the brain then brain will have ischemia so when the pt. loose consciousness and falls down blood supply to the brain will be better, unconsciousness itself will decrease metabolic rate of the brain so it's a protective mechanism. So patient with complete obstruction exhibits no tidal exchange at all that is associated with paradoxical breathing sound . Symptoms of acute upper airway obstruction are dramatic and easy to diagnose .The individual may suddenly begin having difficulty breathing or be unable to breathe at all . Cyanosis, unconsciousness, and death may rapidly follow significant partial or total obstruction , and you can have such cases in your clinic so you have to be able to deal with such cases to save your pts. Life . Most Common causes of acute upper airway obstruction: 1.Foreign bodies (while you are extracting tooth the tooth might obstruct the airway or food) *hotdogs are the most food associated in aspiration fatalities; most common cause of death, because its soft so it's easy to stuck in airway and obstruct it 2.anaphylaxis (like allergy , when you are giving antibiotic or LA , you'll have generalized reaction in the body causes redness in the skin and edema in all the body , most critical thing is the edema inside the airway itself which might lead to death if severe anaphylaxis , the first to do in this case is tracheal intubation it will prevent edema from obstructing airway not from progression) 3.Croup (or what we call it larengeo-tracheo bronchitis we see it in children 1-5 years and usually triggered by acute viral infection) 4.Infection diseases (The infection leads to swelling inside the throat, which interferes with normal breathing and produces the classical symptoms of a "barking" cough, stridor, and hoarseness ) This picture for a child he had croup and edema in the airway , if you notice here the trachea and we have obstruction , if a child came to you with larengeo-tracheo bronchitis you can't just give him antibiotic and tell him to leave , you have to tell him to go to hospital immediately because its easy to change to complete obstruction so its a critical case.

**infection diseases 1. acute bacterial epiglottitis can cause rapid airway obstruction as the epiglottis swells and occludes the airway (very common especially in pre-school age) 2. Retropharyngeal abscess a rapidly expanding abscess can block the airway and cause respiratory distress 3. Peritonsillar abscess **might be an exam question Symptoms of Acute upper airway obstruction might differ from partial to complete obstruction Symptoms vary depending on the cause, but some symptoms are common to all types of obstruction. 1.Choking 2.Gasping for air 3.Wheezing (in the lower airways), crowing, whistling, or other unusual breathing noises indicating breathing difficulty 4.agitation 5.Panic 6.Cyanosis (bluish discoloration of skin caused by lack of oxygen) 7.Changes in consciousness 8.Unconsciousness Signs and tests -Physical examination may show decreased breath sounds -Tests are usually not necessary (but when you want to detect the foreign body and its location you may do X-rays, bronchoscopy, and laryngoscopy ) treatment -If the victim has a complete obstruction and is unable to speak or breath, the Heimlich maneuver may be lifesaving ** Heimlich maneuver >> to press on the lower chest by both of your hands to make ositive intra-thoracic pressure and by that you are trying to push any foreign body outside the airway

Esmarchs maneuver (for example you had a comatose pt. in your clinic ) >> it opens the airway by tilting the head backward, and jaw thrust which elevates the tongue up retracting the patients lower lip (with the rescuers thumbs) and by forceful forward displacement of the mandible (triple airway maneuver).

-Treatment depends on the cause of the blockage. Aspirated objects may be able to be removed with laryngoscopy or bronchoscopy ,always try not to blindly insert your finger inside the pts. Mouth if there is a foreign body because you might cause complete obstruction rather that the partial that the pt. had before entering your finger there unless the object is visible to you -A tube may need to be inserted into the airway (endotracheal tube or nasotracheal tube). Sometimes an opening needs to be made directly into the airway (tracheostomy or cricothyrotomy).
This is Heimlich maneuver for a child , you keep doing like the picture and then upside the child down on his trunk

Complications Inability to relieve the obstruction can cause breathing failure, brain damage, or death.

AYA shahrouri