Keterangan
An acute upper airway obstruction (UAO) is a blockage that occurs in your upper airway. The upper airway of your respiratory system consists of the trachea, larynx or voice box, and throat. A blockage in your airway could prevent your body from getting enough oxygen. A lack of oxygen can cause brain damage, and even a heart attack, in a matter of minutes. Any obstruction of the upper airway has the potential to be life-threatening. Seek emergency medical attention immediately if you suspect that you, or someone you know, has an obstructed upper airway.Acute airway obstruction (the foreign body either completely obstructs the pharynx or acts as a valve on the laryngeal inlet), no warning signs, most frequently in a child 6 months-5 years playing with a small object or eating. Conscience is initially maintained. Perform maneuvers to relieve obstruction only if the patient cannot speak or cough or emit any sound:
Children over 1 year and adults:
Heimlich manoeuvre: stand behind the patient. Place a closed fist in the pit of the stomach, above the navel and below the ribs. Place the other hand over fist and press hard into the abdomen with a quick, upward thrust. Perform one to five abdominal thrusts in order to compress the lungs from the below and dislodge the foreign body.
Children under 1 year:
Place the infant face down across the forearm (resting the forearm on the leg) and support the infant’s head with the hand. With the heel of the other hand, perform one to five slaps on the back, between shoulder plates.
If unsuccessful, turn the infant on their back. Perform five forceful sternal compressions as in cardiopulmonary resuscitation: use 2 or 3 fingers in the center of the chest just below the nipples. Press down approximately one-third the depth of the chest (about 3 to 4 cm).
Ringkasan
- A 48-year-old male with a history of squamous cell carcinoma recurrence presented in severe respiratory distress, characterized by rapid heart and respiratory rates, low oxygen saturation, reduced air entry, stridor, wheezing, massive neck swelling, neck stiffness, limited mobility, and restricted mouth opening. His airway was severely compromised.
- The patient had undergone radical surgery and radiotherapy for buccal mucosa cancer in 2012, followed by a right commandorist section with free fibula graft and tracheostomy in 2015, which was later decannulated. A follow-up PET scan revealed disease recurrence, treated with chemotherapy, leading to tracheal obstruction due to tumor recurrence at the tracheostomy site.
- The CT scan confirmed a 2 cm tracheal obstruction with over 90% luminal compromise located at the suprasternal notch. This location caused both upper and lower airway obstruction, explaining the presence of stridor and wheezing.
- The initial management in the emergency room included non-invasive mask ventilation, bronchodilators, IV steroids, and anti-inflammatory medication, given the high risk of a "crash intubation" scenario.
- Causes of upper airway obstruction in adults include infection, inflammatory disorders, trauma, and external compression. In the presented case, malignancy became a more prevalent problem because of prior tobacco use and exposure to the environmental toxins, and the patient had internal obstruction with the tumor recurrence.
- Assessment of airway obstruction involves identifying noisy breathing, noting whether it occurs during inspiration (proximal obstruction) or expiration (distal obstruction). Difficulty breathing in that improves with crying suggests nasal or pharyngeal obstruction, while deterioration with crying indicates laryngeal involvement.
- The characteristics of airway obstruction sounds vary by location: nasal pharynx (snoring, stridor), larynx (stridor, possible wheezing), trachea/bronchus (predominant wheezing), and smaller airways (wheezing only).
- The severity of airway obstruction correlates with airway diameter reduction; exertional dyspnea occurs around 8 mm, dyspnea at rest around 5 mm. The sound signals from asthmatic wheezes or stridor are of similar frequency leading to errors in diagnosis, an upper aware obstruction due to tumor or foreign body may be mistakenly treated as a low respiratory tract infection.
- The primary goals in managing acute airway obstruction include establishing a secure and patent airway, often involving medical management with oropharyngeal airways, endotracheal intubation, racemic epinephrine, corticosteroids, and helium-oxygen mixtures.
- Surgical interventions may include bi-broptic intubation, Cricothyrotomy, Pritjostomy, laser electrocard tree or balloon dilatation with the help of a bronchoscope and airways tent.
- In the case, establishing a patent airway proved challenging, prompting the use of femoro-femoral veno-venous extracorporeal membrane oxygenation (VV ECMO) to maintain oxygenation.
- Following ECMO initiation, a low tracheostomy was performed below the original site due to tumor recurrence.
- The case highlights the importance of considering alternative approaches like "side of neck access" (SONA) when traditional airway management fails, bypassing the obstructed front of the neck. The case highlighted the utility of ECMO, and emphasized that the anatomical and pathological processes at the different level provide their own unique set of challenges and need own unique solutions.
Contoh Sertifikat
Tentang Pembicara
Dr Pooja Wadwa
Additional Director, Critical Care Medicine, ECMO specialist,FMRI,Gurgoan
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