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Chapter: Medical Surgical Nursing: Emergency Nursing

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Airway Obstruction - Emergency Nursing

Acute upper airway obstruction is a life-threatening medical emergency.

Airway Obstruction

Acute upper airway obstruction is a life-threatening medical emergency. The airway may be partially or completely occluded. If the airway is completely obstructed, permanent brain damage or death will occur within 3 to 5 minutes secondary to hypoxia. Partial obstruction of the airway can lead to progressive hypoxia, hypercarbia, and respiratory and cardiac arrest.

Pathophysiology

Upper airway obstruction has a number of causes, including as-piration of foreign bodies, anaphylaxis, viral or bacterial infection, trauma, and inhalation or chemical burns. In adults, aspiration of a bolus of meat is the most common cause of airway obstruc-tion. In children, small toys, buttons, coins, and other objects are commonly aspirated in addition to food. Peritonsillar abscesses, epiglottitis, and other acute infectious processes of the posterior pharynx can result in airway obstruction.

Clinical Manifestations

Common signs and symptoms include choking, apprehensive ap-pearance, inspiratory and expiratory stridor, labored breathing, use of accessory muscles (suprasternal and intercostal retraction), flaring nostrils, increasing anxiety, restlessness, and confusion. Cyanosis and loss of consciousness develop as hypoxia worsens.

Assessment and Diagnostic Findings

Assessment of the patient who has a foreign object occluding the airway may involve simply asking the person whether he or she is choking and requires help. If the person is unconscious, inspec-tion of the oropharynx may reveal the offending object. X-rays, laryngoscopy, or bronchoscopy also may be performed.

Gerontologic Considerations

For elderly patients, especially those in extended care facilities, sedatives and hypnotic medications, diseases affecting motor co-ordination (eg, Parkinson’s disease), and mental dysfunction (eg, dementia, mental retardation) are risk factors for asphyxia-tion by food. Nursing staff involved in the care of elderly patients must be aware of the symptoms of upper airway obstruction and be skillful in performing the Heimlich maneuver. Typically, the victim with a foreign body airway obstruction cannot speak, breathe, or cough. The patient may clutch the neck between the thumb and fingers (universal distress signal ). The first response is to ask this person whether he or she is choking.

 

If the patient can breathe and cough spontaneously, a partial obstruction should be suspected. The victim is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. There may be some wheezing between coughs. If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, in-creased respiratory difficulty, or cyanosis, the patient should be managed as if there were complete airway obstruction.

 

After the obstruction is removed, rescue breathing is initiated. If the patient has no pulse, cardiac compressions are instituted. These measures provide oxygen to the brain, heart, and other vital organs until definitive medical treatment can restore and support normal heart and ventilatory activity.

Management

Establishing an airway may be as simple as repositioning the pa-tient’s head to prevent the tongue from obstructing the pharynx. Alternatively, other maneuvers, such as abdominal thrusts, the head-tilt–chin-lift maneuver, the jaw-thrust maneuver, or inser-tion of specialized equipment may be needed to open the airway, remove a foreign body, or maintain the airway (Chart 71-3). In all maneuvers, the cervical spine must be protected from injury.


 

HEAD-TILT–CHIN-LIFT MANEUVER

 

The patient is placed supine on a firm, flat surface. If the patient is lying face down, the body is turned as a unit so that the head, shoulders, and torso move simultaneously with no twisting. Next, the airway is opened using either the head-tilt–chin-lift maneu-ver or the jaw-thrust maneuver. In the head-tilt–chin-lift ma-neuver, one hand is placed on the victim’s forehead, and firm backward pressure is applied with the palm to tilt the head back. The fingers of the other hand are placed under the bony part of the lower jaw near the chin and lifted up. The chin and the teeth are brought forward almost to occlusion to support the jaw.

JAW-THRUST MANEUVER

 

After one hand is placed on each side of the patient’s jaw, the an-gles of the victim’s lower jaw are grasped and lifted, displacing the mandible forward. This is a safe approach to opening the airway of a victim with suspected neck injury because it can be accom-plished without extending the neck.

OROPHARYNGEAL AIRWAY INSERTION

An oropharyngeal airway is a semicircular tube or tubelike plas-tic device that is inserted over the back of the tongue into the lower posterior pharynx in a patient who is breathing sponta-neously but unconscious (Chart 71-4). This type of airway prevents the tongue from falling back against the posterior pharynx and obstructing the airway. It also allows health care providers to suction secretions.


ENDOTRACHEAL INTUBATION

 

The purpose of endotracheal intubation is to establish and main-tain the airway in patients with respiratory insufficiency or hy-poxia. Endotracheal intubation is indicated for the following reasons: (1) to establish an airway for patients who cannot be ad-equately ventilated with an oropharyngeal airway, (2) to bypass an upper airway obstruction, (3) to prevent aspiration, (4) to per-mit connection of the patient to a resuscitation bag or mechanical ventilator, and (5) to facilitate the removal of tracheobronchial secretions (Fig. 71-1). Because the procedure requires skill, en-dotracheal intubation is performed only by those who have had extensive training. These include physicians, nurse anesthetists, respiratory therapists, flight nurses, and nurse practitioners. The emergency nurse, however, is commonly called upon to assist with intubation.

ALTERNATIVE INTUBATION METHOD

 

If the patient is outside the hospital and cannot be intubated in the field, the emergency medical personnel may insert a Com-bitube. The tube rapidly provides pharyngeal ventilation. When the tube is inserted into the trachea, it functions like an endotra-cheal tube.

One of the two balloons around the tube can be inflated. One balloon is large (100 mL) and occludes the oropharynx. This could effectively provide for ventilation through forced air by way of the larynx. The smaller balloon is inflated with 15 mL of air and can effectively occlude the trachea if placed there. Breath sounds are auscultated to make sure that the oropharyngeal cuff does not obstruct the glottis. Patients can be ventilated through either port of the tube, depending on its placement.

 

CRICOTHYROIDOTOMY (CRICOTHYROID MEMBRANE PUNCTURE)

 

Cricothyroidotomy is the opening of the cricothyroid mem-brane to establish an airway. This procedure is used in emergency situations in which endotracheal intubation is either not possible or contraindicated, as in airway obstruction from extensive maxillo-facial trauma, cervical spine injuries, laryngospasm, laryngeal edema (after an allergic reaction), hemorrhage into neck tissue, or obstruction of the larynx.

 

After these maneuvers are performed, the patient is assessed for breathing by watching for chest movement and listening and feeling for air movement.

 

In such a case, nursing diagnoses would include ineffective air-way clearance due to obstruction of the tongue, object, or fluids (blood, saliva). The nursing diagnosis may also be ineffective breathing pattern due to obstruction or injury.

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