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What is an upper airway obstruction?

Upper airway obstruction happens when there is an anatomic narrowing or occlusion that results in a reduced ability to exchange gas in and out of the lungs. The obstruction can lead to respiratory failure, arrhythmias, cardiac arrest or death within minutes. Therefore, healthcare professionals must be aware of signs and symptoms, possible causes and management in order to intervene promptly and minimise morbidity and mortality.

Type of upper airway obstruction?

The upper airway includes four compartments: the nose and mouth, the pharynx, the larynx, and the trachea.1 Obstruction can occur in any of these compartments. The onset can be acute or may evolve chronically.1,2 Chronic airway obstruction can also develop into an acute episode with further narrowing of the airway.

Upper airway obstruction is also classified as partial or complete depending on the degree of occlusion.2 Partial obstruction allows for some gas exchange, whilst complete obstruction does not allow any.

Signs and symptoms of upper airway obstruction

Patients presenting with acute upper airway obstruction may be unable to give history and are often in distress. Accessory muscles of respiration may be used (neck and shoulder muscles), and there may be intercostal and subcostal recession and a tracheal tug.3 When obstruction is complete, patients may be unconscious or in cardiopulmonary arrest.

The Resuscitation Council UK (2015, 2017) recommends assessing a possible airway obstruction by the look, listen and feel approach. 3,4

  • LOOK for chest and abdominal movements; 
  • LISTEN and FEEL for airflow at the mouth and nose. 

This approach will help identify whether an obstruction is present, and if it is a partial of complete obstruction. In complete obstructions, there are often no sounds and there may be paradoxical chest and abdominal movements, described as ‘see-saw breathing’ as the patient tries to ventilate.3

Partial Upper Airway Obstruction

In partial airway obstruction, air entry is reduced and usually noisy:3

  • Inspiratory stridor - caused by obstruction at the laryngeal level or above
  • Expiratory wheeze - suggests obstruction of the lower airways, which tend to collapse and obstruct during expiration
  • Gurgling - suggests the presence of liquid or semisolid foreign material in the upper airways 
  • Snoring - arises when the pharynx is partially occluded by the tongue or palate
  • Crowing or stridor - is the sound of laryngeal spasm or obstruction

Common causes of upper airway obstruction

There are several possible causes of upper airway obstruction:

  • Tongue, in patients with CNS depression5
  • Inflammation and infection1,2
  • Blunt trauma of the airway structures1,2
  • Inhalation injury like in a fire and explosion1
  • Anatomic causes may also cause or contribute to obstruction, namely deviated septum macroglossia, tracheal atresia, polyps, enlarged tonsils, lipoma of the neck, naso-oral pharyngeal cancers2
  • Haemorrhage, secretions1
  • Post-intubation (tracheomalacia, tracheal stenosis)1
  • Aspiration of foreign body1,2
  • Obstructive sleep apnoea (chronic cause of airway obstruction)2
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Management of upper airway obstruction

When a patient presents with upper airway obstruction, the immediate goal is relieving the obstruction, so air exchange can occur. In acute obstructions, the condition can worsen rapidly if left untreated. Even though the focus is in correcting the underlying cause, in acute cases, it may be required to correct the obstruction first before identifying the pathology.

Main considerations in upper airway obstruction intervention include the following:3,4

  • Give high-concentration oxygen during the attempt to relieve airway obstruction.
  • Pulse Oximetry (SpO2) and Capnography (EtCO2) are used to monitor airway patency and guide further use of oxygen.
  • If the patient presents with aspiration of foreign object, follow choking algorithm by Resuscitation Council UK and encourage to cough, proceeding to giving up to 5 back blows, and up to 5 abdominal thrusts.
  • If there is liquid or semisolid foreign material (blood, saliva, gastric contents) in the upper airways, use a wide-bore rigid sucker (Yankauer) to remove it.
  • Basic techniques for opening the airway are successful in most cases of airway obstruction caused by loss of muscle tone in the pharynx:
    • Head tilt
    • Chin lift
    • Jaw thrust
  • If still unable to ventilate once the airway is open, an emergency tracheotomy is required.

Conclusion

Upper airway obstruction can be acute or chronic and lead to respiratory failure, arrhythmias, cardiac arrest or death within minutes. Healthcare professionals must be aware of signs and symptoms, possible causes and management described above in order to intervene promptly and minimise morbidity and mortality.

About the author

My name is Andreia Trigo RN BSc MSc, I am a nurse consultant with over a decade of experience in anaesthesia, sedation and pain management.

This involves patient care, as well as lecturing at post grad level on these topics, presenting at conferences and co-developing a very successful sedation course at SedateUK. My passion for creating safer environments for patients and professionals led me to collaborate with Medtronic and share my knowledge and expertise with our professional community.

 

The content of this article is written by a blogger with whom Medtronic has a relationship. However, the contents represent the personal objective views, comments and techniques of the blogger and are not statements from Medtronic. To the extent this material might contain images of patients or any material where a copyright is held by a third party, all necessary written permissions from the patient or copyright holder, as applicable, with respect to use, distribution or copying of such images or copyrighted materials has been obtained by the blogger.

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