Critical Upper Airway Obstruction with Impending Respiratory Failure

Introduction to Airway Management

The American Society of Anesthesiologists recommends immediate preparation for emergency airway management with a double setup for surgical airway access in patients with severe supraglottic pathology and impending complete airway obstruction 1, 2

The British Journal of Anaesthesia suggests that an oxygen saturation of 96% can be falsely reassuring in patients with upper airway obstruction, as they can maintain adequate oxygenation until complete obstruction occurs, at which point rapid decompensation follows 3
A Cormack-Lehane grade 3b view, where the epiglottis cannot be lifted from the posterior pharyngeal wall, significantly reduces the success of standard intubation techniques 1, 4

The British Journal of Anaesthesia recommends summoning the most experienced airway operator available and an ENT/surgical team capable of emergency tracheostomy, and positioning the patient sitting upright at 30-45 degrees to prevent complete obstruction 5
The American Society of Anesthesiologists suggests applying high-flow nasal oxygen (HFNO) or CPAP/NIV to maintain oxygenation and provide PEEP, and continuing supplemental oxygen via non-rebreather mask if HFNO is unavailable 3, 5
Active peroxygenation is critical, as time to desaturation will be extremely short if obstruction worsens 3, 5

The British Journal of Anaesthesia recommends limiting intubation attempts to a maximum of 3, as multiple attempts can cause progressive laryngeal edema and hemorrhage, losing the ability to ventilate, and using video laryngoscopy if available for better success in distorted anatomy 5
The American Society of Anesthesiologists suggests having a gum elastic bougie immediately available, and proceeding immediately to surgical airway if intubation fails after 3 attempts 1, 4

The American Society of Anesthesiologists recommends attempting supraglottic airway (LMA) for temporary oxygenation, and if failed, immediate cricothyroidotomy, as delay can be fatal 1, 6, 7

The American Society of Anesthesiologists suggests monitoring for post-obstructive pulmonary edema, which presents with dyspnea, pink frothy sputum, and bilateral infiltrates on chest X-ray, and treating with positive pressure ventilation (CPAP/PEEP) and supportive care 7, 8