In the field, few situations cause more anxiety than struggling to clear an obstructed airway. However, when a clinician is successful, it can also be one of the most rewarding experiences of their career. Routine training of advanced airway skills will prepare you to successfully manage most obstructed airway cases. But what happens when you run out of options? What do you do when repositioning and a finger sweep don't fix the problem and there's still no air passing into the lungs?
The following cases present some less common techniques for advanced airway management that you might need to apply someday.
You're called to assist a 34-year-old female patient who collapsed while eating dinner. Her husband reports that she was eating steak when she started coughing and subsequently became unresponsive. The patient has a history of stroke, which has affected her ability to speak and swallow in the past six months.
When you arrive, both police and the patient's husband are performing the Heimlich maneuver without success. You take over management of the patient. She's unresponsive and cyanotic with a weak, fast pulse. Your attempts to ventilate are met with resistance, and there's no chest rise.
At this point, what are your options? You could:
- Reposition the patient's head, perform a finger sweep and attempt to ventilate;
- Perform back blows with the patient draped over your arm;
- Insert a suction catheter into the mouth to clear the airway; or
- Attempt visualization using a laryngoscope.
Repositioning the head and performing the finger sweep didn't relieve the obstruction. She's too heavy to drape over your arm, and you get no results with the suction catheter. Your partner suggests intubating her and trying to push the obstruction farther down, hopefully past the carina so you can at least ventilate one lung.
In this actual case, the paramedic performed direct laryngoscopy using a laryngoscope. Upon seeing the glottic opening, she identified a piece of steak at the level of the vocal cords. She successfully removed the food using a Magill forceps and the patient began breathing spontaneously.
Here, the obstructing object was retrieved using a tool found in most airway kits. But what if the object had been too deep to be retrieved or even seen? Is there a way of trying to suction out an object that's past the vocal cords?
One suction technique you can use involves cutting off the bevel and Murphy's eye of an endotracheal (ET) tube to form a flat end. The tube is then attached to suction by using a meconium aspirator as the transition/control piece (see photos, p. 78). The tube is passed through the cords using direct visualization, and suction is applied by covering the port on the aspirator once the tube contacts the obstructing object. With slow, gentle retraction of the ET tube, the aspirated object should come out.
The ultimate disposition of this patient is simple: The Heimlich maneuver was performed on your patient as an attempt to clear her obstruction; therefore, she should be transported to an emergency department (ED) for evaluation.
There are numerous reports in the literature of dangerous complications of the Heimlich maneuver, including esophageal rupture, aortic thrombosis and pancreatic transection.A> 1Ï3 However, a 2007 study reported that 18% of patients who were evaluated for choking refused to be transported against medical advice. 4 So if your patient has had the Heimlich maneuver performed on them, recognize the risk of injury and encourage them to be evaluated in the ED.
You're called to the home of a 68-year-old male who called 9-1-1 gasping for air and unable to speak. You arrive to find the patient has collapsed; first responders are attempting to ventilate him without success. They've placed an oral airway but are getting no chest rise with assisted ventilations due to significant resistance. The patient is pulseless with the monitor showing asystole.
No one is present in the home to provide any medical history on the patient. He appears to be thin, malnourished and older than reported. His oropharynx is normal, although he's edentulous. No obvious foreign bodies are obstructing the airway.
You take over airway management with the same results. No matter how you position the patient's head or squeeze the bag-valve mask, no air is getting into the patient's lungs. When you attempt to intubate, the ET tube gets hung up just past the vocal cords and will go no farther.
You decide to use a flex guide to get past the obstruction; however, the flex guide passes 3 cm beyond the vocal cords, turns right and comes to an abrupt stop. Your partner comments that the patient has a large, firm mass on the neck region where he's attempting to perform cricoid pressure.
What are your options for establishing a patent airway in this patient?
- Place a rescue airway (e.g., Combitube, LMA, King airway);
- Perform a cricothyroidotomy;
- Perform needle jet ventilation; or
- Call medical control and request nebulized epinephrine.
The clinicians in this case performed a surgical cricothyroidotomy and were able to establish an airway with good chest rise; however, the patient did not survive. The procedure was complicated by significant bleeding, later determined to be from the tumor in the patient's neck that was obstructing his airway.
For this reason, a better option may have been performing a needle cricothyrotomy, which is associated with less bleeding due to the absence of an incision in the skin. The technique of placing a needle through the cricothyroid membrane is relatively simple, although it requires some rarely used equipment. Familiarizing yourself with at least one way of connecting your oxygen system to the needle and packaging the equipment together may mean the difference between a successful case and a chaotic mess.
Some ventilation techniques using a needle include the use of oxygen tubing and intermittently disconnecting it to allow for exhalation. However, this reportedly results in inadequate ventilation within 60 seconds. 5 There's better ventilation if a higher-pressure insufflation device is used, though this equipment is often difficult to find in a hurry because it's not often used.
There are many other creative ways to adapt the needle to more commonly used equipment. 6 I recommend using a bag-valve mask and the end of a 3.5-mm ET tube placed into the needle.
Needle jet ventilation is still the recommended option for children under the age of 12 due to potential long-term effects of cricoid cartilage damage.
You arrive on the scene of a 42-year-old male reportedly choking on a muffin. He's currently unresponsive on the floor; first responders continue abdominal thrusts. They've been unable to get any air passage using a bag-valve mask.
The patient's care provider states that the patient has mild mental retardation with no other medical problems. She states the patient was eating breakfast when he suddenly began wheezing and coughing. This persisted despite her attempts to give him water and provide back blows.
The patient has the following vitals: Pulse 70, BP 170/90, respirations assisted 16, O2 sats 45%. He's unresponsive with pale skin and perioral cyanosis. He's making no respiratory effort but is not resisting efforts to open his airway.
You decide to look for a foreign object using a laryngoscope and find nothing.
At this point you could:
- Attempt to suction the patient; or
- Place an ET tube.
You decide to go with the ET tube. The patient is easily intubated, but there's significant resistance with ventilation. There are no breath sounds or chest rise with ventilation and the EtCO2 reading is 2. The patient's condition has declined, and he's now pulseless.
What are your options for restoring oxygenation and ventilation in this patient?
- Perform a bilateral needle thoracostomy;
- Perform a surgical cricothyroidotomy;
- Use a PEEP valve to add more pressure with ventilation; or
- Push the tube farther in to get past the obstruction.
In this case, a surgical airway was performed with no change in the patient's condition. Ultimately, this patient was pronounced dead. At autopsy, a rubber glove was found in the patient's trachea at the level of the carina. In retrospect, there was little the crew could have done to remedy this problem.
A learning point from this case is that a surgical airway wasn't indicated in this situation. A surgical airway is indicated when you can't pass an ET tube, such as in cases of severe facial trauma, angioedema or an obstruction of the upper airway. In this example, the ET tube passed through the cords without difficulty. The true barrier to oxygenating the patient was occurring below the vocal cords, at the level of the carina. There was nothing to be gained by performing a surgical airway.
The most important step in the surgical airway procedure is correctly making the decision to proceed. A cricothyrotomy should be done only when there's no other way to ventilate and oxygenate the patient. It should not be done if a less invasive technique will suffice. An example would be in the case of an unsuccessful rapid sequence intubation (RSI). If the clinician can maintain the patient's respiratory status with a bag-valve mask, then that's what should be done.
Cricothyrotomies have a reasonable success rate. A 2004 study reported an 86% success rate by prehospital providers. 7An older study compared two techniques on cadavers with residents and reported 88% and 94% success rates. 8
Although it appears the right training will lead to success during the procedure, the outcomes of patients who require a cricothyrotomy are often poor. A 1990 study reviewed prehospital cricothyrotomies and found only one patient out of 17 who survived with a good neurologic outcome. 9The 2004 study reported eight survivors out of 61 who underwent prehospital cricothyrotomy, but only two had favorable neurologic outcomes. 7These numbers illustrate the severity of the patient condition in these cases and that good outcomes are rare despite our best efforts.
Most of the time our routine advanced airway skills are sufficient to manage a difficult airway. On the rare occasion that the challenge is far greater, utilizing some of the techniques mentioned here may help save your patient's life. The best way to be successful is to prepare for the worst and anticipate the techniques you may need. Follow that with gathering the necessary tools and familiarizing yourself with them. This preparation will ensure a better chance of success when you encounter a patient with a challenging, obstructed airway.
Paul Satterlee, MD, FACEP, is the associate medical director of Allina Medical Transportation in St. Paul, Minn. He's also the chief medical officer of MN-1DMAT. The author thanks David Page, EMT-P, and Daryl Doering, EMT-P, for their assistance with the development of this article.
- Meredith MJ, Liebowitz R. "Rupture of the esophagus caused by the Heimlich maneuver.". Annals of Emergency Medicine 1986;15:106-107.
- Mack L, Forbes T, Harris K. "Acute aortic thrombosis following incorrect application of the Heimlich maneuver."Annals of Vascular Surgery 2002;16:130-133.
- Feeney SN, Pegoli W, Gestring ML. "Pancreatic transection as a complication of the Heimlich maneuver: A case report and literature review."Journal of Trauma 2007;62:252-254.
- Soroudi A, Shipp HE, Stepanski BM. "Adult foreign body airway obstruction in the prehospital setting."Prehospital Emergency Care 2007;11:25-29.
- Scrase I, Woollard M. "Needle vs surgical cricothyroidotomy: A short cut to effective ventilation."Anaesthesia 2006;61:962-974.
- Gaufberg S. "New Needle Cricothyroidotomy Setup."The American Journal of Emergency Medicine 2004;22:37-39.
- Marcolini EG, Burton JH, Bradshaw JR. "A standing-order protocol for cricothyrotomy in prehospital emergency patients."Prehospital Emergency Care 2004;8:23-28.
- Holmes JF, Panacek EA, Sakles JC. "Comparison of two cricothyrotomy techniques: Standard method versus rapid 4-step technique."Annals of Emergency Medicine 1998;32:442-446.
- Spaite DW, Joseph M. "Prehospital cricothyrotomy: An investigation of indications, technique, complications, and patient outcome."Annals of Emergency Medicine 1990;19:279-285.