Anaesthesia, 2011, 66 (Suppl. 2), pages 93100 doi:10.1111/j.1365-2044.2011.06938.

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Progress in management of the obstructed airway

A. Patel1 and A. Pearce2
1 Consultant Anaesthetist, Royal National Throat Nose & Ear Hospital and University College Hospital, London, UK
2 Consultant Anaesthetist, Guys and St Thomas Hospital, London, UK

Summary
There is no consensus as to the ideal approach for the anaesthetic management of the adult
obstructed airway and there are advocates of awake fibreoptic intubation, inhalational induction
and intravenous induction techniques. This review considers the different options available for
obstruction at different anatomical levels. Decisions must also be made on the urgency of the
required intervention. Particular controversies revolve around the role of inhalational vs
intravenous induction of anaesthesia, the use or avoidance of neuromuscular blockade and the
employment of cannula cricothyroidotomy vs surgical tracheostomy.
. ......................................................................................................
Correspondence to: Dr Anil Patel
Email: anil.patel3@nhs.net
Accepted: 12 Sept 2011

Optimal management of the obstructed adult airway the team available, the location, the surgical expertise,
remains controversial with no consensus as to the ideal the equipment available, the urgency, the patients
approach. Opinions differ as some experts propose comorbidity and the site and extent of airway
techniques that other experts find unacceptable and obstruction?
explicitly criticise [13]. There are advocates of It is also useful to remember that all airway plans can
inducing general anaesthesia by an inhalational route fail. Back-up plans (Plans B, C, D, etc.) are probably
and avoiding neuromuscular blockade [4]; of inducing just as, if not more, important than any primary plan
general anaesthesia by the intravenous route and using (Plan A) [11]. These back-up plans require the same
neuromuscular blockade [5]; of avoiding general level of thought as the primary airway plan. There
anaesthesia altogether and securing an airway by an needs to be early recognition by the team that the
awake fibreoptic intubation technique [6, 7]; of original plan is not working, and good communication
tracheostomy under local anaesthesia [8]; or of inser- and execution of the predetermined back-up plan.
tion of a transtracheal catheter under local anaesthesia Whilst this may seem self-evident, unless this has been
[9]. The advocates of these various techniques claim thought through, the clinical situation can quickly
that each respectively provides the best management deteriorate.
and the range of choices can appear very confusing for For example, unless there is prior communication,
the anaesthetist who is actually faced with a patient the absence of a scrubbed surgeon for an emergency
who has an obstructed airway. Will they be later surgical airway when the airway becomes unmanage-
criticised for using any particular technique? What able, or the absence of vital equipment such as
should they do if the technique they have chosen fails? high-pressure source jet ventilation and a rigid
It is important to remember that the quality of bronchoscope, may all contribute to failure. While
evidence for the management of the obstructed airway there may be little consensus on the initial plan for the
is of a relatively low level. At best, reports are non- management of the obstructed airway, the concept of a
analytical case control or cohort studies with a high risk team approach with surgeon and theatre team is
of confounding or bias [10]. So a more pertinent essential [11].
question may be: what is the best technique or The Fourth National Audit Project (NAP4) of the
techniques for the management of the obstructed Royal College of Anaesthetists and the Difficult
airway, considering the experience of the anaesthetist, Airway Society is the largest and most comprehensive

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A. Patel and A. Pearce Airway obstruction Anaesthesia, 2011, 66 (Suppl. 2), pages 93100
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airway project undertaken in the UK, and important corticosteroids (both to reduce airway oedema) and in
lessons can be learnt for general airway management some instance helium oxygen mixtures (to improve gas
and more specifically, airway management of patients flow into the lungs). The urgency of any subsequent
with head and neck pathology [12, 13]. Seventy-two surgical intervention will be determined by the clinical
patients with head and neck pathology developed presentation and usually, for a chronically obstructed
severe complications of airway management including airway, there is time to undertake investigations that
death, brain damage, emergency surgical airway and an may include computed tomography (CT) or magnetic
unanticipated intensive care unit (ICU) admission or resonance imaging (MRI) scans and careful nasal
prolongation of ICU stay. Seventy percent of these endoscopy to determine the extent and site of the
reported cases were associated with an obstructed obstruction. Ideally, for every patient presenting with
airway, and overall these 72 patients accounted for 40% airway obstruction the site, size, level, extension and
of all the cases reported to NAP4 [11]. nature of the lesion should be established, but when
The obstructed airway describes any obstruction urgent intervention is needed in acute obstruction, this
within the airway from the nasopharynx, pharynx and is not always possible.
larynx through to the trachea and lower airways. The There are three key questions that determine the
classic symptoms and signs of obstruction at the various management of the obstructed airway: (1) What and
sites vary and include stertor at a nasopharyngeal level, where is the lesion? (2) How urgent is the surgical
gurgling at an oropharyngeal level, inspiratory stridor at intervention? (3) Is the obstruction so significant that
a supraglottic level, inspiratory or biphasic stridor at a we should abandon attempts for general anaesthesia and
glottic or subglottic level, and expiratory wheeze at a use an awake technique?
tracheobronchial level [14]. The site of obstruction will
have a great influence on the efficacy and suitability of
Site and cause of obstruction
any given technique.
Patients can present acutely with signs of airway Causes of airway obstruction vary from obstructing
obstruction including altered breathing position, an oropharyngeal lesions, supraglottic lesions such as
inability to lie flat, stridor, tachypnoea, accessory epiglottitis, tongue base lesions, vocal cord paralysis,
muscle use, sternal retraction, tracheal tug, an inability laryngeal lesions, intratracheal masses and extrinsic
to maintain alveolar ventilation, hypoxia and ultimately tracheal compression from mediastinal masses. Airway
exhaustion leading to quiet breathing that may not be management after head and neck trauma has been
appreciated as serious. Patients may also present with a discussed elsewhere, but that approach also emphasised
more chronic obstruction in which they can appear the importance of site and urgency of the requirement
comfortable with no obvious signs or symptoms of for intervention [15]. Thus, also in non-traumatic
airway obstruction despite airway diameters of only a causes, the level at which obstruction exists makes a
few millimetres [11]. The difference in symptoms and significant difference to the suitability of different
signs between acute (minutes hours) and chronic techniques. Optimising the ability to oxygenate is
(weeks months) airway obstruction is due largely to fundamental to any management strategy for the
respiratory muscle conditioning. In acute obstruction obstructed airway and recent work has challenged
the untrained respiratory muscles tire early when trying traditionally held views around neuromuscular block-
to generate the intrapleural pressure changes required ade and routine facemask ventilation [5, 1619].
during the respiratory cycle. The oxygen requirement For obstructing oral cavity and oropharyngeal lesions
of respiratory muscles at maximal effort may be such a the problems are first the ability to ventilate by facemask
substantial proportion of available oxygen delivery that following induction of anaesthesia and second, difficult
the supply demand situation is unstable with a rapid or impossible direct laryngoscopy around obstructing
onset of failure to maintain alveolar ventilation. Fully masses. The challenge in this group is one of bypassing a
trained respiratory muscles can easily sustain an large obstructing mass without traumatising it, while
adequate alveolar minute ventilation at rest through a maintaining a patent airway. If the glottis and lower
3-mm orifice but cannot meet the requirement in airway are normal, an awake technique such as awake
exercise. fibreoptic intubation allows (spontaneous) ventilation to
Primary medical management is directed at main- be preserved until the airway is secured. Alternatively,
taining oxygenation and involves careful observation, the airway can be secured by an awake transtracheal
humidified oxygen, nebulised adrenaline, intravenous catheter or tracheostomy.

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Obstructing lesions at the tongue base and supra- help to show a way through the obstruction, complete
glottis compromise airflow significantly and as they airway obstruction can still occur and it may not be
push the epiglottis downwards, further worsen the possible to pass the tracheal tube [22]. The more
obstruction. There is a danger of total airway obstruc- significant the airway obstruction, the more likely this
tion following intravenous induction in this group as a is to occur. Initial nasendoscopy to inspect the larynx
result of loss of supporting tone from the soft tissues. has been advocated by skilled users of fibreoptic
Oral or nasal airways may be ineffective in relieving the techniques, to assess if it is safe to continue with awake
obstruction as they do not extend this low into the fibreoptic intubation or defer to an awake local
airway, but experienced forceful jaw thrust manoeu- anaesthetic tracheostomy [7].
vres may displace the mandible and tongue base Awake fibrecapnic intubation [23] has been
forwards, creating an airspace. Laryngoscopy can cause described as a technique in which a very narrow
trauma, resulting in bleeding, swelling and complete catheter is passed through the suction channel of a
airway obstruction. An awake fibreoptic technique, bronchoscope and advanced into the airway for carbon
awake transtracheal catheter or awake local anaesthetic dioxide measurement. When capnography has con-
tracheostomy should certainly be considered. firmed the catheter position, the fibrescope is
At the glottis the most common causes of obstruct- railroaded over the catheter and then the tracheal tube
ing lesions are tumours. As these enlarge, patients passed in turn over this. This technique may still cause
initially are able to compensate by changes in breathing total airway obstruction with advanced glottic disease,
patterns or position, but acute deterioration results at a and with severe tumours bleeding and acute airway
point when a critical narrowing is reached. The key obstruction can occur [23].
decision is to identify if it will be possible to pass a The Fourth National Audit Project provides impor-
tracheal tube through the narrowing and if this is felt to tant information on the use of fibreoptic techniques
be unlikely, an awake transtracheal catheter or awake and describes several challenging cases where the initial
local anaesthetic tracheostomy should be considered. decision to perform awake fibreoptic intubation was
Tracheal compression can occur as a result of lesions suitably changed to an awake surgical approach after
within the trachea or compression by thyroid and problems obtaining a view, contamination of the
mediastinal masses. The upper airway may be normal at airway, or a very narrow airway [24]. In patients with
laryngoscopy and it may be possible to pass the tracheal head and neck pathology and airway obstruction, 14 of
tube beyond the glottis but not beyond the obstruction 23 attempted flexible fibreoptic intubations failed. Of
(or even place a surgical airway beyond the obstruc- these, four were attempted in awake patients and failed
tion). because the glottic inlet could not be identified or it
was not possible to pass the fibrescope or tracheal tube.
In 10 patients, fibreoptic intubation was attempted
Fibreoptic intubation
after induction of anaesthesia and despite repeated
The role of awake fibreoptic intubation for the attempts, there was an inability to identify the glottic
management of patients with a difficult airway is inlet, pass the fibrescope, or pass the tracheal tube (with
universally recognised as useful, but its specific role in bleeding and airway obstruction common) [11]. In
the management of an obstructed airway is dependent those patients where fibreoptic techniques were
on the site of the obstruction. Successfully used for unsuccessful, a surgical airway was usually required.
mass lesions within the oral cavity or tongue base, Successful use of awake fibreoptic techniques for an
where passing the fibrescope around the lesion may be obstructed airway requires skill, an understanding of
possible in skilled hands [6, 7], its role for advanced the nature and level or site of obstruction, and
obstructing lesions within the glottis is more contro- recognition that with advanced glottic obstruction,
versial, as the fibrescope has to pass through the small fibreoptic techniques fail [4, 11, 24].
orifice of the obstructive mass with the risk of total
airway occlusion [4].
Inhalational induction
Technically, administering topical anaesthesia for
distorted, large, vascular, friable, necrotic tumours is Inhalational induction and maintenance of spontaneous
challenging and application of local anaesthetic or ventilation was the traditional method of managing a
passage of the fibrescope can cause coughing and total patient with a difficult airway or airway obstruction [4].
airway obstruction [20, 21]. Even if the fibrescope can In a recent debate about managing a patient with

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Anaesthesia  2011 The Association of Anaesthetists of Great Britain and Ireland 95
A. Patel and A. Pearce Airway obstruction Anaesthesia, 2011, 66 (Suppl. 2), pages 93100
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stridor and a retrosternal thyroid mass compressing Recent work [5] during induction and surgery has
the trachea, only two of the eight experts chose shown that positive-pressure ventilation following
an inhalational induction technique. Two experts intravenous induction of anaesthesia and neuromuscu-
chose an intravenous induction technique (includ- lar blockade may be physiologically superior to spon-
ing neuromuscular blockade), while three experts taneous respiration in adult stridulous patients with
selected an awake fibreoptic intubation technique [1]. airway compromise due to laryngotracheal stenosis.
Clearly, even amongst experts, anaesthetic practice is During inhalational induction where spontaneous
varied. ventilation is maintained, there is a reduction in airflow
The theoretical advantage of an inhalational induc- and respiratory drive, and increased collapsibility of the
tion is the maintenance of spontaneous ventilation and airway, leading to an increased work of breathing and
therefore oxygenation. Yet, airway collapse is common critical instability at points of airway narrowing. With a
as the collapsible pharyngeal tissues are affected by the reduction in functional residual capacity, the only
dynamic effects of negative intraluminal pressures mechanism to try to counteract these changes whilst
during inspiration, which favours collapse [25]. The holding a facemask is to provide PEEP and CPAP
traditional view is that the technique is safe because as (logically in that order) manually with a bag. For
the patient looses consciousness, this airway collapse initially non-obstructed airways in adults and children
and obstruction prevents further uptake of inhaled this is often enough and an inhalational induction
volatile agent, allowing the patient to waken. Such technique is successful. However, for a critically
arousal is purported to relieve the airway obstruction. obstructed adult airway, the application of PEEP and
Although modern practice suggests sevoflurane is now CPAP is often not enough to counteract all these
the drug of choice for inhalational induction, studying changes. Active positive-pressure ventilation, by con-
the influence of blood solubility during simulated trast, produces positive pressures during both phases of
airway occlusion in healthy volunteers suggests other- ventilation and potentially better maintains the airway.
wise. The end-tidal concentration of halothane may fall The deterioration in the airway following inhala-
more quickly than that of sevoflurane [26], and tional induction and subsequent inability to maintain
halothane compared with sevoflurane may thus lead spontaneous ventilation is described in NAP4 [11]. In
to a quicker awakening [26]. The application of 12 patients the airway was compromised and sponta-
continuous positive airway pressure (CPAP) and neous ventilation became more difficult with oxygen
positive end-expiratory pressure (PEEP) when assisting desaturation. In 11 of these patients spontaneous
ventilation with bag and mask may help relieve any ventilation became impossible, either because the
obstruction by acting as a pneumatic splint. airway deteriorated further or after direct laryngoscopy
In clinical practice, when an inhalational induction attempts were made. In situations when the airway was
is commenced in a patient with a severely obstructed lost there was reluctance to use (or even an active
airway the induction is slow, despite the application decision to avoid) neuromuscular blockade and con-
of CPAP and PEEP, there are apnoeic periods, and trolled ventilation, despite respiratory distress, airway
the patient often becomes more hypoxic and hyper- obstruction, hypoxia and a peri-arrest state. It was clear
carbic. It is sometimes an unstable scenario with that in these cases patients do not rapidly awaken [11].
arrythmias and episodes of total airway obstruction,
following which the patient in fact often does not
Intravenous induction and administration of
awaken, but instead apnoea continues and the
neuromuscular blockade
hypoxia worsens. Something has to be done and in
practice this often involves manual lung ventilation For routine airway management neuromuscular block-
with bag and mask to relieve severe hypoxia. At this ade can facilitate mask ventilation [28] (occasionally
stage the technique is no longer a spontaneous even if initial mask ventilation is impossible [29]),
ventilation technique at all, and the theoretical abolish laryngeal reflexes and so make tracheal intuba-
advantages of the method are lost. The administration tion easier and less traumatic [30, 31]. Intravenous
of neuromuscular blockers may provide optimum induction and administration of neuromuscular block-
ventilation and intubating conditions, and should be ade is more often the answer rather than the problem
considered (notwithstanding current debate as to the [19].
role of neuromuscular blockade in the ability to mask The reluctance in administering neuromuscular
ventilate) [27, 28]. blockade to a critically obstructed adult airway is based

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Anaesthesia, 2011, 66 (Suppl. 2), pages 93100 A. Patel and A. Pearce Airway obstruction
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on the fear of an inability to mask ventilate and the obstructed airway has to make is to decide if it is safe
impossibility of a prompt return to spontaneous to proceed with some form of general anaesthesia or
ventilation. Pandits recent algorithm describes the whether awake tracheal access is more suitable. This
thought process commonly employed but this may not decision will be guided by a knowledge that, with
apply in full to the case of an obstructed airway [32]. repeated attempts to secure the airway, the risk of
This is because an obstructed airway (as described in total airway obstruction may increase considerably
this algorithm) can equally happen with inhalational [13]. If a CICV situation does arise, an immediate
induction techniques that attempt to maintain sponta- surgical airway is required in a patient with a totally
neous ventilation from the outset [11]. obstructed airway and no other means of oxygenation.
No plan is always successful and both inhalational Yet, these are not ideal conditions to perform a
and intravenous induction techniques can fail. Perhaps surgical tracheostomy.
what is more important is to judge, for any given Therefore, when these high-risk patients have been
patient, which technique is more likely to be successful identified in advance, the anaesthetist and surgeon
in terms of the ability to maintain oxygenation, and should jointly decide which type of awake tracheal
second, which technique leads to fewer cant intubate, access to make. An awake surgical tracheostomy is
cant ventilate (CICV) scenarios when used in a generally undertaken in patients with advanced
critically obstructed airway. There is some evidence in tumours in or around the airway, where postopera-
adult stridulous patients with laryngotracheal stenosis tively, the calibre of the airway is worse and a definitive
that ventilation after intravenous induction and neu- airway is required. This decision is not easy and
romuscular blockade is physiologically superior to depends on urgency, experience, location, the patients
seeking to maintain spontaneous respiration [5] The pathology and the knowledge and skills to perform the
answer to the second question remains unknown, since back-up plans.
evidence from NAP4 has highlighted failures of both On the other hand, in an emergency a junior
inhalational and intravenous induction techniques [11]. anaesthetist, with no immediate senior help available
No study has yet compared alternate modes of and with limited experience of back-up plans or
managing CICV. Perhaps this is why experts have equipment, may well consider an awake surgical
such different approaches when dealing with an adult tracheostomy the safest option. The same patient
obstructed critical airway and advocate techniques with presenting when experienced anaesthetists and
which they are most comfortable [1, 33, 34]. With the surgeons are immediately available might be managed
introduction of sugammadex it may be theoretically in other ways. Technically undertaking an awake
possible to reverse deep neuromuscular block and re- surgical tracheostomy can be challenging, particularly
establish spontaneous ventilation within minutes [35], in a patient who has airway obstruction and cannot lie
making it possible that newer methods will appear flat, extend their head, or tolerate surgical manipulation
based around use of this drug. However, time will tell in the neck. With fewer routine critical care tracheos-
whether this theoretical property of the drug is always tomies being undertaken, current junior surgical staff
translated into practice. Whatever technique is chosen, inevitably have less experience than did their prede-
either inhalational induction or intravenous induction cessors [36].
and administration of neuromuscular blockade, there The use of narrow bore cannula as an elective
will be failures and the importance of well thought technique inserted awake either through the cricothy-
through back-up plans become important. roid membrane or upper trachea has been described
[3739] and in experienced hands allows ventilation
throughout surgery in patients with significant airway
Awake tracheal access
obstruction and stridor [9]. If there are concerns about
Awake direct tracheal access under local anaesthetic the calibre of the patients airway at the end of surgery,
involves the placement of an airway into the trachea the narrow bore cannula can be left in place, or a
either using a narrow or wide bore cannula or definitive surgical tracheostomy performed. Narrow
through a surgical cricothyroidotomy or trache- bore cannulae are not a substitute for a definitive
ostomy. Generally, an awake surgical tracheostomy surgical tracheostomy but in some patients where
is placed by a surgeon and an awake cannula device airway obstruction is improved as a result of the
by an anaesthetist. One of the most important surgery, the technique may avoid an unnecessary
decisions a team looking after a patient with an surgical tracheostomy [9]. The NAP4 data for patients

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Anaesthesia  2011 The Association of Anaesthetists of Great Britain and Ireland 97
A. Patel and A. Pearce Airway obstruction Anaesthesia, 2011, 66 (Suppl. 2), pages 93100
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with head and neck pathology in CICV described 27

Conclusions
uses of cannula cricothyroidotomy of which 12 were
successful and 15 failed. These failures were due to In summary, all airway techniques need back-up plans.
misplacement, inability to place, fracture, kinking, Adequate assessment to identify the site and level of
blockage, dislodgement and barotrauma. This failure obstruction, in particular with nasendoscopy, CT and
rate is of concern and as an accompanying editorial MRI imaging, is useful in guiding the initial airway plan.
observed [12], more research is needed on the relative Awake fibreoptic intubation, inhalational induction,
merits of cannula cricothyrotomy vs surgical trache- direct tracheal access techniques, and even cardiopul-
ostomy [11]. monary bypass (all sometimes argued to be panaceas) in
fact have their limitations. No plan is always successful
but several back-up plans, good communication within
Central airway obstruction and mediastinal
the team, experience, training, adaptability and skill will
masses
all help determine the outcome.
Central airway obstruction can be particularly
challenging because of the risk of fatal airway obstruc-
tion in a site distal to rescue by a surgical airway, and Competing interests
because of adverse effects of large anterior mediastinal No external funding or competing interests declared.
masses on cardiovascular stability. Tracheobronchial
masses, inflammatory stenoses or extrinsic compression
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