ICU · Airway management
Upper-Airway Obstruction — Epiglottitis, Angioedema & Deep Neck Abscess
Also known as Upper-airway obstruction · Epiglottitis · Supraglottitis · Angioedema · ACE inhibitor angioedema · Hereditary angioedema · Retropharyngeal abscess · Peritonsillar abscess · Quinsy · Ludwig's angina · Stridor
Upper-airway obstruction is an airway emergency. The causes run from the nose and mouth (allergic and ACE-inhibitor angioedema of the lip and tongue), through the supraglottis (epiglottitis, peritonsillar abscess), to the subglottis and retropharyngeal space (retropharyngeal abscess, Ludwig's angina, post-extubation oedema). Stridor at rest, drooling, tripoding, and distress signal severe obstruction. The overarching rule is to do no harm: keep the patient upright and calm, call for senior airway help early, avoid upsetting the airway, and secure it in a controlled setting. Epiglottitis is not examined in the unsecured airway; ACE-inhibitor angioedema is bradykinin-mediated and does not respond to adrenaline, antihistamines, or steroids.
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A 52-year-old man arrives with a 12-hour history of severe sore throat, fever, drooling, and difficulty swallowing. He is sitting forward in a tripod position, muffled voice, with stridor at rest. His SpO2 is 94 per cent on room air. This is acute epiglottitis with impending obstruction.[27]
The two questions that decide his next hour are the two that decide every upper-airway obstruction: how bad is the obstruction? and who is here to help me secure the airway? Stridor at rest, drooling, and tripoding answer the first — severe. A senior anaesthetist and an ENT surgeon scrubbed in theatre answer the second. Do not instrument his airway until both are in place — in one adult cohort, 17.1 per cent needed an acute airway intervention, a third of them a surgical airway, and clinicians were urged to be familiar with difficult- and failed-airway algorithms.[3][27]
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