Airway Emergencies
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Direct answer
An obstructed airway announces itself with noise and posture, and dies silently within minutes, so airway emergencies are managed by recognising the level and cause of obstruction and escalating along a rehearsed ladder: suction and positioning, jaw thrust with in-line stabilisation in trauma, adjuncts and supraglottic devices, intubation with preparation for difficulty, and — when all fails — a surgical airway through the cricothyroid membrane. Foreign-body choking in an adult gets back blows and abdominal thrusts; in a child, five back blows then five chest thrusts, with blind finger sweeps abandoned. Infections (epiglottitis, croup), angio-oedema, burns and trauma each reshape the plan; the universal rules are oxygen first, gentle handling and early help, because the difficult airway punishes the lone clinician.
What you must remember
- Stridor localises the level, red flags demand action: inspiratory stridor suggests glottic or supraglottic obstruction, biphasic stridor the subglottic or tracheal region, expiratory noise the lower airway; tripod or sniffing posture, drooling (epiglottitis until proven otherwise), silent chest and drowsiness mean imminent arrest.
- Adult choking sequence: up to five back blows, then up to five abdominal thrusts (Heimlich), alternating until expulsion or unconsciousness — then compressions with an airway check each cycle.
- Paediatric choking: five back blows (head lower than chest in an infant), then five chest thrusts in infants or abdominal thrusts in older children; no blind finger sweeps.
- Epiglottitis rules: calm and upright, no tongue depressor, no forced examination; the airway is secured in theatre by the most experienced hands — the classical answer for the child or the adult with the "hot potato" voice.
- Angio-oedema: histamine-mediated types respond to adrenaline and standard anaphylaxis care; ACE-inhibitor and hereditary types are bradykinin-driven, may not respond, and need early airway planning.
- Burns and smoke: singed nasal vibrissae, carbonaceous sputum, hoarseness — intubate electively early, for the window closes as oedema grows.
- Can't intubate, can't oxygenate: scalpel-bougie cricothyroidotomy (or needle cricothyroidotomy with oxygen insufflation in small children) — the final rung, rehearsed before it is ever needed.
- Post-thyroidectomy neck haematoma: open the wound at the bedside to decompress the trachea — a scenario examinations repeatedly test because minutes decide it.
Escalating through three airways in one shift
The first patient is a 6-year-old with croup and stridor at rest at midnight: kept calm on the parent's lap, oxygen by a mask held nearby, oral dexamethasone and nebulised adrenaline — the stridor softens over an hour without anyone touching the throat. The second is a restaurant patron unable to speak or cough: five back blows land between his scapulae, then abdominal thrusts, and a meat bone flies out on the second thrust; he is observed briefly for aspiration. The third tests the department: a man 12 hours after a crash with expanding facial and neck swelling, saturation drifting, voice thinned. The team prepares simultaneously — two suction units, a video laryngoscope and bougie, the smallest feasible tube, and a cricothyroidotomy kit opened before the first attempt. The first look is Grade 4; the second, with backward-upward-rightward pressure, finds a corner of glottis and the tube passes — the win was preparation, not luck. Had the glottis never appeared, the scalpel was already on the field.
Where students slip
Candidates examine when they should act: the drooling, tripod, muffled-voice child offered "tongue-depression and lateral neck film" options — both are wrong; calm transport with theatre airway control is the answer, because instrumentation can convert obstruction into arrest. The third is the choking sequence order and the paediatric modification — back blows before abdominal thrusts, chest thrusts for infants, no blind sweeps. Indian viva examiners add the ACE-inhibitor angio-oedema trap (bradykinin-driven, adrenaline-refractory, needs early escalation) and the question of who performs a surgical airway when the anaesthetist is far away — the honest answer names the trained provider per departmental protocol, landmarks recited: the cricothyroid membrane between thyroid cartilage and cricoid.
Frequently asked questions
Where does stridor localise the obstruction?
Inspiratory stridor suggests a supraglottic or glottic lesion, biphasic stridor a subglottic or tracheal one, expiratory noise the lower airway — a bedside localising clue before imaging.
What is the correct choking sequence for an adult?
Five firm back blows alternating with five abdominal thrusts until expulsion or collapse; an unconscious patient moves to compressions with the airway checked between cycles.
How does paediatric choking management differ?
Infants receive five back blows head-down followed by five chest thrusts; blind finger sweeps are abandoned at all ages because they can impact the object deeper.
Why is suspected epiglottitis never examined with a tongue depressor?
Instrumentation can precipitate complete obstruction and arrest — the patient stays calm and upright and is intubated under controlled conditions by senior hands.
What defines the can't-intubate, can't-oxygenate situation and its rescue?
Failure to intubate and failure to oxygenate despite supraglottic rescue — calling for scalpel cricothyroidotomy through the cricothyroid membrane, the final rung of every difficult-airway ladder.