Otorhinolaryngology (ENT)
Airway Emergencies and Foreign Bodies
ENT airway emergencies for MBBS: stridor, epiglottitis and croup, inhaled foreign bodies, tracheostomy and cricothyroidotomy, mapped to NMC codes EN2, EN3 and EN4.
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Airway Emergencies and Foreign Bodies
ENT airway emergencies for MBBS: stridor, epiglottitis and croup, inhaled foreign bodies, tracheostomy and cricothyroidotomy, mapped to NMC codes EN2, EN3 and EN4.
This chapter deals with life-threatening airway problems and inhaled foreign bodies. It covers stridor and its localising value, epiglottitis and croup, the emergency management of airway foreign bodies, and the surgical airways of tracheostomy and cricothyroidotomy, all with an emphasis on rapid recognition.
High-yield: Airway Emergencies and Foreign Bodies
- Stridor is a harsh noise from turbulent airflow: inspiratory stridor suggests a laryngeal or supraglottic obstruction, expiratory suggests a lower airway lesion.
- Acute epiglottitis, classically from Haemophilus influenzae type b, causes rapid stridor, drooling and a tripod sitting posture in a toxic child.
- In suspected epiglottitis the throat is not examined with a spatula in the awake child because it may precipitate complete obstruction.
- Croup (laryngotracheobronchitis) is usually viral and gives a barking cough and stridor, and typically responds to steroids and nebulised adrenaline.
- A laryngeal foreign body is a true emergency and complete obstruction is relieved by back blows and abdominal thrusts (Heimlich manoeuvre).
- An inhaled foreign body most often lodges in the right main bronchus because it is wider and more vertical than the left.
- A ball-valve foreign body in a bronchus can cause obstructive emphysema with air trapping on the affected side.
- Tracheostomy is an elective or emergency surgical airway made below the larynx, indicated in upper airway obstruction and prolonged ventilation.
- Cricothyroidotomy is the emergency airway of choice when intubation fails and the patient cannot be oxygenated.
- A foreign body in the throat or airway in a child needs prompt removal, usually by rigid bronchoscopy under anaesthesia.
- Angioedema of the larynx can rapidly obstruct the airway and needs adrenaline, steroids and airway protection.
- Post-tracheostomy care includes suctioning, humidification and preventing tube blockage and displacement.
- Sudden choking while eating followed by cough and unilateral wheeze suggests an inhaled foreign body until proven otherwise.
- Any child with sudden stridor and a witnessed choking episode should be assumed to have inhaled a foreign body.
Emergency airway essentials
- **Epiglottitis:** Toxic child, drooling, tripod posture. Do not examine throat awake. Secure airway.
- **Croup:** Viral, barking cough, stridor. Steroids and nebulised adrenaline.
- **Inhaled foreign body:** Usually right main bronchus. Removed by rigid bronchoscopy.
- **Surgical airway:** Tracheostomy for prolonged need; cricothyroidotomy in a can't-intubate emergency.
NMC competencies in this chapter
- **EN2.13:** Recognition and initial management of ENT emergencies
- **EN3.4:** Airway obstruction and stridor: causes and management
- **EN3.6:** Indications, technique and care of tracheostomy
- **EN4.47:** Acute epiglottitis and croup
- **EN4.48:** Foreign bodies of the airway
- **EN4.50:** Emergency management of the obstructed airway
- **EN4.51:** Cricothyroidotomy and surgical airway procedures
Frequently Asked Questions
Why must the throat not be examined in suspected epiglottitis?
In an awake child with acute epiglottitis, examining the throat with a spatula can trigger laryngospasm and complete airway obstruction. The airway is secured in a controlled setting instead.
Where does an inhaled foreign body usually lodge?
In the right main bronchus, because it is wider, shorter and more vertical than the left. Removal is by rigid bronchoscopy under general anaesthesia.
When is a cricothyroidotomy used?
As an emergency surgical airway when intubation has failed and the patient cannot be oxygenated. It provides quick access to the airway through the cricothyroid membrane.
How is croup different from epiglottitis?
Croup is usually viral with a barking cough and gradual stridor and responds to steroids and nebulised adrenaline. Epiglottitis is a rapid, toxic bacterial illness with drooling that threatens the airway.
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