emDOCs Podcast – Episode 74: Upper Airway Obstruction Part 2

Today on the emDOCs cast with Brit Long, MD (@long_brit), we have Part 2 looking at a challenging case of an upper airway obstruction with Jess Pelletier, MD. Please listen to Part 1 for the first part of the case and discussion on upper airway obstruction.

Jess is an emergency medicine physician and Education Fellow at Washington University School of Medicine.

Episode 74: Upper Airway Obstruction Part 2


Part 1 covered one of Jess’s cases with a 60-year-old male with a 5 cm mass sitting above the epiglottis. We discussed the differential of airway obstruction, predicting the difficult airway, guidelines, and preoxygenation.


Awake fiberoptic endoscopy (flexible intubating endoscopy)

  • Optimal approach for difficult airway or upper airway obstruction if you’re comfortable with this.
    • Caveat: Patient must be somewhat cooperative, and not all upper airway obstructions are passable.
  • Approach: Copious topical analgesia (atomizer, nebulizer, and direct topical application of lidocaine), sedatives (ketamine, dexmedetomidine, or propofol)


Ramped positioning

  • Refers to elevating head of bed by 20-25 degrees.
  • Early studies demonstrated promise, but more recent studies suggest no improvement versus standard approach in first pass success or hypoxemia.
    • A 2021 meta-analysis found no change in glottic view, first-pass success, or time to intubation.
  • No studies have evaluated ramped positioning for those with upper airway obstruction
  • Do what you feel comfortable with or what you think will improve your chance first pass success.

From: https://airwayjedi.com/2016/04/01/position-head-intubation/


Seated oropharyngeal position

  • Alternative method for intubation in patients with tenuous upper airway obstruction is face-to-face or seated oropharyngeal intubation, also known as the “tomahawk” method.

From: https://www.tamingthesru.com/blog/procedural-education/so-you-want-to-tomahawk-somebody?

  • Limited data to support this.
  • Can also opt to have the patient seated, or in a bed with a 75 degree angle. Stand on a stool over the patient and use a videoscope to intubate the patient using the same approach as a normal RSI, standing over the patient. 
  • Similar to ramped positioning, use what you’re comfortable with.


Supraglottic airway devices (SGA)

  • Similar to ramped positioning, use what you’re comfortable with.
  • The Difficult Airway Society guidelines recommend moving to SGA after three unsuccessful attempts at intubation.
  • This is the case for many patients with upper airway obstruction, though obstruction is not technically a contraindication to attempting SGA placement.
  • Consider whether SGA will worsen the obstruction. If the obstruction is at the level of the glottis, the SGA will not be effective.  In Jess’s patient, an SGA was not an option and would not have worked.



  • The Difficult Airway Society Guidelines recommend cricothyrotomy as the invasive airway management technique of choice in the CANNOT INTUBATE, CANNOT VENTILATE scenario.
    • They recommend the stab, twist, bougie, tube method.
      • Using the laryngeal handshake, identify the cricothyroid membrane. A horizontal incision is made through the membrane, and the scalpel is then rotated so that the blade faces toward the feet (this dilates the space). A bougie is passed through the opening in a caudal direction, and a 6-0 ETT is passed over the bougie into the trachea.
    • If the cricothyroid membrane is not palpable, the 2015 Difficult Airway Society Guidelines recommend the scalpel-finger-bougie method.
    • There’s also the “rapid four-step technique,” or RFST.
    • Other methods for cricothyrotomy include needle cricothyrotomy and percutaneous cricothyrotomy.
      • Needle cricothyrotomy is preferred in pediatrics, but should only be a temporizing measure for adults.

From: https://www.acepnow.com/article/tips-tricks-performing-cricothyrotomy/2/


If cricothyrotomy fails, you have several other options…

  • Tracheostomy:  
    • Considered an option in the 2022 ASA Guidelines under “invasive airway techniques”.
    • Performed in a manner similar to Seldinger-techinque cricothyrotomy if cricothyrotomy fails and there is no anesthesia backup available
  • Retrograde intubation
    • Considered one of the acceptable invasive airway techniques in the ASA algorithm.
    • Consists of puncturing the cricothyroid membrane with a large bore needle attached to a syringe, which allows you to confirm entry into the trachea by withdrawing air.
    • A guidewire is advanced through the needle in a cephalad direction, and once visible in the mouth or protruding through the nose, it is secured to a small-bore ETT.
    • The ETT is then advanced into the trachea.
    • The guidewire is left in place until definitive surgical airway management can be accomplished.
    • Potential complications: damage to the vocal cords, airway hemorrhage, subcutaneous emphysema.
    • Indications for retrograde intubation via a tracheal (subcricoid) approach: masses with risk for vascularity, trauma, or other lesions that overlie or involve the cricothyroid membrane, making cricothyrotomy impossible.
    • If percutaneous tracheostomy is attempted via Seldinger technique and the wire cannot be passed caudally, redirect the wire in a cephalad direction and then feed a small-bore endotracheal tube over it to try and intubate the patient.
    • The subcricoid approach to retrograde intubation may have fewer risks than the transcricoid approach since a more caudal entry point of the guidewire decreases the risk of snagging the ETT on the vocal cords and surrounding structures.




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