Putting It All Together

While there is an apparently large array of things involved in assessment, oxygenation, and interventions, in reality the trick is just to work from simplest and fastest to deploy to the more complicated.

All patients should have oxygenation optimized.  We formulate our presumptive diagnosis as we deploy our “airway magic.” Next is the first tier of imaging studies (portable films, bedside ultrasound, endoscopy). We gauge the response to the airway magic interventions, which either solidifies our diagnostic impression or steers us in a different direction.

Labs may help influence management decisions (arterial blood gas, severe acidosis, lactic acid, etc.). Last in the diagnostic realm (requiring more time) is the need for and safety of obtaining CT imaging of neck or chest.

Thinking about the time—speed and simplicity—is tremendously useful for organizing our diagnostic studies and pharmacological interventions. It is also useful for considering the triggers to intubation. All patients should have oxygenation maximized through noninvasive maneuvers as needed (positioning, oxygen administration, PEEP with bag-valve-mask or bilevel positive airway pressure if not improving with supplemental oxygen alone).

Supraglottic airways can be temporarily useful in cardiac arrest situations on initial presentation. Ultimately, however, there is the decision to intubate and determining the necessity and safety of muscle relaxants. There are numerous triggers to intubate. Consider the timeline of the presumed diagnosis and the efficacy and responsiveness of the pathology to therapeutic interventions. Histamine-induced angioedema, pulmonary edema, opioid overdose, foreign bodies, most asthma presentations—these can correct very quickly. These are the pathologies where our airway magic may work.

Most airway emergencies are not immediately fixed, however—traumatic injuries (eg, head, face, chest), infectious processes (eg, epiglottitis, Ludwig’s, pneumonia), and severe lung disease. In considering the trigger to intubate, it’s useful to distinguish the difference between airway emergencies that are potentially quickly reversible and those that are not.

In my rural hospitals, major trauma cases all get transferred—and almost always require intubation simply for safe transport if not for airway protection and oxygenation. Patients with airway pathology not immediately reversible should not be transported with insecure airways. Examples include nonhistamine-induced angioedema, Ludwig’s, expanding neck hematomas and other masses, massive achalasia, and massive nasal bleeding. Critically ill patients with severe lung disease will eventually require intubation. Sooner intervention (after preprocedural optimization of oxygenation) is usually better.

In summary, although the entirety of the diagnostic and therapeutic interventions in the airway seems large, it is manageable mentally (and in practice) by simply working from the simplest and fastest to the more complicated and time-consuming. Consider the underlying pathology and potential responsiveness to airway magic and interventions.

Master clinicians look at the problem in front of them, accept the reality of the situation, understand the priorities, and act—one step at a time.