Abstract
Bleeding in the upper airway is an important cause of airway-related death, even in young and otherwise healthy individuals. The estimated lifetime incidence of epistaxis is approximately 60%; post-tonsillectomy haemorrhage occurs in 6–15% of tonsillectomy cases; and bleeding following surgery for malignancy in the upper airway is one of the leading causes of requirement of an emergency front of neck airway. Pre-oxygenation may be difficult or impossible. Cornerstone techniques commonly employed to secure the airway, such as direct/videolaryngoscopy and flexible optical laryngoscopy, may be ineffective due to soiling of the hypopharynx – and the equipment – with blood. Supraglottic airway devices may be employed but are typically of limited efficacy due to the increased risk of aspiration and their potential interference with surgical access to the bleeding site in the hypopharynx, glottis and trachea. The clinician may thus be forced to use other, less familiar techniques and modify their approach to airway management, particularly if bleeding is profuse and/or conventional intubation and airway rescue techniques are predicted to be difficult. Cardiovascular compromise from blood loss may further complicate airway management and anaesthesia. We identify techniques and strategies that may be employed in this situation.
Introduction
Bleeding in the upper airway is potentially catastrophic and is an important cause of airway-related death, even in young and otherwise healthy individuals. Severe bleeding in the airway is an emergency life-threatening situation. Conventional airway management strategies may be impossible.
The estimated lifetime incidence of epistaxis is approximately 60%; post-tonsillectomy haemorrhage occurs in 6–15% of tonsillectomy cases; and bleeding following surgery for malignancy in the upper airway is one of the leading causes of requirement of an emergency front of neck airway. Cornerstone techniques commonly employed to secure the airway, such as direct/videolaryngoscopy and flexible optical laryngoscopy, may be ineffective due to soiling of the hypopharynx – and the equipment – with blood. Supraglottic airway devices (SGAs) may be employed but are typically of limited efficacy due to the increased risk of aspiration and their potential interference with surgical access to the bleeding site in the hypopharynx, glottis and trachea. The clinician is thus forced to use other techniques and modify their approach to airway management, particularly if bleeding is profuse and/or conventional intubation and airway rescue techniques are predicted to be difficult.
Etiology and Problems of Managing a Bleeding Airway
The potential causes of bleeding in the airway include spontaneous/idiopathic; bleeding tumour/malignancy/vascular malformation; coagulopathy; trauma to the face or neck; post-surgery; iatrogenic – often due to airway management; and cocaine abuse.
Managing the bleeding airway is challenging both technically and non-technically. The following all contribute to make the bleeding airway challenging: all techniques used to manage these situations are likely to be difficult and may fail; videolaryngoscopes and flexible optical bronchoscopes (FOBs) may be ineffective in the bleeding airway; SGAs are often not suitable as definitive airways because of risk of aspiration of blood from the stomach and interference with surgical access; denitrogenation is less efficient and high flow nasal oxygenation may fail; need for urgent intervention; obstructed vision because blood can render any technique that relies on visualisation (including direct laryngoscopy) impossible; there is a need for concomitant suctioning; blood clot can mimic tissue/pathology; the patient often cannot lie flat; hypovolaemia with impending or established circulatory collapse; aspiration risk due to blood in the stomach; ‘waking up the patient’ following failed airway management is rarely an option; the patient may re-bleed upon extubation and clinical care teams may become overwhelmed by stress.
Initial Management
Key points include:
Limit the bleeding
Upright patient positioning
Suctioning and oxygen
Initiate fluid/blood resuscitation and cross-match
Airway evaluation (see Figure 32.1).
Figure 32.1 Flow chart condensing the steps for managing the bleeding upper airway, above the vocal cords.
Limit the Bleeding
If possible, reduce or stop the bleeding before securing the airway. This may make subsequent airway management easier or even unnecessary. In post-tonsillectomy/adenoidectomy or other oral/pharyngeal bleeding situations, transoral compression of the bleeding vessel can be performed with a clamped swab or an index finger. Timely embolisation of the relevant artery may be considered. Epistaxis can be treated with intranasal packs soaked with a topical haemostatic agent, such as adrenaline (epinephrine) or thrombin. Administration of tranexamic acid should be considered.
Oxygenation
Proactive oxygenation throughout airway management is essential and bi-nasal oxygen delivery prior to, and during, intubation is beneficial. This should be supplemented by face mask-delivered oxygen if possible, although this may be poorly tolerated and is relatively contraindicated in facial trauma, particularly in base of skull fractures where it increases the risk of intracranial infection. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) should be used with extreme caution when there is bleeding and is relatively contraindicated as blood may be forced distally into the trachea. Moderate flow rates (8–20 L min−1) may therefore be advisable instead of high flow rates.
Airway Management
A bleeding site in the upper airway (above the vocal cords) is a relatively common situation. Of the many possible ways of managing the airway, only those that result in the placement of a cuffed tube in the trachea fulfil the desired goals of (i) securing a conduit for oxygenation and ventilation, (ii) protecting against further aspiration of blood into the lungs and (iii) providing surgical access to the source of bleeding.
A cuffed tracheal tube can be inserted via the oral or nasal route, cricothyroid membrane (CTM) or tracheal stoma. The choice will be influenced by the bleeding site and the preferred approach for safe airway management. SGAs as a means of securing the airway should be considered only as temporary solutions as they do not definitively isolate the lungs from blood in the upper airway. It is preferable to insert a cuffed tracheal tube either following rapid sequence induction (RSI) or while the patient remains awake. An RSI should only be performed if the pre-anaesthetic airway evaluation does not suggest difficulty with direct laryngoscopy and confirms that the CTM is identifiable, and thus accessible should laryngoscopy fail. A stepwise approach to managing the bleeding upper airway is summarised in Figure 32.1.
Airway Evaluation
Preoperative airway evaluation is mandatory to help inform whether an awake technique, rather than an RSI, would be a safer approach. The focus is on (i) predicting if direct laryngoscopy is likely to be successful (see Chapter 5), (ii) predicting if a front of neck airway (FONA) is likely to be successful, including identification of the CTM. However, even with a reassuring airway assessment, predicting easy direct laryngoscopy, this evaluation will occasionally mislead and therefore preparation must also include provision for a possible cricothyroidotomy or tracheostomy.
Difficult cricothyroidotomy is more likely in cases of female gender, age < 8 years, thick/obese neck, overlying pathology (inflammation, induration, radiation, tumour), a displaced airway or a fixed cervical spine flexion deformity.
Identification of the Cricothyroid Membrane
The potential need for a FONA, either pre-emptively or as part of airway rescue, is substantial in the management of the bleeding airway. The chosen route will depend on the skills and experience of the clinician. For elective FONA in the awake patient, there is less time pressure than in the emergency situation, and thus either a cricothyroidotomy or a tracheotomy may be performed. While the patient is being stabilised, and prepared for definitive airway management, the CTM and trachea should be identified and marked. In patients who are obese or with neck pathology both conventional palpation and the ‘laryngeal handshake’ technique have a high chance of failure to identify the CTM. In such cases, identification of the CTM and trachea may be achieved quickly and reliably using ultrasonography (see Chapter 7), facilitating both pre-emptive and rescue cricothyroidotomy, tracheostomy or even awake retrograde intubation. Once identified, the position of the CTM should be marked with the patient’s head and neck in the same position that the clinician would use to access the CTM.
Rapid Sequence Induction
If the airway evaluation reassures that intubation under direct laryngoscopy is likely to be successful, and that the CTM and trachea are identifiable, then an RSI is indicated. The patient may be hypovolaemic and induction with ketamine should be considered. The patient often needs to be sitting, or even leaning forward, until unconsciousness is achieved and can subsequently be placed in a sniffing, semi-lateral or head-down position depending on circumstance and preference. An assistant solely dedicated to managing haemodynamic changes and fluid resuscitation may be necessary.
Two direct laryngoscopes should be available in case one fails and ideally one of these should be a videolaryngoscope with a Macintosh-shaped blade; this can be used as a direct laryngoscope if blood obscures the video function or as a videolaryngoscope if the blood soiling is less than expected and the direct view is unexpectedly difficult.
Two rigid, large-bore Yankauer-type suction catheters attached to separate suction sources (use of a shared suction source will reduce the suction force achieved) should be available, as well as Magill forceps to retrieve clots deeper in the oropharynx. When the best view of the larynx is achieved, the suction catheter can be wedged to the left side of the laryngoscope, in the upper oesophagus, or in the hypopharynx below the glottis to prevent re-flooding of the airway during intubation. A malleable bougie or introducer may be useful if the larynx is partially covered with blood, as visibility of the epiglottis, and not the larynx, may be sufficient to enable intubation with the aid of one of these devices.
Following intubation, correct tracheal placement must be confirmed with waveform capnography, as the risk of inadvertent oesophageal intubation is greatly increased in the bleeding airway. Inspection with a FOB to confirm correct tracheal placement is an alternative. It is advisable to suction down the tracheal tube prior to commencing assisted ventilation to limit blood contamination of the distal airways.
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