Guest column: Airway protection? Now what?

By Rita Garcia, BAS, LVN, CCDS

The first time I read “airway protection” documented in the medical record, I realized it would require a more in-depth record review and research because airway protection by itself is not a diagnosis. It does, however, imply potential or impending complications related to the patient’s protective airway mechanisms.

On my quest for additional knowledge, it was clear that quite a few articles have been written related to the subject of airway protection in the absence of hypoxia and hypercapnia and respiratory failure. Examples I found included:

• a patient who was obtunded after a cardiac arrest
• an unresponsive patient with a traumatic head injury
• a drug overdosed patient with encephalopathy
• lethargy on presentation to the emergency department (ED)

These examples left me wondering about the patient who arrived at the ED alert and oriented after a traumatic motor vehicle accident that required rapid sequence induction of intubation for “airway protection” and the physician was “unable to protect airway.”

In situations such as this one, the patient was so quickly intubated in the ED, that the medical record included no specific documentation providing a timeline or tracking of trends reflective of an alteration in mental status or a progression or worsening of respiratory distress or respiratory decompensation or decline, no arterial blood gases, respiratory rates, or pulse oximetry monitoring. 

The respiratory therapist’s evaluation generally provides insight to the patient’s diagnosis and goals, but in this case, the initial therapeutic objectives, only stated “airway protection.” The challenge then was identifying clinical indicators supportive of a possible diagnosis of respiratory failure on which to base a query. 

Digging deeper into reports scanned from emergency services showed that while en route to the ED, the paramedic noted that the patient had audible crackles and gurgling of fluid in their upper airway with saturations in the mid-to-low 80s on room air.

Prior to intubation, the ED physician noted the patient’s extensive facial trauma and also documented his tongue was becoming acutely edematous and it appeared the patient had the inability to clear secretions. As the doctor suctioned the airway with a yanquer, it yielded fresh blood from the patient’s oropharyngeal airway. A gastrostomy tube was inserted and placed to wall suction also produced copious dark liquid output. Imaging revealed nasal and maxillary bone fractures, along with multiple rib fractures.

The patient was then placed in the intensive care unit (ICU) and was still intubated on mechanical ventilation on day three. The progress notes presented a conflict in the documentation. The trauma, neurology, and nephrology consultants all continued to document airway protection and that the patient was intubated in the ED with no further explanation or correlation to the underlying etiology that required the intubation. 

The critical care physician did finally break the copy and paste cycle by documenting airway protection and respiratory failure but offered no pathophysiology that clinically validated the diagnosis and need for continued mechanical ventilation. As I continued my concurrent review, the respiratory therapist’s mechanical ventilation management record now revealed a frequent change and titration of vent settings and also reflected a continued fluctuation of the patient’s fraction of inspired oxygen (Fi02). 

At this point, a clinically compliant query might read:

Dear Dr. Airway,

“Airway protection,” “unable to protect airway,” and “respiratory failure” are  documented in the medical record on this patient with audible crackles and gurgling of fluid in the upper airway and saturations to low 80s on room air. The patient has extensive facial trauma, an acutely edematous tongue with the inability to clear secretions, and copious dark liquid fluid output on suction. The patient was emergently intubated in the ED.

Based on your medical judgment, can the diagnosis related to the above findings be further specified as: 

• Acute respiratory failure secondary to obstructed airway
• Acute respiratory failure secondary to other (please specify) ______________
• Airway protection requiring intubation to secure airway from potential compromise without acute respiratory failure.
• Other (please specify): ________________
• Unable to provide any additional information

The circumstances of this admission required an in-depth review of the patient’s condition(s) along with a query to clarify the airway protection and patient’s emergent intubation and to validate the respiratory failure. This case example illustrates not only some of the difficulties associated with capturing respiratory failure, but also emphasizes the importance of ensuring the totality of the medical record gets reviewed from the ED notes, to information from the emergency technicians regarding the patient’s condition en route to the ED.

Further reading

Below is a quick review of the articles that provided me with valuable insight on patients presenting with trauma along with specific observations and considerations clinicians use to guide them in order to stabilize a patient.

• “Acute airway management” by Nikhil Panda and Dean M. Donahue in the Annals of Cardiothoratic Surgery, volume 7, issue 2: The authors recognize that acute airway management has challenged clinicians for nearly four millennia, and further note that “The role of all clinicians in acute airway management is patient stability and emergent control of the airway to ensure patency as well as adequate oxygenation and ventilation.” They also note that the most common cause of acute airway compromise is airway obstruction. This may be from central loss of respiratory drive, as in the comatose patient, leading to collapse of soft tissues over the airway, or else primary obstructing or secondary compressing processes of the airway.
• “Airway management in trauma” by Michael Barrie, MD, Caitlin Rublee, MD, MPH, Colin G. Kaide, MD, FACEP, FAAEM, in Monograph: This article explains that mechanical obstruction due to distortion of the airway can occur in a variety of traumatic injuries. In cases with impending airway obstruction or in which obstruction has already occurred, the decision to intervene is a forgone conclusion. With more subtle injury patterns, an airway may be intact at the moment, but the risk for potential obstruction may exist. A few of their clues for impending airway obstruction include hoarseness, stridor, and poor handling of secretions.

“ABC of major trauma: Major maxillofacial injuries” by I. Hutchinson, M. Lawlor, and D. Skinner in BMJ, volume 301, issue 6752: In this article, Skinner’s guidance of Maxillofacial trauma and airway injuries notes “immediate management of maxillofacial injuries is required mainly when there is impending or existing upper airway compromise and/or profuse hemorrhage occurs.” Hutchinson also provides specific examples of associated conditions that can adversely affect the airway in a patient with maxillofacial trauma:

• Posteroinferior displacement of a fractured maxilla parallel to the inclined plane of the skull base may block the nasopharyngeal airway.
• A bilateral fracture of the anterior mandible may cause the fractured symphysis to slide posteriorly along with the tongue attached to it via its anterior insertion. In the supine patient, the base of the tongue may drop back, thus blocking the oropharynx.
• Fractured or exfoliated teeth, bone fragments, vomitus and blood as well as foreign bodies—dentures, debris, shrapnel etc.—may block the airway anywhere along the upper aero digestive tract.
• Hemorrhage, from distinct vessels in open wounds or severe nasal bleeding from complex blood supply of the nose might also contribute to airway obstruction.
• Soft tissue swelling and edema resulting from trauma to the head and neck may cause delayed airway compromise.

Editor’s note: Garcia is a CDI specialist at Providence St. Joseph Health in Irvine, California. Contact her at rita.garcia@stjoe.org.