Causes of airway compromise

AIRWAY
Can the patient talk?
Yes: if the patient can talk, their airway is
patent and you can move on to the
assessment of breathing.
No:
Look for signs of airway compromise:
cyanosis, see-saw breathing, use of accessory
muscles, diminished breath sounds and added
sounds.
Open the mouth and inspect for anything
obstructing the airway, such as secretions or
foreign objects.
Interventions – HTCL, Jaw thrust (Trauma
Patients), OPA, NPA, Suction, CPR.
•Inhaled foreign body: symptoms may include sudden onset
shortness of breath and stridor.
•Blood in the airway: causes include epistaxis,
haematemesis and trauma.
•Vomit/secretions in the airway: causes include alcohol
intoxication, head trauma and dysphagia.
•Soft tissue swelling: causes include anaphylaxis and
infection (e.g. quinsy, necrotising fasciitis).
•Local mass effect: causes include tumours and
lymphadenopathy (e.g. lymphoma).
•Laryngospasm: causes include asthma, gastro-oesophageal
reflux disease (GORD) and intubation.
•Depressed level of consciousness: causes include opioid
overdose, head injury and stroke.

BREATHING
Respiratory Rate – Normal: 12-20
Bradypnea may be due to sedation, opioid toxicity,
raised intracranial pressure (ICP) or exhaustion in
airway obstruction (e.g. COPD).
Tachypnoea may be due to airway obstruction,
asthma, pneumonia, pulmonary embolism (PE),
pneumothorax, pulmonary oedema, heart failure, or
anxiety.
Oxygen Saturation – 94-98% (88-92% COPD)
Hypoxaemia may be seen in PE, aspiration, COPD,
asthma and pulmonary oedema.
End of Bed inspection:
Cyanosis, SOB, Cough, Stridor, Cheyne stokes
Respiration, Kussmaul’s respiration.
Tracheal Positioning:
The trachea deviates away from tension
pneumothorax and large pleural effusions.
The trachea deviates towards lobar collapse and
pneumonectomy.
Chest Expansion:
Symmetrical: pulmonary fibrosis reduces lung
elasticity, restricting overall chest expansion.
Asymmetrical: pneumothorax, pneumonia, and
pleural effusion can all cause ipsilateral reduced chest
expansion.
Percussion of Chest:
Resonant: Healthy Individuals
Dullness: suggests increased tissue density (e.g.
cardiac dullness, consolidation, tumour, lobar
collapse).
Stony dullness: typically caused by an underlying
pleural effusion.
Hyper-resonance: the opposite of dullness,
suggestive of decreased tissue density (e.g.
pneumothorax).
Chest Auscultation:
Bronchial breathing: harsh-sounding (similar to
auscultating over the trachea), inspiration and
expiration are equal, and there is a pause between.
This type of breath sound is associated with
consolidation.
Quiet/reduced breath sounds: suggest reduced air
entry into that lung region (e.g. pleural effusion,
pneumothorax).
Wheeze: a continuous, coarse, whistling sound
produced in the respiratory airways during breathing.
Wheeze is often associated with asthma, COPD and
bronchiectasis.
Stridor: a high-pitched extra-thoracic breath sound
resulting from turbulent airflow through narrowed
upper airways. Stridor has many causes, including
foreign body inhalation (acute) and subglottic
stenosis (chronic).
Coarse crackles: discontinuous, brief, popping lung
sounds typically associated with pneumonia,
bronchiectasis and pulmonary oedema.
Fine end-inspiratory crackles: often described as
sounding similar to the noise generated when
separating Velcro. Fine end-inspiratory crackles are
associated with pulmonary fibrosis

Interventions:
Oxygen - In COPD, consider using a Venturi mask: 24% (4L) or 28% (4L). Consider discussing non-invasive
ventilation (NIV) with a senior in acute exacerbations of COPD where there is evidence of type 2
respiratory failure. If the patient is conscious, sit them upright, which can also help with oxygenation.
Acute severe asthma
oxygen, nebulisers, steroids and other agents (e.g. magnesium sulphate, aminophylline).
Acute exacerbation of COPD
oxygen, nebulisers, steroids and antibiotics.
Other pathology
pneumonia and pneumothorax.
CPR
If the patient loses consciousness and has no signs of life
CIRCULATION
Heart Rate: 60-99 BPM
Causes of tachycardia (HR>99) include hypovolemia,
arrhythmia, infection, hypoglycemia, thyrotoxicosis,
anxiety, pain and drugs (e.g. salbutamol).
Causes of bradycardia (HR<60) include ACS, ischemic
heart disease, electrolyte abnormalities (e.g.
hypokalemia) and drugs (e.g. beta-blockers).
Blood Pressure: 90/60mmHg and 140/90mmHg
Causes of hypertension include hypervolaemia, stroke,
Conn’s syndrome, Cushing’s syndrome and pre-eclampsia
(in pregnant females).
Severe hypertension (systolic BP > 180 mmHg or diastolic
BP > 100 mmHg) may present with confusion,
drowsiness, breathlessness, chest pain and visual
disturbances.
Causes of hypotension include hypovolaemia, sepsis,
adrenal crisis and drugs (e.g. opioids, antihypertensives,
diuretics).
Fluid Balance:
Reduced urine output (oliguria) is typically defined as
less than 0.5ml/kg/hour in an adult.
Causes of oliguria include dehydration, hypovolaemia,
reduced cardiac output and acute kidney injury.
End of Bed Inspection:
Pallor: a pale skin colour that can suggest underlying
anaemia (e.g. haemorrhage, chronic disease) or poor
perfusion (e.g. congestive cardiac failure).
Oedema: Swelling of the limbs (e.g. pedal oedema) or
abdomen (i.e. ascites) may indicate underlying heart
failure – Assess ankles and Sacrum.
Palpation:
Hands should be symmetrically warm, indicating
adequate perfusion.
Cool hands indicate poor peripheral
perfusion (e.g. congestive cardiac failure, acute
coronary syndrome).
Cool and sweaty/clammy hands – ACS.
Capillary refill time (CRT):
It should be less than two seconds.
Greater than two seconds suggests poor
peripheral perfusion (e.g. hypovolaemia,
congestive heart failure) and the need to
assess central capillary refill time.
Pulses:
An irregular pulse is associated
with arrhythmias such as atrial fibrillation.
A slow-rising pulse is associated with aortic
stenosis.
A pounding pulse is associated with aortic
regurgitation as well as CO2 retention.
A thready pulse is associated with intravascular
hypovolaemia (e.g. sepsis).
Jugular venous pressure (JVP)
Inspect for evidence of raised JVP Causes:
• Right-sided heart failure
• Tricuspid regurgitation
• Constrictive pericarditis
Interventions: IVC, ECG, Hypovolemia Fluid
resuscitation, ACS Interventions, Sepsis?, CPR,
Hemorrhage management, Fluid overload
interventions, AF interventions.

DISABILITY
Assess level of consciousness:
Alert: the patient is fully alert, although not necessarily
orientated.
Verbal: the patient makes some kind of response when you
talk to them
Pain: the patient responds to a painful stimulus Interventions:
Unresponsive: the patient does not show evidence of any eye,
voice or motor responses to pain. GCS – 8 or Below – MANAGE AIRWAY
GCS BM 4.0 – 5.8 mmol/l.
KETONES
Pupils: Opioid toxicity – Naloxone
Size and symmetry of the patient’s pupils (e.g. pinpoint pupils Hypoglycemia – Glucose
in opioid overdose, dilated pupils in tricyclic antidepressant DKA – Iv fluids and insulin
overdose). CPR
Asymmetrical pupillary size may indicate intracerebral
pathology (e.g. stroke, space-occupying lesion, raised
intracranial pressure).
Direct and consensual pupillary responses which may reveal
evidence of intracranial pathology (e.g. stroke).
Drug chart review
Medications which may cause neurological
abnormalities (e.g. opioids, sedatives, anxiolytics).

EXPOSURE
Temperature - 36°c – 37.9°c.
Inspection
>38°c is most commonly caused by infection
Inspect the patient’s skin for evidence of rashes, bruising
(e.g. sepsis).
and signs of infection
Review any in situ intravenous lines for evidence of
< 36°c may also be caused by sepsis or cold
surrounding erythema or discharge.
exposure (e.g. drowning, inadequate clothing
Assess calves for erythema, swelling and tenderness - ?DVT
outside) - Consider warming
surgical wounds for evidence of haematoma, active
bleeding or infection
Interventions:
Output of the patient’s catheter - ?Infection
Haemorrage protocols, Sepsis 6, ?DVT, CPR.