"A distorted airway breaks every rule of routine practice. The plan that keeps the patient safe is the one that keeps them breathing — often an awake technique, sometimes a primary surgical airway — decided before induction, with the surgeon scrubbed and the neck marked."
Synthesised from Miller's Anesthesia; Barash — Clinical Anesthesia; the ATLS airway principles.Approach to the compromised airway
Recognise the threat & call for help early
Stridor, voice change, drooling, tripod posture, surgical emphysema, expanding neck haematoma, soot/singed nares, restlessness or a falling SpO₂. Summon senior anaesthetist + ENT/surgeon and move to a location with a difficult-airway trolley.
Oxygenate & buy time
High-flow O₂ / HFNO, sit the patient up if tolerated, gentle assistance; nebulised adrenaline and steroids for oedema; do not lie a critical airway flat or over-sedate.
Decide: is this a "share & secure awake" airway?
If distortion, obstruction or a full stomach make asleep failure likely → awake tracheal intubation (flexible scope or awake VL) or a primary surgical airway/tracheostomy under local. Do not remove a marginal airway with a drug you cannot reverse.
Have a pre-briefed failure plan & a marked neck
Double set-up: neck prepped and cricothyroid membrane marked (ultrasound if distorted), surgeon scrubbed, eFONA kit open. Verbalise the CICO trigger before you start.
Confirm & protect
Capnography to confirm; secure the tube; plan a staged, at-risk extubation (cuff-leak test, airway-exchange catheter, ICU) because oedema often peaks later.
Airway trauma
| Injury | Airway threat | Key management points |
|---|---|---|
| Maxillofacial / mandibular | Blood, teeth, tissue & oedema; loss of tongue support (bilateral mandible #); disrupted mask seal | Suction; avoid nasal route with mid-face (Le Fort) fractures & suspected base-of-skull #; early definitive airway; awake technique if distorted |
| Laryngotracheal (blunt/penetrating) | Cartilage disruption, surgical emphysema, a "floating" larynx; risk of creating a false passage or complete transection | Do not blindly instrument; awake flexible scope or a surgical airway below the injury; involve ENT; consider CT if stable |
| Penetrating neck / expanding haematoma | Compression & tracheal deviation; rapid deterioration once oedema develops | Secure the airway early before distortion worsens; open the wound to decompress a tension haematoma if in extremis |
| Burns / inhalation injury | Progressive supraglottic oedema; carbonaceous sputum, facial burns, singed nares, hoarseness | Intubate early (before oedema closes the airway) with an uncut, adequate-size tube; suxamethonium safe in the first 24 h then avoid (up-regulated receptors) |
| Cervical-spine injury | Movement risk during laryngoscopy | Manual in-line stabilisation, videolaryngoscopy, minimise neck movement; a second person maintains alignment |
Obstructing & distorting pathology
| Pathology | Problem | Approach |
|---|---|---|
| Head & neck tumour / prior radiotherapy | Fixed, friable, distorted tissues; "SHORT" difficult FONA; trismus | Awake technique; ENT backup; primary tracheostomy if intubation unsafe |
| Ludwig's angina / deep-neck infection | Floor-of-mouth swelling, tongue elevation, trismus, distortion | Awake nasal fibreoptic or surgical airway; avoid blind attempts; senior + ENT present |
| Acute epiglottitis / supraglottitis | Rapidly obstructing supraglottic oedema (adults now > children) | Keep calm/upright, no instrumentation until in theatre; inhalational or awake induction with a surgeon ready |
| Angioedema (ACE-inhibitor / C1-esterase) | Lip, tongue & laryngeal swelling | Early airway if tongue/voice involved; adrenaline, steroids, antihistamine; icatibant/C1-INH for hereditary type |
| Oral submucous fibrosis (OSMF) | Progressive trismus & rigid mucosa (betel-nut chewing — common in India) | Anticipate very limited mouth opening → awake nasal fibreoptic; nasal route often the only option |
| Rheumatoid / ankylosing spondylitis | Atlanto-axial instability, cricoarytenoid arthritis, fixed flexed neck | Careful neck assessment/imaging; videolaryngoscopy or awake fibreoptic; avoid forced positioning |
| Foreign body | Variable, ball-valve obstruction | Do not convert partial to complete obstruction; rigid bronchoscopy in theatre; inhalational induction, spontaneous ventilation |
1) Never abolish spontaneous ventilation in an airway you cannot guarantee you can rescue — keep the patient breathing (awake or inhalational). 2) Plan the surgical airway before you need it — mark the neck, scrub the surgeon, open the kit. Most disasters are decision failures, not technical ones.