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In this section, you will learn about the following topics:

• Airway Management

• Angioedema

• Peritonsillar Abscess

Airway Management

In the dynamic realm of critical care, where every breath matters and the balance between life and crisis can be measured in fractions of a second, the art and science of airway management in the ICU take center stage. Airway management is paramount, where the meticulous orchestration of securing and maintaining a patient's airway is not only essential but can be lifesaving.

From the initial assessment of airway patency to the utilization of advanced airway devices and the art of optimizing oxygenation and ventilation, this journey navigates the critical landscape of airway management, emphasizing the profound impact it has on patient outcomes within the high-stakes environment of the ICU.

Anatomy of the Upper Airway

The upper airway consists of several structures that collectively facilitate the passage of air from the nose and mouth to the lower airway. These structures include the nasal cavity, oral cavity, pharynx, larynx, and trachea. The nasal cavity is lined with a mucous membrane and is responsible for filtering, warming, and humidifying the inspired air. It also contains the olfactory receptors, which are responsible for our sense of smell. The oral cavity, located behind the lips and in front of the oropharynx, serves as an alternative route for air passage and is involved in speech and swallowing.

• The pharynx, commonly known as the throat, is a muscular tube that connects the nasal and oral cavities to the larynx. It is divided into three regions: the nasopharynx, oropharynx, and laryngopharynx. The nasopharynx lies behind the nasal cavity and contains the adenoids, which are part of the immune system. The oropharynx is located behind the oral cavity and contains the tonsils. The laryngopharynx is the lowest part of the pharynx and serves as a common pathway for both air and food.

• The larynx, commonly known as the voice box, is located at the top of the trachea. It consists of cartilages, muscles, and vocal cords. The primary function of the larynx is to protect the lower airway by closing during swallowing to prevent aspiration. It also plays a crucial role in phonation or voice production.

• The trachea, commonly known as the windpipe, is a flexible tube that connects the larynx to the bronchi. It is lined with ciliated epithelium and contains cartilaginous rings that provide structural support. The trachea branches into the right and left main bronchi, which further divide into smaller bronchi and bronchioles, ultimately leading to the alveoli where gas exchange occurs.

The upper airway functions to ensure the smooth passage of air into the lower airway while protecting it from potential threats. Several physiological mechanisms contribute to the proper functioning of the upper airway.

One of the primary functions of the upper airway is to filter the inspired air. The nasal cavity, with its mucous membrane and cilia, traps and removes particulate matter, allergens, and pathogens from the air. The mucous membrane also helps to humidify and warm the inspired air before it reaches the lower airway. The upper airway also plays a crucial role in vocalization. The larynx, with its vocal cords, allows for the production of sound and speech. The vocal cords vibrate as air passes through them, producing different pitches and tones.

Another essential function of the upper airway is protection against aspiration. The larynx closes during swallowing to prevent food or liquid from entering the lower airway. This protective mechanism helps to prevent aspiration pneumonia and other complications. The upper airway also contributes to the regulation of airflow. The muscles surrounding the upper airway, including the pharyngeal muscles, help to maintain airway patency. These muscles contract and relax to adjust the size of the airway, ensuring the smooth passage of air during respiration.

Airway obstruction can present with a range of signs and symptoms, depending on the severity and location of the obstruction. It is important for healthcare providers to be vigilant and recognize these indicators promptly. Some common signs and symptoms of airway obstruction include:

1. Stridor: Stridor is a high-pitched, wheezing sound that occurs during inspiration and indicates upper airway obstruction. It is often heard without the aid of a stethoscope and can be a result of conditions such as angioedema, peritonsillar abscess, or foreign body aspiration.

2. Dyspnea: Dyspnea, or difficulty breathing, is a common symptom of airway obstruction. Patients may describe a sensation of breathlessness or an inability to take deep breaths. It is important to assess the severity of dyspnea and intervene accordingly.

3. Cyanosis: Cyanosis, a bluish discoloration of the skin and mucous membranes, is a late sign of airway obstruction. It indicates inadequate oxygenation and requires immediate attention.

When it comes to assessment of the airway, it is essential to understand its anatomy and if needed proceed with intubation to prevent fulminant respiratory failure. Luckily we have a myriad of tools and techniques that help us in stressful scenarios.

Resources to complete:

FCCS Ch. 2

Pulmcast Airway Track (you are responsible for everything listed below)

• Airway Preparation: Plan

• STOPMAID

• Airway Assessment: Difficult Predictors

• Airway Basics

• Oxygenation

• EmCrit: LAMW: Intubating the Hypotensive Patient

Pulmcast Airway Mayday

Pulmcast: Owning the Airway (when you don’t own the airway)

Angioedema

Angioedema is a condition characterized by the rapid swelling of the deep layers of the skin and mucous membranes. It typically affects areas such as the face, lips, tongue, throat, and genitals. This condition can be quite alarming and potentially life-threatening, especially when it involves the airway. In this section, we will delve into the various aspects of angioedema, including its causes, risk factors, clinical presentation, and available treatment options.

Labs are generally not required for the diagnosis of angioedema. However, in cases of recurrent or chronic angioedema, further investigations may be necessary to identify any underlying causes. These may include blood tests to assess for allergic or autoimmune conditions, as well as imaging studies to evaluate for structural abnormalities.

Causes and Risk Factors

Angioedema can be classified into two main types: allergic and non-allergic.

• Allergic Angioedema: One of the primary causes of angioedema is an allergic reaction. Allergic angioedema occurs when the body's immune system overreacts to a specific allergen. Common allergens that can trigger angioedema include certain foods (such as nuts, shellfish, and eggs), medications (such as antibiotics and nonsteroidal anti-inflammatory drugs), insect bites or stings, and latex. In the ICU, patients may be exposed to various medications, including antibiotics and contrast agents, which can potentially trigger allergic angioedema.

• Non-Allergic Angioedema: Non-allergic angioedema can be further classified into hereditary and acquired forms. Hereditary angioedema (HAE) is a rare genetic disorder caused by a deficiency or dysfunction of C1 esterase inhibitor (C1-INH), a protein involved in regulating inflammation. HAE can be inherited in an autosomal dominant pattern, meaning that a person only needs to inherit one copy of the defective gene from either parent to develop the condition. Acquired angioedema, on the other hand, is not inherited but can develop later in life due to various factors, such as autoimmune diseases, lymphoproliferative disorders, or certain medications.

One of the primary risk factors for angioedema is a history of allergies or a family history of the condition. Individuals with a personal or family history of angioedema are more likely to develop the condition themselves.

Certain medications have been associated with an increased risk of angioedema. ACE inhibitors, commonly used to treat hypertension, are known to cause angioedema in a small percentage of patients. Other medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics (such as penicillin), and anticoagulants, have also been reported to trigger angioedema in some individuals. It is important for healthcare providers to be aware of these potential side effects when prescribing medications to patients in the ICU.

In some cases, the cause of angioedema remains unknown, and it is referred to as idiopathic angioedema. Idiopathic angioedema can be challenging to diagnose and manage, as there may be no identifiable triggers or risk factors. However, healthcare providers should still consider this possibility when evaluating patients with unexplained episodes of angioedema.

Clinical Presentation and Diagnosis

The clinical presentation of angioedema can vary depending on the severity and location of the swelling. In mild cases, individuals may experience localized swelling and redness, which can be itchy or painful. However, in more severe cases, angioedema can lead to significant swelling of the lips, tongue, throat, or other areas, causing difficulty in breathing, speaking, or swallowing.

Diagnosing angioedema involves a thorough evaluation of the patient's medical history, physical examination, and sometimes additional diagnostic tests. The healthcare provider will inquire about any recent exposure to potential triggers, such as allergens or medications. They will also assess the severity and location of the swelling and inquire about any associated symptoms, such as difficulty breathing or swallowing.

In some cases, blood tests may be ordered to check for underlying conditions or to assess the levels of certain substances in the blood, such as complement proteins or specific antibodies. Additionally, skin tests or allergy tests may be performed to identify potential allergens that could be triggering the angioedema.

Treatment Options and Strategies

The management of angioedema involves a combination of identifying and avoiding triggers, symptomatic relief, and, in severe cases, emergency interventions. The primary goal of treatment is to alleviate symptoms, prevent complications, and ensure the patient's safety. The specific treatment options and strategies may vary depending on whether the angioedema is allergic or non-allergic in nature.

For allergic angioedema, the primary treatment approach involves the administration of antihistamines, such as diphenhydramine or cetirizine, to block the effects of histamine and reduce swelling. Intravenous corticosteroids, such as methylprednisolone, may be administered to further suppress the immune response. Additionally, the use of epinephrine may be necessary in cases of anaphylaxis or severe respiratory distress.

Non-allergic angioedema, also known as hereditary angioedema (HAE), requires a different treatment approach. Medications that inhibit the production or activity of bradykinin, such as C1 esterase inhibitors (C1-INH) or bradykinin receptor antagonists, are the mainstay of treatment for HAE. These medications help to prevent the excessive release or accumulation of bradykinin, which is responsible for the swelling seen in HAE.

In some cases, angioedema may be refractory to standard treatment approaches. In such situations, additional interventions may be required, including the use of intravenous fluids to maintain hydration, the administration of pain medications to alleviate discomfort, and the implementation of airway management techniques to ensure adequate oxygenation and ventilation.

Peritonsillar Abscess

Peritonsillar abscess is a localized collection of pus that forms in the tissues surrounding the tonsils. The treatment of peritonsillar abscess involves a combination of medical management and surgical interventions. The primary goals of treatment are to drain the abscess, alleviate symptoms, and prevent complications.

Medical management of peritonsillar abscess typically involves the administration of antibiotics to target the underlying infection. The choice of antibiotics will depend on the suspected causative organisms and local resistance patterns. Commonly used antibiotics include penicillin, clindamycin, and metronidazole. Pain management is also an important aspect of medical treatment, and nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids may be prescribed to alleviate pain and discomfort.

Surgical intervention is often necessary to drain the abscess and provide definitive treatment. The most common surgical procedure performed for peritonsillar abscess is needle aspiration or incision and drainage. This involves the insertion of a needle or scalpel into the abscess to remove the pus and relieve pressure. In some cases, a tonsillectomy may be recommended to prevent recurrent abscess formation.

Postoperative care for peritonsillar abscess includes close monitoring of the patient's vital signs, pain management, and the administration of antibiotics as prescribed. Adequate hydration is also crucial to promote healing and prevent complications. In some cases, the patient may require a short period of observation in the ICU to ensure stability before being transferred to a general ward.