Portal de Periódicos da CAPES

Acute Upper Airway Obstruction

1980; Elsevier BV; Volume: 77; Issue: 3 Linguagem: Inglês

10.1378/chest.77.3.454

1931-3543

Manoon Lee, H Berger, Margarito G. Granada,

Tracheal and airway disorders

To the Editor:The location and clinical features of anticoagulant-induced bleeding are quite variable. Fortunately, such bleeding into the upper respiratory tract with subsequent upper airway obstruction is rare. Retropharyngeal hemorrhage and associated airway obstruction due to sodium warfarin have been described.1Genovesi MG Simmons DH Airway obstruction due to spontaneous retropharyngeal hemorrhage.Chest. 1975; 68: 840-842Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 2Owens DE Calcaterra TC Aarstad RA Retropharyngeal hematoma: A complication of therapy with anticoagulants.Arch Otolaryngol. 1975; 101: 565-568Crossref PubMed Scopus (55) Google Scholar We report the first case of upper airway obstruction from spontaneous hemorrhage into the base of the tongue and epiglottis secondary to sodium warfarin administration.CASE REPORTA 41-year-old woman was admitted to the respiratory intensive care unit of Mount Sinai Services-City Hospital Center at Elmhurst with partial upper airway obstruction. Four days prior to admission she had had a mild upper respiratory tract infection. On the morning of admission she developed a sore throat and dysphagia after a vigorous coughing episode. She noticed swelling of her neck and inability to lie down due to respiratory difficulty. She had been taking digitalis, diuretics, and sodium warfarin 5 to 10 mg daily for the last nine years since mitral valve replacement for rheumatic mitral stenosis. A cardiac catheterization study one year previously revealed moderately severe pulmonary hypertension, severe tricuspid insufficiency, biventricular failure, and a normally functioning mitral valve prosthesis. There was no history of recent trauma to the neck.On physical examination she was sitting anxiously in bed. Vital signs were within normal limits. Examination of the oral cavity revealed a submucosal hematoma at the base of the tongue, vallecula, epiglottis, and right parapharyngeal wall. The right side of her neck below the mandible was swollen and slightly tender. There was mild neck vein distension. In the supine position, inspiratory stridor was heard over the neck. Examination of the heart revealed a pansystolic grade 2/6 murmur at the lower left sternal border and a normal prosthetic click. There was a trace of ankle edema. The remainder of the physical examination was normal.A lateral soft tissue x-ray film of the neck showed swelling of the base of the tongue and epiglottis with obstruction at the junction of the epiglottis and posterior pharyngeal wall (Fig 1). Chest x-ray examination showed cardiomegaly with a prosthetic mitral valve. The partial thromboplastin time was 144 seconds (control 35 sec) and prothrombin time, 60 sec (control 12 sec). Arterial blood gas levels showed no hypoxemia and mild respiratory alkalosis. Our impression was that she had partial upper airway obstruction especially in supine position, and she did not require immediate intubation or tracheostomy because she had adequate alveolar ventilation. She was given two units of fresh frozen plasma, 10 mg phytonadione subcutaneously, and cough suppressants. Within 24 hours, the abnormal coagulation times returned to normal and the submucosal hematoma began to resolve. She was able to lie down and swallow liquids. A repeat lateral soft tissue x-ray film of the neck six days later showed almost complete restoration of the upper airway. Follow-up oral examination revealed mild ecchymosis over the base of the tongue and epiglottis. She continued to improve, was restarted on warfarin, and discharged on the 13th hospital day.DISCUSSIONThis patient developed hemorrhage into the base of the tongue and epiglottis and partial upper airway obstruction while on sodium warfarin. Several factors may have contributed to the occurrence of hemorrhage: the presence of venous congestion due to upper respiratory tract infection and right-sided heart failure, a forceful coughing episode which may have ruptured small blood vessels, and, most significantly, a markedly prolonged coagulation time due to sodium warfarin. Lepore3Lepore ML Upper airway obstruction induced by warfarin sodium.Arch Otolaryngol. 1976; 102: 505-506Crossref PubMed Scopus (43) Google Scholar described a case of sodium warfarin-induced bleeding into the floor of the mouth which involved the sublingual and submaxillary spaces, pushed the tongue upward and backward, and led to upper airway obstruction.Anticoagulant-induced bleeding into the retropharyngeal area,1Genovesi MG Simmons DH Airway obstruction due to spontaneous retropharyngeal hemorrhage.Chest. 1975; 68: 840-842Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 2Owens DE Calcaterra TC Aarstad RA Retropharyngeal hematoma: A complication of therapy with anticoagulants.Arch Otolaryngol. 1975; 101: 565-568Crossref PubMed Scopus (55) Google Scholar sublingual space,8 or base of the tongue and epiglottis as in this report can all lead to upper airway obstruction. This life-threatening condition, when promptly recognized, can be treated successfully with discontinuation of anticoagulants, administration of fresh frozen plasma and vitamin K, close airway monitoring, and immediate intubation or tracheostomy if necessary. To the Editor: The location and clinical features of anticoagulant-induced bleeding are quite variable. Fortunately, such bleeding into the upper respiratory tract with subsequent upper airway obstruction is rare. Retropharyngeal hemorrhage and associated airway obstruction due to sodium warfarin have been described.1Genovesi MG Simmons DH Airway obstruction due to spontaneous retropharyngeal hemorrhage.Chest. 1975; 68: 840-842Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 2Owens DE Calcaterra TC Aarstad RA Retropharyngeal hematoma: A complication of therapy with anticoagulants.Arch Otolaryngol. 1975; 101: 565-568Crossref PubMed Scopus (55) Google Scholar We report the first case of upper airway obstruction from spontaneous hemorrhage into the base of the tongue and epiglottis secondary to sodium warfarin administration. CASE REPORTA 41-year-old woman was admitted to the respiratory intensive care unit of Mount Sinai Services-City Hospital Center at Elmhurst with partial upper airway obstruction. Four days prior to admission she had had a mild upper respiratory tract infection. On the morning of admission she developed a sore throat and dysphagia after a vigorous coughing episode. She noticed swelling of her neck and inability to lie down due to respiratory difficulty. She had been taking digitalis, diuretics, and sodium warfarin 5 to 10 mg daily for the last nine years since mitral valve replacement for rheumatic mitral stenosis. A cardiac catheterization study one year previously revealed moderately severe pulmonary hypertension, severe tricuspid insufficiency, biventricular failure, and a normally functioning mitral valve prosthesis. There was no history of recent trauma to the neck.On physical examination she was sitting anxiously in bed. Vital signs were within normal limits. Examination of the oral cavity revealed a submucosal hematoma at the base of the tongue, vallecula, epiglottis, and right parapharyngeal wall. The right side of her neck below the mandible was swollen and slightly tender. There was mild neck vein distension. In the supine position, inspiratory stridor was heard over the neck. Examination of the heart revealed a pansystolic grade 2/6 murmur at the lower left sternal border and a normal prosthetic click. There was a trace of ankle edema. The remainder of the physical examination was normal.A lateral soft tissue x-ray film of the neck showed swelling of the base of the tongue and epiglottis with obstruction at the junction of the epiglottis and posterior pharyngeal wall (Fig 1). Chest x-ray examination showed cardiomegaly with a prosthetic mitral valve. The partial thromboplastin time was 144 seconds (control 35 sec) and prothrombin time, 60 sec (control 12 sec). Arterial blood gas levels showed no hypoxemia and mild respiratory alkalosis. Our impression was that she had partial upper airway obstruction especially in supine position, and she did not require immediate intubation or tracheostomy because she had adequate alveolar ventilation. She was given two units of fresh frozen plasma, 10 mg phytonadione subcutaneously, and cough suppressants. Within 24 hours, the abnormal coagulation times returned to normal and the submucosal hematoma began to resolve. She was able to lie down and swallow liquids. A repeat lateral soft tissue x-ray film of the neck six days later showed almost complete restoration of the upper airway. Follow-up oral examination revealed mild ecchymosis over the base of the tongue and epiglottis. She continued to improve, was restarted on warfarin, and discharged on the 13th hospital day. A 41-year-old woman was admitted to the respiratory intensive care unit of Mount Sinai Services-City Hospital Center at Elmhurst with partial upper airway obstruction. Four days prior to admission she had had a mild upper respiratory tract infection. On the morning of admission she developed a sore throat and dysphagia after a vigorous coughing episode. She noticed swelling of her neck and inability to lie down due to respiratory difficulty. She had been taking digitalis, diuretics, and sodium warfarin 5 to 10 mg daily for the last nine years since mitral valve replacement for rheumatic mitral stenosis. A cardiac catheterization study one year previously revealed moderately severe pulmonary hypertension, severe tricuspid insufficiency, biventricular failure, and a normally functioning mitral valve prosthesis. There was no history of recent trauma to the neck. On physical examination she was sitting anxiously in bed. Vital signs were within normal limits. Examination of the oral cavity revealed a submucosal hematoma at the base of the tongue, vallecula, epiglottis, and right parapharyngeal wall. The right side of her neck below the mandible was swollen and slightly tender. There was mild neck vein distension. In the supine position, inspiratory stridor was heard over the neck. Examination of the heart revealed a pansystolic grade 2/6 murmur at the lower left sternal border and a normal prosthetic click. There was a trace of ankle edema. The remainder of the physical examination was normal. A lateral soft tissue x-ray film of the neck showed swelling of the base of the tongue and epiglottis with obstruction at the junction of the epiglottis and posterior pharyngeal wall (Fig 1). Chest x-ray examination showed cardiomegaly with a prosthetic mitral valve. The partial thromboplastin time was 144 seconds (control 35 sec) and prothrombin time, 60 sec (control 12 sec). Arterial blood gas levels showed no hypoxemia and mild respiratory alkalosis. Our impression was that she had partial upper airway obstruction especially in supine position, and she did not require immediate intubation or tracheostomy because she had adequate alveolar ventilation. She was given two units of fresh frozen plasma, 10 mg phytonadione subcutaneously, and cough suppressants. Within 24 hours, the abnormal coagulation times returned to normal and the submucosal hematoma began to resolve. She was able to lie down and swallow liquids. A repeat lateral soft tissue x-ray film of the neck six days later showed almost complete restoration of the upper airway. Follow-up oral examination revealed mild ecchymosis over the base of the tongue and epiglottis. She continued to improve, was restarted on warfarin, and discharged on the 13th hospital day. DISCUSSIONThis patient developed hemorrhage into the base of the tongue and epiglottis and partial upper airway obstruction while on sodium warfarin. Several factors may have contributed to the occurrence of hemorrhage: the presence of venous congestion due to upper respiratory tract infection and right-sided heart failure, a forceful coughing episode which may have ruptured small blood vessels, and, most significantly, a markedly prolonged coagulation time due to sodium warfarin. Lepore3Lepore ML Upper airway obstruction induced by warfarin sodium.Arch Otolaryngol. 1976; 102: 505-506Crossref PubMed Scopus (43) Google Scholar described a case of sodium warfarin-induced bleeding into the floor of the mouth which involved the sublingual and submaxillary spaces, pushed the tongue upward and backward, and led to upper airway obstruction.Anticoagulant-induced bleeding into the retropharyngeal area,1Genovesi MG Simmons DH Airway obstruction due to spontaneous retropharyngeal hemorrhage.Chest. 1975; 68: 840-842Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 2Owens DE Calcaterra TC Aarstad RA Retropharyngeal hematoma: A complication of therapy with anticoagulants.Arch Otolaryngol. 1975; 101: 565-568Crossref PubMed Scopus (55) Google Scholar sublingual space,8 or base of the tongue and epiglottis as in this report can all lead to upper airway obstruction. This life-threatening condition, when promptly recognized, can be treated successfully with discontinuation of anticoagulants, administration of fresh frozen plasma and vitamin K, close airway monitoring, and immediate intubation or tracheostomy if necessary. This patient developed hemorrhage into the base of the tongue and epiglottis and partial upper airway obstruction while on sodium warfarin. Several factors may have contributed to the occurrence of hemorrhage: the presence of venous congestion due to upper respiratory tract infection and right-sided heart failure, a forceful coughing episode which may have ruptured small blood vessels, and, most significantly, a markedly prolonged coagulation time due to sodium warfarin. Lepore3Lepore ML Upper airway obstruction induced by warfarin sodium.Arch Otolaryngol. 1976; 102: 505-506Crossref PubMed Scopus (43) Google Scholar described a case of sodium warfarin-induced bleeding into the floor of the mouth which involved the sublingual and submaxillary spaces, pushed the tongue upward and backward, and led to upper airway obstruction. Anticoagulant-induced bleeding into the retropharyngeal area,1Genovesi MG Simmons DH Airway obstruction due to spontaneous retropharyngeal hemorrhage.Chest. 1975; 68: 840-842Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 2Owens DE Calcaterra TC Aarstad RA Retropharyngeal hematoma: A complication of therapy with anticoagulants.Arch Otolaryngol. 1975; 101: 565-568Crossref PubMed Scopus (55) Google Scholar sublingual space,8 or base of the tongue and epiglottis as in this report can all lead to upper airway obstruction. This life-threatening condition, when promptly recognized, can be treated successfully with discontinuation of anticoagulants, administration of fresh frozen plasma and vitamin K, close airway monitoring, and immediate intubation or tracheostomy if necessary.