Upper Airway Emergencies and the Common Itis Conditions

Derek Mendoza

Welcome to the show everyone! I'm Derek Mendoza, and I'm joined as always by your Professor, Heather Murphy. Today, we are diving deep into the upper respiratory tract. And Heather, I have to confess, back when I was a new nurse in the El Paso ER, I used to think of upper respiratory issues as, you know, the simple stuff. The runny noses, the minor sinus headaches. But a couple of severe trauma cases quickly taught me that the upper airway is actually a high-stakes danger zone.

Heather Murphy

Oh, absolutely, Derek. After thirty years in nursing, and now teaching our BSN students at South University in Virginia Beach, I always tell them: the upper airway is your patient's life support pipeline. If that pipeline collapses, nothing else matters. Let's start with the basics of that pipeline's anatomy. The structural division of the upper respiratory tract includes the nose, mouth, pharynx -- which we break down into nasopharynx, oropharynx, and laryngopharynx -- then the epiglottis, the larynx, and the trachea.

Derek Mendoza

And that nose isn't just for smelling or holding up your glasses. It warms, cleanses, and humidifies the air before it ever touches the lungs. Now, when we talk about breathing mechanics, there is a fundamental difference in how we move that air. Inspiration is an active process. The diaphragm contracts, dropping down, which decreases intrathoracic pressure and pulls air inside. But expiration? Under normal, healthy circumstances, expiration is completely passive. It relies entirely on the elastic recoil of the lungs.

Heather Murphy

Exactly. But when a patient loses that elastic recoil, like in chronic obstructive diseases, expiration suddenly becomes a very active, labored process. Now, let's talk about what happens when there is trauma to that beautiful upper airway structure. A nasal fracture is the most common facial fracture, usually from trauma. And as a nurse, your immediate priority is maintaining a patent airway. But there's a hidden complication we have to watch for, especially with complex fractures: meningeal tears leading to a cerebrospinal fluid leak. Or CSF.

Derek Mendoza

Oh, man, the classic CSF leak. I still remember a patient who came into my ER after a motor vehicle accident. He had periorbital ecchymosis -- those classic "raccoon eyes" which should immediately make you suspect a basilar skull fracture. He kept complaining of this constant, watery, salty-tasting run out of his nose.

Heather Murphy

The "raccoon eyes" are a massive red flag. And that clear or pink-tinged nasal drainage is highly suspicious. Now, Derek, how did you check that drainage in the ER? Because there is a very common clinical misconception about using bedside glucose test strips for this.

Derek Mendoza

Yes! I am so glad you brought that up, Heather, because the old school of thought was to just drop some drainage on a bedside glucometer strip. But here is the clinical reality: blood or even normal nasal secretions can contain enough glucose to give you a false positive. So, while you might see a "halo sign" on a gauze pad -- where the blood clusters in the center and a clear ring of CSF expands outward -- the absolute gold standard is laboratory confirmation. You have to send that fluid to the lab for a specific beta-2 transferrin assay. It is way more accurate than a simple glucose dipstick.

Heather Murphy

That is a golden NCLEX tip right there. Do not rely on bedside glucose testing alone for a CSF leak. Now, if we are talking prioritization, an airway obstruction is the ultimate medical emergency. The brain can only survive three to five minutes without oxygen before permanent damage or death occurs. You have to recognize the signs of a partial or complete airway obstruction immediately.

Derek Mendoza

And those signs are unmistakable once you've seen them. We're talking choking, restlessness, tachycardia, nasal flaring, and the use of accessory muscles -- like suprasternal and intercostal retractions where the skin is sucking in around the ribs. But the sound that still makes my hair stand on end is stridor. It's that high-pitched, squeaking vibration on inspiration.

Heather Murphy

Stridor means the airway is narrowed to a pinhole. If you hear that, or see cyanosis and a sudden change in level of consciousness, you do not wait. You act. Whether that means the Heimlich maneuver, preparing for emergency endotracheal intubation, a tracheostomy, or even an emergency cricothyroidectomy. Airway is always number one.

Derek Mendoza

Now, let's step down from the high-trauma emergencies and look at a group of conditions that every nurse will encounter on a daily basis: the "itis" family. Let's start with Allergic Rhinitis versus the common cold, which we clinically call Acute Viral Rhinopharyngitis.

Heather Murphy

This is a classic point of confusion for patients. Allergic Rhinitis is an inflammation of the nasal mucosa caused by an IgE-mediated response to an allergen, like pollen or dust. The symptoms are sneezing, watery, itchy eyes, and a thin, watery nasal drainage. We can test for this using skin tests or a Radioallergosorbent test -- a RAST -- which measures the specific IgE levels in the serum after antigen exposure.

Derek Mendoza

Right, whereas the common cold, Acute Viral Rhinopharyngitis, is an actual viral infection. We're talking over two hundred different viruses, most commonly rhinoviruses, spread by airborne droplets or direct contact. The symptoms usually peak two to three days after infection and include sore throat, fever, headache, fatigue, and that thick, congested drainage.

Heather Murphy

And here is the big nursing education point: the cold is viral. That means no antibiotics. I cannot tell you how many times patients demand a prescription for penicillin because they have a cold. We have to teach them that antibiotics will not work against a virus and only contribute to resistance. Treatment is strictly supportive: rest, hydration, warm saltwater gargles, and maybe some over-the-counter decongestants.

Derek Mendoza

Exactly. But what if it isn't "just a cold"? What if it's Acute Sinusitis? This is where the sinus mucosa becomes so inflamed that it blocks the normal drainage pathways, leading to a backup of secretions. You suspect sinusitis if those nasal symptoms do not improve after a week, or if they actually get worse.

Heather Murphy

Yes! The clinical presentation is different. With acute sinusitis, patients complain of severe facial pain or pressure, purulent nasal drainage, fever, malaise, and even halitosis -- bad breath from the stagnant mucus. If it lasts longer than twelve weeks, we classify it as chronic sinusitis, which is often associated with dental infections or allergies and affects fifty percent of patients with asthma.

Derek Mendoza

You know, I had chronic sinusitis once during my early years of teaching, and I completely lost my voice. Which brings us to Laryngitis. Laryngitis is inflammation of the vocal cords, usually caused by a virus, environmental irritants, or simply overusing your voice. The primary symptom is hoarseness or a complete loss of voice. And the absolute best treatment? Complete voice rest.

Heather Murphy

And when we say voice rest, we mean complete voice rest. Do not even whisper! Whispering actually puts more strain on your vocal cords than speaking softly. Now, let's talk about the back of the throat: Acute Pharyngitis. Ninety percent of cases in adults are viral. But that other ten percent? That's bacterial, most commonly Group A beta-hemolytic streptococci -- or strep throat.

Derek Mendoza

And if strep throat is left untreated, or if it's particularly severe, it can develop into a Peritonsillar Abscess. This is a medical emergency because that localized collection of pus can swell so much that it partially blocks the throat.

Heather Murphy

Oh, the peritonsillar abscess is incredibly painful. The patient will have a high fever, chills, a muffled "hot potato" voice, and massive difficulty swallowing. They will need IV antibiotics, needle aspiration, or a surgical incision and drainage. Sometimes, they even need an emergency tonsillectomy.

Derek Mendoza

And if they do go to surgery for a tonsillectomy, there is one classic nursing assessment that you must know for the NCLEX and clinical practice: monitoring for frequent swallowing.

Heather Murphy

Yes! Frequent swallowing in a post-op tonsillectomy patient is the number one sign of active bleeding or hemorrhage from the surgical site. The patient is quietly swallowing the blood. If you see this, you do not wait. You assess their airway, check for bleeding, and notify the surgeon immediately. Also, remember, do not give them any fluids until their gag reflex has fully returned.

Derek Mendoza

Speaking of bleeding in the upper airway, let's talk about Epistaxis -- a fancy medical term for a nosebleed. Now, growing up in the dry heat of West Texas, I got nosebleeds all the time. And back then, my parents would tell me to tilt my head back and pinch the bridge of my nose. But as a nurse, I now know that is exactly what you should NOT do.

Heather Murphy

Oh, the classic head-tilt! That is a major aspiration hazard. If you tilt your head back, all that blood just runs down your pharynx into your stomach, which causes severe nausea and vomiting, or worse, goes into your lungs. The proper first aid for epistaxis is to sit the patient in a high Fowler's position, have them lean forward slightly, and apply direct, continuous pressure by pinching the soft outer portion of the nose for five to fifteen minutes. Ice can help as well. And tell them: do not blow your nose!

Derek Mendoza

Exactly. Keep that head forward. Now, moving on to another seasonal beast: Influenza. The flu is highly contagious and carries significant morbidity and mortality, especially during the peak months of December to February. Influenza Type A is the most virulent and common. What makes it so tricky is the transmission window: an infected person can shed the virus one day before they even show symptoms, and keep spreading it for five to seven days after.

Heather Murphy

And prevention is our best weapon. We recommend the annual vaccine for everyone over six months of age. For our clinical practice, we have to know our vaccine types. We have the standard Quadrivalent Inactivated Influenza Vaccine, or QIV, which is an IM injection approved for ages six months and older. But we also have the Live Attenuated Influenza Vaccine, which is a nasal spray. This one is only for healthy, non-pregnant individuals aged two to forty-nine.

Derek Mendoza

And don't forget the Recombinant Influenza Vaccine, which is egg-free and recommended for adults eighteen and older, especially those over sixty-five because it contains three times the antigen to provoke a stronger immune response. Now, if a patient does catch the flu, and we want to start them on antivirals like oseltamivir, there is a very strict therapeutic window. These medications must be started within forty-eight hours of symptom onset to be effective in shortening the duration of the disease.

Heather Murphy

Forty-eight hours. If they come in on day three, the benefit is minimal. Now, let's round out today's episode by talking about the absolute peak of complex upper airway nursing care: post-operative management for head and neck cancer surgeries, like a total laryngectomy.

Derek Mendoza

This is where all of your nursing skills are put to the test. These patients will often return from surgery with a new tracheostomy. Your immediate postoperative priorities are airway management and oxygenation. That means frequent, careful tracheostomy suctioning to keep the airway clear of thick secretions.

Heather Murphy

And remember, you do not perform wound care or manipulate the tracheostomy ties unless you have a specific healthcare provider order. Now, many of these reconstructive surgeries involve skin flaps to close the surgical defect. These flaps are incredibly delicate. We typically do not cover them with heavy dressings so we can visualize them easily. As a nurse, you are doing hourly checks on those flaps. You're assessing color, temperature, capillary refill, and sometimes using a Doppler ultrasound to check for a pulse. We want to avoid any excess pressure on that tissue.

Derek Mendoza

And what about nutrition, Heather? These patients usually have a nasogastric tube, or NG tube, placed during surgery because they cannot swallow safely yet.

Heather Murphy

The NG tube is vital. But here is a critical safety rule: do NOT manipulate, reposition, or check the placement of that NG tube by pulling it back or pushing it in. That tube lies directly adjacent to internal pharyngeal and laryngeal suture lines. If you move it, you risk tearing those delicate internal incisions. If you suspect a problem, you call the surgeon.

Derek Mendoza

That is such an important point. It really shows how every single nursing action, from how we position a patient's head during a nosebleed to how we handle an NG tube after major surgery, has a direct, profound impact on their airway and recovery.

Heather Murphy

It really does, Derek. It all comes back to protecting that pipeline. Well, that is all the time we have for today's episode. Thank you so much for joining us, and to all our South University students out there -- keep studying hard, stay curious, and we'll see you next time!

Derek Mendoza

Take care, everyone. Happy studying!