The initial management of any patient with known or suspected DNI is securing the airway. Loss of airway has traditionally been the major source of mortality from DNI. Airway complications should be anticipated in all cases of DNI, especially in those that involve the floor of the mouth and the parapharyngeal and retropharyngeal spaces. Fiberoptic evaluation of the upper airway at the time of initial evaluation will often identify an evolving airway complication before it occurs. Pulse oximetry monitoring is helpful if interpreted in the proper context, but a normal oximetry should not provide false security if the patient clinically displays airway distress. Patients with airway compromise should not be transported out of an intensive care suite for prolonged radiographic testing until the airway is secure. IV access should be obtained to allow rapid administration of medications and anesthetic agents when needed. Firstline airway therapy includes use of an oxygenated face tent with cool mist humidity, IV steroids, and epinephrine nebulizers. If the patient has mild airway symptoms, and the examination reveals mild edema with less than 50% obstruction at the glottic or supraglottic level, the patient will often respond to medical therapy alone while under direct observation in the emergency suite or intensive care unit.
Urgent airway intervention is necessary in the event of greater levels of stridor and dyspnea, which are usually accompanied by airway obstruction of more than 50%. Effective communication between the consulting otolaryngolgist and critical care/ anesthesiology personnel is mandatory. The otolaryngologist needs to convey the results of the initial airway evaluation with the anesthesiologist and should be actively involved in intubation planning. In general, an awake fiberoptic intubation can be successfully performed if the airway is visualized to be large enough to allow the passage of the average flexible bronchoscope (5 to 6 mm). Airway preparation with lidocaine nebulizers and lidocaine jelly–lubricated nasal trumpets with or without light sedation will allow most adult patients to be intubated comfortably while awake. The patient should be sitting upright, and strong suction should be available to clear airway secretions to improve visualization. A tracheotomy set should be available in the room in the event that a surgical airway is required. An elective tracheotomy may be considered if extubation is not anticipated within 24 to 48 hours, or if surgical drainage procedures are likely to result in significant or prolonged airway edema. In such situations, elective tracheotomy has been associated with reduced hospital stays and reduced costs compared with prolonged intubation.

An awake tracheotomy should be planned in cases
where minimal or no airway lumen is visualized. Increasing peak airway pressures and frothy airway secretions following successful intubation may indicate the onset of postobstructive pulmonaryedema, which typically resolves with positive-pressure mechanical ventilation and judicious use of IV diuretics.

Source: Cummings Otolaryngology, 6E (2015)