Surgical Airway Tintinalli Chap 20, 244

1. Surgical AirwayTintinalli Chap 20, 244 Nicholas Cardinal, DO

2. Surgical Airway Management • Rate of failed ED intubations requiring surgical airway placement is below 0.6%

3. Indications • Most due to inability to establish orotracheal or nasotracheal intubation • Anatomy • Short, obese neck • Disease state • Epiglottitis • Laryngeal edema • Paralyzed vocal cords • Retropharyngeal abscess • Trauma • Cervical fracture • Major vessel injury • Aspiration of blood • Mandibular fracture

4. Type of Emergency Airway • Surgical Cricothyroidotomy • Preferred d/t larger diameter tube • Tracheostomy tube is easier to maintain, stabilize • Needle Cricothyroidotomy • Preferred in children less than 10-12 • 12-14 gauge catheter • Emergency Tracheostomy • Rarely indicated and extremely difficult

5. Conversion to Tracheostomy • If airway will be needed longer than 2-3 days • Cricothyroidotomy has a higher incidence of airway stenosis

6. Surgical Cricothyroidotomy

7. Cricothyroid Membrane • Located between the thyroid and cricoid cartilages • 1/3 distance from manubrium to chin in patient’s with normal habitus

8. Complications • Bleeding from Insertion Site • Venous • Occurs from small veins and usually stops spontaneously • Vertical incision decreases risk • Arterial • Thyroid ima artery • Branch of the aorta that runs up to thyroid gland in the midline • Must be surgically ligated if injured • Tube Misplacement • Placement anterior to larynx/trachea into the mediastinum • High airway pressures, absent breath sounds, subcutaneous emphysema • Laceration of Structures of the Neck • Rare • Trachea • Esophagus • Recurrent laryngeal nerves • Pneumothorax • Likely d/t barotrauma from ventilation • Late Airway Complication • Occurs in up to 52% • Voice changes • Laryngeal/Tracheal Stenosis

9. Procedure • Stand on side of dominant hand • Place index finger at sternal notch and palpate cephalad until 1st rigid structure. Roll index finger one finger breadth above to locate the “hollow” between the cricoid and thyroid cartilages • Stabilize the 2 cartilages with the nondominant hand • Make a vertical incision in the midline between the 2 cartilages • Horizontally perforate the cricothyroid membrane by inserting the scapel blade one-half its length • Insert the scapel handle into incision to widen the opening • Place ETT or tracheostomy tube in the opening no more than 2-3 cm • Secure the tube • Connect to bag-valve-mask device • Check for breath sounds

10. Needle Cricothyroidotomy • Insertion of a catheter through the cricothyroid membrane • Preferrred emergency surgical airway in children under 10-12 • Adult patients can only be ventilated for 15-20 minutes

11. Complications • Bleeding at puncture site • Infection • Perforation of esophagus or back wall of trachea/larynx • Catheter misplacement in neck soft tissue

12. Procedure • Operator positioned above the head of the patient • Palpate cricothyroid membrane • Attach 3-ml syringe to catheter • Introduce catheter at 90 degree angle. Aspirate gently while advancing catheter over needle. Change angle to 45 degrees when air returns suddenly and advance catheter into the larynx • Disconnect syringe from needle • Withdraw plunger from syringe and attach syringe barrel to the catheter • Attach adapter from ETT or place a 7-mm ETT into the syringe and inflate the cuff • Attach oxygen source and ventilate • Operator must hold catheter in place until another choice of airway is established

13. Complications of Endotracheal Intubation • Minor • Lip lacerations • Corneal abrasions • Dental fractures • Tongue injuries • More Serious • Usually d/t repetitive or blind attempts • Damage to soft tissues of pharynx/larynx • Bleeding • Subcutaneous emphysema • Septic shock (Late) • Dislocation of arytenoid cartilage • Obstruction • Kinking • Biting the tube • Inspissated secretions • Overinlated cuff

14. Tracheostomy Tubes • Skills needed in ED • Replacement of an uncuffed with a cuffed tube for mechanical ventilation • Replacement after decannulation • Correction of tube obstruction • Control of bleeding or infection at tracheostomy site

15. Fenestrated Trach Tubes • Have an opening along the dorsal surface allowing passage of air to the vocal cords • Must be fitted with no contact of the anterior neck or posterior tracheal wall • If contact is present • Respiratory movement leads to granulation tissue • Can lead to bleeding, obstruction, and difficulty removing the tube • ENT consult

16. Changing a Trach Tube • If less than 7 days old, call ENT • Equipment • Suction • Trach tube with obturator • Additional tube one size smaller • Tube tie • Cricoid hook • Tracheal dilator

17. Tracheostomy Tube Obstruction • Mucus Plugging • May act as ball-valve mechanism • Management • Suction with saline • Removal and cleaning of inner cannula or entire tube

18. Mechanical Ventilation • Uncuffedtracheostomy tube will have a large air leak • Replace with cuffed tube or ETT

19. Tracheostomy Dislodgement • Suction catheter cannot be passed through the tube • May extrinsically compress the trachea • Management • Immediate removal • Nasopharyngoscope • ENT consult • Oral intubation if necessary

20. Tracheostomy Site Infection • Stomal skin infection, tracheitis, and bronchitis can be recurring problem • Staph aureus • Pseudomonas • Candida • Management • Broad-spectrum antibiotics • Dressing changes with gauze soaked in 0.25% acetic acid

21. Bleeding • Sources • Granulation tissue • Erosion of thyroid vessels or gland • Tracheal wall • Innominate artery • Management • Pack with saline-soaked gauze • Silver nitrate/electrocautery • Cuffed ETT below bleeding site • Tracheo-innominate Artery Fistula • Rare but life-threatening complication • Results from direct pressure of tip of tracheal cannula against the innominate artery • Apply direct pressure; OR

22. Tracheal Stenosis • Can present weeks to months after decannulation • Results from mucosal necrosis and subsequent scarring • Symptoms include dyspnea, wheezing, stridor, and inability to clear secretions • Chest Xray shows narrowed airway • Treatment includes humidified oxygen, nebulizedracemic epinephrine, steroids, and ENT consult

23. Laryngeal Stent • Used for severe stenosis • Requires tracheostomy until stent is removed • Dislodgement may occur • Should only be removed by ENT

24. Montgomery T-tube • Commonly used in adult laryngotracheal reconstruction • Does not have inner cannula and commonly becomes obstructed • Management includes suctioning of both upper and lower limbs and possible replacement with ETT or trachostomy tube

25. Speech Devices • Passy-Muir Valve • One-way valve that fits directly over opening of an uncuffedtracheostomy tube • Allows patient hands-free speech • If signs of obstruction, remove valve and check trach tube • Tracheo-esophageal Prostheses • One-way valve surgically placed between posterior tracheal wall and anterior esophageal wall • Complications • Aspiration of valve • Extrusion of valve