Surgical Airway Management - Tracheostomy,Cricothyroidectomy

It include surgical airway management procedured like Tracheostomy,cricothyridectomy..

1. Surgical Airway Management Submitted by Aswanth E P

2. Contents Introduction Needle Cricothyrotomy Cricothyrotomy Tracheostomy Pediatric considerations Conclusion Reference

3. Introduction Surgical airway management is essentil in life thretening situations. 3 methods involved are 1)Needle cricothyrotomy & translaryngeal jet ventilation 2) Cricothyrotomy 3) Tracheostomy In emergency sitation,cricothyrotomy preffered.But it is avoid in children due to smalll anatomy Of cricoid cartilage and associated complications .

4. Airway anatomy

5. SURGICAL AIRWAY Establishing a surgical airway can be a last resort in response to failed intubation attempts for a critical patient with a compromised airway. These situations consist of extreme facial trauma or a completely compromised airway, because serious brain damage can occur in a short period of time if the airway remains obstructed 3 methods used : needle cricothyrotomy and translaryngeal jet ventilation cricothyrotomy and tracheostomy .

6. In an emergency situation, cricothyrotomy has been shown to be faster and have lower morbidity and mortality rates than tracheostomy . It should be avoided in infants and approached cautiously in children younger than 10 to 12 years because of the small anatomy of the cricoid cartilage and the associated high complication rates

7. Needle Cricothyrotomy & Translaryngeal Jet Ventilation Sanders first described the percutaneous placement of a tracheal needle with jet ventilation. Indications In pediatric settings Severe hemorrhaging of the airway E dema S ome facial fractures Dislocations . It is used temporarily until a definitive airway can be secured . It oxygenate the patient for up to 45 minutes while the physician establishes a more stable Airway.

8. Contraindications When airway is maintainable through non invasive means. Anterior neck swellings that obscures landmarks. Bleeding disorder.

9. Cricothyroidectomy : Anatomy

10. Technique Consists of the insertion of a catheter through the cricothyroid membrane. There are catheter devices made specifically for this procedure, such as the emergency transtracheal airway catheter . They tend to kink less frequently than standard angiocatheters . Most adults require a 12- to 16-gauge standard angiocatheter . Infants and small children typically require 16- to 18-gauge catheters.

11. Cricothyroid membrane with syringe catheter in the midline Needle-catheter-syringe combination inserted at 30 degree caudal angle

12. Needleless safety catheters should be avoided because of their inability to connect to a syringe. Trachea is stabilized by the thumb and middle finger of the nondominant hand while the index finger locates the cricothyroid membrane Skin is anesthetized with 1% lidocaine or a similar local anesthetic. A 10-mL syringe filled with 5-mL of saline is attached to the catheter & the needle is directed caudally at the inferior aspect of the cricothyroid membrane. Ideally, the needle enters the skin at a 30- to 45-degree angle to the horizontal and avoids injury to the surrounding vessels

13. Negative pressure is applied to the syringe on insertion of the needle and continues throughout advancement of the catheter. The entrance of air bubbles into the syringe confirms proper tracheal placement and the catheter is advanced until the hub reaches the level of the skin. Once the catheter has been advanced, the needle and syringe are withdrawn. oxygen source is connected to the catheter and oxygen is delivered at 50 psi, with a flow rate of 15 liters/min.

14. Administrating high pressure ventilatiom through translaryngeal catheter

15. Throughout the ventilation process, the catheter is manually secured in place until a definitive airway can be maintained It only provide temporary airway control, a direct laryngoscopy may be performed at any time. The air bubbles within the trachea because of the translaryngeal jet ventilation may serve as a helpful guide for laryngoscopy

16. Complications Barotrauma Subcutaneous emphysema Pneumothorax . infection, damage to surrounding tissues and structures, and bleeding Subcutaneous emphysema is often the result of a kinked catheter or multiple puncture sites. The use of a specific needle cricothyrotomy catheter (kink-resistant) helps decrease the chance of subcutaneous emphysema during or after the procedure.

17. It is unavoidable if there is leakage at the original puncture site / if there is significant catheter movement during ventilation causing subcutaneous air and swelling Preventive measures should be taken to avoid excessive insufflation of oxygen, minimizing the risk of pneumothorax

18. Cricothyrotomy / Cricothyroidotomy An incision through the cricoid cartilage.

19. Cricothyrotomy is indicated in cases in which orotracheal and nasotracheal intubation are unsuccessful . Airway device such as the LMA may be used until the proper equipment and personnel are in place to perform a cricothyrotomy . In young children, cricothyrotomy is contraindicated because of the size of the cricothyroid membrane and narrowing of the pediatric airway.

20. Surgical Anatomy

21. Procedure can be done under local or general anesthesia The head and neck should be slightly extended, unless a cervical spine injury is suspected or has not been ruled out. When working on a conscious patient, a local anesthetic (1% lidocaine ) is administered to the skin and subcutaneous tissues after the anterior neck is prepped with an antiseptic solution. A right-handed surgeon performs the procedure by standing on the patient’s right side. Technique

22. Armamentarium

23. Thumb and middle finger of the nondominant hand are used to immobilize the larynx while the index finger locates the cricothyroid membrane. Stabilization of the larynx should be maintained at all times during the procedure A 2-cm horizontal incision is made through the skin and subcutaneous tissue.

24. The incision is carried down through the cricothyroid membrane without going through the posterior wall of the airway, and is directed caudally to avoid the vocal cords. The nondominant index finger is used to hold the incision open and to minimize the bleeding. A Trousseau dilator or a large hemostat is inserted to spread the incision vertically.

25. This increased opening in the cricothyroid membrane eases placement of the tracheal hook. A properly sized tracheostomy tube (no. 6 Shiley for average men, no. 4 for average women) is inserted into the opening and advanced into the trachea. The dilator and tracheal hook are carefully removed to avoid causing any damage. The obturator is then removed before the inner cannula is inserted and the cuff or balloon of the tracheostomy tube is inflated.

26. The tube is attached to a bag-valve device or a mechanical ventilator and is secured with umbilical tape that is tied around the neck before ventilation begins. Because of the potential for the development of subcutaneous emphysema and pneumomediastinum , especially during mechanically supported respirations, the skin is not sutured as a method for securing the tube in place.

27. Rapid Four Step Technique (RFST) Only equipment needed for the rapid fourstep technique (RFST) is a no. 20 scalpel, hook, and tracheostomy tube. 1. Palpate and identify the cricothyroid membrane. 2. Using the no. 20 scalpel, make a 1- to 2-cm horizontal incision through the skin, subcutaneous tissue, and cricothyroid membrane. 3. Place the tracheal hook (before removing the scalpel) and direct it inferiorly to provide caudal traction. 4. Insert the tracheostomy tube

28. Complications Perioperative Complications Hemorrhage Improper placement of the tube Prolonged execution time Injury or laceration to the thyroid or cricoid cartilage, Injury to the esophagus or laryngeal nerve, Pneumomediastinum , Perforation of the posterior trachea Subcutaneous emphysema

29. Postoperative Complications Hemorrhage Infection Aspiration tube occlusion Paralysis of the vocal cords, Dysphonia and hoarseness Subglottic stenosis

30. Tracheostomy Indications Blunt neck trauma Tracheal transection Upper airway obstruction Need for prolonged mechanical ventilation Complex facial fractures Large or expanding neck hematomas Edema Deep space neck infections Lacerations to the floor of the mouth.

31. Contraindications If an airway can be secured by any other method. The difficulty level, amount of time needed, and potential complications are greater for tracheostomy than for other definitive airways.

32. Surgical anatomy

33. The neck is prepped with an antiseptic solution and a local anesthetic, such as 1% lidocaine , is injected into the incision site. Additionally, 2 mL of the local anesthetic is inserted into the cricothyroid membrane and injected into the trachea.This blunts the cough reflex. The airway stabilized with the nondominant hand Both vertical and horizontal incisions can provide adequate access to the airway. In an emergency tracheostomy , the vertical incision maintains midline dissection and reduces the potential for anatomic damage when the direction of the incision is changed.

34. 3- or 4-cm vertical incision is made through the skin, subcutaneous tissue, and platysma muscle. It begins just below the cricoid cartilage and extends to the suprasternal or supraclavicular notch. In an elective tracheostomy , the horizontal incision is preferred for better cosmetic results.

35. A 4- to 5-cm horizontal incision is made approximately 2 cm below the cricoid cartilage. Through subcutaneous tissue and platysma muscle until the superficial layer of the deep cervical fascia is identified

36. As the space of Burns is entered bluntly, the inferior thyroid veins are identified, clamped, and tied before cutting them to minimize bleeding. By vertically retracting the midline tissue away from the trachea, injury to major vessels, nerves, and glandular tissue can be avoided. Thyroid gland is retracted out of the field, exposing the tracheal rings. If the thyroid isthmus cannot be retracted out of the field, it must be transected, which can be done by cutting the suspensory ligament .

37. Cricoid cartilage and first tracheal ring must not be cut or injured. Second, the incision into the trachea must stop at or above the fourth tracheal ring A tracheostomy hook is placed just below the first tracheal ring. This acts to immobilize and elevate the trachea The tracheal incision can be made by the following Techniques : U,inverted U, T flap, and cruciform.

38. In emergent situations, a vertical midline incision between the second and fourth tracheal rings is recommended. Trousseau dilator or Kelly hemostat is inserted and spread vertically Tracheostomy tube should be inserted under direct vision once the Trousseau dilator is in place. The cuff and tip of the tube are advanced into position, just inferior to the vocal cords. The cuff is then inflated and the skin can be left open or loosely sutured.

39. If the skin is sutured too tightly, subcutaneous emphysema may result from not allowing air to escape during forced expiration or continuous positive pressure Ventilation. Once it has been determined that the tube is in the right location, a tracheostomy gauze dressing should be placed under the tracheostomy tube phalanges and around the cannula . Chest x-ray is obtained to verify tube placement and to check for pneumothorax .

40. Complicaions 1)Acute hemorrhage postoperative hemorrhages, most occur in the first 2 to 4 weeks after the procedure. 2)Infection Potential postoperative infection includes surgical site infection, tracheitis , mediastinitis , and pneumonia The pathogens most commonly isolated from tracheostomy infections are Pseudomonas aeruginosa , Staphylococcus aureus , hemolytic streptococci, and Candida.

41. 3)Tracheal stenosis 4) Pneumothorax In infants, children, and those with chronic obstructive pulmonary disease 5)Aspiration Postoperative care Trach care describes the specific techniques for proper tube care, consists of tube aspirations and frequent suctioning in the days and weeks after surgery. If blood,mucus , or other secretions build up in the airway and cause occlusion of the tube, the patient will lose the ability to breathe.

42. To aspirate ,patient’s lungs be filled with 100% oxygen for 2 or 3 minutes before suctioning occurs Then 5 mL of sterile saline is injected into the tracheal tube, immediately followed by 2- to 3-second suctioning intervals. The steps should be repeated as long as notable secretions are removed from the airway. Trach care is completed once every hour for the first 48 hours. The following 2 days, it should be completed once every 2 hours. After the first 4 days, it should be completed every 4 hours.

43. Pediatric considerations Their airways are smaller and tend to become obstructed more easily. Foreign bodies, secretions,or even edema can cause an obstructed airway. Furthermore, the tongue and tonsils of a child are large in relation to the rest of the oral cavity. Thus,have a tendency to get in the way during airway interventions Larynx is located higher and more anteriorly in children than in adults. This is important to note because hyperextension of the neck may further obstruct the airway.

44. Needle cricothyrotomy with transtracheal jet ventilation: This is the preferred surgical airway method in children because it is straightforward and provides a patent airway for close to an hour. Cricothyrotomy : This procedure has a high complication rate and should not be done in children younger than 10 years. Tracheostomy : This should also be avoided in children because it is a time-consuming procedure. However, in emergent cases, if needle cricothyrotomy with transtracheal jet ventilation has failed in a very small child, a tracheostomy may be performed

45. Conclusion Surgical airway mnagement is essental in critical situations. Needle cricothyrotomy with transtracheal jet ventilation: Cricothyridectomy & Trachoiostomy are common procedures used. In emergency sitation,cricothyrotomy preffered.But it is avoid in children due to smalll anatomy Of cricoid cartilage and associated complications .

46. Reference 1)Oral & Maxillofacial trauma : 4 th edition :FONSICA,WALKER,BARBER,POWERS,FROST 2)Textbook of Oral & Maxillofacial Surgery : 3 rd edition : S.MBALAJI

47. Thank you