2. OUTLINE
• INTRODUCTION
• HISTORY
• RELEVANT ANATOMY OF UPPER AIRWAY
• CLASSIFICATION
• INDICATIONS
• TYPES
• TECHNIQUES
• COMPLICATIONS AND POST OP
MANAGEMENT
• CONCLUSION
• REFERENCES
3. INTRODUCTION
• The major responsibility of the
anaesthesiologist is to provide adequate
ventilation to the patient.
• The most vital element in providing this
functional respiration is the airway.
• Surgical airway is a surgical procedure of
ensuring an open airway between the lower
airway and outside
4. • Rely on making an incision below the glottis
in order to achieve a direct access to the
lower airway by bypassing the upper airway
• Its often performed as a last resort in cases
where intubation (orotracheal or
nasotracheal) is impossible or
contraindicated
• Surgical airway is also used when a patient
will need a mechanical ventilator for a longer
5. History
• History of surgical airway can be dated back to
5000yrs, Egyptian hieroglyphs portray images
suggestive of this procedure with sharp pointed
instruments
• The term tracheotomy was first published in 1649 by
Thomas fienus, and referred to the creation of an
opening in to the anterior tracheal wall to secure
airway
• In the early 19th century, tracheotomy was employed
6. • In the 1930s, tracheotomy was performed in
patient with bulbar poliomyelitis to facilitate
access to airway for removal of secretions
• In the late 1940s to the early 1950s, many
began trialing the application of positive
pressure ventilation through a tracheotomy
• Also in 1950s, this surgical procedure was
extended to multiple neurologic disorders
including coma, brain tumours, multiple
sclerosis, and so on.
7. • This growing use led to many considering
it to be a routine procedure that was both
effective and relatively safe, which sharply
contrast equating tracheotomy to a
pronouncing sentence of death
8. Laryngo-tracheal airway
Larynx is made up of the
• Cartilages that are
connected by
• Ligaments and membranes,
lined by
• Mucus membranes and
moved by
• Muscles
9.
10. Average measurements of
larynx
• Length
• Transverse diameter
• A-P diameter
• Circumference
Males
Females
44 mm 36mm
43 mm 41 mm
36 mm 26 mm
136mm 112 mm
11. Trachea
• 10-11cm long, 2.5cm diameter
in males and 1.5-2cm in
females
• Begins at C6 and ends at T5
• Lumen is about 3mm in
newborns and remain so up to
3rd year of life, then increases
by 1mm/yr up to 12yrs
• Composed of 16-20 c-shaped
rings of hyaline cartilages
(deficient post)
12. Peculiarities of Paediatric
Airway
• Infant larynx is higher in the neck, with
cricoid cartilage being located
approximately at the 4th cervical vertebra
• The epiglottis is proportionally more
posterior, narrower and omega shaped
13. • Normal glottis of the infant has a very
small opening about 7mm in the AP
dimension and 4mm in the transverse
dimension, so that 1mm of oedema may
cause an obstruction
• Cartilages, muscle and submucosal
tissues are softer, friable and provide
greater inflammatory reaction with oedema
and reduction of airway lumen
15. Cricothyrotomy
• Its an incision made through the skin And
cricothyroid membrane to establish a
patent airway during life-threatening
situations
• Its easier and quicker to perform than
tracheostomy
• Does not require manipulation of c-spine,
and is associated with fewer complications
16. • However, while cricothyrotomy may be life-
saving in extreme circumstances, this
technique is only intended to be
temporizing measure until a definitive
airway can be established
17. Indications
• Inability to intubate.
• Inability to ventilate.
• Known or likely unstable cervical spine
where manipulation of the neck is
contraindicated.
• Severe maxillofacial trauma.
• Edema of the glottis and inability to
18. • Severe oropharyngeal or tracheobronchial
hemorrhage.
• Fracture of the base of the skull.
• Foreign body obstruction of airways
19. Contraindications
• Inability to identify landmarks (cricothyroid mb)
• Underlying anatomical abnormality. E.g tumour
or huge goiter
• Tracheal transection
• Acute laryngeal disease due to infection or
trauma
• Small children under 12yrs old
20. Technique
• First described by Felix vicq in 1805
• Patient is positioned supine, head and neck
extended
• Lower border of thyroid cartilage and cricoid ring
are identified, and skin around the area infiltrated
with a LA
• The area is incised vertically, and cricothyroid
membrane exposed and cut with a transverse
incision
21. • A small size tracheostomy tube or ETT is
then inserted, cuff is inflated, and tube
secured
• Confirmation of placement is assessed by
bilateral auscultation of the lungs and
observation of the rise and fall of the chest
22.
23. Note.
Its essential to perform an orderly
tracheostomy as soon as possible
because perichondritis, subglottic oedema,
and laryngeal stenosis can follows
prolonged cricothyrotomy
24. Complications
• EARLY
COMPLICATIONS
Bleeding
Incorrect placement,
resulting in creation of
false passage though
tissues
Oesophageal or
mediastinal perforation
Obstruction, Aspiration
Vocal cord injury
Pneumothorax, Laryngeal
injury
Posterior tracheal wall
perforation
• LATE COMPLICATIONS
Infection, haematoma,
scarring, persistent stoma
Glottic or subglottic
stenosis
Laryngeal stenosis
Tracheo-esophageal
fistula
Tracheomalacia
25. Needle cricothyrotomy
• Is a procedure where a large-bore
intravenous catheter is introduced though the
cricothyroid membrane
• Its only an emergency procedure till patient
can be intubated or tracheotomised
• Its considerably simpler
• The procedure does not provide adequate
ventilation
26. Technique
• Position the patient supine with neck
exposed and extended (if possible)
• Identify surface landmarks i.e. thyroid
cartilage, cricoid cartilage and crico-thyroid
membrane
• Prepare a sterile field, and infiltrate with
1% xylocain
27. • Fix the thyroid cartilage with the 1st & 3rd
fingers of the non-dominant hand leaving the
2nd finger free to locate the cricothyroid
membrane
• With the dominant hand, pass a 14-gauge
intravenous cannula attached to a syringe
filled with normal saline, through the
cricothyroid membrane, directing it caudally
28. • Apply negative pressure to the syringe as the
needle is advanced. Air bubbles will appear in
the fluid-filled syringe as the needle traverses
the membrane and enters the trachea
• Advance the cannula and then retract the
needle
• Fit a 2 or 3ml syringe to the cannula with
plunger removed; insert the connection piece of
29. • an ambubag or ventilator can be attached
and patient is ventilated
30.
31. Tracheostomy
• It’s a making of an opening in the anterior
wall of the trachea and converting it into a
stoma on the skin surface.
• Tracheotomy means opening the trachea,
which is a step in tracheostomy operation
• Sometimes the terms "tracheotomy" and
"tracheostomy" are used interchangeably.
• The opening, or hole, is called a stoma.
32. Indications
• To bypass upper airway obstruction
• To provide pulmonary toilet (in retained
secretions)
• To provide a long-term route for mechanical
ventilation in cases of respiratory insufficiency
• Prophylaxis (as preparation for extensive
head and neck procedures and the
33. UPPER AIRWAY OBSTRUCTION
• Congenital anomalies:
– bilateral Choanal atresia, subglottic
stenosis/web, laryngeal web/cysts,
Tracheomalacia, Vocal Cord Paralysis (VCP),
Congenital abnormalities of the airway,
Treacher Collins and Pierre Robin Syndromes
35. – TRAUMA:
Foreign body obstruction, Airway burns from
inhalation of corrosive material, smoke or
steam, radiation, Severe neck or mouth
injuries, Laryngeal injury or spasms
– TUMOURS:
Benign (e.g. Recurrent respiratory
papillomatosis, Haemangioma, Cystic
Hygroma, etc) or Malignant (e.g. Squamous
cell carcinoma)
36. Retained secretions
1) Inability to cough
Coma of any cause; head injuries, CVA
Paralysis of respiratory muscles: spinal injuries,
polio, Guillain- Barre syndrome,
Spasm of respiratory muscles: tetanus
2) Painful cough: chest injuries, multiple rib
fracture
3) Aspiration of pharyngeal secretions: bilateral
pharyngeal paralysis
37. Functions of tracheostomy
1)Alternative pathway for breathing. This
circumvents any obstruction in the upper airway
from lips to the tracheostome.
2) Improves alveolar ventilation. In cases of
respiratory insufficiency, alveolar ventilation is
improved by:
(a) Decreasing the dead space by 30–50%
(normal dead space is 150 ml).
38. 3) Permits removal of tracheobronchial
secretions.
4) Intermittent positive pressure respiration
(IPPR). If
IPPR is required beyond 72 hr, tracheostomy
is superior to intubation.
5) To administer anesthesia. In cases where
endotracheal intubation is difficult or
40. Tracheostomy tube
• The ideal tube should be rigid enough to
maintain an airway and yet flexible to limit
tissue damage and maximize pt’s comfort
• Shapes are designed to allow correct entry
angle into the trachea and facilitate
ventilation and clearance of secretions
• It is arched shaped =Jackson Curve
41. The selection of TT depends on reason for the
procedure and post operative needs.
-Cuffed: for protection of lower airways from
aspiration of pharyngeal secretions or
haemorrhage
-Double lumen: inner tube can be removed and
secretions and crusted materials cleaned
-Fenestrated: allows passage of air upward
through the glottis allowing phonation
42. • Broadly divided into 2 classes metallic and
synthetic
• Metallic: have an obturator, an outer and inner
tube which has an expiratory flap valve on inner
tube which allows for phonation
• -it is noncuffed. E.g. silver tube of Chevalier
jackson and Negus which are short and used in
pt with thin neck, Durham tube has an
adjustable flange and used in pt with thin or fat
43. • Synthetic: made from PVC, silicon and other
nontoxic synthetic plastic. E.g. Portex and
Shilley
• Both can be connected to an anaesthetic
machine
• Have low pressure cuff
• Others include franklin tube of Great Ormond
street, Portex and Shilley for paediatrics or
neonatal
47. Technique
• Position: Supine with neck extension
• Anaesthesia:
No anesthesia is required for an unconscious
patient
1-2% xylocain+adrenaline is infiltrated in the
line of incision and area of dissection
General anaesthesia with intubation can also
be used
48. Steps
A vertical incision is made
in the midline of the neck,
extending from cricoid
cartilage to just above the
sternal notch
A transverse incision, 5cm
long and 2 fingers breadth
above the sternal notch
can be used in elective
49. • After incision, tissues are dissected in the
midline. Dilated veins are either displaced
or ligated.
• Strap muscles are separated in the midline
and retracted laterally.
• Thyroid isthmus is displaced upwards or
divided between the clamps, and suture
ligated.
50. • A few drops of 4% lignocaine are injected into
the trachea to suppress cough when trachea
is incised.
• Trachea is fixed with a hook and opened with
a vertical incision in the region of third and
fourth or third and second rings. This is then
converted into a circular opening.
• The first tracheal ring is never divided as
perichondritis of cricoid cartilage with
stenosis can result
51. • Tracheostomy tube of appropriate size is
inserted and secured by tapes
• Skin incision should not be sutured or
packed tightly as it may lead to
development of subcutaneous
emphysema.
• Gauze dressing is placed between the
skin and flange of the tube around the
52. Post operative care
1.Care of the patient
• Close and constant nursing care 4 at least 1st 24hrs
post op
• Should be in a well supported upright position
• Extra care in infant so that chin does not occlude the
tracheostomy
• Provide communication means e.g. writing pad,
notebook, bell
• Teach pt hw 2 occlude the tube to enable them speak
53. • Taking care of apnea when it occurs
• Swallowing difficulty may result because of
either the cuff effect or TT interfering wt
normal mobility of the larynx.
• May be relieved by deflating d cuff
• Some may need NG tube 4 feeding
54. Tube care
• Suction: depending on the amount of secretion,
suction may be required every 1/2hr using a
sterile catheter
• Prevention of crusting and tracheitis by
a. proper humidification using humidifiers, steam
tent, ultrasonic nebulizers, or keeping boiling
kettle in the room. Also switching off the fans.
55. b. If crusting occurs, a few drops of N/S,
hypotonic or R/lactate or sodium bicarbonate
are instilled 3-4hrs
• In case of double lumen, inner cannula should
be removed cleaned as and when indicated for
the 1st 3 days
• The outer tube unless blocked or displaced
should not be touched until after 3-4 days to
allow tract to form
56. • Outer tube may then be removed daily for
cleaning
• If cuffed tube is used, it should be periodically
deflated to prevent pressure necrosis.
• Keep by the side of the pt spare tubes and
tracheal dilator in event of any problem
57. Complications
1. Immediate (at the time of operation):
(a) Haemorrhage.
(b) Apnoea.
(c) Pneumothorax due to injury to apical pleura.
(d) Injury to recurrent laryngeal nerves.
(e) Aspiration of blood.
(f) Injury to oesophagus. This can occur with tip of
knife while incising the trachea and may result in
tracheooesophageal fistula
58. 2. Intermediate (during first few hours or days):
(a) Bleeding, reactionary or secondary.
(b) Displacement of tube.
(c) Blocking of tube.
(d) Subcutaneous emphysema.
(e) Tracheitis and tracheobronchitis with crusting
in trachea.
(f) Atelectasis and lung abscess.
(g) Local wound infection and granulations.
59. 3. Late (with prolonged use of tube for weeks
and months):
(a) Haemorrhage, due to erosion of major
vessel.
(b) Laryngeal stenosis, Tracheal stenosis
(c) Tracheo-oesophageal fistula, due to
prolonged use of cuffed tube or erosion of
trachea by the tip of tracheostomy tube.
(e) Problems of decannulation.
60. (f) Persistent tracheocutaneous fistula.
(g) Problems of tracheostomy scar. Keloid or
unsightly scar.
(h) Corrosion of tracheostomy tube and
aspiration of its fragments into the
tracheobronchial tree.
61. PERCUTANEOUS DILATATION
TRACHEOSTOMY
• PDT is a bedside procedure requiring a
small surgical field and avoiding need for
op room
• This type of tracheostomy is done in ICU
where patient is already intubated and
being monitored.
• It is done under sedation
62. Indications
• PDT is indicated for selected ventilator-
dependent patients in ICU
Prolonged ventilatory support
Airway control
Pulmonary toilet
Upper airway obstruction
64. Technique
• Patient is positioned supine
• Neck is extended with a pad under the
shoulders
• Neck is prepared and draped and 1.5–2 cm
incision is made 2 cm below the lower border of
cricoid
• Trachea is exposed by dissection and palpation
65. • Now a small caliber flexible bronchoscope,
to which a camera has been attached, is
passed through the endotracheal tube to
monitor the passage of the needle, guide
wire and dilator
• Entry into the trachea is made between
second and third rings. After dilatation
tracheostomy tube is inserted.
66. • 15G introducer needle is inserted under
direct bronchoscopic/endoscopic vision
• Needle is removed, guide wire and catheter
inserted
• Dilator is lubricated and introduced, held like
a pencil and passed in to the trachea until
there is loss of resistance
• Dilator guiding catheter and wire are removed
67. • Tracheostomy tube lubricated, deflated,
attached to dilator and introduced under
direct visualization
• Inner cannula inserted, and cuff inflated
• Ventilator tube can then be connected and
ETT is removed
68.
69.
70. Advantages
• Done in ICU by the bedside
• Reduces risk associated with possible
transfer of critically ill patient out of the
ICU
• Does not require operating theatre, thus
less expensive in terms of human and
economic resource
71. Complications
• Bleeding
• Paratracheal insertion
• Local hemorrhage
• Wound infection
• Tube dislodgement or inability to complete the
procedure
• Tracheal stenosis
72. Conclusion
• Surgical airway procedures are a life saving
procedures that has been practiced since
ancient time and requires experience.
Maintainance of which is labourous requiring
multiprofessional hands esp. 1st 72hrs.
• It is rewarding.
• REMEMBER: The best time to create a
surgical airway is when you think of it!
73. References
• Dhingra P.L.(2014) Diseases of Ear, Nose, Throat,
and head and neck surgery. 6th edition. India:
Elsevier. PP.316-320.
• Sakshi H.A(2017) Self assessment and review in
ENT. 8th edition. London: jaypee. PP.425-428
• Bennett JD, Guha SC, Sankar AB. Cricothyrotomy:
the anatomical basis. JR Coll Surg Edimb.
1996feb. 57-60
• Klock PA. et al (2008). Managing Airway. In:
Anesthesiology. The McGraw-Hill Companies, pg.
686-708.
• Open access Atlas of ENT, Head and Neck
surgery (2015). Available at www.entdev.uct.ac.za
• International journal of critical illness and injury
science. Available at:
https://www.ncbi.nlm.nih.gov/pmc/articles
