Surgical airway procedures

SURGICAL AIRWAY SURGICAL AIRWAY PROCEDURESPROCEDURES

Dr. FarooqDr. Farooq

Medical OfficerMedical Officer

E.N.T Department,E.N.T Department,

Capital HospitalCapital Hospital

Anatomy & PhysiologyAnatomy & Physiology

Anatomy in childrenAnatomy in children

Local Anatomy in Children:Local Anatomy in Children: Larynx

Lies higher Arytenoids are proportionately larger Epiglottis is Omega shaped –

Mushrooms over V.Cords and airway in presence of oedema and inflammation.

Glottis: Size:» Ant-post – 7 mm» Interarytenoid – 4 mm

Area: 14 mm2

( 1 mm of oedema reduces apperture by 9 mm2 or 65%.- So airway compromise)

Normal adult laryngeal inlet

Cricoid: In adult or child is solid cartilaginous ring which does not expand – any swelling of soft tissue expands into lumen.

Throughout entire larynx esp. sub-glottis there is abundance of loose areolar tissue in sub-mucosa favoring oedema formation.

Functions of LarynxFunctions of Larynx

• PhonationPhonation

• Fixative Function.Fixative Function. During manual labor, defaecation, parturition, muscles of shoulder girdle, chest,

diaphragm and abdomen compress the chest to raise intrathoracic pressure, the vocal cords come together and do not allow air to escape, thus fixing the latter to serve as solid base.

• Protective Function.Protective Function. Prevents food from entering airway Coughing throws off foreign material from airway

• Respiratory FunctionRespiratory Function It is an active airway which allows correct amount of inspired air depending upon

state of activity. The upper airway warms, cleans and moistens the air we breath. The trachy tube

bypasses these mechanisms, so that the air via the tube is cooler, dryer and not as clean. In response to these changes, the body produces more mucus.

A tracheostomy will result in loss of these functionsA tracheostomy will result in loss of these functions

What is a Tracheostomy?What is a Tracheostomy?

A tracheotomy is an incision into the trachea (windpipe) that forms a temporary or permanent opening which is called a tracheostomy.

Sometimes the terms "tracheotomy" and "tracheostomy" are used interchangeably.

…….Tracheostomy.Tracheostomy

The opening, or hole on the skin, is called a stoma.

The incision is usually vertical in children and

runs from the second to the fourth tracheal ring and

horizontal or vertical in adults.  

…….Tracheostomy.Tracheostomy

A tube is inserted through the opening.

Patient will now breathe through the tracheostomy tube.

HistoryHistoryThe tracheotomy is one of the The tracheotomy is one of the

oldest surgical procedures. oldest surgical procedures.

The first successful tracheotomy was performed by Prasavola, an Italian physician, in1546. The patient, suffered from a

laryngeal abscess and recovered from the procedure.

Tracheotomies were used in the early 1800's for airway inflammation in children due to Diphtheria. The first documented successful tracheotomy performed on a child was reported in 1808.

In 1909, a lower tracheotomy technique was introduced in which the tracheal incision extends to the 4th or 5th tracheal ring. This operative technique was refined by Chevalier Jackson when faced with the challenge of the polio epidemic of the 1940's. This technique is basically the same today.

IndicationsIndications

To relieve Upper Airway To relieve Upper Airway Obstruction:Obstruction:

Congenital Anomalies: Vocal Cord Palsy

(Abductor palsy) Laryngeal webs and stenosis Tracheomalacia Tracheosophageal fistulas Vascular anomalies like

hemangioma & lymphangioma

Laryngeal cysts

Acquired Disorders: Inhaled impacted F. body larynx. Acute Inflammatory conditions

like: Acute epiglottis Diphtheria Acute laryngotracheobronchitis Acute laryngeal oedema. Laryngeal carcinoma receiving

radiation

Space occupying lesions like: Carcinoma of larynx Papillomatosis.

For Bronchial Toilet:For Bronchial Toilet: Conditions with Central Respiratory Depression

Coma, CV A, Head Injury Neurological Problems such as poliomyelitis, cervical cord

lesions, polyneuritis etc. Acute Infections

Acute Laryngotracheobronchitis

To provide Assisted Ventilation:To provide Assisted Ventilation: It is safer to perform tracheostomy in cases where

endotracheal tube is required beyond 72 hrs.

Major Head & Neck Surgery:Major Head & Neck Surgery: To maintain airway and protect against

haemorrhage.

Tracheostomy TubesTracheostomy Tubes

In double-cannula tubes, The main parts of a double

cannula tracheostomy tube are: the outer tube (or cannula), The

outer tube has ties to secure it the inner tube (or cannula).It

acts as a removable liner for the more permanent, outer tube and

the obturator.The obturator is used only to guide the outer tube during insertion

•A tracheostomy (trach) tube is a curved tube that is inserted into a tracheostomy stoma (the hole made in the neck and windpipe).

•These tubes can be made of metal, portex plastic or silicone.tubes can be made of metal, portex plastic or silicone.

•The tube size and type is determined by the doctor depending on the reason for the trach tube as well as the size, age and medical needs of the patient.

Silicone double cannula tube.

Outer/ Inner tube Sizes Phonation holes Corkable

Metallic double cannula tube (Silver Jackson Type)

Single Cannula Tubes For infants and small children, the trach tube is usually a single-

cannula plastic tube and is generally not cuffed

Parts of a Tracheostomy TubeSingle Cannula Silicone Tube

…….Tracheostomy Tubes.Tracheostomy Tubes• Portex Tubes:Portex Tubes:

Widely used Cuffed/ Uncuffed Stent/ Introducer Sizes

• RadcliffeRadcliffe Right angle tube Indicated in patients with thick fat neck

• Durham’s TubeDurham’s Tube Adjustable flange can fit any size of neck.

. . Fenestrated tubes have an opening in the tube that permits speech through the upper airway when the external opening is blocked. Fenestrated tubes are not recommended for small children,

Types of Surgical Airway Types of Surgical Airway ProceduresProcedures

1.1. Laryngotomy Laryngotomy (cricothyrotomy)(cricothyrotomy)

2.2. Elective Temporary Elective Temporary Tracheostomy:Tracheostomy:

This is performed as a planned procedure, usually under G/A, as a temporary stage in patients management

3.3. Permanent Tracheostomy:Permanent Tracheostomy: In an operation involving

removal of larynx. Tracheal remnant is brought to surface as a permanent mouth.

4.4. Emergency TracheostmyEmergency Tracheostmy Nowadays there ought to be very few indications for this. On

occasion a patient will be seen first with a large laryngeal tumor and require an emergency tracheostomy.

To have to do an emergency tracheostomy in conditions such as acute epiglottitis, respiratory failure, coma etc is a sign of poor forward planning in the management of the patient.

It is to be done under L/A if is a true emergency and this, to the inexperienced, is a difficult, dangerous operation.

5.5. Paediatric TracheostomyPaediatric Tracheostomy6.6. Micro Laryngeal tube placement for airway Micro Laryngeal tube placement for airway

management of tracheal stenosis.management of tracheal stenosis.7.7. Percutaneous TracheostomyPercutaneous Tracheostomy

ComplicationsComplications

Unfortunately many regard the operation as minor one.

Operation is not necessarily a simple one, and short term as well as long term complications commonly occur if it is not properly executed.

Many of the complications are attributed to poor surgical technique and judgment.

Problems often begin at the outset of operation b/c some attempt to perform tracheostomies at bedside.

Bed side tracheostomy is particularly hazardous in children because margin of error is so small.

• ApnoeaApnoea Abrupt decrease in CO2 on opening trachea may result in an apnoea.

Administration of 5% CO2i in oxygen may be required.

• BleedingBleeding Primary Haemorrhage may occur from anterior jugular veins, thyroid isthmus or

tracheal wall. Haemostasis must be obtained before opening trachea.

Sec. Haemorrhage may occur and enter trachea around the tube. A cuffed tube should be inserted immediately and would reopened to stop haemorrhage.

Fatal erosion of large artery may occur from ulceration of anterior wall of trachea by pressure of tip.

Only careful selection of tube is the answer. Very small amounts of bleeding (pink or red streaked mucus) often occur as a

result of routine suctioning. This bleeding can be managed with close observation and by modifying the care that

might have caused the problem.

• Respiratory Distress and Tube ObstructionRespiratory Distress and Tube Obstruction Occur due to lack of humidification or poor toilet. The tube may have become

blocked with dried secretions or blood. Mucus plugs are the most common cause of respiratory distress in children.

Suction trach or change trach tube as needed for respiratory distress. Thick mucus plugs may be suctioned following instillation of saline.

• Subcutaneous Emphysema & PneumothroaxSubcutaneous Emphysema & Pneumothroax Unnecessary dissection of tissue planes be avoided. Clear airway may be maintained. Skin should not be tightly closed. Repair pleura if inadvertently incised.

• InfectionInfection May occur from tracheostomy tube, endotracheal

aspiration or overspill.Children with tracheostomies are at high risk for respiratory infections.

. • Tracheal Stenosis & Granulation tissue Tracheal Stenosis & Granulation tissue

formationformation Keep the incision away from the cricoid preferably

below 2nd ring. Proper selection of Tracheostomy tube. Keeping cuff pressure low.

• Tracheoesophageal FistulaTracheoesophageal Fistula

• Pressure Necrosis of skin.Pressure Necrosis of skin.

• Tube displacementTube displacement..

• Difficult DecannulationDifficult Decannulation

• Failure of closure of fistula after Failure of closure of fistula after decannulation.decannulation.

Tracheostomy CareTracheostomy Care

NursingNursing A nurse who understands care of tracheostomy

should be attendance for first 48 hrs

HumidificationHumidification Use of humidifiers attached to trachy. Or place wet gause on opening.

Suctioning a TracheostomySuctioning a Tracheostomy Generally, patient should be suctioned every 4 to 6

hours and as needed. There may be large amounts of mucus with a new tracheostomy & frequent suction may be needed.

Care of Inflatable CuffCare of Inflatable Cuff For trach tubes with cuffs, it may be necessary to deflate the

cuff periodically for Suctioning to prevent pooling of secretions above trach cuff. To prevent pressure erosion and injury to tracheal mucosa.

Daily DressingDaily DressingCleaning of Tubes with Inner CannulaCleaning of Tubes with Inner Cannula

Disposable Inner Cannula. These should be changed daily, Reusable cannulas. The cannula should be cleaned atleast1

to 3 times a day. Do not leave the inner cannula out for more than 15 minutes

Thank You