Surgical Airway Surgical Airway Sybile Val, MD SUNY Downstate Medical Center Center August 6, 2009 www.downstatesurgery.org
Surgical AirwaySurgical AirwaySybile Val, MD
SUNY Downstate Medical CenterCenter
August 6, 2009
www.downstatesurgery.org
Case PresentationCase Presentation• HPI • MedsHPI
– 42 YOF presented to ED on 4/18 with
Meds– Singulair– Advair
dyspnea• PMH
A th
– Albuteral– Sensipar
– Asthma– ESRD on HD
• PSH
• Allergies– NKDA
• PSH– RUE fistula
creation
www.downstatesurgery.org
Case PresentationCase Presentation
• In EDIn ED– Afebrile, BP 97/66 HR 109 RR 22 Sat
96%96%– On Exam
• Mild respiratory distressMild respiratory distress• No JVD• Rales in lower 1/3 of b/l lung fields, no
wheezing• No Peripheral edema
www.downstatesurgery.org
Case PresentationCase Presentationwww.downstatesurgery.org
Case PresentationCase Presentation
• LabsLabs– Unremarkable
• Plan• Plan– Admit to Medicine w/ Dx of CHF
exacerbationexacerbation– Renal for HD
O th i iti t d– Oxygen therapy initiated
www.downstatesurgery.org
Case PresentationCase Presentation
• Post DialysisPost Dialysis– No improvement in SOB
Alterations in mental status– Alterations in mental status– ABG: 7.17/94/237/36/100%
BiPAP initiated– BiPAP initiated– MICU consult called
R d tiRecommendations:Intubate the patient
www.downstatesurgery.org
Case PresentationCase Presentation• Anesthesia consultedest es a co su ted
– Using accessory muscles– Obtunded with saturation of 91-96%– Attempts at intubation with fiberoptic
scope x 2Gastric contents regurgitated– Gastric contents regurgitated
• Surgery consultedCricothryoidotomy attempted @ bedside– Cricothryoidotomy attempted @ bedside
– Pt taken to OR for revision and control of bleeding
www.downstatesurgery.org
Case PresentationH it l CHospital Course
• POD#1 • POD#39– ENT consulted
• Cricoid cartilage palpable below stoma
• POD#2
– New onset A. fib w/ RVR
– Cardioverted– Started on heparin and
– Tracheostomy revision • POD#6
– Weaned from ventilator
Started on heparin and amniodarone
• POD#45– Will watching TV,
bright red blood noted • POD#9– Trach downsized – on HD
POD#15
bright red blood noted from trach
– Desaturated to 38%– Excessive blood in
• POD#15– Cleared for discharge
• POD#26Developed Vfib while on
oropharynx– Coded, ACLS initiated– Pt pronounced @7pm
Autopsy declined– Developed Vfib while on HD
– Autopsy declined
www.downstatesurgery.org
Questions??
www.downstatesurgery.org
Surgical AirwaySurgical Airwaywww.downstatesurgery.org
Indications f I t b tifor Intubation
PHYSIOLOGIC• Persistent hypoxemia with oxygen
supplementation• PACO2 >55, Ph <7.25• Vital capacity <15ml/kg with NM d/o
www.downstatesurgery.org
Indications f I t b tifor Intubation
CLINICAL• Altered mental status
R i t di t ith HD i t bilit• Respiratory distress with HD instability• Upper airway obstruction
– Angioedema– Trauma– Infection– Bleeding– Tumor– Tracheomalacia– Tracheal Stenosis
• Copious secretion requiring frequent s ctioningsuctioning
www.downstatesurgery.org
Indications f S i l Aifor Surgical Airway
• Upper Airway pp yObstruction
• Prolonged intubation• Chronic respiratory
insuff.• Neuromuscular Neuromuscular
disorders
www.downstatesurgery.org
Surgical AirwaySurgical Airway• Historically • TypesHistorically
– Acute or impending airway
Types– Cricothyrotomy– Standard
obstruction• Now…
Ai t l i
tracheostomy– Percutaneous
dilatation – Airway control in conjunction with prolonged usage
dilatation tracheostomy
p g gof mechanical ventilation
www.downstatesurgery.org
AnatomyAnatomy
CMAJ • April 22, 2008 • 178(9)
www.downstatesurgery.org
CricothyrotomyCricothyrotomywww.downstatesurgery.org
Standard TracheostomyStandard Tracheostomywww.downstatesurgery.org
Standard TracheostomyStandard Tracheostomywww.downstatesurgery.org
Standard TracheostomyStandard Tracheostomywww.downstatesurgery.org
Standard TracheostomyStandard Tracheostomywww.downstatesurgery.org
Standard TracheostomyStandard Tracheostomywww.downstatesurgery.org
ComplicationsComplicationsEarly Latey
• False passage• Decannulation
• Granulation• Tracheomalacia
• Pneumomediastinum• Pneumothorax• Bleeding
• Stenosis• Tracheoinnominate
fistula• Bleeding • Infection• Mucous Plug
fistula• Tracheoesophageal
fistulaMucous Plug• Negative Pressure
Pulm Edema
www.downstatesurgery.org
Could we have done somethingCould we have done something different in this case??
www.downstatesurgery.org
• Retrospective study atRetrospective study at Cook County
• Between August 2001 gto October 2003
• 197 subjects in study j ywith 244 day follow up– 107 standard trach
– 90 using awake technique
www.downstatesurgery.org
• Awake Technique:Awake Technique:– Semirecumbent position
– No general anesthetic
– Subcutaneous lidocaine
– Wide incision and use of i id h kcricoid hook
– Direct laryngoscopy if neededneeded
– Availability of GA and OR
www.downstatesurgery.org
This group had a more significant set of complicationsThis group had a more significant set of complications
www.downstatesurgery.org
C l i• Conclusion:Awake tracheostomy should be considered in any
patient with impending or ongoing airway
obstruction or potentially difficult intubation
www.downstatesurgery.org
When is the best time to offer a tracheostomy?tracheostomy?
www.downstatesurgery.org
ReferencesReferences
• ACS Surgeryg y• Sabiston• Altman et al.: Urgent Surgical Airway Intervention. Laryngoscope 2005; 115:2101‐2104
• Freeman et al.: Relationship between tracheostomy timing and duration of mechanicaltracheostomy timing and duration of mechanical ventilation in critically ill patient. Crit Care Med 2005;33:2513‐2520
• Bourjeily et al.: Review of Tracheostomy Usage: Types and Indications Clin Pulm Med 2002;9(5):267‐2722002;9(5):267 272
www.downstatesurgery.org