Surgical Airway

8/9/2019 Surgical Airway

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The Surgical Airway

Joseph B. Carter MD, MS, FACS

Department of Otolaryngology - Head and NeckSurgery


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Goals and Objectives

I will discuss:

Brief history

General principles

Complications, acute and delayed

Indications

Routine management

Basic technique

Hopefully you will gain: Understanding of basic principles, procedures, risks, and

possible complications

Appreciation of indications and limitations of various

techniques


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Tracheotomy in Popular Culture

M*A*S*H (TV) - Father Mulcahy performs atracheotomy on a patient whose swollen tongueprevents him from breathing

House M.D. Several episodes (including the pilot)include tracheotomies - often in great detail

Scrubs episode (My Drive-By), Dr. Turk used aknife from a nearby taco stand to perform a trach on a

man choking on a burrito Jerico (pilot episode), JakeGreen performs

emergency trach on a young girl who sustained aneck injury


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Tracheotomy or Tracheostomy?

Used interchangeably (incorrectly?) todesignate an opening in the anterior neck into

the trachea Tracheotomy: The incision made into the

trachea

Tracheostomy: Surgical creation of a stomathrough which air may pass to the lungs,bypassing the upper airway (implies suturingskin edges to trachea)


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History of Tracheostomy

Long, and until recently maligned

Earliest buried in legend

Pictured on Egyptian tablets circa 3600 B.C.

Sacred Hindu book Rig Veda, written between 2000 and1000 B.C. The bountiful one who can cause thewindpipe to reunite when the cervical cartilages are cutacross.

Asclepiades (b 124 BC) generally considered first to

carry out the procedure Galen and Aretaeus, 2nd and 3rd centuries A.D. - first

detailed reports

Originally used for emergency management of upperairway obstruction (limited success)


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Arteria aspera or rough artery - Cartilagedoes not heal - Hippocrates

Known as the Scandal of surgery and Asemi-slaughter throughout the middle ages

No surgeons account until Brasavola (1500 -1570) described his successful surgicalmanagement of Ludwigs Angina in 1546.

Surgical attempts feared - only 28 successfultracheotomies were reported from 1546 - 1833.


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* C. Jackson, Laryngoscope 1909


1718 Lorenz Heister coined the term tracheotomy

Did not become respectable until Bretonneau and

Trousseau popularized for diptheria in the early 19thcentury, 25% success rate was excellent at that time

Chevalier Jackson, modern incarnation in early 20th

century, standardized technique, reduced operative

mortality from 25% to 2%, proscription against

incising cricoid, 1st ring, or below 5th ring*


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C. Jackson, Laryngoscope, 1909, 1921


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C. Jackson, Laryngoscope, 1909, 1921

The profession hesitates longer to advise tracheotomy than itdid 50 years ago.

The percentage of mortality is almost as high as of stab

wounds inflicted with homicidal intent.

In the hands of the most skillful and experienced the incisionis usually badly placed; in the hands of the unskilled orexcitable, serious accidents have occurred, such as the openingof the esophagus or a large vessel.

Between the skin and the trachea, in the middle line, there isno large vessel, and no important structure. There should be nomore mortality from the operationper se than from opening ofsuperficial abscesses by an incision of equal length.


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Wilson 1932 - management of airway, toilette,

respiratory paralysis (Polio)

Galloway 1950s, further expanded indications- head injury, severe chest injury, barbiturate

intoxication, post-surgical airway control

1960s-70s, neonatal support, development ofsynthetics, improved tubes, low pressure/high

volume cuffs greatly reduced morbidity


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* Stauffer JL, Am J Med 1981

Not a Slam Dunk

Modern mortality rate 2-5%

Complication rate 14-66%*

Study design

Definition of complication

Patient follow-up

Increased risk of complications in:

Emergency situations ICU patients

Children and infants


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Pediatric Tracheostomy

Consistently associated with a greater

mortality and complication rate

Inverse relationship of age/size to mortality Pre-term and very low birth weight infants

have a mortality ~ 11% related to tracheotomy

Not so much from procedure as care issues: Decanulation

Tube plugging

Poor pulmonary toilette


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Complications of Tracheostomy

Generally convenient though not entirely

accurate to categorize by interval from

procedure to onset

Continuum - overlap

Early

Operative Immediate post-op

Late


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Intra-operative

Hemorrhage

~ 5% rate of intra-op (or immediate post-op) hemorrhage

Major rare but even minor can interfere with identification and

access

Most commonly an error in surgical technique (one of Jacksons

major contributions - meticulous midline dissection)

Frequent sites: Anterior jugular veins

Thyroid isthmus

High innominate artery

Thyroid ima artery


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Intra-operative

Inability to identify trachea

Recurrent nerve injury

Tube misplacement

Into bronchus

Outside tracheal lumen


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* Rabuzzi DD, Laryngoscope 1971


Intra-operative

Pneumothorax / pneumomediastinum

Adults 2-5%

Peds up to 17% (70% in children < 2 years old*) Exact cause not always apparent

Generally accepted mechanism - forceful inspiration leads to high

negative intra-thoracic pressure - pathway through wound edges

into mediastinum - air trapping / rupture through pleura

Direct injury to apical pleura (esp in children due to highposition)

Rupture of lung bleb

Surgical technique / errors


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* Barlow DW, Otol Rhinol Laryngol 1994


Intra-operative

Pneumothorax / pneumomediastinum

Prevention - meticulous operative technique

Maintain midline dissection Minimize amount of dissection

Airway control - ET tube or rigid bronchoscope (less negativepressure and better identification of trachea)

Avoid tight closure / packing

Evaluation - the role of the post-op CXR Historically routine in all

Children, difficult , or emergent, displaced tube, signs orsymptoms of intra-thoracic complication*


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Intra-operative

Fires

One of the most common causes of operative fires High O2 concentrations

Electrocautery

Post obstructive pulmonary edema


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Tube obstruction / decannulation

Common

Impingement on posterior tracheal wall

Displacement (partial or total) into mediastinum

Blood clot

Mucous plug

Most serious post-op complication in children -

decannulation in first 24 hours - 25% mortality


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False Passage


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Infection

Clean contaminated wound

Incidence of infection highly dependent upon

criteria Reported rates of stomal infections 3-36%

True cellulitis / purulence 3-8%

Stomal infections usually indolent, mildcellulitis/granulation - respond to local care

Serious infections, mediastinitis, fasciitis, abscess,clavicular osteomyelitis rare


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* Sasaki CT, Laryngoscope 1979


Infection

Bacterial colonization, 75% pseudomonas within10 days

Stomal cultures meaningless Antibiotic prophylaxis highly controversial

Most feel not efficacious and only selects for resistantorganisms

Infectious contribution to sub-glottic stenosis*

Local wound care

Ascetic acid (0.25% to 0.5%)


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* Weymuller EA, Ann Otol Rhinol Laryngol 1983

Late Complications

Tracheal damage

Direct pressure necrosis from cuff or tip of tube

Capillary flow occluded at 30 - 50 mm Hg*

Tube / cuff can exert > 400 mm Hg*

Modern tubes 25 mm Hg

Mucosal ulceration -> cartilage exposure ->bacterial colonization/invasion -> necrosis ->

fibrosis with contraction / stricture / malacia

Alternatively, progressive tracheal dilationIncreasing the tube size is not the answer!


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Late Complications

Tracheal damage

Typical stenosis at cuff or tip site, 1 to 3.5 cm

below stoma 0.5 to 4.0 cm in length

Granulation at site of tube fenestration

Stenosis at stoma - excessive traction on trach tube

by connecting tubing or patient motion (much less

frequent now due to light, flexible connectors, etc.,

but vigilance still needed)


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* Bryant LR, Am J Surg 1978

Late Complications

Tracheal damage

Stomal stenosis - role of tracheal incision

In children - vertical incision in trachea - do not

remove cartilage In adults

Vertical tracheal incisions or incisions incorporatingfirst ring or cricoid increase risk

Excessive cartilage removal Transverse, H incisions, Bjork flaps better

Incisions that disturb anatomy least are best.*


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* Jones JW, Ann Surg 1977

Late Complications

Massive hemorrhage from vessel erosion

Dramatic

Usually erosion into innominate artery, right carotid

reported Tracheal necrosis from erosion/infection, usually at distalend of tube

Associated with low placement of tube (not below 5thring) and/or high innominate artery

0.4% to 4.5% 50% sentinel bleed ( > 10ml p 24 hours)

Peak incidence 1-2 weeks p surgery, 72% in first 3 weeks*


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* Jones JW, Ann Surg 1977

Late Complications

Massive hemorrhage - Management

Suspicion mandates tube removal, flexible scope exam

Angiography not helpful and may dangerously delaydefinitive treatment

Protect airway / Control bleeding - Prompt tamponade

Finger pressure - successful in 89%*

Tube balloon - 85%*

Fluid resuscitation

Surgical intervention Resection of artery and muscle flap best

Attempt at repairing/grafting artery > 85% mortality

Of 175 documented cases in 1991 - only 24% long term survivors


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Late Complications

Tracheo-esophageal fistula

Rare, 0.1% - Ive never seen one other than

tumor

Not as dramatic as tracheo-innominate fistula but

same potential morbidity/mortality

Incidental damage at time of surgery - rare

Pressure necrosis of party wall by trach tube andstiff NG tube

Poor perfusion


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Late Complications


Increased tracheal secretions, coughing, esp. with

feedings N.B. all patients with trachs aspirate!

Gastric distention, paralytic ileus from insufflation

Dx.

Contrast esophagram

Endoscopy (usually simplest flex via trach stoma)


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Late Complications


No evidence these ever close spontaneously

Virtually 100% mortality if not addressedsurgically

Direct closure with muscle flap interposition

Staged closure

Esophageal diversion


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Late(er) Complication

Ugly scars

Persistent tracheocutaneous fistula

Vertical vs. horizontal skin incisions?


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* Fisher SR, Laryngoscope 1991

Persistent Tracheocutaneous

Fistulae Difficulty with phonation, skin irritation from

secretions, susceptibility to respiratory

infections, dysphagia 3.3 - 29%

Directly related to duration of cannulation

70% if cannulation > 16 weeks*

Surgical closure, most simple, some frustrating


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Vertical vs. Horizontal Skin

Incisions Horizontally

Cosmetically better?

Vertical

Less bleeding or bleeding less likely

Tube can seek its own level

Helps keep you in the midline?


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Laryngeal Function

Inhibited by tracheostomy

Limitation of laryngeal elevation prevents supra-glottic closure

Dysphagia from tube/cuff pressure on posteriortracheal wall

Adductor reflex threshold increase

Diminished -> absent abductor activity (phasicactivity returns in 3-5 minutes with airflow -implications for periodic plugging of tube)

Increased aspiration


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Indications for Tracheostomy

Decreasing

Improved endotracheal airway management /

expertise Better training

Better equipment

Tubes

Cuffs

Flexible endoscopes


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Respiratory obstruction

Secretion / Foreign body retention

Respiratory insufficiency / support

If you think about doing a tracheotomy, do it(sooner rather than later)

vs.If you think about doing a tracheotomy,intubate and think again


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Respiratory obstruction Trauma

Facial fractures

Laryngotracheal injuries

Laryngeal / pharyngeal surgery Head and neck surgery

Foreign bodies

Irritants/corrosives

Infections (esp. supraglottic)

Congenital anomalies Angio-edema

Laryngeal dysfunction

Cysts, neoplasms

OSA


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Secretory retention

Obstruction of the trachea or lower airway

Alveolar hypoventilation

Respiratory insufficiency

Presently the most common indication for tracheostomy is

in the elderly /ventilator dependent patient with cardio-pulmonary deficiencies


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Obstructive Sleep Apnea and

Tracheostomy

Effective but radical?

Permanent stoma

Dynamic stoma, Eliashar


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Advantages of Tracheostomy

Emergency control of airway

Sparing further direct laryngeal injury from

trans-laryngeal tube Facilitating care

Oral

Tracheo-bronchial toilette Increasing patient mobility - more secure tube

Faster transfer from ICU / hospital


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Advantages of Tracheostomy

Improved comfort

Speech

Facilitating oral nourishment Psychological

Better and more flexible airway control - long

term ventilation Assisting weaning

Decreased work of breathing


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Disadvantages of Tracheostomy

A hole in my neck?

Surgical procedure

(remember all those complications?)

Lack of understanding / discomfort of care

givers Skilled care placement


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Patient Selection

Who?

When?

Where? How?


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Timing of Elective Tracheostomy

Adult

Controversy still exists concerning ideal time ofconversion from trans-laryngeal intubation to

tracheostomy Consideration of complications:

Cuff / tip - same with both

Laryngeal - trans-laryngeal only

Stomal - tracheostomy only

Surgical - tracheostomy only

Other - sinusitis, lip, commissure, etc.


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Timing of Elective Tracheostomy

Currently accepted guidelines (adult)

If anticipated need < 10 days, use trans-laryngeal

route If > 21 days, perform tracheostomy

Obviously large middle ground

Individual circumstances

Frequent evaluation

Communication (team, family, etc.)

Once decision made, expeditious performance


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Logistics of Elective Tracheostomy

OR vs. Bedside

Open vs. Percutaneous

Operating room - costly, scheduling, moving

patients, IVs, hyperal, monitors, Foleys, Chest

tubes, etc. - require multiple people, elevators,

hallways, etc.

Bedside - safety?, less support


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Operating Room vs. Bedside

Contra-indications for bedside

Pediatric

Unprotected airway

Emergent, acute obstruction (if time)

Neck mass (large goiter, tumor, high innominate)

Short, thick neck / non-palpable landmarks

Cricoid at or below sternal notch (some say lessthan 3 cm above notch)

Coagulopathy (relative)


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Open vs. Percutaneous

Contra-indications for percutaneous,

virtually the same

Pediatric

Unprotected airway

Emergent, acute obstruction

Neck mass (large goiter, tumor, high innominate)

Short, thick neck / non-palpable landmarks

Cricoid at or below sternal notch (some say less than 2 cm

above notch)

Coagulopathy (less relative)


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Cricothyroidotomy


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Cricothyroidotomy

1921, C. Jackson, No end of laryngealstenosis is the result of these high operations.

- effectively abolished this procedure 1976, Grow & Brantigan re-introduce -

reporting lower complication rates - flawed,poor f/u

Numerous f/u studies - avoid in acutelaryngeal pathology, professional or high voicedemand patients


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J. Thorac Cardiovasc Surg 71:72-81:1976


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Cricothyroidotomy

While operative simplicity is an advantage,

higher incidence of laryngeal, subglottic, and

tracheal complications and more difficultsurgical repair make this procedure

undesirable except in emergency situations

In controlled situations in cadavers only 33%

of non-surgeons were able to successfully

cannulate the trachea via cricothyroidotomy


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Cricothyroidotomy

Maybe? The emergency procedure of choice

Stabilization / definition of anatomy KEY!

Patient positioning: sniffing position Surgeon position:

Stand on dominant hand side

Scalpel in dominant hand (assume right)


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Landmarks


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Landmarks


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Landmarks


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Landmarks


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Landmarks


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Landmarks

Positioning


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Positioning

NO!


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Cricothyroidotomy

Technique:

Left little finger toward chin

Left thumb on placed on right side of thyroid-cricoid

complex Left third finger placed on the left side of the complex

Index finger, pointing caudal, palpates the cricoid

The thyro-cricoid complex is firmly held between thethumb and third fingers (left hand) - a 3-4 cm vertical

incision is made in the midline with caudal end over but notpast the cricoid - single stroke to underlying cartilage


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Cricothyroidotomy

Technique (2)

Insert forefinger (left hand) into wound and palpate thespace between the thyroid cartilage and cricoid

Keeping your forefinger in the wound - palpate the inferioredge of the thyroid cartilage

Turn the scalpel from vertical to horizontal, place it alongthe index finger into the cricothyroid space

Push it into the airway

To open the airway - twist the knife with the sharp edgeagainst the cricoid

Hold in place until suitable stent (tube) can be inserted


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Cricothyroidotomy


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Charles Vaugh MD, 2005

Cricothyroidotomy

Start to finish takes less than 5 seconds

Critical elements are fixing the airway in the

midline, locating the cricoid - both done withsurgeons non-dominant hand

Can be done blindfolded - or in the dark


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Open Tracheostomy

Basic Technique

Positioning


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Positioning

Maybe OK for this


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MIDLINE!

MIDLINE!

MIDLINE!


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T-Tubes


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T-Tube


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Summary

Usually sick or injured

In an emergency - any landing (airway) you

walk away from keep your head, know your

anatomy!

Minor surgery with potential for disaster

Meticulous technique - MIDLINE - MIDLINE

- MIDLINE!

Teamwork


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ThatcherGW, Laryngoscope 2003

Obs uc ve S eep p e d

Tracheostomy

Thatcher and Maisel 2000

Retrospective study - 79 patients followed 3 months to 20years

70 men, 9 women Age 25 - 70 years, mean 47 y/o

RDI 45 - 146, mean 81

Eliminated OSA in all

16 patients decannulated

14 deaths

2 related to trach - one postop MI, one tracheo-innominate fistula

5 cardiopulmonary, 2 postop unrelated surgery, 1aspiration



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p p

Tracheostomy

Severe obstructive sleep apnea and its comorbid

conditions are effectively treated by

tracheostomy. Significant morbidity andmortality are low. Chances of obstructive

sleep apnea resolution allowing decannulation

remain poor.

Surgical Airway

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