77 Intubation & Tracheotomy

Question 1

What are common airway grading systems to consider prior to intubation?

Answer 1

What are common airway grading systems to consider prior to intubation?

Friedman Palate Position (Figure 77-1):
I—Visualization of entire uvula and tonsils/tonsillar pillars
II—Visualization of the uvula, but not tonsils
III—Visualization of the soft palate, but no uvula
IV—Visualization of hard palate only

Similarly, the Mallampati Score (more commonly used in anesthesiology):
Class I—Soft palate, uvula, fauces, pillars visible
Class II—Soft palate, uvula, fauces visible
Class III—Soft palate, base of uvula visible
Class IV—No soft palate visible

The higher the score, the more difficult exposure of the larynx may be during intubation.

Question 2

What does the size of the endotracheal tube refer to?

Answer 2

What does the size of the endotracheal tube refer to?

The number refers to the inner diameter of the endotracheal tube. Thus, a 5.0 ET tube will have an inner diameter of 5 mm, a 5.5 ET tube will have an inner diameter of 5.5 mm, and so on. The outer diameter of the ET tube can vary by material, manufacturer, and type of tube.

Question 3

How can you quickly estimate the properly sized endotracheal (ET) tube for children?

Answer 3

How can you quickly estimate the properly sized endotracheal (ET) tube for children?

• Cuffed tube = age/4 + 3
• Uncuffed tube = age/4+4

This is generally accurate for children ages 1 through 12.

Question 4

How are ET tube sizes chosen for other patients?

Answer 4

How are ET tube sizes chosen for other patients?

See Table 77-1.

As a general rule, if between two ET tube sizes it is safer to put in a slightly smaller ET tube rather than one that is too large and difficult to pass. If ventilation is difficult with a small tube, some ventilation can be administered to stabilize the patient, and a tube exchanger can be used to change the ET tube, with very low risk of losing the airway.

Question 5

What is the common airway classification measured during intubation?

Answer 5

What is the common airway classification measured during intubation?

Cormack-Lehane Classification grades the view of the larynx during direct laryngoscopy:

• Grade I—Visualization of entire glottis
• Grade II—Partial view of glottis
• Grade III—Visualization of the epiglottis only
• Grade IV—Not even epiglottis is visible

Question 6

What are the typical sounds of obstruction at different levels of the airway?

Answer 6

What are the typical sounds of obstruction at different levels of the airway?

• Trachea—Usually expiratory, occasionally inspiratory
• Subglottis—biphasic stridor, barking cough, hoarse voice
• Glottis—biphasic or inspiratory stridor, hoarse voice
• Supraglottic—inspiratory stridor, muffled voice, inability to feed, no cough
• Oropharynx/nasopharynx—stertor, muffled or hyponasal voice

Question 7

What are some conservative interventions for upper airway obstruction?

Answer 7

What are some conservative interventions for upper airway obstruction?

Chin lift with jaw thrust, oropharyngeal airway, and nasopharyngeal airway are anatomic manipulations that can help alleviate upper airway obstruction. The first two are generally used for unconscious patients. The latter is best used for patients with oral obstruction (i.e., trauma, Ludwig’s angina), or in neonates with nasal obstruction who are obligate nasal breathers. Heliox can be used to deliver oxygen in cases of airway obstruction. Heliox is a mixture of helium and oxygen and is a lower density gas compared to room air or pure oxygen. This allows a higher flow rate, which reduces turbulent flow past an obstruction delivering more oxygen distally to the lungs. This reduced turbulent flow also decreases the pressure gradient needed to move air across an obstruction, thus reducing airway resistance and work of breathing. Typical concentrations are 21%:79% oxygen to helium. Helium is inert, insoluble in human tissues, and noncombustible. Heliox is used as a temporizing measure while planning to perform a more definitive airway stabilization.

Question 8

What other noninvasive interventions can improve upper airway obstruction?

Answer 8

What other noninvasive interventions can improve upper airway obstruction?

• Racemic epinephrine—administered via nebulizer to cause vasoconstriction and reduce mucosal edema. Racemic epinephrine has been shown to help treat croup and postextubation stridor from laryngeal edema. Racemic epinephrine is not as effective for epiglottitis and the practice of trying to administer it can be dangerous because agitation for these patients can cause acute obstruction by the swollen epiglottis.
• IV steroids—glucocorticoids, such as dexamethasone, are used to reduce airway inflammation and edema. This is thought to occur through reduced capillary dilation and decreased plasma extravasation and inflammatory mediator release. They are also indicated for croup and laryngeal edema, and are often used for other causes of upper airway obstruction (i.e., abscess or other infectious edema including epiglottitis, angioedema). IV steroids act gradually, unlike racemic epinephrine, which acts fairly rapidly.

Question 9

What are the indications for fiber-optic intubation (FOI)?

Answer 9

What are the indications for fiber-optic intubation (FOI)?

• History of difficult intubation requiring FOI
• Micrognathia or other craniofacial anomalies
• Cervical spine issues (fused disks, unstable C-spine)
• Facial trauma
• Upper airway obstruction (glottis level or above)
• Necessity for awake intubation (cannot mask ventilate)
• Trismus

Question 10

What are the most common indications for tracheostomy?

Answer 10

What are the most common indications for tracheostomy?

• Emergent upper airway obstruction or inability to intubate
• Prolonged intubation/ventilatory support
• Glottic/supraglottic obstruction (including tumor, infection, trauma, surgical changes)
• Pulmonary toilet
• Chronic aspiration (relative indication)
• Severe sleep apnea not controlled by CPAP or less-invasive surgery

Question 11

What is the difference between tracheostomy and tracheotomy?

Answer 11

What is the difference between tracheostomy and tracheotomy?

A tracheotomy is any procedure that cuts an opening into the trachea. Tracheostomy is technically a term for a more permanent tract that is formed from trachea to skin. In reality, a tracheotomy is typically performed, which naturally becomes a tracheostomy as the tract from skin to airway matures. However, a tracheostomy can be performed at the time of a tracheotomy by suturing skin to the trachea, thus allowing a more stable airway in case of accidental decannulation. These terms are often used interchangeably.

Question 12

What are the surgical landmarks for tracheotomy?

Answer 12

What are the surgical landmarks for tracheotomy?

Using a surgical marking pen, the thyroid notch, the cricoid cartilage, and sternal notch should be marked.

Question 13

On what area on the trachea should the tracheotomy be made?

Answer 13

On what area on the trachea should the tracheotomy be made?

Between the second and third tracheal rings. Above this, the tube may erode or fracture the cricoid cartilage, which can lead to subglottic stenosis. Below this, there is risk to mediastinal structures such as the innominate artery.

Question 14

What are the basic steps of a tracheotomy?

Answer 14

What are the basic steps of a tracheotomy?

1. The procedure starts with positioning the patient supine with the neck extended. A shoulder roll is very effective in maximizing this extension.
2. Next, the proper landmarks are marked, and the neck is injected with a mixture of lidocaine and epinephrine.
3. The tracheostomy tube cuff is tested with inflation of the balloon, completely deflated, and then lubricated for ease of insertion. During insertion, the balloon can tear and the lubricant minimizes the trauma to the balloon.
4. An incision is made in the skin in either a vertical or horizontal direction depending on surgeon preference and age of patient. This incision is centered over the second to third tracheal rings, which can be approximated by incising two fingerbreadths above the sternal notch. Incision is carried through skin, subcutaneous fat, and platysma. Anterior jugular veins may be encountered during this portion of the dissection.
5. Strap muscles are encountered next, and are divided vertically along the midline raphe to reveal pretracheal fascia and the thyroid isthmus inferiorly. By staying in the midline with your dissection, you will minimize bleeding and inadvertent injury to other structures.
6. The thyroid isthmus is either retracted inferiorly or superiorly depending on its mobility. If it lacks mobility then the isthmus is transected to expose the trachea.
7. At this point, the anesthesia team should be notified. The anterior surface of the trachea is cleared of its fascial and soft tissue attachments, and any bleeding is attended to in order to ensure a clear vision of the trachea prior to incision.
8. Incision into trachea is made between second and third rings. This is done with cold steel to avoid risk of airway fire with electrocautery. Most commonly, either a square section of tracheal cartilage is removed (“tracheal window”) or a Björk flap (described later in this chapter) is created.
9. The ETT is slowly removed by anesthesia under direct visualization by surgery team. Once it has moved past the opening in the trachea, the tracheostomy tube is inserted using the obturator. The ETT remains in place until the tracheostomy tube location is confirmed and the tube is fixed in place.

Question 15

What are the proper steps and precautions after the tracheostomy tube has been placed into the airway?

Answer 15

What are the proper steps and precautions after the tracheostomy tube has been placed into the airway?

One hand should be kept on the tube AT ALL TIMES. The obturator should be removed and the inner cannula is inserted into the tracheostomy tube. The cuff should be inflated. Next, the anesthesia circuit is immediately connected and ventilation should be administered. Several items should immediately be assessed: (1) CO2 return, (2) chest rise, (3) the connection to the tracheostomy tube is checked for condensation, (4) integrity of the balloon is confirmed, and (5) passage of a flexible suction catheter through the tracheostomy tube confirms patency. The anesthesiologist may listen for equal breath sounds. The tube is then sutured into place, and a trach collar is applied.

Question 16

What is a cricothyroidotomy?

Answer 16

What is a cricothyroidotomy?

In contrast to the tracheotomy procedure described above, a cricothyroidotomy is an emergency procedure to establish an airway during a life-threatening situation. Many believe that this procedure is easier and quicker than a tracheotomy for the vast majority of medical personnel. There are several kits and techniques that can be used for a percutaneous or open cricothyroidotomy, but it typically begins with proper positioning and palpation of the cricothyroid membrane between the inferior border of the thyroid cartilage and superior border of the cricoid. The membrane is approximately 1 cm in height, depending on neck positioning. Next, a vertical incision is made through the overlying skin. The cricothyroid membrane is then palpated again, visualized, and a horizontal incision is made into the airway. Following the visualization of air bubbling from the wound, the wound is retracted open (using a tracheal hook, Trousseau dilator, or curved hemostat, etc.), and the tube can be placed with direct visualization of the airway. Some kits involve placing a needle percutaneously, followed by guide wire passage and dilation through a Seldinger technique.

Question 17

Tracheotomy versus cricothyroidotomy?

Answer 17

Tracheotomy versus cricothyroidotomy?

For a planned procedure, a tracheotomy is preferred because it is a long-term and stable airway. A cricothyroidotomy should be converted to a tracheotomy as soon as possible to prevent erosion of the cricoid cartilage or tracheal stenosis.

In emergent procedures, there is some debate. Some ENT surgeons feel they are used to tracheotomies, so they should do this in an emergent situation as well. Others feel that a cricothyrotomy is quicker, with less blood loss, and generally a more reliable landmark in patients with anatomic differences (i.e., short and/or obese necks).

Infants and young children do not have a cricothyroid membrane, thus a tracheotomy is required in these populations.

Question 18

What are the most important intraoperative complications of tracheotomy?

Answer 18

What are the most important intraoperative complications of tracheotomy?

Complications can be avoided with appropriate communication with your anesthesiologist and operating room staff. For example, an airway fire is one of the more devastating complications. This can result from the use of electrocautery during tracheotomy if the FiO2 concentration is too high. It is imperative to inform your anesthesiologist to turn down the FiO2 several minutes before there is any chance of inadvertently cutting into the trachea with electrocautery. Prior to this point, a high FiO2 may be needed to properly preoxygenate the patient for extubation and placement of the tracheostomy tube. The ETT should be slowly removed under direct visualization by the surgeon through the tracheotomy incision. If possible, the anesthesiologist may also watch over the surgical drape barrier. There should be constant communication between surgeon and anesthesiologist during this period.
Additional perioperative complications include subcutaneous emphysema, pneumothorax, and/or pneumomediastinum. Subcutaneous emphysema is thought to occur when air is forced through the incision into tissue planes of the neck. The mechanisms of pneumothorax or pneumomediastinum are less well understood. Pneumomediastinum is thought to occur when subcutaneous emphysema is forced further into the chest, through negative intrathoracic pressure or a cough that forces air into deep tissue planes of the neck and mediastinum. One theory for formation of a pneumothorax is through direct injury to the pleural apices when operating low in the neck. Another is progressive pneumomediastinum causing pleural injury followed by air tracking into the thoracic cavity.

Question 19

What is the first intervention for subcutaneous emphysema in a postoperative tracheotomy patient?

Answer 19

What is the first intervention for subcutaneous emphysema in a postoperative tracheotomy patient?

Cutting sutures and inflating the cuff (if it is not already) is the first step. This is followed by a stat chest x-ray and further investigation into the cause.

Question 20

What are other life-threatening postoperative complications of tracheotomy?

Answer 20

What are other life-threatening postoperative complications of tracheotomy?

• Bleeding and/or tracheo-innominate fistula
• Mucus plugging
• Accidental decannulation
• False passage during placement of tracheotomy tube

Question 21

What is a tracheo-innominate (TI) fistula?

Answer 21

What is a tracheo-innominate (TI) fistula?

A TI fistula occurs from erosion of the tracheotomy tube through the tracheal wall into the innominate (brachiocephalic) artery. This is an emergency requiring immediate intervention. The fistula typically comes from pressure necrosis from the inflated cuff or distal tip of the tracheostomy tube. Contributing factors include an overinflated cuff, poor wound healing, and a poorly fitting tube. Fistula formation usually occurs at about 2 weeks post-op, but has been described as early as 2 days. Mortality rate is approximately 73%. Classically, a “sentinel bleed” is described hours or even days prior, wherein there is a brief and intense period of bleeding that spontaneously resolves. This is important to identify, and a CTA may be used to evaluate a stable patient.

Question 22

How do you handle an urgent bleed in a patient with a tracheotomy?

Answer 22

How do you handle an urgent bleed in a patient with a tracheotomy?

If there is a large amount of bleeding from in or around the stoma, the first step is to inflate or overinflate the cuff. If the tube is cuffless, or the patient is coughing up blood through the tube despite overinflation, it should be replaced with a cuffed 6.0 ET tube. The cuff should be placed distal to the site of bleeding and inflated. Finally, if TI fistula is suspected, an index finger should be placed through the tracheotomy in an attempt to apply pressure anteriorly against the innominate artery such that it is compressed against the sternum. The patient should then be taken emergently to the OR.

Question 23

What is a Björk flap?

Answer 23

What is a Björk flap?

A Björk flap is created by utilizing the section of tracheal cartilage that is normally removed during tracheotomy. Superior and lateral cuts are made into the cartilage, but the inferior portion of the cartilage is left intact, leaving an inferiorly based cartilage flap. This flap is then sutured to muscle/fascial layers and skin of the stoma, such that it serves as the “floor” of the stomal tract. This assists in maintaining a patent stoma in the case of accidental decannulation. The Björk flap creates a tracheostomy that is less likely to spontaneously close upon decannulation (a tracheocutaneous fistula), therefore it is generally used in patients who will have the tracheostomy long term (Figure 77-2).

Question 24

What is the basic postoperative care for a tracheotomy?

Answer 24

What is the basic postoperative care for a tracheotomy?

Some practitioners prefer to obtain a postoperative chest x-ray to ensure there is no pneumothorax. However, recent literature has demonstrated that this is generally low-yield in patients without signs or symptoms of a complication such as pneumothorax. Patients are typically admitted to the surgical ICU for airway monitoring.

A standard protocol for tracheotomy care is necessary to avoid a number of the frequent postoperative issues. The suctioning should be very frequent early on and it can even be necessary every 15 minutes for the first few hours. As the secretions change and lessen, it will be needed less frequently. The nurse and respiratory staff should instill saline lavage with suctioning to avoid any mucus plugging, and humidified air is administered to avoid crusting and plugging issues as the innate humidification system of the upper airway has been bypassed due to the tracheotomy.

Question 25

When is a cuffed tracheotomy tube indicated? Do they help prevent aspiration?

Answer 25

When is a cuffed tracheotomy tube indicated? Do they help prevent aspiration? Controversy

A cuffed tube is used when positive airway pressure is needed for ventilation. This includes complete ventilatory support, as well as BiPAP/CPAP. Cuffed tubes can also help slow aspiration in patients not controlling their secretions. Otherwise, cuffs should always be left deflated. This will allow phonation and reduce the risk of pressure-induced injury to the tracheal mucosa.

Tracheotomy is generally not indicated for aspiration. Cuffed tracheotomy tubes may be helpful in dealing with pulmonary toilet/suctioning of the aspirating patient, or decreasing secretions from entering the lungs in patients with sensory or muscle problems of the upper airway. However, cuffed tubes do not prevent chronic aspiration. In fact, tracheotomies can increase the risk of aspiration, by preventing proper hyolaryngeal elevation during swallowing.

Question 26

What are advantages of an open versus percutaneous tracheotomy?

Answer 26

What are advantages of an open versus percutaneous tracheotomy? Controversy

Open tracheotomy is a surgical procedure that takes place in the OR. It involves an open wound, with the advantage of better visualization of the trachea prior to entering into the airway. It also allows for the identification and control of structures such as small and large blood vessels or the thyroid gland, which theoretically may allow for fewer minor and major complications during the procedure, as well as less postoperative bleeding. However, there have been several large-scale studies looking at the safety of bedside percutaneous tracheotomy in an ICU setting, usually through a dilatational/Seldinger method. The vast majority of these studies have suggested that they are as safe as OR procedures and with similar long-term complications, even in obese patients. Proponents argue that these procedures are faster and far more cost efficient than open tracheotomies. Critics, however, argue that there is a lack of prospective data, and that potentially complicated airways require open procedures. Some critics feel that a potentially catastrophic complication such as transecting a high-riding innominate artery during a percutaneous tracheotomy is enough risk to avoid such procedures. Additionally, in forcing somewhat blunt objects through the skin and trachea, tracheal rings can be crushed, causing long-term tracheal stenosis and/or tracheomalacia.