Laryngology surgical airway Flashcards
What are the indications for a surgical airway?
● More than three failed attempts at intubation by an
experienced laryngoscopist
● > 10 minutes since initiation of induction
● O2 saturations < 65% during the first or second intubation
attempt
● Difficulty or inability to mask ventilate
● Experienced airway staff decides that additional intuba-
tion attempts would be unsuccessful
In an emergent “can’t intubate, can’t ventilate”
situation, what is traditionally the preferred
surgical airway approach?
Cricothyrotomy (Some studies report that in practice
tracheotomy may be used more often than cricothyrotomy.)
Describe the relative contraindications to cricothyrotomy.
● Child younger than 10 to 12 years
● Inability to palpate landmarks (neck trauma)
● Expanding cervical hematoma
● Subglottic extension of known laryngeal disease
Describe the surgical steps involved in cricothyrotomy.
● Palpate landmarks (correctly identify cricothyroid space)
and stabilize the larynx in your nondominant hand,
maintaining the position of the cricothyroid membrane
with your pointer finger.
● Make a vertical incision through skin to, but not through,
the laryngeal cartilaginous framework.
● Horizontal incision through the cricothyroid membrane
● Spread open the space using a clamp, back end of the
scalpel, or other available instrument.
● Carefully place cuffed breathing tube (tracheostomy or
ETT).
When is needle cricothyrotomy or transtracheal
needle ventilation indicated?
● It is indicated only in unique emergency settings in which
intubation and surgical airway are not possible or in
pediatric patients in whom a surgical airway is considered
unsafe because of compressibility of the laryngeal
cartilage framework.
● It is used as a temporizing measure until a secure airway
is possible. In adults, this is seen more in the prehospital
setting. However, staff must be comfortable putting the
equipment together and ventilating through this ap-
proach, which can be challenging.
How long can a patient be ventilated via trans-
tracheal needle ventilation?
Reports range from 30 minutes to 2 hours.
Describe the technique of needle cricothyrotomy
and subsequent ventilation.
● Connect a 12- or 14-gauge angiocatheter to a 3-mL
syringe filled partially with saline or a commercially
available needle cricothyrotomy device such as the
Ravussin catheter.
● After identifying the cricothyroid space, the needle is
advanced at a 0- to 30-degree (caudal) angle while pulling
back on the plunger. Once air is aspirated, the catheter is
inserted over the needle at a 30- to 45-degree angle.
● The angiocatheter is then connected to 100% oxygen at
50 psi using a Luer-Lok connector or oxygen tubing
containing a y-connection attached to a jet insufflator
and oxygen source (preferred). If this is not available, the
angiocatheter can be connected to a bag-valve system
via a 3.5-mm ETT connector, a 3-mL syringe without the
plunger, and a 7.0 ETT connector, a 10-mL syringe
without the plunger, and a 7.0 ETT inserted into the
syringe with the cuff inflated or via cut IV infusion tubing
connected to a 2.5 ETT connector.
● Ventilation is most effective with a jet ventilation system:
however, the airway may be temporized with a bag-valve
system.
Describe the primary indications for tracheotomy
● Prolonged endotracheal intubation
● Upper airway obstruction
● Management of tracheobronchial secretions (pulmonary
toilet)
● Airway management associated with head and neck surgery
● Management of major head and neck trauma
What are the nonemergent indications for surgical
tracheotomy?
P Pulmonary toilet: Aspiration, inability to clear secretions
(e.g., stroke, neurologic impairment, etc.)
O Obstruction: Malignancy, obstructive sleep apnea (not
amenable to noninvasive treatment)
P Prevent complications associated with prolonged intuba-
tion (e.g., subglottic stenosis, tracheal erosion, etc.)
Tracheotomy should be performed after how many days of endotracheal intubation?
Although tracheotomy is generally performed after 14 days,
there is no specific rule regarding optimal timing and
should be individualized based on risk of continued
intubation (i.e., subglottic stenosis) versus the likelihood of extubation.
At what level should the tracheal incision be made during open tracheostomy?
Between the second and third tracheal rings (or third and
fourth if necessary)
What are the basic steps in open surgical
tracheotomy?
● A horizontal incision is placed between the sternal notch
and cricoid cartilage at approximately the level of the
second tracheal ring.
● Dissection through the subcutaneous tissue to the strap
musculature
● Division of the midline raphe between the sternohyoid
and sternothyroid muscles
● Division (electrocautery or clamp and tie) or displace-
ment of the thyroid isthmus
● Identification of the cricoid cartilage and tracheal rings
● Horizontal incision between rings 2–3 or 3–4
● Creation of a Bjork flap using scalpel or heavy scissors and
fixation of flap to subcutaneous tissue and or skin
● Withdrawal of the ETT, suctioning, if needed, and
placement of the desired tracheostomy tube
● Inflate the cuff and secure tracheostomy with sutures to
skin and tracheostomy tie.
Note: Minimal lateral dissection around the trachea will limit
disruption of the vascular supply to the trachea and
resultant stenosis as well as injury to the recurrent laryngeal
nerves.
What pressure is the maximum pressure accept-
able for any endotracheal or tracheostomy tube cuff and why?
30 cm H2O; must not exceed mucosal capillary pressure
When should a tracheostomy tube cuff be deflated?
When the patient no longer needs mechanical ventilation
and is not aspirating
What are early and late complications of tracheostomy?
● Early: Tracheostomy tube occlusion, granulation tissue
formation, false passage, tube dislodgement, hemor-
rhage, wound infection, subcutaneous emphysema (possible pneumothorax or pneumomediastinum), postoperative pulmonary edema
● Late: Hemorrhage (e.g., tracheoinnominate fistula), tra-
cheoesophageal fistula, tracheal stenosis, persistent tracheocutaneous fistula (after decannulation)
