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SAM Sx > Tracheal Surgery > Flashcards

Tracheal Surgery Flashcards

1
Q

2 functions of the annular ligaments of the trachea:

A

Shape

length accomodation

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2
Q

Is the trachealis muscle on the dorsal or ventral aspect?

A

Dorsal connection

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3
Q

What important structure lives on the lateral aspect of the wall of the trachea?

A

Recurrent Laryngeal nerve – laryngeal dysfunction if damage on the lateral side of trachea

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4
Q

What 2 muscles are split when doing the cervical ventral midline approach?

A

Sternohyoideus m.

Sternothyroideus m.

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5
Q

4 structures in the carotid sheath:

A

Carotid
Vagosympathetic trunk
Vagus n.
Internal Jugular vein

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6
Q

For the cranial cervical trachea, what surgical approach is used:

A

Cervical Ventral Midline

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7
Q

Approach the trachea from the ____ side :

A

Right

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8
Q

For the caudal cervical & cranial thoracic trachea, what surgical approach is used:

A

Median Sternotomy

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9
Q

Name the ICS for Intercostal thoracostomy:

A

Right 3rd ICS ==> Cranial thoracic trachea

Right 4th ICS ==> Tracheal bifurcation

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10
Q

What process/ surgical dz is tracheal collapse:

A

Degenerative change – progressive, irreversible degeneration of lower airway (Laxity of the trachealis muscle = weakness of tracheal rings)

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11
Q

Factors cause increased weakness/ pliability in tracheal collapse:

A

Decreased water retention secondary to loss of glycoprotein and GAG.
Decreased Calcium and chondroitin.

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12
Q

Name 3 things associated with the progressive cough seen in squamous metaplasia:

A
  1. Squamous Metaplasia
  2. Reduction of ciliated cells
  3. Increased viscosity to secretions
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13
Q

Cor pulmonale (aka Right heart failure) is associated with tracheal collapse. Name the 2 factors associated with this:

A
  1. Pulmonary Hypertension

2. RV enlargement

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14
Q

Most common secondary factor in tracheal collapse:

A

OBESITY – fat deposits in the thoracic cavity causes inability for the lungs to expand creating resp probz.

Wt loss = minimize CS

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15
Q

Name the 4 secondary factors of tracheal collapse:

A
  1. Obesity
  2. Enviromental allergens
  3. Respiratory irritants - Cig smoke, aerosol sprays, fireplaces
  4. Kennel cough

– of 100 cases of tracheal collapse, 55% had >1 coexisting disease.

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16
Q

Is tracheal collapse common in small or large breed dogs?

A

Small breed or toy breed dogs

– Yorkie, Poms, mini/toy poodles, Chihuahuas, and pugs

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17
Q

What age is most commonly effected for tracheal collapse:

A

Middle Age dogs

    • signs at an earlier age consistent with more severe dz.
    • no evidence of sex predilection for tracheal collapse.
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18
Q

“GOOSE HONKING” cough is a characteristic sign of:

A

Tracheal collapse

–progressive

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19
Q

Clinical signs of tracheal collapse are:

A
    • Goose honk cough
    • wax and waning dyspnea
    • exercise intolerance
    • cyanosis
    • syncope
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20
Q

Differentials for tracheal collapse:

A
    • Heart dz / Cardiomegaly
    • Kennel cough
    • Bronchitis
    • Pneumonia
    • other lower airway dz (neoplasia/ infectious/inflammatory/ FB)
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21
Q

Important diagnostic for tracheal collapse:

A

IMAGING – shows severity & location

others diagnostics are based on: Signalment / history/ CS / PE

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22
Q

T/F: Radiographs have variable sensitivity & low specificity for tracheal collapse but can be useful to determine if collapse if cervical or thoracic.

A

True

– must image entire trachea

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23
Q

If it is a cervical collapse, the collapse happens during inspiration or expiration?

A

Inspiration

    • Cervical = Inspiration [CI]
    • Thoracic = Expiration [TE]
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24
Q

if it is a thoracic collapse, the collapse happens during inspiration or expiration?

A

Expiration

    • Cervical = Inspiration [CI]
    • Thoracic = Expiration [TE]
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25
Q

What is the term that refers to ‘Real time radiographic imaging’ that allows visualization of the entire respiratory cycle:

A

Fluoroscopy

Disadvantage: This method has had false positives reported & hard to interpret.
Advantage: No sedation or anesthesia is typically required (may require Anxiolytic for dyspnea)

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26
Q

Gold Standard diagnostic for tracheal collapse:

A

TRACHEOSCOPY

    • allows direct visualization of collapse (Grading of severity)
    • allows visualization of tracheal mucosa & dorsal tracheal membrane
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27
Q

Tracheoscopy allows visualization of:

A
    • collapse
    • tracheal mucosa
    • dorsal tracheal membrane
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28
Q

Advantage of Tracheoscopy:

A

Can obtain samples for cytology & bacterial culture/ sensitivity.

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29
Q

Disadvantage of Tracheoscopy:

A

Requires anesthesia which may incite DYSPNEIC EPISODE

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30
Q

If the lumen reduction is 25%, what grade is the tracheal collapse:

A

Grade 1

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31
Q

If the lumen reduction is 75%, what grade is the tracheal collapse:

A

Grade 3

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32
Q

If the lumen reduction is 50%, what grade is the tracheal collapse:

33
Q

if there is almost NO lumen, what grade is the tracheal collapse:

A

Grade 4 (IV)

34
Q

When is surgery indicated in tracheal collapse:

A

ONLY WHEN MEDICAL MANAGEMENT FAILS IS SURGICAL TREATMENT CONSIDERED!!!!

– wt loss drugs (medical management)

35
Q

What is the only time you would use external prosthetic tracheal rings for tracheal collapse:

A

CERVICAL TRACHEA collapse only!

36
Q

What surgical approach is used when placing external prosthetic tracheal rings for tracheal collapse:

A

VENTRAL midline cervical approach

– Pope said this twice.

37
Q

What do you secure the external tracheal rings to:

A

secure to cartilaginous rings of normal trachea

– must start & end ring placement in area of normal trachea

38
Q

T/F: External Prosthetic tracheal rings have a good outcome with IMMEDIATE improvement in clinical signs

39
Q

What type of syringe is cut & used as a external prosthetic tracheal ring:

A

Polypropylene syringe cut into barrels with tiny holes in them to secure to cartilaginous rings of the normal trachea.

—Non-absorbable Monofilament Polypropylene suture as well as the polypropylene syringe ( less inflammation than nylon).

40
Q

3 complications of using External Prosthetic tracheal rings:

A
  1. Laryngeal paralysis
  2. Tracheal Necrosis
  3. Pneumothorax
41
Q

What complication of an External Prosthetic Tracheal ring can become life threatening:

A

Tracheal necrosis

    • secondary to damage to trachea’s segmental blood supply (disruption of blood supply)
  • – life threatening (Cough, SQ emphysema)
42
Q

Pneumothorax is a complication of External prosthetic tracheal rings. How does the pneumothorax occur:

A

The holes placed could create pneumothorax or pneumediastinum.

    • diffusion of air through mediastinum during sx
    • accidental penetration of thoracic cavity near caudal cervical trachea
43
Q

Which complication of external prosthetic tracheal rings have been reported in 11-30% of surgical cases:

A

Laryngeal Paralysis

– damage during sx to the laryngeal nerve vs. continued trauma from implants

44
Q

What structure provides circumferential support, for tracheal collapse, WITHOUT affecting surrounding vessels or nerve:

A

Intraluminal Stent

45
Q

How is a intraluminal stent placed:

A

Fluroscopically or endoscopically

    • self expanding nitinol stent
  • -constrained on a delivery system
    • sizing (diameter & length) based on imaging, Esophageal measurement probe
46
Q

Complication of intraluminal stents:

A

Once the stent opens you cannot get it back. make sure you check the position

47
Q

What can be combined with external rings when the tracheal collapse extends up to the crycocartilage:

A

intraluminal stent can be combined with external rings

48
Q

Name the Intraluminal stent advantages:

A

Intraluminal Advantages:

    • minimally invasive
    • shortened anesthesia time
    • **Can be used in the cervical AND thoracic trachea
    • immediate improvement in clinical signs
49
Q

Name the intraluminal stent disadvantages:

A

Intraluminal Disadvantages:

    • requires fluoroscopy or endoscopy
    • $$$
    • shorter life span than tracheal rings
    • moderate to high complication rate
50
Q

What can be used to fix tracheal collapse in the cervical AND thoracic trachea:

A

Intraluminal stent

51
Q

Name 6 complications of stenting:

A
  1. Stent fracture
  2. Stent migration
  3. Tracheitis
  4. Collapse beyond stented region
  5. Tracheal obstruction secondary to granulation tissue formation
  6. Tracheal rupture
52
Q

T/F: If stent fracture occurs, it can be life threatening if pieces migrate

A

True

Other complications:

    • Stent migration: secondary to incorrect sizing
    • Tracheitis: documented in 60% of patients
    • collapse beyond stented region: Mainstem bronchi collapse
    • tracheal obstruction secondary to granulation tissue formation: can respond to tx with corticosteroids and colchine.
    • tracheal rupture
53
Q

What drugs are used to treat tracheal obstruction secondary to granulation tissue formation after a stent has been placed:

A

Corticosteroids & Colchicine

– Colchicine: prevents intercross linking so it doesn’t mature so it can stay flexible

54
Q

60% of patients with complications from a intraluminal stent have:

A

Tracheitis

55
Q

What is the treatment for collapse of the mainstem bronchi or lower:

A

NO current treatment for collapse of mainstem bronchi or lower

56
Q

T/F: Surgery is always desired for tracheal collapse.

A

FALSE–

  • -surgery should be avoided if possible = Salvage procedures
    • progression of disease can happen in the face of surgery
57
Q

Causes of internal tracheal trauma:

A
  1. Rupture or necrosis secondary to ET tube (common in cats & dental procedures)
  2. FB
58
Q

Causes of external tracheal trauma:

A

Blunt or penetrating injuries:

  1. Bite wounds
  2. Lacerations (Puncture/ Avulsions/ Transection vs. loss of tissue )

Tx conservatively = Puncture
Tx surgically = avulsions & transection

59
Q

Main clinical signs associated with tracheal trauma:

A

SQ emphysema – “Snap, crackle, and pop”

other signs of tracheal trauma:

    • anorexia
    • lethargy
    • stridor coughing
    • Dyspnea

Progression of pathology in severe cases of tracheal trauma

    • mediastinal Emphysema
    • pneumothorax
60
Q

What 2 clinical signs are associated with severe tracheal trauma:

A
  1. Mediastinal emphysema
  2. Pneumothorax

Mediastinum is not very thick so if it ruptures it can lead to pneumothorax.

61
Q

Why would we put in a temporary tracheostomy:

A

Temporary Tracheostomy:
– reduces SQ emphysema by bypassing the upper airway( where most resistance is occurring) so they do not have to work so hard to breathe.

62
Q

T/F: Minor rupture of the trachea can be treated with medical management.

63
Q

What is the medical management for a minor tear or minor rupture in the trachea:

A

Minor Tracheal tear/ rupture tx:

    • cage rest
    • oxygen supplementation
    • sedatives
  • -thoracocentesis or thoracostomy tube for pneumothorax
    • consider temporary tracheostomy
64
Q

T/F: If dyspnea persists or worsens, in a minor tracheal tear/rupture, then surgical repair is indicated

A

True

    • primary closure of tear
    • simple continuous pattern
    • fine, absorbable suture
65
Q

What must be monitored long term in tracheal minor tears/ruptures:

A

Monitor for scarring & tracheal narrowing long term for minor tracheal tears/ruptures

66
Q

In severe tracheal tears/ruptures, surgical intervention is indicated when:

A
    • dyspnea persists or worsens with medical management
    • if pneumothorax persists > 2-3 days
    • severe tracheal damage is visible
67
Q

What 2 surgical options are for severe tracheal tear/ruptures:

A

Surgical options for severe tracheal tear/rupture:

  1. primary closure of tear
  2. tracheal resection & anastomosis
68
Q

Common place for severe tracheal tear:

A

Near the base of the heart

69
Q

Tracheal repair ( Resection & Anastomosis) for big dogs:

A
  1. Incise edges
  2. Split 2 big rings & bring them together (Anastomosis) – reduces risk of stenosis post. [ not done on small dogs = small rings ]
  3. Place tension relieving suture – reduces tension on primary suture line

> 4-5 rings = Tension

70
Q

Tracheal repair (Resection & Anastomosis) complications:

A

Tracheal repair complications:

    • SQ emphysema
    • Pneumomediastinum & pneumothorax
    • infection
    • STRICTURE **

complications occur if tension or poor healing (stricture requires surgery)

71
Q

What nerve should be avoided in a permanent tracheostomy:

A

– Recurrent laryngeal nerve

72
Q

Name the salvage procedure for treatment of untreatable upper airway obstruction.

A

Permanent Tracheostomy

73
Q

Permanent Tracheostomy complications:

A
  1. infection
  2. bleeding
  3. stenosis
  4. FB
  5. increase risk of pneumonia
  6. drowning
74
Q

T/F: After a permanent tracheostomy, it is normal to have excessive secretions for weeks post op until the squamous metaplasia of mucosa is complete.

75
Q

In a permanent tracheostomy, how much will the stoma decrease (%)?

A

40-50%

Must oversize stoma at time of surgery.
The stoma will decrease in size by 40-50%

76
Q

What procedure creates permanent opening at the level of proximal cervical trauma:

A

Permanent Tracheostomy

Steps:

  1. ventrally access the trachea
  2. elevate trachea up by dissecting underneath ( caution: recurrent laryngeal n.) and placing metzenbaun scissors underneath
  3. Suture the hyoid muscles underneath trachea to keep trachea elevated next to surface
  4. create hole 40-50% more than what you want - take ring off & leaving mucosa
  5. suture mucosa of trachea to skin – skin apposition is VERY important to prevent scarring.
77
Q

Most important component in success of a permanent tracheostomy

A

Accurate apposition of mucosa to skin because it reduces scarring & inflammation

78
Q

T/F: Careful at home monitoring is required for permanent tracheostomy

A

True – LOTS of work

    • clip hair around stoma
    • no swimming or water submersion
    • protect stoma from FB ( plant material, debri)
  • -must use harness
    • avoid airway irritants
79
Q

Which species has the best prognosis for permanent tracheostomy:

A

Dogs

Dog prognosis – Good for indoor dogs if underlying disease is benign process. Owners must be diligent with care & may require symptomatic tx for tracheitis.

Cat prognosis – guarded to POOR.

    • mucus plugs very common leading to acute death
    • median survival times reported to be 20.5 and 42 days.
    • soft tracheal cartilage may predispose trachea to collapse ( consider placement of external rings adjacent to tracheostomy)

SAM Sx (6 decks)

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