Upper airway obstruction and tracheostomy

Question 1

What is LARYNGOTRACHEOBRONCHITIS (CROUP)?

Answer 1

Characterized by oedema and vascular engorgement of airways particularly of subglottis
o Low-grade respiratory tract infection (e.g. with para-influenza virus)
o Then inspiratory stridor with general deterioration and toxicity
o Brassy cough like bark of dog
o Inspiratory stridor with recession signals significant subglottic oedema and is potentially life-threatening

Question 2

If croup fails to respond what needs to be done?

Answer 2

Endoscopy to exclude
subglottic stenosis
subglottic haemangioma

Question 3

What is the modified Wesley croup score?

Answer 3

Inspiratory stridor 
Retractions 
Air entry 
Cyanosis 
Level of consciousness

Question 4

What are the guidelines for management of croup based on modified Wesley croup?

Answer 4

< or 3: Home, supportive
4-8: Hospital, ward- admitted for observation, croup tents, nebuliser racemic adrenaline, systemic steroids, antibiotics
8+: hospital, intensive care,- heliox (acute presentation), nebuliser racemic adrenaline, systemic steroids, intubation, antibiotics

Question 5

What is epiglottis?

Answer 5

Affects children and adults, life threatening 
Hib causing marked erythema and oedema 
May start as URTI
Toxic, lethargic, febrile 
Young children drool 
Stridor can develop rapidly

Question 6

How do you avoid precipitating airway obstruction?

Answer 6

Do not cause child causing them to cry
Do not examine throat
Do not send for x-rays
Do not insert intravenous cannulae

Question 7

What do suspected cases of epiglottis require?

Answer 7

o fibreoptic or direct laryngoscopy
o endotracheal intubation for 3-4 days (rarely tracheostomy) after gas induction with the child in the sitting position
o blood cultures
o Heliox (Helium and Oxygen mixture)
o intravenous antibiotics e.g. Ceftriaxone
o ? intravenous steroids
o NB Hib epiglottitis is a notifiable disease

Question 8

What are rare infective conditions involving larynx?

Answer 8

• Recurrent respiratory papillomatosis (Human Papilloma Virus)
• Tuberculosis
• Diptheria (Corynebacterium diphtheriae)
• Herpes

Question 9

What are the main reasons for performing a tracheostomy?

Answer 9

Certain infections (inflammation of the epiglottis)
Benign or cancerous growths
Anaphylaxis
Inhaled objects
Obstructive sleep apnoea
Swelling of the tissues after major operations
Prevent scarring of the larynx after long-term artificial ventilation
To prevent overspill of secretions into lungs
Alternative means of air entry into the lungs after a laryngectomy

Question 10

What’s an end tracheostomy?

Answer 10

• with the larynx removed and disconnected from the trachea the open lower end of the trachea is sutured to the edges of the skin in the lower neck
• this effectively separates the lower airways from the upper airways and also the pharynx (throat)
• inspired air can no longer be warmed and humidified by the nose and so mucus dries in the trachea and can form crusts
• artificial means of humidification such as filters attached over the stoma, a moistened bib or room humidification are necessary
• speech needs to be relearned by getting other parts of the pharynx to vibrate in lieu of the vocal cords

Question 11

What is a side tracheostomy?

Answer 11

• Here the larynx is still in place and a small hole is created between the skin over the lower neck and the trachea

Question 12

What is the traditional open procedure for a side tracheostomy?

Answer 12

o A 3-5 cm incision is made in the lower neck and a hole made into the trachea. The fat, muscles and part of the thyroid gland and skin and superficial fascia and the strap muscles (sternohyoid and sternothyroid) separated in the midline
o The thyroid isthmus is exposed and usually divided in the midline thus exposing the trachea
o A 12mm vertical slit (or a round window) are made in the anterior wall of the trachea

Question 13

What is the percutaneous procedure for a side tracheostomy?

Answer 13

o Technique favoured by Intensivists in ITU
o Needle inserted through skin into airway and confirmed by aspiration of air
o Guide wire inserted into airway through needle lumen
o Serial dilators threaded over guide wire to dilate soft tissues
o Finally tracheostomy tube threaded over guide wire and introducer
• A cuffed tracheostomy tube is inserted and the anaesthetic tubing attached
• The flanges of the tracheostomy tube are sutured and/or taped in position to help prevent displacement of the tube

Question 14

What are the complications for a tracheostomy?

Answer 14

• Tube displacement
• Blocked tube from dried secretions or blood clot
• Pneumothorax (especially in babies)
• Surgical emphysema
Rare (late)-
• tracheocutaneous fistula on removing the tube
o normally fistula closes spontaneously, occasionally it requires suturing
• tracheo-oesophageal fistula
o Tube erodes through posterior wall of trachea into oesophagus behind
• tracheal stenosis
o usually if too much cartilage has been removed in creating the window

Question 15

What is stridor?

Answer 15

o Inspiratory stridor: laryngeal level
o Expiratory stridor: the wheeze of asthma (bronchi/bronchioles)
o Mixed inspiratory & expiratory stridor: tracheal or laryngeal and lower airways

Question 16

What is stertor?

Answer 16

• Noises produced at the level of the oro/nasopharynx i.e.snoring

Question 17

What are the common causes of stridor?

Answer 17

Congenital:
Laryngomalacia, vocal cord palsy, vocal cord web, subglottic stenosis
Acquired:
Trauma, foreign body, angioedema, epiglottis, croup, vocal cord palsy, laryngeal carcinomas, subglottic stenosis, laryngeal papillomata, large laryngeal polyps/cysts, external compression from a mass

Question 18

What is the management of stridor?

Answer 18

• Basic history
• First Aid
• Assess severity of stridor
• Improve and secure airway as necessary (earlier rather than later)
• Investigate and treat underlying cause as necessary

Question 19

How do you assess the severity of stridor?

Answer 19

• Only present on exertion
• Only present on deep inspiration
• Audible all the time but able to hold a normal conversation
• Has to talk in short phrases
• Only able to get odd words out as concentrating on breathing
• Unable to talk, using accessory muscles of respiration (intercostal recession or tracheal tug)
• Cyanosed
• Respiratory arrest

Question 20

What is the management of airway obstruction?

Answer 20

If respiratory arrest:
Clear mouth and oropharynx of vomit, dentures or foreign bodies by suction or sweeping the airway with gloved finger (if unable to visually inspect)
If cyanosed and still breathing give Heliox (mixture of Helium and Oxygen). The Helium is a light carrier gas with a low viscosity and is easier to breath in than Oxygen alone

Question 21

How do you use a brown intravenous cannula?

Answer 21

o Attach syringe to intravenous cannula
o Palpate thyroid cartilage
o Find cricothyroid groove beneath lower edge of thyroid cartilage
o Insert cannula through cricothyroid membrane
o Aspirate air with syringe to confirm in lumen
o Remove syringe and place high flow of oxygen (or Heliox) over cannula – some will diffuse or be sucked in with respiratory effort or cardiopulmonary resuscitation
o As second cannula may be inserted if nothing else is available
o Get help!

Question 22

Whether endotracheal intubation or a tracheostomy is performed depends on what?

Answer 22

o	nature of the obstruction
o	severity of the condition 
o	relative expertise available (anaesthetist and surgeon)
o	equipment available
o	anxiety of the patient