surgical airway access technique

1. TECHNIQUE’S OF
SURGICAL AIRWAY
ZIKRULLAH

2.  Emergency surgical airway management
comprises of techniques that gain access to the
infraglottic airway.
 These are needle cricothyrotomy, percutaneous
cricothyrotomy, surgical cricothyrotomy, and
surgical tracheostomy.
 The airway is very superficial at the level of the
cricothyroid membrane, separated from the
skin only by the subcutaneous fat and anterior
cervical fascia.

3.  1. Direct trauma to airway/ obstruction
 2. Severely wounded (e.g. profound
bleeding, head injury, comatose, etc.)
 3. Resp failure secondary to blast or
inhalational injury, or exposure to chemical
agents
 4. Controlled airway during surgery

4.  Airway control can be a challenge and it
requires good preparation, staying focused, the
right tools and the right decisions.

5. DIFFICULT AIRWAY
GENERAL ANESTHESIA
+/- PARALYSIS
RECOGNIZED
PROPER
PREPARATION
ASA DIFFICULT AIRWAY ALGORITHM
UNRECOGNIZED
AWAKE
INTUBATION
CHOICES
SUCCEED
FAIL
SURGICAL
AIRWAY
MASK
VENTILATION
NO
YES
EMERGENCY
PATHWAY
NON -EMERGENCY
PATHWAY
LMA
COMBITUBE
TTJV
INTUBATION
CHOICES
INTUBATION
CHOICES
SURGICAL
AIRWAY
SUCCEED
FAIL
CONFIRM
ANESTHESIA
WITH MASK
VENTILATION
AWAKEN
SURGICAL
AIRWAY
EXTUBATE
OVER JET
STYLET
REGIONAL
ANESTHESIA
CANCEL
CASE
REGROUP
Intubation choices include use of different
laryngoscope blades, LMA as an intubation
conduit (with or without fiberoptic guidance),
fiberoptic intubation, intubating stylet or tube
changer, light wand, retrograde intubation,
and blind oral or nasal intubation.
*
*
*
AWAKEN

6. 1
alternative
2
alternative
3
alternative
4
alternative
1
Manipulation of airway c
different blade, bougie
2
LMA, ILMA, Combitube
3
Trantracheal Jet Ventilation
4
Cricothyrotomy, Tracheostomy

7.  Failure of conventional Methods to rescue the
Airway
 Cannot intubate cannot ventilate situation
 Sometimes even a primary method

8. Situations in which a Surgical Airway should be
considered as the primary method include
 Major Maxillo-Facialary Injury (eg
compound mandibular fractures, Le Forte III
Midface Fracture),
 Oral Burns
 Fractured Larynx.

9.  􀂄 Retrograde intubation.
 􀂄 Surgical Cricothyrotomy
 􀂄 Needle Cricothyrotomy
 􀂄 Jet ventilation
 􀂄 Open Tracheotomy
 􀂄 Percutaneous Tracheotomy

10. – Indications
 Abnormal anatomy
– Pt. W/ epiglottitis
– Severe kyphosis
– Cervical spondylosis
 Trauma
 Reasonable alternative to Surg and Needle
Crico

11. Trismus
Coagulopathy
Enlarged thyroid

18.  Cricothyrotomy is an emergency procedure
involving incising or puncturing the
cricothyroid membrane to access the trachea
for ventilation purposes.

19.  Cricothyrotomy
 Indications (Identified need for intubation)
 Maxillofacial trauma
 Oropharyngeal obstruction
 Edema
 FBAO
 Mass Lesion
 Cancer
 Unsuccessful oral/nasal tracheal
 Difficult anatomy
 Massive hemorrhage/regurgitation

20.  Contraindications:
 Age <10-12
 Laryngeal crush injury
 Laryngeal tumor/stricture
 Tracheal transsection
 subglottic stenosis
 Expanding hematoma
 Coagulopathy
 Unfamiliar w/ procedure

21.  Determine that the patient’s ABC’s is in
jeopardy.
 Determine that the patient requires an
emergency cricothyroidotomy.
 Assemble required equipment, quickly.
 Do it. Don’t hesitate

22.  Position the patient’s head/neck
 The patient is placed in a supine or semi-recumbent position
 The neck is placed in a neutral position

23.  Palpate the thyroid and
cricoid cartilage for
orientation
 A - Cricoid Cartilage
 B - Cricothyroid
Membrane
 C - Incision Site
 D - Thyroid Cartilage

24.  Locate the cricothyroid membrane
 Stabilize the thyroid cartilage using your non-
dominant hand
 Swab the incision site with alcohol or betadine
swabs
 Make a vertical incision through the skin
approximately 2-5 cm (1 inch+) long over the
cricothyroid membrane
 Visualize the cricothyroid membrane

25.  Make a transverse incision into the cricothyroid
membrane
 DO NOT make the incision more than 1/2 inch deep or
you may perforate the esophagus

26.  Insert the endotracheal
tube (adult 6.5mm)
directing the tube
distally down the
trachea
 Inflate the endotracheal
tube’s cuff with 10 cc’s
of air
 Check for proper
placement of the ET
 Observing the chest
rise
 Auscultate for
bilateral breath
sounds

27.  Indications
 Same as for any surgical airway
 Considered safer and quicker than surgical crike
 Will not compromise c-spine in trauma pt.
 Contraindications
 Total obstruction at or near the cords
 Complications
 Misdirection
 Puncture tracheal wall
 Vocal cord damage
 Does not prevent aspiration!

30.  1.supraglottic or glottic pathology
eg: swelling, abscess, tumor or foreign
body
 2. Unfavorable anatomy
eg: limited mouth opening

31.  Contraindication:
1. distorted airway
2. bleeding diathesis
3. Complete airway obstruction?
 Adverse effect:
1. Barotrauma
2. Bleeding at insertion site
3. Loss of position of the catheter if it is not
held firmly during ventilation

33.  Tracheotomy
 operative procedure that creates an
artificial opening in the trachea.
 Tracheostomy
 creation of permanent or semi
permanent opening in trachea.

34. 1. Upper Airway Obstruction
a. Trauma
b. Foreign body
c. Infections
d. Malignant lesions

35. 2. Pulmonary Ventilation
• Tracheostomy should be
performed in a patient requiring
ventilation through an
endotracheal tube for more than
10 days.

36. 3. Pulmonary Toilet
• Those who cannot cough and clear
their chest.
• Prevent aspiration by low pressure
high volume cuff tracheostomy
tube.

37. 4. Elective Procedures
• For major head and neck operations.

38.  Intraopertaive Complications.
 Bleeding and injury to big vessels
 Injury to tracheoesophageal wall
 Pneumothorax
 Pneumomediastinum
 Subcutaneous emphysema
 Tracheal rupture
 Paratracheal placement

39.  Early Complications
 Bleeding
 Tracheostomy tube obstruction
 Tracheostomy tube displacement
 Infection

40.  Late Complications
 Tracheal Stenosis
 Granulation tissue
 Tracheocutaneus fistula
 Tracheo - inominate fistula
 Tracheo esophageal fistula

44.  DONE MAINLY ON PATIENTS IN ICU

45.  The patient is positioned with the head
extended on the neck.
 Standard preparation and drape are applied.
The skin and subcutaneous tissues are
infiltrated with 2% lidocaine and 1:100,00
epinephrine one or two fingers below cricoid
cartilage.
 1.5-cm horizontal skin incision is made
 subcutaneous tissues are bluntly separated
with a curved hemostat.

46.  Bronchoscope is advanced until its tip is flush
with the ET.
 bronchoscope and ET are withdrawn slowly
until the incision is maximally
transilluminated.
 The bronchoscope is maintained in this
position throughout the procedure, allowing
direct visualization of every step.
 The 16 or 17G introducer needle is then
inserted between the first and second or
second and third tracheal rings.

47.  A midline placement is verified .
 The needle is withdrawn, leaving the
overlying catheter sheath.
 Guidewire is then passed through .
 sheath is removed and replaced by a 14 Fr
introducer dilator, which is advanced over the
guidewire
 12 Fr guiding catheter is placed.
 The guiding catheter and guidewire are left in
place and single dilator is used over it.

48.  The opening is dilated.
 Dilator is then replaced by the preloaded
tracheostomy tube, which is advanced into
the trachea.
 The guidewire, guiding catheter, and dilator
are removed and replaced by the inner
cannula.
 The ventilatory apparatus is connected.
 tracheostomy secured with four corner
sutures. When ventilation is adequate, the ET
is removed while examining the vocal folds.

49.  􀂄 Absolute Contra-indications:
 • Emergency
 • Pediatric patient
 • Midline neck mass
 • Non-intubated patients
 􀂄 Relative Contra-indications:
 • PEEP > 15
 • Coagulopathy
 • Obesity
 • Previous tracheostomy
 • C-spine immobilization

50.  􀂄 No transfer to OR
 􀂄 Shorter waiting time to procedure
 􀂄 Cheaper

51. Plastic Dilator
• Ciaglia Technique
Forcep Dilator
• Rapitrach
• Griggs Technique
Other
• Fantoni Translaryngeal Technique
• PercuTwist

52.  • PCT with bronchoscopy is the
percutaneous technique of choice
 • PCT complication rates are comparable
to open tracheostomy
 • PCT advantages:
􀂄 Faster
􀂄 Cheaper
􀂄 Lower post-op complications

53.  􀂄 Alternative strategies
 􀂄 Advantages & disadvantages of each
 􀂄 The cost of each option

56. THANKS