1. The document discusses tracheostomy and anaesthesia considerations for microlaryngeal surgery. It covers the definition, history, steps of the procedure, complications, types of tubes, and techniques for airway management including endotracheal intubation and jet ventilation. 2. Lasers are commonly used in microlaryngeal surgery and ENT procedures. Safety precautions are required due to the risks of burns, fires and smoke inhalation. Special endotracheal tubes coated in metal foil or other fire-resistant materials help protect the airway during laser use. 3. Careful planning is needed for airway management and ventilation during these delicate procedures to provide optimal surgical conditions while protecting the patient's air

1. 1
Tracheostomy
and
anaesthesia
for
Microlaryngeal surgery
Dr Poonam Bhadoria
MD
Professor
Department of anaesthesia
Maulana Azad medical college & Lok Nayak hospital
New Delhi-110002

2. 2
D Definition
It's a surgical incision into the trachea for
establishing airway.
A A tube is placed in the trachea just below 2nd and 3rd
tracheal rings bypassing the epiglottis.
May be high in 2nd tracheal ring,
mid in 3rd to 4th tracheal
low tracheal ring 5th to 6th
“Better too often than too late”

3. 3
History
A reference was made in a Hindu medicine text
written in 2000 BC
In 15th century, Prasovala reported 1st successful
tracheostomy
In 1799 – George Washington died of an UAO.
From 1830s to 1930: emergency procedure in
children with diphtheria.
In 1907 – Chevalier Jackson wrote a book and
standardized the technique.
Galloway expanded its use in treatment of paralysis
and management of secretions.
In mid 1980s - brief popularity of mini-tracheostomy.

4. 4
Anesthesiologist?
Otolaryngologist?
Paramedic personnel?

5. 5
CRICOTHYROTOMY
whether to perform it?
Suspicion of acute upper airway problem
Worsening stridor
Reducing self-ventilation

6. 6
CRICOTHYRODOTOMY
how to perform it?
Extend the neck
Palpate the cricoid arch : enter just above it
Enter larynx just above the cricoid
Midline incision using either blade or IV
cannula
Knife may be rotated through 90o to keep the
incision open
Convert to formal tracheostomy as soon as
possible.

7. 7
ANATOMY OF LARYNX
The larynx lies in the front of hypopharynx opposite
the 3rd –6th cervical vertebrae.
Cartilages
-Unpaired : thyroid cricoid, epiglottis
-Paired :arytenoid, comiculate,
cuneiform

8. 8
STEPS OF SURGERY
● The degree of urgency in establishing
tracheostomy will determine the method but preference
should always be given to elective procedure.
● Secure the airway with minimum time and
complications.
1. CONSENT
2. PREMEDICATION
3. POSITION
supine with a pillow under shoulder to extend the neck
to bring the trachea forward.
4. ANAESTHESIA
Local anaesthesia with 1-2% lignocaine with
epinephrine in line of incision.
.

9. 9
EMERGENCY ELECTIVE
1. No or local anaesthesia 1. LA/GA with MAC
2. Consent – may or may not be 2. Consent-must
3. No pre-op preparation 3. Pre-op preparation
care regimen control of
medical problem
4. Vertical incision with gives rapid
access
4. Horizontal incision
5. Prime importance is securing
airway than bleeding
5. Control of bleeding prior
to securing airway.

10. 10
STEPS
1) Cleaning & draping with full aseptic
precautions
2) Inspection and palpation of the neck to assess
laryngotracheal anatomy.
3) Collar incision 2 cm > suprasternal notch.
4) Tissues are directed & strap muscles are
separated
5) Thyroid & isthmus is displaced upwards
continues

11. 11
6) Trachea is fixed with a hook and opened with a
horizontal incision in 3rd tracheal space which is
converted into a circular opening by excising a part
of one tracheal ring.
7) In children- vertical incision in trachea and insert
two stay suture.
8) No LA in trachea (cough reflex) or paratracheal
gutter (recurrent laryngeal nerve).
9) Insert tube.
10) Skin incision should not be sutured or packed
tightly.
11) Dressing.

12. 12

13. 13

14. 14

15. 15
INDICATIONS FOR TRACHEOSTOMY
the five “Rs”
1.Respiratory Obstruction
congenital, traumatic infection, neoplasm, foreign
body, bilateral abductor palsy
2. Respiratory failure
to prevent aspiration in unconscious patient
3. Respiratory paralysis
neurological disease, prolonged coma, spinal cord
injury
4. Removal of retained secretions
Inability to cough (polio, GBS)
5. Reduction of dead space
6. Planned tracheostomy
failed intubation, CaLx, burn contracture

16. 16
PHYSIOLOGICAL EFFECTS
Decrease in dead space by 100 ml.
Decrease work of breathing
Decrease in airway resistance
Prevent speech.
Prevents humidification and warming of inspired air
Loss of cilia, mucous secretions result in squamous
metaplasia
Interfere with elevation of larynx during swallowing.
Increase risk of chest infection.

17. 17
TYPES OF TRACHEOSTOMY TUBES
•Metal (Jackson), Non-metallic or plastic (Portex)
•Cuffed or uncuffed
•Single cannula or Double cannula
•Fenestrated (for speaking) or non-fenestrated
•Disposable and permanent
•Special Tubes
-Durham's tube for obese patient which has
adjustable flange
-Celebes – double cuffed
-Shiley (long term PVC for children)

18. 18
COMPLICATIONS
IMMEDIATE (0.1-22.9%)
Haemorage, aspiration of blood, pneumothorax,
local damage, air embolism.
POST-OP (within Ist few hrs-few days, 0-37%)
Hemorrhage, tube displacement, respiratory
obstruction, local wound infection, granulation
tracheatis with crusting, tracheobronchitits,
atelactasis,, lung abscess, subcutaneous
and mediastinal emphysema
continues
Apnoea
&
Cardiac
arrest

19. 19
LONG TERM (for weeks-months, 01.9%)
Haemorage, tracheomalacia, tracheal
stenosis, TO fistula, transcutaneous
fistula, hoarseness, dysphagia,
incoordination of swallowing reflex,
problem of decanulation, corrosion
of tracheostomy tube, tracheostomy
scar

20. 20
POST OP TRACHEOSTOMY CARE
Constant supervision
Suction
Change of Tracheostomy Tube
Prevention of crusting (Humidification)
Proper stabilization
Care of inflatable cuff
Breathing exercises
Dressings
Nursing

21. 21
FUNCTIONS Of TRACHEOSTOMY
Alternative pathway for breathing
Improves alveolar ventilation
Protects the airway
Permits removal of secretions
Permits adequate ventilation
To administer anaesthesia

22. 22
ADVANTAGES IN ICU
Lower doses of sedation
Preservation of cough reflex
More efficient pulmonary toilet
Reduced duration of ventilation
Less laryngeal trauma

23. 23
COMPLICATIONS
ASSOCIATEDWITH SUCTIONING
Hypoxemia, dysarrhythmias, hypotension,
cardiac arrest
Atelactasis or lung collapse
Mucosal damage
Bronchospasm
Tracheobronchial bacterial growth

24. *How to prevent these complications?
1.Follow a septic precautions.
2.Suction time <15 Sec.
3.<1/3 int. diam. Of suction catheter.
4.Vacuum Pr. 80-120mmHg.

25. 25
EMERGENCY EQUIPMENT TO BE KEPT AT
BEDSIDE
Suction apparatus
Sterile catheter
10 ml. Syringe for cuff inflation and deflation
Oxygen equipment
Ambu Bag
Sterile gloves, pair of dilators and seizers
Spare tracheostomy tube and ET
Wright’s spirometer

26. 26
PROBLEMS DURING DECANULATION
Because of tracheal edema or subglotic stenosis.
Persistence of condition for which tracheostomy was
done.
Obstructing granulations around and below the stoma.
Tracheomalacia
Incurved tracheal wall
Psychological dependence
Ventilator dependence

27. 27
PRINCIPLES OF DECANNULATION
•Tube is corked off for increasing periods
•Self-ventilating for at least one full night
•No further need for tracheal suction
•Remove tube; plug tracheostomy site.
•Tube size reduced before decanulation

28. 28
ABG should be normal.
Depends on duration of Tracheostomy
<2 weeks
uncuffed- plug- watch 24 hours – remove the
tube and close the stoma
2-6 weeks
either immediate or gradual
>6 weeks
gradually to smaller size every 48 hours till
<size 5. TT removed, stoma left to heal by
granulation

29. 29
LIMITATION OF PERMANENT
TRACHEOSTOMY
Swimming
Climbing stairs
Heavy exercise
Can speak aloud

30. 30
PERCUTANEOUS TRACHEOSTOMY
Seldinger puncture of tracheal wall
Pass dilators over the guide wire
Insert lubricated tube
Variants: one-stage tracheal spreader,
endoscopic control

31. 31
ADVANTAGES OFPERCUTANEOUS
TRACHEOSTOMY IN ICU
No need to book OT time
No patient transport hazards
Comparable complication rates to open
tracheostomy

32. 32
CONTRAINDICATIONS
Children
Bleeding diathesis
Previous Surgery
Infection
Enlarged thyroid

33. 33
EQUIPMENT FOR PERCU. TRACHEOSTOMY
Scalpel
14 G intravenous needle and cannula
10 ml. syringe
Flexible Teflon-coated guide wire
Plastic dilator
Pair of tracheal dilating forceps
Tracheostomy tube with a hollow obturator to slide
over the guide wire.
Maintain 100% O2 with monitoring SPO2, capno, ECG,
BP

34. 34

35. 35
MICROLARYNGEAL SURGERY
GOALS
Clear view
Immobile field
Sufficient space to work
PRESENTING COMPLAINTS OF
Hoarseness,
stridor
associated haemoptysis

36. 36
ANAESTHETIC CONCERNS (MLS)
Protection to trachea
Ensure good ventilation & oxygenation
Minimize secretions and reflexes
Rapid awakening & return of protective airway
reflexes

37. 37
PREOP. CONSIDERATIONS (MLS)
-Airway evaluation for TYPE OF LESION
(95% ant. & 5% post.)
-I/L & D/L (laryngeal inlet), CT, MRI
-Discuss with surgeon for SIZE OF TUMOUR
-Review on table
-Preoxygenation
-Glycopyrrolate 0.2-0.3mg IM

38. 38
VENTILATION & OXYGENATION
A). ETT – 5mm ID, long with standard cuff
(Micro laryngeal tube)/Mallincordt critical
care low pressure high volume tube
Control ventilation-advantages:
- prevent aspiration
-maintain inhalation anaesthesia
-monitor ETCO2

39. 39
Alternatives
(balanced technique-injector below vocal folds/lx)
B). Jet ventilation
ETT not required
Unobstructed view (profound messeter relax)
Alignment of laryngoscope & tracheal axis.
(pneumatic knife)
Full relaxation of V.C.
Free egress of gas
Monitor chest wall motion
continues

40. 40
Ventilatory rate – 6-7 bpm at 30-50 PSI I/E 1.5:6
sec (Saunder’s jet injector)
Cuffed Carden tube.
Contraindicated in children, obese & bullous
emphysema.
Risks - barotrauma, stomach dilatation, forcing
of blood & tumour in lungs, pneumothorax,
hypotension.
C). Intermittent ETT and apneic period.
D). HFPPV, less risk of barotrauma. (80-300/min)

41. 41
Reflex responses : -HT, tachycardia, arrhythmia
-Use :I/V or topical lignocaine,
-I/V fentanyl, esmolol
Anaesthesia : -Propofol, fentanyl,
-tropical anaesthesia of larynx,
-appropriate muscle relaxation.
-Ensure adequate depth

42. 42
Monitoring : ECG, BP, Oximetry,
ETCO2
Post op. Risk : -MI or Ischemia 1.5-4%
-laryngospasm,
-laryngeal edema
-strider
-restlessness
(hypoxia, pain)

43. 43
Microscopic ear surgery
Goal: relatively bloodless field.
Methods:
-placing patients in 15O head up position
-vasodilators e.g. SNP, trimetaphan
-NTG drip
-controlled ventilation with VA
-propofol infusion (100µg/kg/min)
-fentanyl bolus (1-3µg/min)
-avoid inadvertent PEEP
-balance the risk/benefits

44. 44
LASERS AND ANAESTHESIA
Laser : Light amplification by stimulated
emission of radiation
By Einstein in 1917
Aggregation of PHOTONS with intense energy
Useful tool in modern surgery
First used in 1960- as Ruby laser
First used in medicine in 1964
First use in OT in 1970

45. 45
Laser beam is intense light, emitting identical,
coherent, excited photons in one direction.
Consists of power supply, lasing medium &
optical cavity.
Beam focused to small spot - precise controlled
coagulation,
Incision or vaporarization of tissue.

46. 46
TYPES : Solid, gas and liquid
Solid - Ruby, YAG & Dyed
Gas- CO2 Argon Krypton, Excimer
Neodymium : YAG
– Invisible near infra red
– Deeper tissue penetration & haemeostasis
– Can be transmitted via fibreoptics tubes
– Better absorbed by pigmented tissue
(hemangioma)

47. 47
CO2 laser
-Invisible infra red light
-Absorbed by tissue water
-Precise incision independent of tissue
colour with minimal damage to
adjacent tissue
-suitable for vocal cord & laryngeal surgery
(10 W power with 0.1 sec pulses & a small
spot)

48. 48
LASER HAZARDS
To staff and patient
Misdirected - burn
Eyes are vulnerable
CO2 – corneal burn
Fire & explosion (thermal effect)
continues…

49. 49
Ignition of inflammable materials
ETT, breathing circuits, drapes
Prep. solutions, lubricants & appliances
Atmospheric contaminations with smoke &
plume (fine), particulate product of
combustion due to tissue vaporization by
laser

50. 50
SAFETY CONSIDERATIONS
OT warning sign for laser use.
Restrict entry into OT
Wear protective eye glasses (wave length
specific).
Avoid flammable materials (drapes, plastic
tubes, adhesives etc.).
Patient's eyes – taped closed & cover with wet
pads (CO2 laser), protection glass – Nd : YAG
laser.
Wet towels to drape.
continues…

51. 51
Competent personnel for equipment
use
Avoid misdirection of beam
Avoid ETT in short procedures use
venturi
Use fire proof tubes with saline filled
cuffs
Cover visible cuff area with moist
cotton pledgets
Ready bucket of clean water for
dipping the tube
Smoke evacuators at surgical site

52. 52
SPECIAL ETT & PROTECTION
Wrapping with wet muslin, dental acrylic
coating
(disadvantage: mucosal trauma)
Wrapping with metalised foil tape (CO2 laser)
(Aluminum, copper, plastic + metal)
Solid copper foil or aluminum (3m)
No.425/423)
(Protect from Nd:YAG laser for 60
sec)
Cuffs remain unprotected – fill them with
saline

53. 53
FDA APPROVED – MATERIAL & ETT
Merocel laser guard (tube wrap)
(Metal foil with sponge surface)
Xoned laser shield tube for CO2 laser
(Silicone with outer aluminum powder
coating)
Laser shield II – silicone tube with cuff

54. 54
METAL ENDOTRACHEAL TUBE
Norton’s
Stainless steel spiral coil without cuff
(Walls not air tight)
Laser flex tube
Air tight stainless steel spiral with two distal
cuffs
Bivona foam cuff
aluminum spiral tube with outer silicone
Coat and self inflating foam sponge filled
cuff

55. 55
AIRWAY CONTROL
Management directly affected in airway surgery
Sharing of airway
Use micro laryngeal ETT, ventilating
bronchoscope, jet ventilation,
intermittent intubation
Irregular respiratory movement
use muscle relaxant
Post op laryngeal edema
Use adrenaline, steroids, head up
position, remove stimulus

56. 56
AIRWAY FIRE (0.1%) PROTOCOL
Fatal due to
Thermal injury, Chemical burn –
brochospam & edema, melting & burning
ETT lead to obstruction
Management
-use of special tubes
-stop O2, remove ETT, flood with saline
-bag & mask/venturi ventilation
-if difficult airway, remove ETT on guide wire
-check bronchoscopy
-post operative: sitting position, X-ray chest ,
antibiotics, humidified O2, steroids

57. 57
THANK YOU