This document discusses different surgical airway techniques that can be used when endotracheal intubation fails or is not possible. It describes needle cricothyrotomy with translaryngeal jet ventilation, cricothyrotomy, and tracheostomy. In emergency situations, cricothyrotomy is preferred over tracheostomy due to its faster speed and lower risks. However, cricothyrotomy should be avoided in children younger than 10-12 years due to the small size of the cricoid cartilage and higher complication rates. The document provides details on how to perform each technique and notes important pediatric considerations for surgical airways.

1. Surgical Airway
Management
Submitted by
Aswanth E P

2. Contents
•Introduction
•Needle Cricothyrotomy
•Cricothyrotomy
•Tracheostomy
•Pediatric considerations
•Conclusion
•Reference

3. Introduction
Surgical airway management is essentil in life
thretening situations.
3 methods involved are
1)Needle cricothyrotomy& translaryngeal jet ventilation
2)Cricothyrotomy
3)Tracheostomy
In emergency sitation,cricothyrotomy preffered.But
it is avoid in children due to smalll anatomy
Of cricoid cartilage and associated complications.

4. Airway anatomy

5. SURGICAL AIRWAY
Establishing a surgical airway can be a last resort in
response to failed intubation attempts for a critical
patient with a compromised airway.
These situations consist of extreme
facial trauma or a completely compromised airway,
because serious brain damage can occur in a short period
of time if the airway remains obstructed
3 methods used :
needle cricothyrotomy and translaryngeal
jet ventilation
cricothyrotomy and
tracheostomy.

6. In an emergency situation, cricothyrotomy has
been shown to be faster and have lower morbidity and
mortality rates than tracheostomy.
It should be avoided in infants and approached cautiously
in children younger than 10 to 12 years because of the
small anatomy of the cricoid cartilage and the associated
high complication rates

7. Needle Cricothyrotomy & Translaryngeal Jet
Ventilation
Sanders first described the percutaneous
placement of a tracheal needle with jet ventilation.
Indications
In pediatric settings
Severe hemorrhaging of the airway
Edema
Some facial fractures
Dislocations.
It is used temporarily until a definitive airway can be
secured.
It oxygenate the patient for up to 45
minutes while the physician establishes a more stable
Airway.

8. Contraindications
When airway is maintainable through non invasive
means.
Anterior neck swellings that obscures landmarks.
Bleeding disorder.

9. Cricothyroidectomy : Anatomy

10. Technique
Consists of the insertion of a catheter through the
cricothyroid membrane.
There are catheter devices made specifically
for this procedure, such as the emergency transtracheal
airway catheter .
They tend to kink less frequently than standard
angiocatheters.
Most adults require a 12- to 16-gauge standard
angiocatheter .
Infants and small children typically
require 16- to 18-gauge catheters.

11. Cricothyroid membrane with syringe catheter in the
midline Needle-catheter-syringe combination inserted at
30 degree caudal angle

12. Needleless safety catheters should be avoided because of
their inability to connect to a syringe.
Trachea is stabilized by the thumb and middle finger of
the nondominant hand while the index finger locates the
cricothyroid membrane
Skin is anesthetized with 1% lidocaine or a similar local
anesthetic.
A 10-mL syringe filled with 5-mL of saline is attached to the
catheter & the needle is directed caudally at the inferior
aspect of the cricothyroid membrane.
Ideally, the needle
enters the skin at a 30- to 45-degree angle to the horizontal
and avoids injury to the surrounding vessels

13. Negative pressure is applied to the syringe on insertion
of the needle and continues throughout advancement of
the catheter.
The entrance of air bubbles into the syringe confirms
proper tracheal placement and the catheter is advanced
until the hub reaches the level of the skin.
Once the catheter has been advanced, the needle and
syringe are withdrawn.
oxygen source is connected to the catheter and oxygen
is delivered at 50 psi, with a flow rate of 15 liters/min.

14. Administrating high pressure ventilatiom through
translaryngeal catheter

16. Throughout the ventilation process, the catheter is
manually secured in place until a definitive airway can be
maintained
It only provide temporary airway control, a direct
laryngoscopy may be performed at any time.
The air bubbles within the trachea because of the
translaryngeal jet ventilation may serve as a helpful guide
for laryngoscopy

17. Complications
Barotrauma
Subcutaneous emphysema
Pneumothorax.
infection,
damage to surrounding tissues and structures, and
bleeding
Subcutaneous emphysema is often the result of a kinked
catheter or multiple puncture sites.
The use of a specific needle cricothyrotomy catheter
(kink-resistant) helps decrease the chance of
subcutaneous emphysema during or after the procedure.

18. It is unavoidable if there is leakage at the
original puncture site / if there is significant catheter
movement during ventilation causing subcutaneous air
and swelling
Preventive measures should be taken to avoid excessive
insufflation of oxygen, minimizing the risk of pneumothorax

19. Cricothyrotomy/Cricothyroidotomy
An incision through the cricoid cartilage.

20. Cricothyrotomy is indicated in cases in which orotracheal
and nasotracheal intubation are unsuccessful.
Airway device such as the LMA may be used until the
proper equipment and personnel are in place to perform a
cricothyrotomy.
In young children, cricothyrotomy is contraindicated
because of the size of the cricothyroid membrane
and narrowing of the pediatric airway.

21. Surgical Anatomy

23. Procedure can be done under local or general anesthesia
The head and neck should be slightly extended, unless a
cervical spine injury is suspected or has not been ruled out.
When working on a conscious patient, a local anesthetic (1%
lidocaine) is administered to the skin and subcutaneous
tissues after the anterior neck is prepped with an antiseptic
solution.
A right-handed surgeon performs
the procedure by standing on the patient’s right side.
Technique

24. Armamentarium

25. Thumb and middle finger of the
nondominant
hand are used to immobilize the
larynx while the index finger locates
the cricothyroid membrane.
Stabilization of the larynx should be
maintained at all times during the
procedure
A 2-cm horizontal incision is made
through the skin
and subcutaneous tissue.

26. The incision is carried down
through the cricothyroid
membrane without going
through the posterior wall of
the airway, and is directed
caudally to avoid the vocal
cords.
The nondominant index finger is
used to hold the
incision open and to minimize
the bleeding.
A Trousseau dilator or a large
hemostat is inserted to spread
the incision vertically.

27. This increased opening in the
cricothyroid membrane eases
placement of the tracheal hook.
A properly sized tracheostomy tube
(no. 6 Shiley for average men, no. 4
for average women) is inserted into
the opening and advanced into the
trachea.
The dilator and tracheal hook are
carefully removed to avoid causing
any damage.
The obturator is then
removed before the inner cannula is
inserted and the cuff or balloon of
the tracheostomy tube is inflated.

28. The tube is attached to a bag-valve
device or a mechanical ventilator and
is secured with umbilical tape that is
tied around the neck before
ventilation begins.
Because of the potential for the
development of subcutaneous
emphysema and pneumomediastinum,
especially during mechanically
supported respirations, the skin is
not sutured as a method for securing
the tube in place.

30. Rapid Four Step Technique (RFST)
Only equipment needed for the rapid fourstep technique
(RFST) is a no. 20 scalpel, hook, and tracheostomy tube.
1. Palpate and identify the cricothyroid membrane.
2. Using the no. 20 scalpel, make a 1- to 2-cm horizontal
incision through the skin, subcutaneous tissue,
and cricothyroid membrane.
3. Place the tracheal hook (before removing the
scalpel) and direct it inferiorly to provide caudal
traction.
4. Insert the tracheostomy tube

32. Complications
Perioperative Complications
Hemorrhage
Improper placement of the tube
Prolonged execution time
Injury or laceration to the thyroid or cricoid cartilage,
Injury to the esophagus or laryngeal nerve,
Pneumomediastinum,
Perforation of the posterior trachea
Subcutaneous emphysema

33. Postoperative Complications
Hemorrhage
Infection
Aspiration tube occlusion
Paralysis of the vocal cords,
Dysphonia and hoarseness
Subglottic stenosis

34. Tracheostomy
Indications
Blunt neck trauma
Tracheal transection
Upper airway obstruction
Need for prolonged mechanical ventilation
Complex facial fractures
Large or expanding neck hematomas
Edema
Deep space neck infections
Lacerations to the floor of the mouth.

35. Contraindications
If an airway can be secured by any other
method.
The difficulty level, amount of time needed,
and potential complications are greater for
tracheostomy than for other definitive
airways.

36. Surgical anatomy

38. The neck is prepped with an antiseptic solution and a
local anesthetic, such as 1% lidocaine, is injected into the
incision site.
Additionally, 2 mL of the local anesthetic is
inserted into the cricothyroid membrane and injected
into the trachea.This blunts the cough reflex.
The airway stabilized with the nondominant hand
Both vertical and horizontal incisions can provide adequate
access to the airway.
In an emergency tracheostomy, the vertical incision
maintains midline dissection and reduces
the potential for anatomic damage when the direction of
the incision is changed.

39. 3- or 4-cm vertical incision is
made through the skin,
subcutaneous tissue, and
platysma muscle.
It begins just below the cricoid
cartilage
and extends to the suprasternal
or supraclavicular notch.
In an elective tracheostomy,
the horizontal incision is
preferred for better cosmetic
results.

40. A 4- to 5-cm horizontal
incision is made approximately
2 cm below the cricoid
cartilage.
Through subcutaneous tissue
and platysma muscle until the
superficial layer of the deep
cervical fascia is
identified

42. As the space of Burns is entered bluntly, the inferior
thyroid veins are identified, clamped, and tied before
cutting them to minimize bleeding.
By vertically retracting the midline tissue away from the
trachea, injury to major vessels, nerves, and glandular
tissue can be avoided.
Thyroid gland is retracted out of the field, exposing
the tracheal rings.
If the thyroid isthmus cannot be retracted out of the
field, it must be transected, which can be done by cutting
the suspensory ligament
.

43. Cricoid cartilage and first tracheal
ring must not be cut
or injured. Second, the incision into
the trachea must
stop at or above the fourth tracheal
ring
A tracheostomy hook is placed just
below the first
tracheal ring. This acts to immobilize
and elevate the
trachea
The tracheal incision can be made by
the following
Techniques :
U,inverted U, T flap, and cruciform.

44. In emergent situations, a vertical midline incision between
the second and fourth tracheal rings is recommended.
Trousseau dilator or Kelly hemostat is inserted and
spread vertically
Tracheostomy tube should be inserted under direct vision
once the Trousseau dilator is in place.
The cuff and tip of the tube are advanced into position,
just inferior to the vocal cords.
The cuff is then inflated and the skin can be left open
or loosely sutured.

45. If the skin is sutured too tightly, subcutaneous
emphysema may result from not allowing air to escape
during forced expiration or continuous positive pressure
Ventilation.
Once it has been determined that the tube is in the
right location, a tracheostomy gauze dressing should be
placed under the tracheostomy tube phalanges and
around the cannula.
Chest x-ray is obtained to verify tube placement and to
check for pneumothorax.

46. Complicaions
1)Acute hemorrhage
postoperative hemorrhages, most occur in the first 2 to
4 weeks after the procedure.
2)Infection
Potential postoperative infection includes
surgical site infection, tracheitis, mediastinitis, and
pneumonia
The pathogens most commonly isolated
from tracheostomy infections are Pseudomonas
aeruginosa, Staphylococcus aureus, hemolytic
streptococci, and Candida.

47. 3)Tracheal stenosis
4)Pneumothorax
In infants, children, and those with chronic obstructive
pulmonary disease
5)Aspiration
Postoperative care
Trach care describes the specific techniques for proper
tube care, consists of tube aspirations and frequent
suctioning in the days and weeks after surgery.
If blood,mucus, or other secretions build up in the airway and
cause occlusion of the tube, the patient will lose the
ability to breathe.

48. To aspirate ,patient’s lungs be filled with 100%
oxygen for 2 or 3 minutes before suctioning occurs
Then 5 mL of sterile saline is injected into the tracheal tube,
immediately followed by 2- to 3-second suctioning intervals.
The steps should be repeated as long as notable
secretions are removed from the airway.
Trach care is completed once every hour for the first 48
hours.
The following 2 days, it should be completed once every 2
hours.
After the first 4 days, it should be completed every
4 hours.

49. Pediatric considerations
Their airways are smaller and tend to become obstructed
more easily. Foreign bodies, secretions,or even edema can
cause an obstructed airway.
Furthermore, the tongue and tonsils of a child are large
in relation to the rest of the oral cavity. Thus,have a
tendency to get in the way during airway interventions
Larynx is located higher and more anteriorly in children
than in adults. This is important to note because
hyperextension of the neck may further obstruct the
airway.

50. Needle cricothyrotomy with transtracheal jet
ventilation:
This is the preferred surgical airway method in
children because it is straightforward and provides a
patent airway for close to an hour.
Cricothyrotomy: This procedure has a high complication
rate and should not be done in children younger
than 10 years.
Tracheostomy: This should also be avoided in children
because it is a time-consuming procedure.
However, in emergent cases, if needle cricothyrotomy
with transtracheal jet ventilation has failed in a very
small child, a tracheostomy may be performed

51. Conclusion
Surgical airway mnagement is essental in critical situations.
Needle cricothyrotomy with transtracheal jet ventilation:
Cricothyridectomy & Trachoiostomy are common
procedures used.
In emergency sitation,cricothyrotomy preffered.But it is
avoid in children due to smalll anatomy Of cricoid cartilage
and associated complications.

52. Reference
1)Oral & Maxillofacial trauma : 4th edition
:FONSICA,WALKER,BARBER,POWERS,FROST
2)Textbook of Oral & Maxillofacial Surgery : 3rd edition
: S.MBALAJI

53. Thank you