it is about upper airway obstruction, tracheostomy and its management.

1. ADAMA HOSPITAL MEDICAL COLLEGE
DEPARTMENT OF SURGERY
Seminar on
Upper airway obstruction Tracheostomy indication and care
By C1 students
1.Tayachew Desalegn
2.Tita Tegegne
3.Tewodros Alemu
Moderator: Shimelis Zewdie (MD, Surgeon)
September 24, 2021 GC ,Adama.
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2. Outline
• Anatomy and physiology of upper airway
• Upper airway obstruction
o Definition
o Cause
o Clinical presentation
• Airway management
o Basic
o Advanced
• Tracheostomy
o Definition
o Indication & care
• Reference 2
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3. Objectives
• At the end of this presentation;
o Describe anatomy & physiology of respiratory system
o Explain upper airway obstruction
o Identify causes of upper airway obstruction
o Mention appropriate management of UAO
o Provide a definition of a tracheostomy
o Identify the indications and complications of a
Tracheostomy 3
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4. Introduction
• The term Respiration can be:
1.Ventilation of the lungs (breathing),
2.The exchange of gases between air and blood
3.The use of oxygen in cellular metabolism.
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5. Anatomy and physiology
• Functionally
A. Conducting division
B. Respiratory division
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6. Structurally
A. Upper respiratory tract
B. Lower respiratory tract
Functions
1. Gas exchange
2. Regulation of blood pH.
3. Voice production
4. Olfaction
5.Protection
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7. Upper airway
• It is the air conducting passage that extends from
the nose or mouth to the trachea.
• Part;
o Nasal cavity
o Pharynx
o Larynx
o Trachea
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8. Nose
• It is a means of entrance to the respiratory
system
Functions
• sense of smell,
• filters inspired air,
• produces sounds and
• excretes water and heat.
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9. Nasal Cavity
• Large space that extends from nostrils to
choanae.
Function
• Increase the surface area
• Make skull lighter
• Increase the resonance of sound
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10. Pharynx
• Tube that extends from the base of the
skull to 6th cervical vertebra
• Forms the upper part of the
respiratory and digestive passages
• Inferiorly connected to;
– respiratory system at the larynx
– digestive system at the esophagus
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11. • The pharynx is divided into three regions:
o Nasopharynx
o Oropharynx
o Laryngopharynx
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12. Nasopharynx
• Extends from the choanae to the soft palate
• lies anterior to the first cervical vertebra
• The adenoids in Waldeyer`s ring are situated
• It undergoes physiological hypertrophy during
early childhood
• Eustachian tubes is a common site for the
development of nasopharyngeal carcinoma
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13. Oropharynx
• Space between the soft palate and root of the tongue
• Common passage of air, food, and drink
• It is bounded:
o Soft palate------- superiorly
o epiglottis--------- inferiorly
o Fauces pillars ----anteriorly
• Palatine and lingual tonsils are located between the
anterior and posterior pillars of the fauces. 13
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14. Laryngopharynx
• Begins at the level of the hyoid bone
• Extends to cricoid cartilage and
• Ends to;
o Larynx -------------anteriorly
o Esophagus-------- posteriorly
• Innervation
o glossopharyngeal (IX),
o vagus (X)
o Hypoglossal (XII) nerves.
• Damage causes dysphagia and/or aspiration.
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15. Larynx
• Connects laryngopharynx with trachea.
• It lies in the midline of the neck anterior
to C4–C6.
• the main function of the larynx is
protection of the tracheobronchial airway
and lungs.
• The wall is composed of nine pieces of
cartilage
o Three paired
o Three single 15
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16. Laryngeal Cartilages and ligaments
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17. Nerve supply
• Sensory nerve supply
– above the vocal folds is from the superior
laryngeal nerve
– below the vocal folds is from the recurrent
laryngeal nerve.
– Both these nerves are branches of the vagus
nerve (X).
• Motor nerve supply
– recurrent laryngeal nerve, which supplies all
intrinsic muscles.
• Damage to this nerve will cause paralysis of the
vocal fold on the side of the damage.
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18. Trachea
• Trachea lies in midline of the neck
extending from cricoid cartilage (C6)
superiorly to the tracheal bifurcation
at the level of sternal angle (T5).
• Comprises 16-20 C shaped cartilage
rings.
• Length 10-12cm.
• Diameter 15-20mm.
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19. Upper Airway Obstruction
Definition
• Obstruction of the portion of the airways located
above the thoracic inlet.
• It is an obstruction at or above vocal cord
characterized by inspiratory stridor.
• The oropharynx is the most common site of
upper airway obstruction
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20. Etiology
• Upper airway obstruction may be
o Functional
o Mechanical
o Infections
o Burns
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21. Functional causes
• CNS depression
• Peripheral nervous system and neuromuscular
abnormalities
• Recurrent laryngeal nerve interruption
• Hypocalcaemia
• Paralysis of vocal cord or vocal fold
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22. Mechanical causes
• Tumors of nose and sinuses
• Enlarged adenoid
• Tumors of nasopharynx
• Laryngotracheal trauma
• Foreign body aspiration
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23. Infectious causes
• Epiglottitis
• Tonsillitis
• Quinsy
• Diphtheria
• Croup
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24. Clinical Signs and Symptoms
• Respiratory distress
• Altered voice
• Dysphagia
• The hand-to-the-throat choking sign
• Stridor
• Facial swelling
• Prominence of neck veins
• Absence of air entry into the chest, and
• Tachycardia.
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25. Investigations
• Full blood count
• Blood Group and cross match
• Direct and indirect laryngoscopy
• Imaging

26. Investigations…
Direct laryngoscopy
• Both diagnostic and therapeutic
• Remove or suction
o Foreign bodies
o Blood
o Vomitus and secretions
• Endotracheal intubation
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27. Indirect Laryngoscopy
• Ideal for small mouth opening
• Minimizes cervical spine movement
• UAO
o Angioedema
o Retropharyngeal or Laryngeal masses and other
glottic pathology
o Facial deformity or trauma
• Both diagnosis and management of UAO

28. Indirect Laryngoscopy
• Awake
o Predicted inability to ventilate by mask
o UAO
• Asleep
o Failed intubation
o Minimal cervical spine movement
• Oral
o Facial /skull injuries
• Nasal
o Poor mouth opening
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29. Advantages
• Directly see upper airway and make an accurate
diagnosis
• Spontaneously breathing and awake patient
• If care is taken it is atraumatic and should not
worsen obstruction
• Definitive airway control can be achieved at
conclusion of examination by tracheal intubation.
29

30. Disadvantages
• Need for a skilled operator, cooperative patient
• Difficult in presence of blood and secretions
• Necessity for good local analgesia
• Difficult in the emergency setting
• Traumatic
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31. Bronchoscopy
• Rigid bronchoscope - can be used in the emergency setting to
secure the airway by carefully passing it through the stenotic
segment.
• Flexible bronchoscopy - can be used to establish the
Diagnosis as well management
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32. Disadvantages
• Necessity for good local analgesia
• Often difficult in the emergency setting
• General anaesthesia with the resultant risk that
spontaneous breathing and airway control is
completely lost
• Traumatic procedure and may lead to worsened
bleeding and edema.
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33. Plain Chest & Neck Radiographs
• May be useful as screening test
o Tracheal deviation
o Extrinsic compression
o Radiopaque foreign bodies
• Lateral plain neck radiographs
o Retropharyngeal mass
o Epiglottitis
• Lateral view should be obtained during inspiration with
the neck fully extended
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34. Computed Tomography
• High spatial and contrast resolution
• Stable patient or unstable patient with an already
secured airway
• Can help identify
o Intrinsic and extrinsic tumors or compressive airway
lesions
o vascular structures
o foreign bodies
• Degree and extension of airway compromise
• Status of the airway lumen
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35. MRI
• Preferred in imaging of trachea in infants and
young children
• Good resolution without contrast
• Evaluation of mediastinal content
• Has been used to image the UAW
• Use in obstruction is unproved
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36. Spirometery
• Often used in elective setting
• Used in gradual and mild symptoms of UAO
• The location and functional severity of the obstruction
• Relatively insensitive
• No role in the Management of a patient with ARD
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37. Management

38. Examination of the patient
• Quick History & Physical Examination
o Separate severe symptoms and less severe
symptoms
o Start management simultaneously with the
diagnostic process

39. Examination..
• ABC of life
• Observe
o Sign of obstruction
o Skin color
• Listen
o Wheeze , snore
• Feel
o Air entry

40. Examination…
• Fracture
• Bleeding and secretions
• Soft tissue injuries
• Mass
• Foreign body
• Infection
• Mental status
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41. AIRWAY MANAGEMENT
A. Basic Airway Management
o Airway Maneuvar
oAirway Devices (OPA& NPA…)
B. Advanced airway Management
oDirect Laryngoscopy & Tracheal Intubation
oSurgical Airway Devices
– Cricothyroidectomy
– Tracheostomy
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42. BASIC AIRWAY MANAGEMENT
1. Airway Maneuvers
• Head-tilt Chin –lift
• Jaw-Thrust maneuver
• Cervical Spine Immobilization
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43. Basic Airway …
• Removing foreign bodies
o Encouraging the victim to cough
o Back blows
o Chest thrust
o Back slaps
o Heimlich maneuver
o Finger sweep techniques
o Removing with forceps
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44. 44

45. 45

46. 2. Airway devices
• Oropharyngeal airway
46

47. Airway Devices…

48. Advanced airway management
• Can be performed blindly or by using a
laryngoscope
• Relies on the use of equipments
1. Orotracheal tube
oLMA
oEndotracheal tube
2. Nasotracheal tube
3. Surgical airway
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49. 1.Orotracheal tubes
• Laryngeal mask airway
o wide-bore airway with an inflatable cuff at the distal
o An alternative to ventilation through mask or TT
o Inserted into the patients pharynx and mask is inflated
o Forms a seal in the pharynx around the laryngeal inlet
o Partially protects larynx from pharyngeal secretions

51. Orotracheal…
• Endotracheal intubation
o Securing an airway by passing an endotracheal
tube via the oro- or nasotracheal route.
o The intubated patient is unable to speak, or
swallow
o It requires a degree of sedation
o Very uncomfortable in an awake patient
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52. Equipment for intubation
• Oxygen source
• BMV
• Laryngoscope
• ETT
• Airways
• Magill forceps
• Suction
• Stylet
• Oximetry
• Stethoscope
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53. Orotracheal Intubation
53

54. Indication
• Protect airway
o Airway obstruction
 Hematoma or facial bleeding
 soft tissue swelling
o patient with altered mental status
• Secretion clearance and prevent aspiration
• Mechanical ventilation
• Receiving general anesthesia
• Surgery involving or adjacent to the airway

55. Contraindication
• Absolute
o supraglottic or glottic pathology which may be exacerbated
by insertion of the ETT or laryngoscope.

56. Relative
o Penetrating injuries to the neck and an expanding hematoma
o Evidence of chemical or thermal injury to the mouth, nares, or
hypopharynx
o Extensive subcutaneous air in the neck
o Airway bleeding

57. Nasotracheal Intubation
• Indication
o Trismus
o severe mandibular
injuries
o Obstructing mass in oral
cavity
o Faciomaxillary surgery
• Contraindications
oCoagulopathy
oSevere intranasal
pathology
oFracture of skull
base

58. Extubation
• Muscle relaxant fully reversed
• Patient awake & responsive, stable vital signs
• 100% oxygen at high flow 2-3 min
• Remove secretion in trachea or pharynx
• Turn patient to lateral position
• Deflate cuff and remove ETT
• Continue 100% oxygen by facemask
• In semiconscious patient can provoke
laryngospasm
58

59. Complication of laryngoscopy &
Intubation
1.During Endotracheal Intubation
oProlonged attempt
oWith inadequate anesthesia
oTrauma
oTube malpositioning
oPhysiological response to airway instrumentation
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60. Complication…
2. With tube in situ
oAccidental extubation
oEndobronchial intubation
oTube malfunction
oBronchospasm
oAspiration
oSinusitis
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61. Complication…
3. After extubation
o Hypoxia
o Laryngospasm
o Pulmonary edema
o Stridor
o Hoarsness and sore throat
o VC paralysis
o Granuloma of cords
o Laryngeal or tracheal Stenosis
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62. Surgical airway management
• Endotracheal intubation is not possible
• Unstable cervical spine is
• Expected difficult intubation
• Includes
Surgical and needle Cricothyroidectomy
Transtracheal jet ventilation
Tracheostomy
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63. Cricothyroidectomy
• Placing a tube through an incision in the
cricothyroid membrane
• Oxygenation and ventilation
• Extremely effective in the emergency situation
• Requiring little equipment and surgical expertise
• Patient can be ventilated for up to 24–48 hr
• It should be converted to a formal Tracheostomy
63

64. Cricothyroidectomy…
• INDICATIONS
o Emergency airway is required
Massive hemorrhage
Profound emesis
Trismus
Obstructing lesions
 Eg.tumor, polyp
Traumatic and congenital deformities
o Orotracheal or nasotracheal intubation is either
unsuccessful and clinician cant intubate and cannot
ventilate the patient
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65. 65

66. Cricothyroidotomy …
• Palpate
o Thyroid notch
o Cricothyroid interval
o Sternal notch for orientation
• Transverse skin incision over the cricothyroid
membrane
• Incise through the membrane transversely
• Insert hemostat or tracheal spreader into the incision
and rotate it 90 degrees to open the airway
• Insert a proper-size, cuffed endotracheal tube or
tracheostomy tube
• Direct the tube distally into the trachea
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70. Contraindications
• No absolute contraindications to emergency
cricothyrotomy
• Relative contraindications
o Possible or known transection of the trachea
o laryngotracheal disruption with retraction of the
distal trachea into the mediastinum
o Fractured larynx
70

71. Complications of Surgical cricothyrodotmy
• Early complications
o Bleeding
o Aspiration
o Laceration of the thyroid cartilage, cricoid cartilage, or tracheal
rings
o Perforation of the posterior trachea
o Unintentional tracheostomy
o Passage of the tube into an extratracheal location
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72. Complication
• Late complications
o Creation of false passage into the tissue
o Subglottic stenosis (edema)
o Laryngeal stenosis
o Hemorrhage or hematoma formation
o Vocal cord paralysis or hoarseness
o Infection
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73. Complications
• Long-term
o subglottic stenosis and voice change
Prolonged intubation
Underlying laryngeal disease
 Younger age
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74. Transtracheal ventilation

75. Tracheostomy
• It is an operative procedure that creates a surgical
airway in the cervical trachea.
• A procedure done to relief airway obstruction or to
protect the air way by a direct entrance into the
trachea through the skin of the neck.
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76. FUNCTION
• Alternative pathway for breathing
• It bypasses the obstruction.
• Improves alveolar ventilation.
• Delivery of anesthesia
• remove tracheobronchial secretion
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77. Indications for tracheostomy
A.Upper airway obstruction
B. Retained secretions
C. Respiratory insufficiency
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78. Indications…
A. Acute upper airway obstruction
• Infections
• Trauma
• Neoplasms
• Foreign body Aspiration
• Laryngeal Edema
• Congenital anomalies
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79. B. Retained secretions
• Inability to cough
• Painful cough
• Aspiration of pharyngeal secretions
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80. C. Respiratory insufficiency
o Emphysema
o Chronic bronchitis
o Bronchiectasis
o Atelectasis - lung collapse
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81. Contraindications
• Laryngeal carcinoma
• Uncorrectable bleeding diathesis
• Gross distortion of neck due to hematoma
• extensive Infection of soft tissues of the neck
• Cervical spine instability
• Obese and short necked
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82. Types of Tracheostomy
Includes:
• Emergency tracheostomy
• Elective tracheostomy
• Permanent tracheostomy
• Percutaneous dilatational tracheostomy
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83. Emergency tracheostomy
• A vertical midline skin
incision is made from
the inferior aspect of
the thyroid cartilage
to the suprasternal
notch and continued
down between the
infrahyoid muscles.
• vertical incision
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84. Elective tracheostomy
Advantage:-
• complete airway control at
all times.
• unhurried dissection and
• careful placement of an
appropriate tube
• Transverse incision.
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85. Surgical techniques
• Open procedure
• Percutaneous procedure
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86. Surgical techniques open procedure
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87. Cont…
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88. Cont…
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89. Tracheostomy tube
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90. • Is made either between
the second and third
tracheal rings or
between the third and
fourth rings.
90
Cont…
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91. • Appropriate
position
while incision
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92. Tracheostomy Advantages
• Anatomical dead space is reduced ( by ~50%)
• Increase patient mobility and comfort
• The airway is protected
• Improved airway suctioning
• Improved communication & nutritional support.
Reduce work of breathing and increase alveolar
ventilation
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93. Disadvantage
• Loss of heat and moisture exchange mechanism.
• Desiccation of tracheal epithelium.
• loss of ciliated cell and metaplasia.
• stimulates mucus production.
• splinting of the larynx.
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94. Risk factors for complications
• Age: infants and adults over 75
• Obesity
• Smoking
• Poor nutrition
• Alcoholism
• Chronic illness
• Diabetes
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95. Complications
1. Intraoperative complications
• Haemorrhage (anterior jugular veins)
• Injury to paratracheal structures
• Damage to the trachea and larynx
• Air embolism
• Apnea
• Cardiac arrest(sudden shift acidosis-alkalosis)
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96. 2. Early postoperative complications
• Apnoea
• Haemorrhage
• Subcutaneous emphysema
• Tube displacement & blockage
• pneumomediastinum and pneumothorax (COPD)
• Infection
• Swallowing dysfunction 96
Cont….
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97. 3. Late postoperative complications:-
• Haemorrhage
• Difficult decannulation
• Fistula (traechoinnominate artery fistula)
• Laryngotracheal stenosis
• Granuloma formation
• Tracheostomy scar
97
Cont…
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98. Percutaneous Tracheostomy
• Tracheostomy performed percutaneously with
bronchoscopic assistance
• A transverse incision is made between the
first and second tracheal rings
• A 22-gauge needle is inserted between the
second and third tracheal rings
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99. Cont…
Advantages
• performed at the patient’s bedside.
• Significant bleeding is rare.
• post procedural infections are almost nonexistent
• Lesser cost.
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100. Tracheostomy care
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101. • Monitoring vital sign
• Check symmetry of chest expansion
• Auscultate breath sounds
101
Immediately After Intubation
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102. Cont…
Three major factors must be considered
in the care of the tracheostomy patient:
A. Humidification
B. Mobilization of secretions
C. Airway patency.
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103. A. Humidification
• The nasopharynx has been bypassed by tracheostomy.
• It is absolutely essential that adequate humidity be
provided to keep the airway moist.
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104. • Frequent turning, encouragement of deep
breathing, and ambulation are important in the
prevention of pulmonary complications.
• Regular chest physiotherapy and postural drainage
are both very effective in the mobilization of
secretions
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B. Mobilization of Secretions
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105. • All patients who are on tracheostomy tube need
suctioning and follow up.
• Suctioning of the tracheostomy tube is necessary
to remove mucus, secretions & maintain a patent
airway.
• pressure setting for tracheal suctioning is 80-
120mmHg (10-16kpa)
105
C. Airway patency
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106. • Special and frequent suctioning care should be given
for those.
o signs of respiratory distress
o Suspicion of a blocked or partially blocked tube
o Inability by the child to clear secretions by coughing
o Desaturation on pulse oximetry
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107. Tracheostomy Decannulation
• is a permanent removal of the tracheostomy tube
after weaning from mechanical ventilation
• Occluded using a decannulation cap and
• Child is observed for any signs of increased
respiratory effort or respiratory distress before
removal
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108. Patients who fulfill all the following criteria
• No upper airway obstruction.
• The ability to clear secretions that are neither too
copious nor too thick.
• No aspiration during swallowing
• The presence of an effective cough.
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109. References
• Bailey & Loves: short practice of surgery ,26th
edition
• Principles of Human Anatomy ,Gerard
J.Tortora,12th edition
• Schwartz's principles of surgery,10th edition
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Thank You!!!
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