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SURGICAL MANAGEMENT
OF DIFFICULT ADULT
AIRWAY
DR.ASHWIN MENON M
CLINICAL ANATOMY
CLINICAL ANATOMY
• Depth from skin: 18 mm to 32 mm
• Length: 11 cm
• Levels: C6 to Upper border of T5
• Rings: 16 to 20
• ...
Definition
No universally accepted definition of the difficult airway
exists, but in broad terms, difficult airway control...
 The incidence of difficult intubation in the operating room
ranges between 1.15% and 3.80% , with failed attempts in
0.0...
Hypoxia from the difficult airway is commonly
due to:
1. Excessive number of attempts performed by different
operators uns...
SIGNS & SYMPTOMS
• Dyspnoea at rest or on exertion.
• Stridor
• Neck swelling
• Voice changes
• Haemoptysis
• Dysphagia
• ...
CAUSES OF DIFFICULT AIRWAY
Pierre Robin Syndrome Cleft soft palate, glossoptosis,
retrognathia
Treacher Collins Syndrome A...
Pierre Robin Syndrome Treacher Collins Syndrome
Goldenhar’s Syndrome Down’s Syndrome
Kilppel-Feil Syndrome
ACQUIRED
Infections
Supraglottitis
Croup
Abscess
Ludwig’s angina
Laryngeal oedema
Laryngeal oedema
Distortion of the airwa...
AIRWAY ASSESSMENT INDICES
1. Individual indices.
2. Group indices - Wilson’s score
- Benumof’s analysis
- Saghei & safavi ...
EVALUATION OF MANDIBULAR SPACE
THYROMENTAL DISTANCE (PATIL’S TEST)
• Distance from the tip of thyroid cartilage to the tip...
HYO MENTAL DISTANCE
• Distance between mentum and hyoid
bone
• Grade I : > 6cm
• Grade II: 4 – 6cm
• Grade III : < 4cm – I...
STERNOMENTAL DISTANCE
(SAVVA TEST)
• Distance from the upper border of the manubrium to the
tip of mentum, neck fully exte...
CORMACK - LEHANE
(Grading at direct laryngoscopy)
Grade 1: Full exposure of glottis (anterior + posterior
commissure)
Grad...
ASSESSMENT OF TMJ FUNCTION
TM joint exhibits 2 function.
1. Rotation of the condyle in the synovial cavity.
2. Forward dis...
INTER-INCISOR GAP
• Inter-incisor distance with maximal mouth opening
• Normal value > 5 cm / admits 3 fingers.
Significan...
Significance-
Class B and C: difficult laryngoscopy
UPPER LIP BITE /CATCH TEST
• Class I: Lower incisors can bite the upper lip above
vermilion line
• Class II: can bite the ...
Evaluation of Neck Mobility
Patient is asked to hold the head erect, facing directly to
the front  maximal head extension...
Grade Reduction of A.O.Extension
1 none
2 One third
3 Two third
4 complete
Grades 3 and 4 : Difficult laryngoscopy
Grading...
ASSESMENT OF A.O. EXTENSION
• Flexion movement of the cervical spine can be assessed by
asking the patient to touch his ma...
Warning sign of DELIKAN
Place the index finger of each hand, one underneath the chin and
one under the inferior occipital ...
PALM PRINT & PRAYER SIGN
Palm print sign:
Patient’s fingers and palms painted with blue ink and pressed
firmly against a w...
Palm Print as a Predictor of
Difficult Airway in DM
PRAYER SIGN
A positive "prayer sign" can be
elicited on examination with the
patient unable to approximate the
palmar surf...
1. SAGHEI & SAFAVI’S
• Weight
• Tongue protrusion
• Mouth opening
• Upper incisor length
• Mallampati class
• Head extensi...
2.“LEMON” Assessment
• Look externally.
• Evaluate the 3-3-2 rule.
• Mallampati.
• Obstruction.
• Neck mobility.
L: Look Externally
• Obesity or very small.
• Short Muscular neck
• Large breasts
• Prominent Upper Incisors (Buck Teeth)
...
E Evaluate the 3-3-2 rule
 3 fingers fit in mouth
 3 fingers fit from mentum
to hyoid cartilage
 2 fingers fit from the...
Cormack & Lehane Grading
(Grading at direct laryngoscopy)
Grade 1: Full exposure of glottis (anterior +
posterior commissu...
O Obstruction
 Blood
 Vomitus
 Teeth
 Epiglottis
 Dentures
 Tumors
N Neck mobility -Measurement of
Atlanto-Occipital Angle
Grading of reduction in A.O.Extension
Grade I : > 35°
Grade II : 22-34°
Grade III : 12-21°
Grade IV : < 12°
3. WILSON SCORING SYSTEM
5 factors - Weight, upper cervical spine mobility, jaw
movement, receding mandible, buck teeth
• ...
4. BENUMOF’S 11 PARAMETER ANALYSIS
Parameter
1. Upper inciors length
2. Buck teeth
3. Subluxation
4. Interincisor gap
5. P...
Rule of 1-2-3
• 1 finger breadth for subluxation of mandible.
• 2 finger breadth for adequacy of mouth opening.
• 3 finger...
1. X-Ray neck (lateral view) :
• Occiput - C1 spinous process
distance< 5mm.
• Increase in posterior mandible
depth > 2.5c...
2. CT Scan:
• Tumors of floor of mouth, pharynx, larynx
• Cervical spine trauma, inflammation
• Mediastinal mass
3. Helica...
Surgical Airway Procedures
Types of Surgical Airway Procedures
1. Laryngotomy (cricothyrotomy)
2. Elective Temporary Tracheostomy:
– This is performe...
4. Emergency Tracheostomy
– Nowadays there ought to be very few indications for this. On occasion
a patient will be seen f...
1. Laryngotomy (cricothyrotomy)
“Laryngotomy is opening the airway through the
cricothyroid membrane”
• It is used for acu...
Techniques
1. Standard technique
2. Rapid four step technique
3. Seldinger technique
1. Standard technique
Step 1: Immobilize the larynx and
palpate the cricothyroid
membrane.
Step 2: Incise the skin vertica...
Step 4: Insert the tracheal
hook.
Step 5: Insert the Trousseau
dilator and open it to enlarge
the incision vertically.
Step 6: Insert the tracheostomy tube. Step 7: Remove the obturator.
Step 8: Insert the inner cannula.
Step 9: Attach the tracheostomy
tube to the mechanical ventilator
or a bag valve device.
2. Rapid four step technique
The rapid four-step technique (RFST) can be done quickly and
requires only a number 20 scalpe...
STEP 2
Step 3: Prior to removal of the scalpel, the hook is placed and
directed inferiorly. Caudal traction is used to stabilize ...
3. Seldinger technique
Commercial cricothyrotomy kits are available that contain all
essential equipment to perform the Se...
Technique
Step 1: Be certain all equipment is present and functioning. Insert
the dilator into the airway catheter. Palpat...
Be careful not to insert it too far as this may damage the posterior
wall of the trachea. Watch for the appearance of bubb...
Step 5: Thread the combined tissue dilator-airway catheter over
the guide wire and advance it into the skin incision. Foll...
COMPLICATIONS
Emergency surgical cricothyrotomy has a much higher
complication rate than elective cricothyrotomy.
Early co...
• Long-term complications include subglottic stenosis
and voice changes.
• Rapid Four Step Technique (RFST) involves crico...
Tracheostomy
• A tracheotomy is an incision into the trachea (windpipe) that
forms a temporary or permanent opening which ...
• Anaesthesia:
– Endotracheal anaesthesia or
– Local anaesthesia (in
obstructive pathologies)
obtained by injection of ski...
• Incision:
– A Transverse/vertical 5 cm incision 2 cm below the lower
border of cricoid cartilage, through skin, S/C fat ...
• Separation of Infra hyoid
Muscles:
• The fibrous median raphe
b/w the sternohyoid
muscles is defined and
separated with ...
• Identification of Thyroid Isthmus:
• Anatomical variations in size and
position of thyroid isthmus should
be expected
• ...
• Opening of the Trachea:
• Trachea is retracted in an
anterio-superior direction by
a tracheal hook below the
cricoid.
• ...
• Insertion & fixation of Tracheostomy
tube:
• The type of tracheosomy tube should
be selected prior to surgery.
• A Soft ...
• Wound Closure and Dressing:
– Wound loosely approximated with
skin sutures and sterile sponge
trachesotomy dressing is d...
Complication
• Intraoperative Complications
 Bleeding and injury to big vessels
 Injury to tracheoesophageal wall
 Pneu...
• Late Complications
 Tracheal Stenosis
 Granulation tissue
 Tracheocutaneus fistula
 Tracheo - inominate fistula
Micro Laryngeal tube placement for airway
management of tracheal stenosis
Percutaneous Tracheostomy
Percutaneous tracheostomy is a bedside procedure requiring a
small surgical field and avoiding t...
TECHNIQUE
Percutaneous tracheostomy is similar to using a
Seldinger technique to cannulate veins and arteries.
 The trach...
Difficult airway:
The patient must be easy to intubate in the event that alternative
techniques of ventilation by oro- or ...
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
Surgical management of difficult adult airway by Dr.Ashwin Menon
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Surgical management of difficult adult airway by Dr.Ashwin Menon

  1. 1. SURGICAL MANAGEMENT OF DIFFICULT ADULT AIRWAY DR.ASHWIN MENON M
  2. 2. CLINICAL ANATOMY
  3. 3. CLINICAL ANATOMY • Depth from skin: 18 mm to 32 mm • Length: 11 cm • Levels: C6 to Upper border of T5 • Rings: 16 to 20 • 2nd, 3rd, 4th rings are covered by thyroid isthmus • Cartilaginous ring C-shaped i.e. incomplete posteriorly. • The edges of the C are connected by trachealis muscle which helps in narrowing the tracheal lumen during coughing-Thus higher velocity of air is generated.
  4. 4. Definition No universally accepted definition of the difficult airway exists, but in broad terms, difficult airway control may be defined as problematic ventilation using a face mask, incomplete laryngoscopic visualization, or as a difficult intubation with standard airway equipment.
  5. 5.  The incidence of difficult intubation in the operating room ranges between 1.15% and 3.80% , with failed attempts in 0.05% to 0.35% of cases.  In the emergency department, difficult intubation occurs in 3.0% to 5.3% of cases with failure rates ranging from 0.5% to 1.1%.
  6. 6. Hypoxia from the difficult airway is commonly due to: 1. Excessive number of attempts performed by different operators unsuccessfully. 2. Subsequent attempts with the same devices. 3. Inadequate oxygenation between attempts. 4. Aspiration of gastric contents during face mask ventilation. 5. Traumatic oedema of the laryngeal aditus.
  7. 7. SIGNS & SYMPTOMS • Dyspnoea at rest or on exertion. • Stridor • Neck swelling • Voice changes • Haemoptysis • Dysphagia • Odynophagia • Cough
  8. 8. CAUSES OF DIFFICULT AIRWAY Pierre Robin Syndrome Cleft soft palate, glossoptosis, retrognathia Treacher Collins Syndrome Auricular & ocular defect, molar & mandibular hypoplasia Goldenhar’s Syndrome Auricular and ocular defects, molar and mandibular hypoplasia; occipitalization of atlas. Down’s Syndrome Poorly developed or absent bridge of the nose, macroglossia Kilppel-Feil Syndrome Congenital fusion of a variable number of cervical vertebrae; restriction of neck movement.
  9. 9. Pierre Robin Syndrome Treacher Collins Syndrome Goldenhar’s Syndrome Down’s Syndrome
  10. 10. Kilppel-Feil Syndrome
  11. 11. ACQUIRED Infections Supraglottitis Croup Abscess Ludwig’s angina Laryngeal oedema Laryngeal oedema Distortion of the airway and trismus Distortion of the airway and trismus. Arthritis Larynx Rheumatoid Arthritis Ankylosing spondylitis TMJ ankylosis, cricoarytenoid, deviation of restricted mobility of Cervical spine. Ankylosis of cervical spine, less commonly ankylosis of TMJ; lack of mobility of cervical spine. Tumor Benign Tumor Malignant Tumor Stenosis or distortion of the airway Fixation of larynx to adjacent tissues. Trauma Oedema of airway, unstable#, haematoma Obesity Short thick neck, sleep apnoea Acromegaly Macroglossia, Prognanthism Acute Burns Oedema of airway
  12. 12. AIRWAY ASSESSMENT INDICES 1. Individual indices. 2. Group indices - Wilson’s score - Benumof’s analysis - Saghei & safavi test - Lemon assesment 3. Radiological indices.
  13. 13. EVALUATION OF MANDIBULAR SPACE THYROMENTAL DISTANCE (PATIL’S TEST) • Distance from the tip of thyroid cartilage to the tip of inside of the mentum. • Neck fully extended / mouth closed Significance • Negative result – the larynx is reasonably anterior to the base of tongue >6.5 cm No problem with laryngoscopy & intubation 6 – 6.5 cm Difficult laryngoscopy but possible <6 cm Laryngoscopy may be impossible
  14. 14. HYO MENTAL DISTANCE • Distance between mentum and hyoid bone • Grade I : > 6cm • Grade II: 4 – 6cm • Grade III : < 4cm – Impossible laryngoscopy & Intubation
  15. 15. STERNOMENTAL DISTANCE (SAVVA TEST) • Distance from the upper border of the manubrium to the tip of mentum, neck fully extended, mouth closed • Minimal acceptable value – 12.5 cm • Single best predictor of difficult laryngoscopy and intubation ( Has high sensitivity & specificity).
  16. 16. CORMACK - LEHANE (Grading at direct laryngoscopy) Grade 1: Full exposure of glottis (anterior + posterior commissure) Grade 2: Anterior commissure not visualized Grade 3: Epiglottis only Grade 4: No glottic structure visible.
  17. 17. ASSESSMENT OF TMJ FUNCTION TM joint exhibits 2 function. 1. Rotation of the condyle in the synovial cavity. 2. Forward displacement of the condyle. First movement is responsible for 2-3cm mouth opening & the second is responsible for further 2-3cm mouth opening. Index finger is placed in front of the tragus & the thumb is placed in front of the the lower part of the mastoid process. patient is asked to open his mouth as wide as possible. Index finger in front of the tragus can be intented in its space and the thumb can feel the sliding movement of the condyle as the condyle of the mandible slides forward. SUBLUXATION OF THE MANDIBLE
  18. 18. INTER-INCISOR GAP • Inter-incisor distance with maximal mouth opening • Normal value > 5 cm / admits 3 fingers. Significance : • Positive results: Easy insertion of a 3 cm deep flange of the laryngoscope blade • < 3 cm: difficult laryngoscopy • < 2 cm: difficult LMA insertion • Affected by TMJ and upper cervical spine mobility
  19. 19. Significance- Class B and C: difficult laryngoscopy
  20. 20. UPPER LIP BITE /CATCH TEST • Class I: Lower incisors can bite the upper lip above vermilion line • Class II: can bite the upper lip below vermilion line • Class III: cannot bite the upper lip Significance • Assessment of mandibular movement and dental architecture • Less inter observer variability
  21. 21. Evaluation of Neck Mobility Patient is asked to hold the head erect, facing directly to the front  maximal head extension  angle traversed by the occlusal surface of upper teeth( can also measured by goniometer). Minimum 35⁰ extension is possible at AOJ in normal individuals.
  22. 22. Grade Reduction of A.O.Extension 1 none 2 One third 3 Two third 4 complete Grades 3 and 4 : Difficult laryngoscopy Grading of reduction in A.O.Extension Grade I : > 35° Grade II : 22-34° Grade III : 12-21° Grade IV : < 12°
  23. 23. ASSESMENT OF A.O. EXTENSION • Flexion movement of the cervical spine can be assessed by asking the patient to touch his manubrium sternii with his chin. If done, the above maneuver assures a neck flexion of 25- 35 degree. Flexion and the extension movement if within the normal range ,three axis ( oral,pharyngeal & laryngeal axis) can be brought into a straight line. can also be done by asking the patient to look at the floor and at wall after fully flexing and fixing the neck as shown
  24. 24. Warning sign of DELIKAN Place the index finger of each hand, one underneath the chin and one under the inferior occipital prominence with the head in neutral position. The patient is asked to fully extend the head on neck. If the finger under the chin is seen to be higher than the other, there would appear to be no difficulty with intubation. If level of both fingers remains same or the chin finger remains lower than the other, increased difficulty is predicted.
  25. 25. PALM PRINT & PRAYER SIGN Palm print sign: Patient’s fingers and palms painted with blue ink and pressed firmly against a white paper • Grade 1- all phalangeal areas visible • Grade 2- deficient inter phalangeal areas of 4th and 5th digits • Grade 3- deficient inter phalangeal areas of 2nd to 5th digits • Grade 4- only tips seen. Prayer sign: Limited-mobility joint syndrome (stiff-joint sydrome) 30-40% of Type I diabetics positive "prayer sign“. TM joint and C-spine (e.g. atlanto-occipital joint) may be involved
  26. 26. Palm Print as a Predictor of Difficult Airway in DM
  27. 27. PRAYER SIGN A positive "prayer sign" can be elicited on examination with the patient unable to approximate the palmar surfaces of the phalangeal joints while pressing their hands together; this represents cervical spine immobility and the potential for a difficult endotracheal intubation.
  28. 28. 1. SAGHEI & SAFAVI’S • Weight • Tongue protrusion • Mouth opening • Upper incisor length • Mallampati class • Head extension Any 3 indices if present - >80kg < 3.2cm <5cm >1.5cm >1 <70 degree Prolonged laryngoscopy GROUP INDICES
  29. 29. 2.“LEMON” Assessment • Look externally. • Evaluate the 3-3-2 rule. • Mallampati. • Obstruction. • Neck mobility.
  30. 30. L: Look Externally • Obesity or very small. • Short Muscular neck • Large breasts • Prominent Upper Incisors (Buck Teeth) • Receding Jaw (Dentures) • Burns • Facial Trauma • Stridor • Macroglossia
  31. 31. E Evaluate the 3-3-2 rule  3 fingers fit in mouth  3 fingers fit from mentum to hyoid cartilage  2 fingers fit from the floor of the mouth to the top of the thyroid cartilage
  32. 32. Cormack & Lehane Grading (Grading at direct laryngoscopy) Grade 1: Full exposure of glottis (anterior + posterior commissure) Grade 2: Anterior commissure not visualized. Grade 3: Epiglottis only. Grade 4: No glottic structure visible.
  33. 33. O Obstruction  Blood  Vomitus  Teeth  Epiglottis  Dentures  Tumors
  34. 34. N Neck mobility -Measurement of Atlanto-Occipital Angle
  35. 35. Grading of reduction in A.O.Extension Grade I : > 35° Grade II : 22-34° Grade III : 12-21° Grade IV : < 12°
  36. 36. 3. WILSON SCORING SYSTEM 5 factors - Weight, upper cervical spine mobility, jaw movement, receding mandible, buck teeth • Each factor: score 0-2 • Total score < 5 – Easy laryngoscopy. 6 to 7 - Moderate difficulty. > 7 - Severe difficulty.
  37. 37. 4. BENUMOF’S 11 PARAMETER ANALYSIS Parameter 1. Upper inciors length 2. Buck teeth 3. Subluxation 4. Interincisor gap 5. Palate configuration 6. Mallampati class Minimum acceptable value <1.5cm Absent Yes >3cm No arching/narrowness <2 7. TM distance 8. SMS compliance 9. Neck thickness 10. Length of neck 11. Head /neck mvt > 5cm Soft to palpation. Qualitative ( >33cm DI) >8cm Normal range 2 for mandibular space 3 for neck examination. 4-2-2-3 rule 4 for tooth 2 for inside of mouth
  38. 38. Rule of 1-2-3 • 1 finger breadth for subluxation of mandible. • 2 finger breadth for adequacy of mouth opening. • 3 finger breadth for hyomental distance. Significant difficulty in 2 or more of these components requires detailed examination. • 4 finger breath for thyromental distance • 5 movements- ability to flex the neck upto the manubrium sterni, extension at the AOJ, rotation of the head along with right & left movement of the head to touch the shoulder. Rule of 1-2-3-4-5 • 3 finger in the interdental space. • 3 finger between mentum and hyoid bone. • 3 finger between thyroid cartilage & sternum. Significant difficulty in 2 or more of these components requires detailed examination. Rule of Three’s
  39. 39. 1. X-Ray neck (lateral view) : • Occiput - C1 spinous process distance< 5mm. • Increase in posterior mandible depth > 2.5cm. • Ratio of effective mandibular length to its posterior depth <3.6. • Tracheal compression. RADIOGRAPHIC PREDICTORS
  40. 40. 2. CT Scan: • Tumors of floor of mouth, pharynx, larynx • Cervical spine trauma, inflammation • Mediastinal mass 3. Helical CT (3D-reconstruction): • Exact location and degree of airway compression • Flow volume loop • Acoustic response measurement • Ultra sound guided • CT / MRI • Flexible bronchoscope ADVANCED INDICES
  41. 41. Surgical Airway Procedures
  42. 42. Types of Surgical Airway Procedures 1. Laryngotomy (cricothyrotomy) 2. Elective Temporary Tracheostomy: – This is performed as a planned procedure, usually under G/A, as a temporary stage in patients management 3. Permanent Tracheostomy: – In an operation involving removal of larynx. Tracheal remnant is brought to surface as a permanent stoma.
  43. 43. 4. Emergency Tracheostomy – Nowadays there ought to be very few indications for this. On occasion a patient will be seen first with a large laryngeal tumor and require an emergency tracheostomy. – To have to do an emergency tracheostomy in conditions such as acute epiglottitis, respiratory failure, coma etc is a sign of poor forward planning in the management of the patient. – It is to be done under L/A. 5. Micro Laryngeal tube placement for airway management of tracheal stenosis 6. Percutaneous Tracheostomy
  44. 44. 1. Laryngotomy (cricothyrotomy) “Laryngotomy is opening the airway through the cricothyroid membrane” • It is used for acute complete airway obstruction when endotracheal intubation/ ventilation is not possible. • The procedure can be accomplished in 15 to 30 seconds.
  45. 45. Techniques 1. Standard technique 2. Rapid four step technique 3. Seldinger technique
  46. 46. 1. Standard technique Step 1: Immobilize the larynx and palpate the cricothyroid membrane. Step 2: Incise the skin vertically. Step 3: Incise the cricothyroid membrane horizontally.
  47. 47. Step 4: Insert the tracheal hook. Step 5: Insert the Trousseau dilator and open it to enlarge the incision vertically.
  48. 48. Step 6: Insert the tracheostomy tube. Step 7: Remove the obturator.
  49. 49. Step 8: Insert the inner cannula. Step 9: Attach the tracheostomy tube to the mechanical ventilator or a bag valve device.
  50. 50. 2. Rapid four step technique The rapid four-step technique (RFST) can be done quickly and requires only a number 20 scalpel, hook, and cuffed tracheostomy tube. For this technique, stand at the head of the patient in the same position as when performing endotracheal intubation. Next, perform the following four steps in sequence: Step 1: Identify the cricothyroid membrane by palpation. Step 2: Make a horizontal stab incision through both skin and cricothyroid membrane with the scalpel. The size of the skin incision is approximately 1 to 2 cm.
  51. 51. STEP 2
  52. 52. Step 3: Prior to removal of the scalpel, the hook is placed and directed inferiorly. Caudal traction is used to stabilize the larynx. This marks a significant change from the standard method, in which the tracheal hook is placed under the thyroid cartilage. Also in contrast with the Standard technique, this step does not require an assistant to manage the hook. Step 4: Insert the tracheostomy tube into the trachea STEP 3 STEP 4
  53. 53. 3. Seldinger technique Commercial cricothyrotomy kits are available that contain all essential equipment to perform the Seldinger technique. As an example, the Cook® Melker kit includes the following: a. 6 ml Syringe b. 18 Gauge Needle With Overlying Catheter c. Guide Wire d. Tissue Dilator e. Modified Airway Catheter f. Tracheostomy Tape.
  54. 54. Technique Step 1: Be certain all equipment is present and functioning. Insert the dilator into the airway catheter. Palpate the cricothyroid membrane with the index finger of the non dominant hand while immobilizing the larynx with the thumb and middle finger. Step 2: Attach the introducer needle to the syringe, and, if time permits, fill it with a small amount of saline or water. Apply a small amount of negative pressure on the syringe and insert the needle carefully into the cricothyroid membrane at a 45 degree angle with the needle oriented caudaly.
  55. 55. Be careful not to insert it too far as this may damage the posterior wall of the trachea. Watch for the appearance of bubbles in the water, or feel for the free flow of air into the syringe, indicating the needle is in the airway. Step 3: When bubbles appear, remove the syringe and then remove the needle, leaving the catheter in place, with its distal tip in the trachea. Thread the guide wire through the catheter into the trachea. Remove the catheter, sliding it over the guide wire. Step 4: Make a 1 to 2 cm incision in the skin at the entrance point of the guide wire with a number 15 scalpel blade. The cricothyroid membrane must also be incised at this point.
  56. 56. Step 5: Thread the combined tissue dilator-airway catheter over the guide wire and advance it into the skin incision. Following the curve of the dilator, advance the dilator-catheter unit through the subcutaneous soft tissue and into the trachea until the cuff of the catheter is flush against the skin of the neck. A slight twisting motion may be needed. Step 6: Remove the tissue dilator and guide wire as a unit, leaving the airway catheter in the trachea. Step 7: Secure the airway catheter to the neck with the 'trach tape' provided in the kit or other appropriate means.
  57. 57. COMPLICATIONS Emergency surgical cricothyrotomy has a much higher complication rate than elective cricothyrotomy. Early complications • Bleeding. • Laceration of the thyroid cartilage, cricoid cartilage, or tracheal rings. • Perforation of the posterior trachea. • Unintentional tracheostomy. • Passage of the tube into an extra tracheal location (ie, false tract). • Infection.
  58. 58. • Long-term complications include subglottic stenosis and voice changes. • Rapid Four Step Technique (RFST) involves cricoid injury.
  59. 59. Tracheostomy • A tracheotomy is an incision into the trachea (windpipe) that forms a temporary or permanent opening which is called a tracheostomy. • Best performed as an elective procedure under endotracheal anesthesia, in an adequately equipped operation theatre and aseptic measures. • Position: o Supine position with a sandbag under patient’s shoulders to give extension of head and prominence to the trachea and larynx. o Under local anesthesia a compromised position of extension will have to be found.
  60. 60. • Anaesthesia: – Endotracheal anaesthesia or – Local anaesthesia (in obstructive pathologies) obtained by injection of skin and subcutaneous tissues with Xylocaine 2% 1:200000 adrenaline solution. – Drugs which depress resp. system better avoided.
  61. 61. • Incision: – A Transverse/vertical 5 cm incision 2 cm below the lower border of cricoid cartilage, through skin, S/C fat and deep cervical fascia. – Flaps are raised by undermining with blunt dissection to expose ant. Jugular veins and infrahyoid muscles.
  62. 62. • Separation of Infra hyoid Muscles: • The fibrous median raphe b/w the sternohyoid muscles is defined and separated with blunt dissection – The sternothyroid muscles on a deeper plane are identified and retracted laterally.
  63. 63. • Identification of Thyroid Isthmus: • Anatomical variations in size and position of thyroid isthmus should be expected • The thyroid isthmus may be small and not interfere with the approach but in most patients it is of sufficient size to need dividing. • A small horizontal incision is made in the pre tracheal fascia • Pull thyroid isthmus up or down or • Divide the thyroid isthmus b/w large haemostats and ligate or are over sewn
  64. 64. • Opening of the Trachea: • Trachea is retracted in an anterio-superior direction by a tracheal hook below the cricoid. • A transverse incision into intercartilaginous membrane below the 2nd or 3rd ring and converted into a circular opening.
  65. 65. • Insertion & fixation of Tracheostomy tube: • The type of tracheosomy tube should be selected prior to surgery. • A Soft cuffed tube (ported) will be needed if anaesthesia is to be continued or positive pressure ventilation required or if entry of secretions and blood into trachea are to be avoided. • Position of tube is retained by tapes passed around the neck and tied to each other on one side of neck.
  66. 66. • Wound Closure and Dressing: – Wound loosely approximated with skin sutures and sterile sponge trachesotomy dressing is done around the tube. – There should be sufficient space remaining around the tube to minimize the danger of subcutaneous emphysema.
  67. 67. Complication • Intraoperative Complications  Bleeding and injury to big vessels  Injury to tracheoesophageal wall  Pneumothorax • Early Complications  Bleeding  Tracheostomy tube obstruction  Tracheostomy tube displacement  Infection
  68. 68. • Late Complications  Tracheal Stenosis  Granulation tissue  Tracheocutaneus fistula  Tracheo - inominate fistula
  69. 69. Micro Laryngeal tube placement for airway management of tracheal stenosis
  70. 70. Percutaneous Tracheostomy Percutaneous tracheostomy is a bedside procedure requiring a small surgical field and avoiding the need for an operating room. It was popularised in the 1990’s as a minimally invasive technique requiring only a small skin incision. Anatomical factors: Laryngeal and tracheal anatomy may vary widely depending on the patient and his/her age. A larynx situated in the thoracic inlet (laryngoptosis) makes all kinds of tracheostomy difficult and one gets critically close to big mediastinal vessels. In such cases open dissection under direct surgical vision is required.
  71. 71. TECHNIQUE Percutaneous tracheostomy is similar to using a Seldinger technique to cannulate veins and arteries.  The trachea is entered percutaneously with a thin needle through which a guide wire is advanced into the trachea.  A bougie is passed over the guide wire and the tract between the skin and trachea is dilated until a tracheostomy tube can be advanced into the trachea. Unlike with conventional surgical tracheostomy, the trachea, thyroid gland and vascular structures cannot be visualised during placement of the tracheostomy or to achieve haemostasis should bleeding occur.
  72. 72. Difficult airway: The patient must be easy to intubate in the event that alternative techniques of ventilation by oro- or naso-tracheal intubation is required should the patient’s airway obstruct following removal of the endotracheal tube e.g. with in-correct placement of the percutaneous tracheostomy, accidental decannulation, bleeding etc.
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Surgical management of difficult adult airway

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