infra- glottic invasive airways

INFRA-GLOTTIC

INVASIVE AIRWAYS

Dr. S.A.Rajkumar, Intensivist, Tirunelveli.

INTRODUCTION Airway access can be

Supra-Glottic Infra-Glottic

Routine ET intubation is by supra-glottic

Alternative access to airway includes supra-glottic and infra-glottic access

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DEFINITIONSupra-Glottic airway access

Access to the airway by any means from the upper part of glottis into the trachea for ventilation or maintenance of airway.

Infra-Glottic airway accessAccess to the airway by means of opening

the trachea below the glottis for ventilation or maintenance of airway.

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Non-invasive& Invasive

Invasive

INFRA-GLOTTIC AIRWAY ACCESSBroad classification:

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CricothyrotomyTracheostomyAccess to them by:

Percutaneously Surgically

INFRA-GLOTTIC AIRWAY ACCESSDone usually for:

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Emergency ICU patientssituations

CNV / CNIConditions when the airway access

becomes an emergency procedure

For airway access or maintenance of airway

CNV / CNI Could Not Ventilate / Could Not Intubate

condition [airway can not be maintained by either mask ventilation or intubation] warrents emergency methods of alternative airway access.

Required inOTEmergency ward ICUother departments as an emergency 2010K AN ISAC O N

HISTORY 3000 years ago – India and Egypt 1300 years ago – Spanish person Vesalius Upto 1970 – Chavelier Jackson advised

against Percutaneous procedures. After 1970 invent of Ciaglia dilatational

techniques and Cooks dilational set, these were popularised.

Fiberoptic bronchoscopy - safety2010K AN ISAC O N

TECHNIQUESPercutaneous jet ventilation

(through needle)[and needle ventilation]

Retrograde intubationPercutaneous cricothyrotomyPercutaneous tracheostomySurgical cricothyrotomySurgical tracheostomy 2010K AN ISAC O N

ANATOMY

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ANATOMY – LATERAL VIEW

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VASCULAR ANATOMY

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CRICOTHYROID MEMBRANE (CTM)

Between thyroid cartilage above and cricoid cartilage below.

1 cm in height and 2 cm in width. Central part – thick and triangular

shape with apex below. (Conus elasticus)

Does not calcify with age. Upper part of membrane – vascular

anastamosis. 2010K AN ISAC O N

TRACHEAL RINGS Usual entry between 2nd and 3rd ring

or 3rd and 4th ring. Tracheal rings are cartilagenous in

front and membraneous behind. Space between the rings is 1-2 mm.

(but expandable) Thyroid gland comes in front. Innominate artery arches below.

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ANAESTHESIA IV sedation

MidazolamFentanyl / other narcoticsPropofol

Topical 1% Lidocaine – Intratracheal Nerve blocks

Superior Laryngeal nerveGlossopharyngeal nerve

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PERCUTANEOUS JET VENTILATION

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PERCUTANEOUS JET VENTILATION Transtracheal Jet ventilation (TTJV) Used in

CNV / CNI situations Surgeries of upper airways Interim procedure till ET is placed

12 – 16 G needle High pressure O2 source [0.8 – 4 bar] O2 concentration 30 – 100 % I:E ratio = 1:1 Ventilation frequency = 150 cycles per second Venturi principle involves 2010K AN ISAC O N

TTJV

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TTJV

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RETROGRADE INTUBATION

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RETROGRADE INTUBATIONTranslaryngeal guided intubation Popularised by Waters in 1963.

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Indications: CNV / CNI condition upper airway trauma bleeding and secretions – unable to see glottis

Relative Contraindications: unfavourable anatomy (obesity, enlarged thyroid) laryngotracheal diseases coagulopathy infection

RETROGRADE INTUBATION

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Procedure Through CTM epidural needle is pierced.

- ROUTINE TECHNIQUE

RETROGRADE INTUBATION ROUTINE TECHNIQUE

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Epidural catheter is inserted into oral cavity. Catheter tip is taken out of mouth.

RETROGRADE INTUBATION ROUTINE TECHNIQUE

2010K AN ISAC O N ET tube railroaded and pulled into the trachea with the help of catheter.

RETROGRADE INTUBATION ROUTINE TECHNIQUE

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Then the epidural catheter is removed from the oral end.

RETROGRADE INTUBATION ROUTINE TECHNIQUE

2010K AN ISAC O N Now the ET tube is kept in situ.

RETROGRADE INTUBATION

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Here silk is threaded with the help of the epidural catheter.

- SILK PULL-THROUGH TECHNIQUE

RETROGRADE INTUBATION SILK PULL-THROUGH TECHNIQUE

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Silk is tied at Murphy’s eye of ET tube

RETROGRADE INTUBATION SILK PULL-THROUGH TECHNIQUE

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ET tube is placed into the trachea with the help of pulling of silk

RETROGRADE INTUBATION SILK PULL-THROUGH TECHNIQUE

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Advantage: Reintubation is easy

RETROGRADE INTUBATIONComplications: esophageal perforation hemoptysis hematoma edema laryngospasm infection, tracheitis tracheal fistula vocal cord damage subcutaneous emphysema 2010K AN ISAC O N

PERCUTANEOUS CRICOTHYROTO

MY

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PERCUTANEOUS CRICOTHYROTOMYDefinition:

Cricothyrotomy can be defined as a technique for providing an opening in the space between the anterior inferior border of the thyroid cartilage and the anterior superior border of the cricoid cartilage for the purpose of gaining access to the airway.

Other names:s coniotomy, s cricothyroidotomy, s cricothyrostomy,s intercricothyrotomy, s minitracheostomy ands percutaneous dilatational tracheostomy.

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PERCUTANEOUS CRICOTHYROTOMY

Indications: failed intubation head and neck trauma acute respiratory obstruction alternative to tracheostomy

It is done as an emergency procedure during transport of patients in the prehospital scenario in the emergency department in ICU in OT

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PERCUTANEOUS CRICOTHYROTOMY

Relative Contraindications: intubated patients (> 3 days)

- subglottic stenosis infants and children (< 10 years)

- narrow airway preexisting laryngeal disease bleeding disorders

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PERCUTANEOUS CRICOTHYROTOMY

Techniques Melker percutaneous dilational cricothyrotomy device Pertrach percutaneous dilational cricothyrotomy device

(guidewire and dilator are in a single unit) Nutrake percutaneous dilational cricothyrotomy device Portex and Melker Military (without guidewire) device

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[Used in emergenciesIn expert hands – 90 seconds (Ref: Benumof)]

PERCUTANEOUS CRICOTHYROTOMY - TECHNIQUE

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entry through the CTM.

PERCUTANEOUS CRICOTHYROTOMY - TECHNIQUE

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usually horizontal incision of skin.

PERCUTANEOUS CRICOTHYROTOMY - TECHNIQUE

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entry by 14 Fr. introducer and 17 G needle.

the position is confirmed by air aspiration.

PERCUTANEOUS CRICOTHYROTOMY - TECHNIQUE

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then guidewire is inserted into trachea.

PERCUTANEOUS CRICOTHYROTOMY - TECHNIQUE

2010K AN ISAC O N serial dilator or horn like single dilator or tracheostomy tube loaded dilator.

PERCUTANEOUS CRICOTHYROTOMY - TECHNIQUE

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now the tracheostomy tube is kept in situ.

PERCUTANEOUS CRICOTHYROTOMYComplications Early:

asphyxia hemorrhage improper or unsuccessful tube placement subcutaneous emphysema pneumothorax esophageal / mediastinal perforation vocal cord injury

Late: tracheal / subglottic stenosis TE fistula infection tracheomalacia

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PERCUTANEOUS TRACHEOSTOMY

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PERCUTANEOUS TRACHEOSTOMYDefinition:

Tracheostomy can be defined as a technique for providing an opening in the space between any two tracheal rings (usually between 2nd and 3rd or 3rd and 4th rings) for the purpose of gaining access to the airway.

Except the entry point it is same like crico thyrotomy. Yet because of entry point there are some basic differences between two.

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CRICOTHYROTOMY & TRACHEOSTOMYSl. No. Cricothyrotomy Tracheostomy

1. Used in emergencies Slightly more time consuming

2. As a temporary airway access Long term maintenance of airway

3. Fiberoptic view not necessary Recommended

4. LA / Sedation less required Adequate analgesia is needed

5. Done only in adults In adults and children

6. Less bleeding & complications Needs more expertise

7. Ideal in obese patients, huge thyroid, innominate artery Ideal for upper airway masses

8. Speed and simplicity For ICU patients

PERCUTANEOUS TRACHEOSTOMYIndications: usually done in ICU patients for

continuation of airway maintenanceweaning from ventilatorobstruction in airwaytracheal toileting

in childrenin emergency situationsalso in elective conditions (as Cricothyrotomy

is not given preference in children) 2010K AN ISAC O N

PERCUTANEOUS TRACHEOSTOMYRelative Contraindications: midline neck mass (including thyroid) high innominate artery inability to palpate cricoid and trachea unprotected airway with PEEP > 20 cmH2O coagulopathy

[Now it is recommended to use fiberoptic bronchoscope to add safety to this procedure.]

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PERCUTANEOUS TRACHEOSTOMY - TECHNIQUE

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after adequate analgesia incision of skin over trachea is made at the access site.

PERCUTANEOUS TRACHEOSTOMY - TECHNIQUE

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needle position is confirmed by aspiration of air as well as fiberoptic viewing of trachea.

PERCUTANEOUS TRACHEOSTOMY - TECHNIQUE

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PERCUTANEOUS TRACHEOSTOMY - TECHNIQUE

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through guidewire with a horn like gradational dilator, trachea is dilated upto the required size.

PERCUTANEOUS TRACHEOSTOMY - TECHNIQUE

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then the tracheostomy tube is kept in situ.

COOKS DILATOR SET (CIAGLIA TECHNIQUE)

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PERCUTANEOUS TRACHEOSTOMY http://www.youtube.com/watch?

v=XkGHpzrEI0Y

PERCUTANEOUS TRACHEOSTOMYComplications Early:

hemorrhagesubcutaneous emphysemapneumothoraxrecurrent laryngeal nerve injury

Late: infectionTE fistulagranuloma laryngotracheal stenosis 2010K AN ISAC O N

SURGICAL INVASIVE AIRWAYS

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SURGICAL CRICOTHYROTOMY Open Cricothyrotomy:

instead of piercing of needle, incision is made and tracheostomy tube is inserted.

Advantages:rapid procedure – in emergenciesspecial instrumentations not required

Disadvantages:Surgeon’s jobOT required – cost factorbleeding

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SURGICAL CRICOTHYROTOMY Indications:

trauma patients – to secure airway fasterairway obstruction due to

trauma FB stenosis mass

Relative Contraindications: in children laryngeal fracture

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SURGICAL TRACHEOSTOMYFaster

SaferDefinite

The limitations are:it needs a surgeon to perform,it requires an operating room (becomes expensive)

it requires an anesthesiologist to be with the patient

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Gold standard

TAKE HOME MESSAGE Infra-glottic invasive airway access

techniques are easy to perform – only need is mindset

Cricothyrotomy for emergencies Tracheostomy for ICU patients and paediatric

patients.Our goal is to be a safe

anaesthesiologist. To be safe at times you have to be bold.

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THANK YOU