Presentation on theme: "Infra-glottic invasive airways"— Presentation transcript:
1Infra-glottic invasive airways Dr. S.A.Rajkumar, Intensivist, Tirunelveli.
2Introduction Airway access can be Supra-GlotticInfra-GlotticRoutine ET intubation is by supra-glotticAlternative access to airway includessupra-glottic and infra-glottic access
3Definition Supra-Glottic airway access Infra-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.Non-invasive& InvasiveInvasive
4Infra-Glottic Airway Access Broad classification:Cricothyrotomy TracheostomyAccess to them by:Percutaneously Surgically
5Infra-Glottic Airway Access Done usually for:Emergency ICU patientssituationsCNV / CNIConditionswhen the airway access becomes an emergency procedureFor airway access or maintenance of airway
6CNV / CNICould 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 wardICUother departments as an emergency
7History 3000 years ago – India and Egypt 1300 years ago – Spanish person VesaliusUpto 1970 – Chavelier Jackson advised against Percutaneous procedures.After 1970 invent of Ciaglia dilatational techniques and Cooks dilational set, these were popularised.Fiberoptic bronchoscopy - safety
12Cricothyroid 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.
13Tracheal RingsUsual 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.
14Anaesthesia IV sedation Topical 1% Lidocaine – Intratracheal MidazolamFentanyl / other narcoticsPropofolTopical 1% Lidocaine – IntratrachealNerve blocksSuperior Laryngeal nerveGlossopharyngeal nerve
32Percutaneous Cricothyrotomy Definition: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.
33Percutaneous Cricothyrotomy Indications:failed intubationhead and neck traumaacute respiratory obstructionalternative to tracheostomyIt is done as an emergency procedureduring transport of patientsin the prehospital scenarioin the emergency departmentin ICUin OT
34Percutaneous Cricothyrotomy Relative Contraindications:intubated patients (> 3 days)- subglottic stenosisinfants and children (< 10 years)- narrow airwaypreexisting laryngeal diseasebleeding disorders
35Percutaneous Cricothyrotomy TechniquesMelker percutaneous dilational cricothyrotomy devicePertrach percutaneous dilational cricothyrotomy device (guidewire and dilator are in a single unit)Nutrake percutaneous dilational cricothyrotomy devicePortex and Melker Military (without guidewire) device[Used in emergenciesIn expert hands – 90 seconds (Ref: Benumof)]
36Percutaneous Cricothyrotomy - Technique entry through the CTM.
37Percutaneous Cricothyrotomy - Technique usually horizontal incision of skin.
38Percutaneous Cricothyrotomy - Technique entry by 14 Fr. introducer and 17 G needle.the position is confirmed by air aspiration.
39Percutaneous Cricothyrotomy - Technique then guidewire is inserted into trachea.
40Percutaneous Cricothyrotomy - Technique serial dilator or horn like single dilator or tracheostomy tube loaded dilator.
41Percutaneous Cricothyrotomy - Technique now the tracheostomy tube is kept in situ.
44Percutaneous Tracheostomy Definition: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.
45Cricothyrotomy & Tracheostomy Sl. No.CricothyrotomyTracheostomy1.Used in emergenciesSlightly more time consuming2.As a temporary airway accessLong term maintenance of airway3.Fiberoptic view not necessaryRecommended4.LA / Sedation less requiredAdequate analgesia is needed5.Done only in adultsIn adults and children6.Less bleeding & complicationsNeeds more expertise7.Ideal in obese patients, huge thyroid, innominate arteryIdeal for upper airway masses8.Speed and simplicityFor ICU patients
46Percutaneous Tracheostomy Indications:usually done in ICU patients forcontinuation of airway maintenanceweaning from ventilatorobstruction in airwaytracheal toiletingin childrenin emergency situationsalso in elective conditions (as Cricothyrotomy is not given preference in children)
47Percutaneous Tracheostomy Relative Contraindications:midline neck mass (including thyroid)high innominate arteryinability to palpate cricoid and tracheaunprotected airwaywith PEEP > 20 cmH2Ocoagulopathy[Now it is recommended to use fiberoptic bronchoscope to add safety to this procedure.]
48Percutaneous Tracheostomy - Technique after adequate analgesia incision of skin over trachea is made at the access site.
49Percutaneous Tracheostomy - Technique needle position is confirmed by aspiration of air as well as fiberoptic viewing of trachea.
50Percutaneous Tracheostomy - Technique through 14 G needle a guidewire is inserted.
51Percutaneous Tracheostomy - Technique through guidewire with a horn like gradational dilator, trachea is dilated upto the required size.
52Percutaneous Tracheostomy - Technique then the tracheostomy tube is kept in situ.
57Surgical Cricothyrotomy Open Cricothyrotomy:instead of piercing of needle, incision is made and tracheostomy tube is inserted.Advantages:rapid procedure – in emergenciesspecial instrumentations not requiredDisadvantages:Surgeon’s jobOT required – cost factorbleeding
58Surgical Cricothyrotomy Indications:trauma patients – to secure airway fasterairway obstruction due totraumaFBstenosismassRelative Contraindications:in childrenlaryngeal fracture
59Surgical Tracheostomy }FasterSaferDefiniteThe limitations are:it needs a surgeon to perform,it requires an operating room (becomes expensive)it requires an anesthesiologist to be with the patientGold standard
60Take home messageInfra-glottic invasive airway access techniques are easy to perform – only need is mindsetCricothyrotomy for emergenciesTracheostomy for ICU patients and paediatric patients.Our goal is to be a safe anaesthesiologist. To be safe at times you have to be bold.