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Infra-glottic invasive airways

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Presentation on theme: "Infra-glottic invasive airways"— Presentation transcript:

1 Infra-glottic invasive airways
Dr. S.A.Rajkumar, Intensivist, Tirunelveli.

2 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

3 Definition 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 access Access to the airway by means of opening the trachea below the glottis for ventilation or maintenance of airway. Non-invasive & Invasive Invasive

4 Infra-Glottic Airway Access
Broad classification: Cricothyrotomy Tracheostomy Access to them by: Percutaneously Surgically

5 Infra-Glottic Airway Access
Done usually for: Emergency ICU patients situations CNV / CNI Conditions when the airway access becomes an emergency procedure For airway access or maintenance of airway

6 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 in OT Emergency ward ICU other departments as an emergency

7 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 - safety

8 Techniques Percutaneous jet ventilation Retrograde intubation
(through needle) [and needle ventilation] Retrograde intubation Percutaneous cricothyrotomy Percutaneous tracheostomy Surgical cricothyrotomy Surgical tracheostomy

9 Anatomy

10 Anatomy – Lateral View

11 Vascular Anatomy

12 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.

13 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.

14 Anaesthesia IV sedation Topical 1% Lidocaine – Intratracheal
Midazolam Fentanyl / other narcotics Propofol Topical 1% Lidocaine – Intratracheal Nerve blocks Superior Laryngeal nerve Glossopharyngeal nerve

15 Percutaneous Jet Ventilation

16 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



19 Retrograde Intubation

20 Retrograde Intubation
Translaryngeal guided intubation Popularised by Waters in 1963. 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

21 Retrograde Intubation
- Routine Technique Procedure Through CTM epidural needle is pierced.

22 Retrograde Intubation Routine Technique
Epidural catheter is inserted into oral cavity. Catheter tip is taken out of mouth.

23 Retrograde Intubation Routine Technique
ET tube railroaded and pulled into the trachea with the help of catheter.

24 Retrograde Intubation Routine Technique
Then the epidural catheter is removed from the oral end.

25 Retrograde Intubation Routine Technique
Now the ET tube is kept in situ.

26 Retrograde Intubation
- Silk Pull-Through Technique Here silk is threaded with the help of the epidural catheter.

27 Retrograde Intubation Silk Pull-Through Technique
Silk is tied at Murphy’s eye of ET tube

28 Retrograde Intubation Silk Pull-Through Technique
ET tube is placed into the trachea with the help of pulling of silk

29 Retrograde Intubation Silk Pull-Through Technique
Advantage: Reintubation is easy

30 Retrograde Intubation
Complications: esophageal perforation hemoptysis hematoma edema laryngospasm infection, tracheitis tracheal fistula vocal cord damage subcutaneous emphysema

31 Percutaneous Cricothyrotomy

32 Percutaneous 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 and s percutaneous dilatational tracheostomy.

33 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

34 Percutaneous Cricothyrotomy
Relative Contraindications: intubated patients (> 3 days) - subglottic stenosis infants and children (< 10 years) - narrow airway preexisting laryngeal disease bleeding disorders

35 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 [Used in emergencies In expert hands – 90 seconds (Ref: Benumof)]

36 Percutaneous Cricothyrotomy - Technique
entry through the CTM.

37 Percutaneous Cricothyrotomy - Technique
usually horizontal incision of skin.

38 Percutaneous Cricothyrotomy - Technique
entry by 14 Fr. introducer and 17 G needle. the position is confirmed by air aspiration.

39 Percutaneous Cricothyrotomy - Technique
then guidewire is inserted into trachea.

40 Percutaneous Cricothyrotomy - Technique
serial dilator or horn like single dilator or tracheostomy tube loaded dilator.

41 Percutaneous Cricothyrotomy - Technique
now the tracheostomy tube is kept in situ.

42 Percutaneous Cricothyrotomy
Complications 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

43 Percutaneous Tracheostomy

44 Percutaneous 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.

45 Cricothyrotomy & Tracheostomy
Sl. 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

46 Percutaneous Tracheostomy
Indications: usually done in ICU patients for continuation of airway maintenance weaning from ventilator obstruction in airway tracheal toileting in children in emergency situations also in elective conditions (as Cricothyrotomy is not given preference in children)

47 Percutaneous Tracheostomy
Relative 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.]

48 Percutaneous Tracheostomy - Technique
after adequate analgesia incision of skin over trachea is made at the access site.

49 Percutaneous Tracheostomy - Technique
needle position is confirmed by aspiration of air as well as fiberoptic viewing of trachea.

50 Percutaneous Tracheostomy - Technique
through 14 G needle a guidewire is inserted.

51 Percutaneous Tracheostomy - Technique
through guidewire with a horn like gradational dilator, trachea is dilated upto the required size.

52 Percutaneous Tracheostomy - Technique
then the tracheostomy tube is kept in situ.

53 Cooks dilator set (ciaglia technique)

54 Percutaneous Tracheostomy

55 Percutaneous Tracheostomy
Complications Early: hemorrhage subcutaneous emphysema pneumothorax recurrent laryngeal nerve injury Late: infection TE fistula granuloma laryngotracheal stenosis

56 Surgical Invasive Airways

57 Surgical Cricothyrotomy
Open Cricothyrotomy: instead of piercing of needle, incision is made and tracheostomy tube is inserted. Advantages: rapid procedure – in emergencies special instrumentations not required Disadvantages: Surgeon’s job OT required – cost factor bleeding

58 Surgical Cricothyrotomy
Indications: trauma patients – to secure airway faster airway obstruction due to trauma FB stenosis mass Relative Contraindications: in children laryngeal fracture

59 Surgical Tracheostomy
} Faster Safer Definite 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 Gold standard

60 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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