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

17. TTJV

18. TTJV

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.

61. THANK YOU