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I NFRA - GLOTTIC INVASIVE AIRWAYS Dr. S.A.Rajkumar, Intensivist, Tirunelveli.

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Presentation on theme: "I NFRA - GLOTTIC INVASIVE AIRWAYS Dr. S.A.Rajkumar, Intensivist, Tirunelveli."— Presentation transcript:

1 I NFRA - GLOTTIC INVASIVE AIRWAYS Dr. S.A.Rajkumar, Intensivist, Tirunelveli.

2 I NTRODUCTION 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 D EFINITION Supra-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 I NFRA -G LOTTIC A IRWAY A CCESS Broad classification: CricothyrotomyTracheostomy Access to them by: PercutaneouslySurgically

5 I NFRA -G LOTTIC A IRWAY A CCESS Done usually for: EmergencyICU 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 H ISTORY 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 T ECHNIQUES Percutaneous jet ventilation (through needle) [and needle ventilation] Retrograde intubation Percutaneous cricothyrotomy Percutaneous tracheostomy Surgical cricothyrotomy Surgical tracheostomy

9 A NATOMY

10 A NATOMY – L ATERAL V IEW

11 V ASCULAR A NATOMY

12 C RICOTHYROID M EMBRANE (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 T RACHEAL R INGS Usual entry between 2 nd and 3 rd ring or 3 rd and 4 th 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 A NAESTHESIA IV sedation Midazolam Fentanyl / other narcotics Propofol Topical 1% Lidocaine – Intratracheal Nerve blocks Superior Laryngeal nerve Glossopharyngeal nerve

15 P ERCUTANEOUS J ET V ENTILATION

16 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 O 2 source [0.8 – 4 bar] O 2 concentration 30 – 100 % I:E ratio = 1:1 Ventilation frequency = 150 cycles per second Venturi principle involves

17 TTJV

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19 R ETROGRADE I NTUBATION

20 Translaryngeal guided intubation Popularised by Waters in 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 R ETROGRADE I NTUBATION Procedure Through CTM epidural needle is pierced. - R OUTINE T ECHNIQUE

22 R ETROGRADE I NTUBATION R OUTINE T ECHNIQUE Epidural catheter is inserted into oral cavity. Catheter tip is taken out of mouth.

23 R ETROGRADE I NTUBATION R OUTINE T ECHNIQUE ET tube railroaded and pulled into the trachea with the help of catheter.

24 R ETROGRADE I NTUBATION R OUTINE T ECHNIQUE Then the epidural catheter is removed from the oral end.

25 R ETROGRADE I NTUBATION R OUTINE T ECHNIQUE Now the ET tube is kept in situ.

26 R ETROGRADE I NTUBATION Here silk is threaded with the help of the epidural catheter. - S ILK P ULL -T HROUGH T ECHNIQUE

27 R ETROGRADE I NTUBATION S ILK P ULL -T HROUGH T ECHNIQUE Silk is tied at Murphys eye of ET tube

28 R ETROGRADE I NTUBATION S ILK P ULL -T HROUGH T ECHNIQUE ET tube is placed into the trachea with the help of pulling of silk

29 R ETROGRADE I NTUBATION S ILK P ULL -T HROUGH T ECHNIQUE Advantage: Reintubation is easy

30 R ETROGRADE I NTUBATION Complications: esophageal perforation hemoptysis hematoma edema laryngospasm infection, tracheitis tracheal fistula vocal cord damage subcutaneous emphysema

31 P ERCUTANEOUS C RICOTHYROTOMY

32 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: coniotomy, cricothyroidotomy, cricothyrostomy, intercricothyrotomy, minitracheostomy and percutaneous dilatational tracheostomy.

33 P ERCUTANEOUS C RICOTHYROTOMY 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 P ERCUTANEOUS C RICOTHYROTOMY Relative Contraindications: intubated patients (> 3 days) - subglottic stenosis infants and children (< 10 years) - narrow airway preexisting laryngeal disease bleeding disorders

35 P ERCUTANEOUS C RICOTHYROTOMY 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 P ERCUTANEOUS C RICOTHYROTOMY - T ECHNIQUE entry through the CTM.

37 P ERCUTANEOUS C RICOTHYROTOMY - T ECHNIQUE usually horizontal incision of skin.

38 P ERCUTANEOUS C RICOTHYROTOMY - T ECHNIQUE entry by 14 Fr. introducer and 17 G needle. the position is confirmed by air aspiration.

39 P ERCUTANEOUS C RICOTHYROTOMY - T ECHNIQUE then guidewire is inserted into trachea.

40 P ERCUTANEOUS C RICOTHYROTOMY - T ECHNIQUE serial dilator or horn like single dilator or tracheostomy tube loaded dilator.

41 P ERCUTANEOUS C RICOTHYROTOMY - T ECHNIQUE now the tracheostomy tube is kept in situ.

42 P ERCUTANEOUS C RICOTHYROTOMY 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 P ERCUTANEOUS T RACHEOSTOMY

44 Definition: Tracheostomy can be defined as a technique for providing an opening in the space between any two tracheal rings (usually between 2 nd and 3 rd or 3 rd and 4 th 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 C RICOTHYROTOMY & T RACHEOSTOMY Sl. No. CricothyrotomyTracheostomy 1.Used in emergenciesSlightly more time consuming 2.As a temporary airway accessLong term maintenance of airway 3.Fiberoptic view not necessaryRecommended 4.LA / Sedation less requiredAdequate analgesia is needed 5.Done only in adultsIn 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 simplicityFor ICU patients

46 P ERCUTANEOUS T RACHEOSTOMY 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 P ERCUTANEOUS T RACHEOSTOMY Relative Contraindications: midline neck mass (including thyroid) high innominate artery inability to palpate cricoid and trachea unprotected airway with PEEP > 20 cmH 2 O coagulopathy [Now it is recommended to use fiberoptic bronchoscope to add safety to this procedure.]

48 P ERCUTANEOUS T RACHEOSTOMY - T ECHNIQUE after adequate analgesia incision of skin over trachea is made at the access site.

49 P ERCUTANEOUS T RACHEOSTOMY - T ECHNIQUE needle position is confirmed by aspiration of air as well as fiberoptic viewing of trachea.

50 P ERCUTANEOUS T RACHEOSTOMY - T ECHNIQUE through 14 G needle a guidewire is inserted.

51 P ERCUTANEOUS T RACHEOSTOMY - T ECHNIQUE through guidewire with a horn like gradational dilator, trachea is dilated upto the required size.

52 P ERCUTANEOUS T RACHEOSTOMY - T ECHNIQUE then the tracheostomy tube is kept in situ.

53 C OOKS DILATOR SET ( CIAGLIA TECHNIQUE )

54 P ERCUTANEOUS T RACHEOSTOMY

55 P ERCUTANEOUS T RACHEOSTOMY Complications Early: hemorrhage subcutaneous emphysema pneumothorax recurrent laryngeal nerve injury Late: infection TE fistula granuloma laryngotracheal stenosis

56 S URGICAL I NVASIVE A IRWAYS

57 S URGICAL C RICOTHYROTOMY 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: Surgeons job OT required – cost factor bleeding

58 S URGICAL C RICOTHYROTOMY Indications: trauma patients – to secure airway faster airway obstruction due to trauma FB stenosis mass Relative Contraindications: in children laryngeal fracture

59 S URGICAL T RACHEOSTOMY 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 T AKE 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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