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

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

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

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

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

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

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

Anatomy

Anatomy – Lateral View

Vascular Anatomy

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.

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.

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

Percutaneous Jet Ventilation

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

TTJV

TTJV

Retrograde Intubation

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

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

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

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

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

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

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

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

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

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

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

Percutaneous Cricothyrotomy

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.

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

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

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)]

Percutaneous Cricothyrotomy - Technique entry through the CTM.

Percutaneous Cricothyrotomy - Technique usually horizontal incision of skin.

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

Percutaneous Cricothyrotomy - Technique then guidewire is inserted into trachea.

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

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

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

Percutaneous Tracheostomy

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.

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

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)

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.]

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

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

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

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

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

Cooks dilator set (ciaglia technique)

Percutaneous Tracheostomy http://www.youtube.com/watch?v=XkGHpzrEI0Y

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

Surgical Invasive Airways

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

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

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

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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