U pper A irways O bstruction

Assess L ook / L isten / F eel (Anytime) Degree of obstruction Site of Obstruction

Act CL/HT - JT High flow oxygen Nasopharyngeal airway Oral airway Nebulized adrenaline Steroids Bag and mask Intubation Cricothyroidotomy Tracheotomy??(Tracheostomy)

Guedel Airway

Tracheostomy

Indications 1. Relief of respiratory obstruction above upper tracheal level. causes: Congenital · Bilateral choanal atresia. · Laryngeal web or cyst · Upper tracheal stenosis. · Tracheo-oesophageal anomalies. Traumatic · External · Internal (1) Inhalation of steam or irritating fumes. (2) Foreign bodies. (3) Swallowing of corrosives. Infections · Acute laryngotracheobronchitis. · Acute epiglottitis. · Diphtheria. · Ludwig's angina. Tumors Tongue, pharynx, larynx, upper trachea and thyroid gland. Miscellaneous : Haemophilia, Angioneurotic oedema. Bilateral laryngeal nerve palsies;after thyroidectomy, &with bulbar palsies. Cord fixation due to rheumatoid arthritis.

2. Protection of tracheobronchial tree. Inhalation & Stagnation · Bulbar poliomyelitis. · Polyneuritis. · Tetanus. · Myasthenia gravis. · Coma due to many causes (including head injuries, drug overdose and cardiac arrest). · Cervical cord lesions and injuries. · Burns of face and neck. · Multiple fractures of mandible.

3. Treatment of conditions leading to respiratory insufficiency. Any of (1) and (2) Pulmonary disease · Chronic bronchitis and emphysema.. Postoperative pneumonia. Severe chest injuries ('flail chest') Neuromuscular incoordination,. Leading to (2) above. · Needing artificial or intermittent positive-pressure respiration (IPPR).

Tracheostomy aids respiration by: 1. Reducing the 'dead space' (lips to tracheostome) by about 50%. 2. By-passing resistance to airflow in nose, mouth and glottis. 3. Allowing easy 'toilet' of bronchi. 4. Use of mechanically assisted respiration.

Criteria for intervention Inspiratory stridor, recession of the suprasternal notch and intercostal spaces, and with anxious, pale. sweating facies, operation must not be delayed. Cyanosis indicates a late and grave stage. With paralyzing disease and normal lungs; if the vital capacity falls to a quarter of normal or if, with deep breath, the patient can count only to 20 and not to 60. With pulmonary disease; if patient loses consciousness or PCo2 exceeds 70 mmHg. With crushed chest; clinical judgment is usually sufficient, but PC02 measurement is valuable. In real urgency Without proper facilities and training, a laryngotomy must be performed. With well trained & skilled staff of RCU, endotracheal tube may be a best solution.

Emergency tracheostomy 1. Anaesthesia Best intubation & G.A, but usually infiltration with lignocaine 0.5 %. 2. Position Head extended in supine position. 3. Incision Midline vertical, from lower border of thyroid cartilage to manubrium sterni. Cricoid cartilage is the guide and felt with the left index finger. 4. Midline separation of strap muscles with scissors. 5. Thyroid isthmus divid and ligat, or retract it upwards or downwards.

6. Trachea exposed and opened Circular cut at level of third ring (2 nd -4 th ). The first ring must never be divided. In children a vertical incision is used. 7. Insertion of tube A suitable tube is inserted and firmly secured by tapes 8. Choice of tube The best type is a cuffed plastic (Portex) tube, but a silver tube may be preferred. The size and shape of the curve are very important, as the anterior and posterior walls must not be trauma- tized to avoid ulceration and fatal haemorrhage. 9. Closure of wound Ligation of bleeding points is essential. The wound is loosely closed, for fear of emphysema.

Elective tracheostomy 1. General anaesthetic almost always used. 2. The incision is transverse 'collar‘ about 2 cm below level of cricoid cartilage. 3. Hinged flaps of the tracheal wall are not advisable.

Postoperative management 1. Nursing is essential for the first 24 h at least. 2. Position sitting upright in bed. 3. Suction regularly, with aseptic technique, passmg a sterile catheter into trachea and main bronchi. 4. Humidification is essential, using humidifier or moistened gauze over the tracheostomy tube. 5. Prevention of crusting by irrigation with N/S & suction 6. Prevention of apnoea In cases of long-standing obstruction, apnoea may occur immediately after opening of trachea, caused by sudden lowering of the PC02. Carbon dioxide (5-7% in oxygen) is given via flow- meter through the tracheostome if this occurs.

7. Care of tube Metal type ; the inner tube should project about 0.25 cm beyond the distal end of the outer one, to collect crust. The inner tube is taken out and cleaned hourly at first. the outer tube must be held firmly while withdrawing the inner one. Cuffed plastic tubes ; The cuff should be of adequate length and not inflated too much, to avoid pressure necrosis of tracheal mucosa, necessity of periodic deflation of cuff : 5/60, Low-pressure cuffed tubes or double-cuffed type must always be employed, to minimize the risk of tracheal stenosis.

8. Decannulation The tube is removed when the patient is comfortable with its corked off. Difficulty occurs. especially with children. if the tracheostomy has been present for a long time. Gradual reduction in the size of tube, then sealing off

Complications A.Early 1.Apnoea 2. Haemorrhage May occur if haemostasis is not secured at operation or ulceration by the tip of the tube if of the wrong shape.

3. Displacement of tube If complete it must be reinserted at once after the wound and tracheal opening are adequately dilated. Partial dislodgement may pass unobserved for a time, with the tube lying just in front of the tracheal opening.

3. Surgical emphysema and pneumothorax More common in children. If tracheostomy is too low. If wound closed tightly. If tissue planes are dissected too much. Under L.A more than G.A. Admintration of high pressure O2 4. Syncope &Cardiac arrest Manipulation of sucker catheter

B. Late 1. Local sepsis; septicaemia. 2. Perichondritis and stenosis May develop in the subglottic region if the tracheostome is too high A smaller tube, of non-irritating Portex, may help. A stricture above a well-placed trache- ostome may result from trauma by an ill- fitting tube or a small opening. A low tracheal stricture may be a late sequel of prolonged over-inflation of a cuffed tube.

3.Tracheo-oesphageal fistula Due to pressure of an ill-fitting tube against the posterior wall.