Surgical airway:Surgical airway:

If the upper airway is obstructed because If the upper airway is obstructed because of foreign body or massive trauma or if of foreign body or massive trauma or if ventilation cannot be accomplished by ventilation cannot be accomplished by other means, surgical entry into the other means, surgical entry into the trachea is required.trachea is required.

CricothyrotomyCricothyrotomy

Can establish an emergency airway, the patient lies supine, Can establish an emergency airway, the patient lies supine, shoulders raised by pillows or sheets, and neck shoulders raised by pillows or sheets, and neck extended extended

After sterile preparation, the larynx is grasped with one After sterile preparation, the larynx is grasped with one hand while a blade is used to incise the skin of the neck hand while a blade is used to incise the skin of the neck just below the "just below the "Adam's apple", or thyroid cartilage,, ", or thyroid cartilage,, subcutaneous tissue, and cricothyroid membrane subcutaneous tissue, and cricothyroid membrane precisely in the midline. An appropriately sized precisely in the midline. An appropriately sized tracheostomy tube is advanced through the opening into tracheostomy tube is advanced through the opening into the trachea. In an out-of-hospital, immediately life-the trachea. In an out-of-hospital, immediately life-threatening airway obstruction, a knife handle, threatening airway obstruction, a knife handle, disposable pen barrel, or other hollow object can be disposable pen barrel, or other hollow object can be used to keep the airway open.used to keep the airway open.

CricothyrotomyCricothyrotomy

If other equipment is unavailable, a 12- to 14-If other equipment is unavailable, a 12- to 14-gauge IV catheter can be passed into the gauge IV catheter can be passed into the trachea through the cricothyroid membrane. The trachea through the cricothyroid membrane. The larynx is grasped with one hand while the sterile larynx is grasped with one hand while the sterile needle-catheter is inserted percutaneously needle-catheter is inserted percutaneously through the precise midline of the cricothyroid through the precise midline of the cricothyroid membrane, pointing the needle tip slightly membrane, pointing the needle tip slightly inferiorly, aspirating while advancing, and taking inferiorly, aspirating while advancing, and taking care not to perforate the posterior tracheal wall care not to perforate the posterior tracheal wall or to stray out of the midline into large vessels. or to stray out of the midline into large vessels. Once tracheal position is confirmed by aspiration Once tracheal position is confirmed by aspiration of air, the catheter is advanced into the trachea. of air, the catheter is advanced into the trachea. A 3-way stopcock and an O2 pressure source A 3-way stopcock and an O2 pressure source provide oxygenation but limited ventilation provide oxygenation but limited ventilation

ComplicationsComplications

Complications include hemorrhage, Complications include hemorrhage, subcutaneous emphysema, and subcutaneous emphysema, and pneumomediastinum.pneumomediastinum.

TracheostomyTracheostomy

Tracheostomy is a more complex procedure involving Tracheostomy is a more complex procedure involving surgical exposure and opening of the trachea. It is surgical exposure and opening of the trachea. It is preferably performed in an operating room by a surgeon. preferably performed in an operating room by a surgeon. In emergencies, the procedure has a higher rate of In emergencies, the procedure has a higher rate of complications than cricothyrotomy and offers no complications than cricothyrotomy and offers no advantage. It is, however, the preferred procedure for a advantage. It is, however, the preferred procedure for a long-term (> 48 h) surgical airway.long-term (> 48 h) surgical airway. Percutaneous tracheostomy is an attractive alternative Percutaneous tracheostomy is an attractive alternative for critically ill patients who should not be moved to the for critically ill patients who should not be moved to the operating room. This bedside technique uses a simple operating room. This bedside technique uses a simple skin puncture and single or multiple dilators to insert a skin puncture and single or multiple dilators to insert a tracheostomy tube tracheostomy tube

Uses for a tracheotomyThe conditions in which a tracheotomy may be used are:

Acute setting - maxillofacial injuries, large tumors of the head and neck, congenital tumors, e.g. branchial cyst, acute inflammation of head and neck, and Chronic / elective setting - when there is need for long term mechanical ventilation and tracheal toilet, e.g. comatose patients, surgery to the head and neck.

Uses for a tracheotomyUses for a tracheotomy

The conditions in which a tracheotomy may be The conditions in which a tracheotomy may be used are:used are:

Acute setting - maxillofacial injuries, large Acute setting - maxillofacial injuries, large tumors of the head and neck, congenital tumors, tumors of the head and neck, congenital tumors, e.g. branchial cyst, acute inflammation of head e.g. branchial cyst, acute inflammation of head and neck, and and neck, and

Chronic / elective setting - when there is need Chronic / elective setting - when there is need for long term mechanical ventilation and tracheal for long term mechanical ventilation and tracheal toilet, e.g. comatose patients, surgery to the toilet, e.g. comatose patients, surgery to the head and neck.head and neck.

Completed tracheotomy:1 - Vocal cords2 - Thyroid cartilage3 - Cricoid cartilage4 - Tracheal cartilages5 - Balloon cuff

Complications:Complications:

Tracheostomy insertion can rarely cause hemorrhage, Tracheostomy insertion can rarely cause hemorrhage, thyroid damage, pneumothorax, recurrent laryngeal thyroid damage, pneumothorax, recurrent laryngeal nerve paralysis, injury to major vessels, or late tracheal nerve paralysis, injury to major vessels, or late tracheal stenosis at the insertion site.stenosis at the insertion site.Erosion of the trachea is uncommon. It occurs more Erosion of the trachea is uncommon. It occurs more commonly from excessively high cuff pressure. Rarely, commonly from excessively high cuff pressure. Rarely, hemorrhage from major vessels (eg, innominate artery), hemorrhage from major vessels (eg, innominate artery), fistulas (especially tracheoesophageal), and tracheal fistulas (especially tracheoesophageal), and tracheal stenosis ensue after intubation. Using high-volume, low-stenosis ensue after intubation. Using high-volume, low-pressure cuffs with tubes of appropriate size and pressure cuffs with tubes of appropriate size and measuring cuff pressure frequently to maintain it at < 30 measuring cuff pressure frequently to maintain it at < 30 cm H2O decrease the risk of ischemic pressure necrosis, cm H2O decrease the risk of ischemic pressure necrosis, but patients in shock, with low cardiac output, or with but patients in shock, with low cardiac output, or with sepsis remain especially vulnerable.sepsis remain especially vulnerable.