i nfra - glottic invasive airways dr. s.a.rajkumar, intensivist, tirunelveli

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

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DEFINITIONSupra-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 accessAccess to the airway by means of opening

the trachea below the glottis for ventilation or maintenance of airway.

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Non-invasive& Invasive

Invasive

INFRA-GLOTTIC AIRWAY ACCESS

Broad classification:

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CricothyrotomyTracheostomy

Access to them by:

Percutaneously Surgically

INFRA-GLOTTIC AIRWAY ACCESS

Done usually for:

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Emergency ICU patientssituations

CNV / CNIConditions 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 inOTEmergency ward ICUother departments as an emergency 2010K

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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 2010KAN ISAC O

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TECHNIQUES

Percutaneous jet ventilation(through needle)

[and needle ventilation]

Retrograde intubation

Percutaneous cricothyrotomy

Percutaneous tracheostomy

Surgical cricothyrotomy

Surgical tracheostomy 2010KAN ISAC O

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ANATOMY

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ANATOMY – LATERAL VIEW

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VASCULAR ANATOMY

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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.

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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.

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ANAESTHESIA

IV sedationMidazolamFentanyl / other narcoticsPropofol

Topical 1% Lidocaine – Intratracheal

Nerve blocksSuperior Laryngeal nerveGlossopharyngeal nerve

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PERCUTANEOUS JET VENTILATION

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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

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TTJV

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TTJV

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RETROGRADE INTUBATION

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RETROGRADE INTUBATIONTranslaryngeal guided intubation Popularised by Waters in 1963.

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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

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Procedure Through CTM epidural needle is pierced.

- ROUTINE TECHNIQUE

RETROGRADE INTUBATION ROUTINE TECHNIQUE

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Epidural catheter is inserted into oral cavity. Catheter tip is taken out of mouth.

RETROGRADE INTUBATION ROUTINE TECHNIQUE

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N ET tube railroaded and pulled into the trachea with the help of catheter.

RETROGRADE INTUBATION ROUTINE TECHNIQUE

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Then the epidural catheter is removed from the oral end.

RETROGRADE INTUBATION ROUTINE TECHNIQUE

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N Now the ET tube is kept in situ.

RETROGRADE INTUBATION

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Here silk is threaded with the help of the epidural catheter.

- SILK PULL-THROUGH TECHNIQUE

RETROGRADE INTUBATION SILK PULL-THROUGH TECHNIQUE

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Silk is tied at Murphy’s eye of ET tube

RETROGRADE INTUBATION SILK PULL-THROUGH TECHNIQUE

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ET tube is placed into the trachea with the help of pulling of silk

RETROGRADE INTUBATION SILK PULL-THROUGH TECHNIQUE

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Advantage: Reintubation is easy

RETROGRADE INTUBATION

Complications: esophageal perforation hemoptysis hematoma edema laryngospasm infection, tracheitis tracheal fistula vocal cord damage subcutaneous emphysema 2010K

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PERCUTANEOUS CRICOTHYROTO

MY

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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 ands percutaneous dilatational tracheostomy.

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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

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PERCUTANEOUS CRICOTHYROTOMY

Relative Contraindications: intubated patients (> 3 days)

- subglottic stenosis

infants and children (< 10 years) - narrow airway

preexisting laryngeal disease

bleeding disorders

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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

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[Used in emergenciesIn expert hands – 90 seconds (Ref: Benumof)]

PERCUTANEOUS CRICOTHYROTOMY - TECHNIQUE

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entry through the CTM.

PERCUTANEOUS CRICOTHYROTOMY - TECHNIQUE

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usually horizontal incision of skin.

PERCUTANEOUS CRICOTHYROTOMY - TECHNIQUE

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entry by 14 Fr. introducer and 17 G needle.

the position is confirmed by air aspiration.

PERCUTANEOUS CRICOTHYROTOMY - TECHNIQUE

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then guidewire is inserted into trachea.

PERCUTANEOUS CRICOTHYROTOMY - TECHNIQUE

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N serial dilator or horn like single dilator or tracheostomy tube loaded dilator.

PERCUTANEOUS CRICOTHYROTOMY - TECHNIQUE

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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

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PERCUTANEOUS TRACHEOSTOMY

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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.

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CRICOTHYROTOMY & TRACHEOSTOMYSl. 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 maintenanceweaning from ventilatorobstruction in airwaytracheal toileting

in childrenin emergency situationsalso in elective conditions (as Cricothyrotomy

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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.]

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PERCUTANEOUS TRACHEOSTOMY - TECHNIQUE

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after adequate analgesia incision of skin over trachea is made at the access site.

PERCUTANEOUS TRACHEOSTOMY - TECHNIQUE

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needle position is confirmed by aspiration of air as well as fiberoptic viewing of trachea.

PERCUTANEOUS TRACHEOSTOMY - TECHNIQUE

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N through 14 G needle a guidewire is inserted.

PERCUTANEOUS TRACHEOSTOMY - TECHNIQUE

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

PERCUTANEOUS TRACHEOSTOMY - TECHNIQUE

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then the tracheostomy tube is kept in situ.

COOKS DILATOR SET (CIAGLIA TECHNIQUE)

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PERCUTANEOUS TRACHEOSTOMY

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

PERCUTANEOUS TRACHEOSTOMY

Complications Early:

hemorrhagesubcutaneous emphysemapneumothoraxrecurrent laryngeal nerve injury

Late: infectionTE fistulagranuloma laryngotracheal stenosis

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SURGICAL INVASIVE AIRWAYS

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SURGICAL CRICOTHYROTOMY Open Cricothyrotomy:

instead of piercing of needle, incision is made and tracheostomy tube is inserted.

Advantages:rapid procedure – in emergenciesspecial instrumentations not required

Disadvantages:Surgeon’s jobOT required – cost factorbleeding 2010K

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SURGICAL CRICOTHYROTOMY

Indications:trauma patients – to secure airway fasterairway obstruction due to

trauma FB stenosis mass

Relative Contraindications: in children laryngeal fracture

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SURGICAL TRACHEOSTOMY

FasterSafer

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

}

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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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THANK YOU