Surgically-Altered Airways: What you NEED to Know to Avoid Disasters!!

Today we have the pleasure of welcoming Dr. Megan Graybill Anders, a new addition to the Maryland Anesthesiology-Critical Care department and all-around airway guru! Over the last year, she has started an initiative to tag all surgical airways with a simple “How-to guide” in regards to handling any and all disasters. Dr. Anders was generous enough to donate 45 minutes from her day to ease the anxiety and palpitations often associated with a crashing patient possessing unfamiliar tracheal access.

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(Thank you to Ellen Marciniak for the great summary)

Tracheostomy 101:

• Dual has “inner cannula” which can be removed (to clear clots, mucus plugs, etc)-many of ours are dual cannula.
• Dual lumen = smaller internal diameter = potential for increased work of breathing
• Single lumen = bigger internal diameter = less work of breathing BUT it is harder to clear out any plugs

• Percutaneous
  • Bedside for STRAIGHTFORWARD Upper Airway anatomy (and thus be easier to intubate if needed)
  • Stoma will close almost immediately if trach is removed within first 3-5 days; you will be UNLIKELY to replace the trach if this happens
• Open
  • More stable if lost accidentally
  • Most will have Stay Sutures: long, taped-down sutures around a fresh trach used to allow opening of the incision and elevation of the trachea; assist in replacement of trach

3) Bleeding:

• <48 hrs: not a fistula (surgery-related bleeding or granulation tissue irritation)
• >48 hrs: Worrisome for a TIF (tracheoinnominate fistula)
  • Risk factors: malposition of the tube, high cuff pressures
  • 50%+ have a sentinel bleed in the first few days
  • Treatment:
    1. Hyperinflate the cuff
    2. Look for intra-airway bleeding (asphyxiation before exsanguination)
    3. Remove offending tube and endotracheally intubate aiming for the carina
    4. Then use your finger to compress the artery against the sternum while
    5. Operative assistance!

Laryngectomy 101:

VERY important is terminology

1) Complete Laryngectomy:

• Total re-routing of trachea; a very stable solution
• You CANNOT intubate these patients from above (“The Nose is just an accessory!”)
• You can place an ET tube in their stoma if needed

2) Partial Laryngectomy:

• A temporary tracheostomy often due to postoperative edema
• Plan being removal of the tracheostomy after swelling goes down
• You CAN intubate from above

Initial steps during emergencies:

1. Apply oxygen to face and stoma
2. Assess gas exchange (capnography, listen around tube)
3. Watch for subcutaneous air which may signify a dislodged tube
4. Ensure patency of tube:
   • Remove inner cannula(if present)
   • Pass suction catheter
   • Deflate cuff
   • Lastly: Remove if not patent!!!