Tisherman: Preventing surgical airway disasters

Clinical Pearls (Special thanks to Raffy Trinidad, MD)

When to attempt a surgical airway?

1. Emergency Situations
2. Elective Situations
3. Special Situations
4. Complications

Always remember: the inability to intubate the trachea is the only indication for creating a surgical airway!

Requirements:

• Best intubator – Anesthesia attending
• Surgical airway – Trauma attending
  • Difficult Airway Equipment

Options:

1. Needle cricothyroidotomy
   • Have to have direct wall oxygen
   • Pitfalls:
     • Pt selection: need a special kit, need a compliant pt
     • Procedurally difficult: easy to pierce the back wall of trachea, can cause SQ emphysema
     • Catheter is kinked easily
     • Difficult to use with increased secretions or with complete airway obstruction
     • Difficult to remove CO2
2. Surgical cricothyroidotomy
   • Requires: hands, knife, tube!
     • landmarks: thyroid cartilage, cricothyroid membrane
   • Stand to right of pt (if right handed)–> grab thyroid and don’t let go–>vertical incision (avoid blood vessels)–> dilate with finger–> bougie–> ETT
   • Pitfalls:
     • CI in pediatrics (narrowest part of airway, can cause stenosis)
     • Pt selection: most pts are already apniec and stress level is high
     • Anatomy: destructive maxillofacial/neck injuries, poor landmarks
3. Awake tracheostomy
   • Must be: compliant and breathing spontaneously

Tracheostomy vs Cricothyroidotomy

• Cricothyoroidotomy is easier because:
  • Cricothyroid membrane is more superficial, thus easier to target
  • Has less bleeding
  • Causes less recurrent laryngeal injury, pneumothorax, etc.
  • Requires less instruments, assistance, and lighting

When to trach?

Percutaneous or Open?

• Open is more advantageous because
  • Faster with less bleeding and smaller scars
  • Far easier to learn and requires less assistance
  • Requires fewer instruments and less lighting
  • Less infection and/or tracheal erosion (theoretical)
• Would not use open on an obese patient

Pitfalls of any tracheostomy:

• Trachea-Innominate artery fistula
  • Peak incidence 1st to 2nd week post-op (0.3% incidence)
  • Juxtaposition of trachea and innominate artery –> pressure necrosis from tube
  • Prevention
    • Avoid neck hyperextension and accurately place the trach 2nd or 3rd ring
    • Monitor cuff pressure<20mm Hg
    • Avoid tight closure of skin incision
    • Promptly treat all peristomal infections
    • Use long flexible connecting tubing and avoid a stiff trach tube
  • Emergency treatment:
    • Overinflation of cuff OR remove trach–> intubate from above–> stick your finger in and hold pressure at the bleeding site (Utley maneuver)