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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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