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

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.



(Thank you to Ellen Marciniak for the great summary)

Tracheostomy 101:

1) Dual vs. Single Cannula



* 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



2) Percutaneous vs. Open



* 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: 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:



* Hyperinflate the cuff

* Look for intra-airway bleeding (asphyxiation before exsanguination)

* Remove offending tube and endotracheally intubate aiming for the carina

* Then use your finger to compress the artery against the sternum while

* 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:



* Apply oxygen to face and stoma

* Assess gas exchange (capnography, listen around tube)

* Watch for subcutaneous air which may signify a dislodged tube

* Ensure patency of tube:



* Remove inner cannula(if present)

* Pass suction catheter

* Deflate cuff

* Lastly: Remove if not patent!!!









Suggested Web Links:



National Tracheostomy Safety Project-check out the algorithms page for sure. Also, there are a bunch of Youtube videos (that’s right) to demonstrate steps of the algorithm for your viewing pleasure

Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies

Tracheo-innominate fistula



a href="http://www.surgicalcriticalcare.net/Guidelines/post%20tracheostomy%20hemorrhage%202009.