Surgical Airway - SUNY Downstate Medical Centerdownstatesurgery.org/files/cases/surgical_airway.pdf · • Bourjeily et al.: Review of Tracheostomy Usage: Types and Indications Clin

Surgical AirwaySurgical AirwaySybile Val, MD

SUNY Downstate Medical CenterCenter

August 6, 2009

www.downstatesurgery.org

Case PresentationCase Presentation• HPI • MedsHPI

– 42 YOF presented to ED on 4/18 with

Meds– Singulair– Advair

dyspnea• PMH

A th

– Albuteral– Sensipar

– Asthma– ESRD on HD

• PSH

• Allergies– NKDA

• PSH– RUE fistula

creation


Case PresentationCase Presentation

• In EDIn ED– Afebrile, BP 97/66 HR 109 RR 22 Sat

96%96%– On Exam

• Mild respiratory distressMild respiratory distress• No JVD• Rales in lower 1/3 of b/l lung fields, no

wheezing• No Peripheral edema


Case PresentationCase Presentationwww.downstatesurgery.org


• LabsLabs– Unremarkable

• Plan• Plan– Admit to Medicine w/ Dx of CHF

exacerbationexacerbation– Renal for HD

O th i iti t d– Oxygen therapy initiated



• Post DialysisPost Dialysis– No improvement in SOB

Alterations in mental status– Alterations in mental status– ABG: 7.17/94/237/36/100%

BiPAP initiated– BiPAP initiated– MICU consult called

R d tiRecommendations:Intubate the patient


Case PresentationCase Presentation• Anesthesia consultedest es a co su ted

– Using accessory muscles– Obtunded with saturation of 91-96%– Attempts at intubation with fiberoptic

scope x 2Gastric contents regurgitated– Gastric contents regurgitated

• Surgery consultedCricothryoidotomy attempted @ bedside– Cricothryoidotomy attempted @ bedside

– Pt taken to OR for revision and control of bleeding


Case PresentationH it l CHospital Course

• POD#1 • POD#39– ENT consulted

• Cricoid cartilage palpable below stoma

• POD#2

– New onset A. fib w/ RVR

– Cardioverted– Started on heparin and

– Tracheostomy revision • POD#6

– Weaned from ventilator

Started on heparin and amniodarone

• POD#45– Will watching TV,

bright red blood noted • POD#9– Trach downsized – on HD

POD#15

bright red blood noted from trach

– Desaturated to 38%– Excessive blood in

• POD#15– Cleared for discharge

• POD#26Developed Vfib while on

oropharynx– Coded, ACLS initiated– Pt pronounced @7pm

Autopsy declined– Developed Vfib while on HD

– Autopsy declined


Questions??


Surgical AirwaySurgical Airwaywww.downstatesurgery.org

Indications f I t b tifor Intubation

PHYSIOLOGIC• Persistent hypoxemia with oxygen

supplementation• PACO2 >55, Ph <7.25• Vital capacity <15ml/kg with NM d/o


Indications f I t b tifor Intubation

CLINICAL• Altered mental status

R i t di t ith HD i t bilit• Respiratory distress with HD instability• Upper airway obstruction

– Angioedema– Trauma– Infection– Bleeding– Tumor– Tracheomalacia– Tracheal Stenosis

• Copious secretion requiring frequent s ctioningsuctioning


Indications f S i l Aifor Surgical Airway

• Upper Airway pp yObstruction

• Prolonged intubation• Chronic respiratory

insuff.• Neuromuscular Neuromuscular

disorders


Surgical AirwaySurgical Airway• Historically • TypesHistorically

– Acute or impending airway

Types– Cricothyrotomy– Standard

obstruction• Now…

Ai t l i

tracheostomy– Percutaneous

dilatation – Airway control in conjunction with prolonged usage

dilatation tracheostomy

p g gof mechanical ventilation


AnatomyAnatomy

CMAJ • April 22, 2008 • 178(9)


CricothyrotomyCricothyrotomywww.downstatesurgery.org

Standard TracheostomyStandard Tracheostomywww.downstatesurgery.org





ComplicationsComplicationsEarly Latey

• False passage• Decannulation

• Granulation• Tracheomalacia

• Pneumomediastinum• Pneumothorax• Bleeding

• Stenosis• Tracheoinnominate

fistula• Bleeding • Infection• Mucous Plug

fistula• Tracheoesophageal

fistulaMucous Plug• Negative Pressure

Pulm Edema


Could we have done somethingCould we have done something different in this case??


• Retrospective study atRetrospective study at Cook County

• Between August 2001 gto October 2003

• 197 subjects in study j ywith 244 day follow up– 107 standard trach

– 90 using awake technique


• Awake Technique:Awake Technique:– Semirecumbent position

– No general anesthetic

– Subcutaneous lidocaine

– Wide incision and use of i id h kcricoid hook

– Direct laryngoscopy if neededneeded

– Availability of GA and OR


This group had a more significant set of complicationsThis group had a more significant set of complications


C l i• Conclusion:Awake tracheostomy should be considered in any

patient with impending or ongoing airway

obstruction or potentially difficult intubation


When is the best time to offer a tracheostomy?tracheostomy?


ReferencesReferences

• ACS Surgeryg y• Sabiston• Altman et al.: Urgent Surgical Airway Intervention. Laryngoscope 2005; 115:2101‐2104

• Freeman et al.: Relationship between tracheostomy timing and duration of mechanicaltracheostomy timing and duration of mechanical ventilation in critically ill patient. Crit Care Med 2005;33:2513‐2520

• Bourjeily et al.: Review of Tracheostomy Usage: Types and Indications Clin Pulm Med 2002;9(5):267‐2722002;9(5):267 272


Documents

Surgical Airway - SUNY Downstate Medical Centerdownstatesurgery.org/files/cases/surgical_airway.pdf · • Bourjeily et al.: Review of Tracheostomy Usage: Types and Indications Clin