TracheaTracheaMark Perna Mark Perna

Sunday, May 02, 2010Sunday, May 02, 2010

IntroductionIntroduction

AnatomyAnatomy Discuss emergent and elective surgical Discuss emergent and elective surgical

AirwaysAirways Discuss complications of surgical airwaysDiscuss complications of surgical airways Review repair of tracheal traumaReview repair of tracheal trauma Review tracheoinnominate fistulaReview tracheoinnominate fistula Discuss tracheoesophageal fistulaDiscuss tracheoesophageal fistula Foreign BodyForeign Body

Emergent Surgical AirwayEmergent Surgical Airway

When When Sooner than you think Sooner than you think Usually three strikes and your outUsually three strikes and your out Knife, Clamp, 4 or 6 ET tube, Betadine Knife, Clamp, 4 or 6 ET tube, Betadine CricothyroidotomyCricothyroidotomy TracheotomyTracheotomy

• Crushed LarynxCrushed Larynx

Elective Surgical AirwayElective Surgical Airway

When When Sooner than you think Sooner than you think 7 days or less on ventilator7 days or less on ventilator Early weaning of ventEarly weaning of vent Patient comfortPatient comfort Improved Pulmonary Toilet Improved Pulmonary Toilet

Elective Surgical AirwayElective Surgical Airway

TracheostomyTracheostomy PercutaneousPercutaneous

• Blue Rhino Kit, Selindger Technique, Blue Rhino Kit, Selindger Technique, Use BronchUse Bronch OpenOpen

• Define anatomy visually, stay sutures, T incision in Define anatomy visually, stay sutures, T incision in trach or Bjork flaptrach or Bjork flap

Semi OpenSemi Open• Define anatomy visually, Blue Rhino KitDefine anatomy visually, Blue Rhino Kit

Early ComplicationsEarly Complications Loss of AirwayLoss of Airway False Passage False Passage DecannulationDecannulation BleedingBleeding Mucus PlugMucus Plug PneumomediasteumPneumomediasteum PneumothoraxPneumothorax InfectionInfection Negative Pressure Pulmonary Edema Negative Pressure Pulmonary Edema

Late ComplicationsLate Complications

TracheomalaciaTracheomalacia Dynamic obstructionDynamic obstruction

StenosisStenosis Obstructive symptomsObstructive symptoms

Tracheoinnominate FistulaTracheoinnominate Fistula Herald BleedHerald Bleed

Granulation Tissue Granulation Tissue Bleeding Bleeding

Tracheal TraumaTracheal Trauma

Tracheobronchial injury generally very Tracheobronchial injury generally very appearentappearent

Blunt tracheal traumaBlunt tracheal trauma 22% have concomitant esophageal injuries22% have concomitant esophageal injuries 16% have major vessel injury16% have major vessel injury 40% have hemothorax40% have hemothorax

Repair of Tracheal TraumaRepair of Tracheal Trauma

Small defect - Small defect - 3-0 or 4-0 absorbable sutures transversely 3-0 or 4-0 absorbable sutures transversely

including two tracheal ringsincluding two tracheal rings Large anterior defect-Large anterior defect-

Convert to tracheostomyConvert to tracheostomy Large lateral or posterior defect-Large lateral or posterior defect-

Moblize and repair primarily and protect with Moblize and repair primarily and protect with tracheostomy tracheostomy

Drains? Drains? Only if esophageal injury Only if esophageal injury

Tracheoinnominate FistulaTracheoinnominate Fistula

Late complication of tracheostomyLate complication of tracheostomy Low lying tracheal Low lying tracheal

Rings 3-4Rings 3-4 Herald BleedsHerald Bleeds Bronch can rule outBronch can rule out

Plan for initial managementPlan for initial management

DecannulateDecannulate Quickly reintubate from aboveQuickly reintubate from above

Get ET past the bleeding siteGet ET past the bleeding site Blow up the cuffBlow up the cuff

Insert finger and tamponade the Insert finger and tamponade the innominate arteryinnominate artery

Call OR and for helpCall OR and for help

Definitive Management Definitive Management

Sternotomy and likely neck incisionSternotomy and likely neck incision Proximal and distal controlProximal and distal control Leave trachea aloneLeave trachea alone Resect artery with autologous bypassResect artery with autologous bypass Protect with sternohyoid flapProtect with sternohyoid flap

Tracheosophageal FistulaTracheosophageal Fistula

Classically pediatric surgery issueClassically pediatric surgery issue Enteral feeding access and electively repairEnteral feeding access and electively repair

Adults with prolong intubationAdults with prolong intubation High cuff pressuresHigh cuff pressures

Bronchoscopy (Rigid)

Esophagoscopy (Rigid or Flexible)

Bronchoscopy

Summary

Anatomy Complicated Emergent Airways Be ready and do it

quickly Elective Airways Be prepared Tracheal Trauma Look for other injuries Tracheoinnomiate Fistula Prevention is best

treatment Tracheoesophageal Fistula Close defects

and protect with muscle flap Foreign Body - Think Rigid Scope