Surgical airway management

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Surgical airway management

Larynx external en.svg

In cricothyrotomy, the incision or puncture is made through the cricothyroid membrane in between the thyroid cartilage and the cricoid cartilage
ICD-9-CM 31.1-31.3

Surgical airway management (bronchotomy [1] or laryngotomy) is the medical procedure ensuring an open airway between a patient’s lungs and the outside world. Surgical methods for airway management rely on making a surgical incision below the glottis in order to achieve direct access to the lower respiratory tract, bypassing the upper respiratory tract. Surgical airway management is often performed as a last resort in cases where orotracheal and nasotracheal intubation are impossible or contraindicated. Surgical airway management is also used when a person will need a mechanical ventilator for a longer period. The surgical creation of a permanent opening in the larynx is referred to as laryngostomy. Surgical airway management is a primary consideration in anaesthesia, emergency medicine and intensive care medicine.

Respiratory tract Organs involved in transmission of air to and from the point where gases diffuse into tissue

In humans, the respiratory tract is the part of the anatomy of the respiratory system involved with the process of respiration. Air is breathed in through the nose or the mouth. In the nasal cavity, a layer of mucous membrane acts as a filter and traps pollutants and other harmful substances found in the air. Next, air moves into the pharynx, a passage that contains the intersection between the esophagus and the larynx. The opening of the larynx has a special flap of cartilage, the epiglottis, that opens to allow air to pass through but closes to prevent food from moving into the airway.

Lung essential respiration organ in many air-breathing animals

The lungs are the primary organs of the respiratory system in humans and many other animals including a few fish and some snails. In mammals and most other vertebrates, two lungs are located near the backbone on either side of the heart. Their function in the respiratory system is to extract oxygen from the atmosphere and transfer it into the bloodstream, and to release carbon dioxide from the bloodstream into the atmosphere, in a process of gas exchange. Respiration is driven by different muscular systems in different species. Mammals, reptiles and birds use their different muscles to support and foster breathing. In early tetrapods, air was driven into the lungs by the pharyngeal muscles via buccal pumping, a mechanism still seen in amphibians. In humans, the main muscle of respiration that drives breathing is the diaphragm. The lungs also provide airflow that makes vocal sounds including human speech possible.

Glottis

The glottis is the opening between the vocal folds.

Contents

Surgical methods for airway management include cricothyrotomy and tracheostomy

Cricothyrotomy incision of the skin and cricothyroid membrane, used to establish a clear airway

A cricothyrotomy is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive facial trauma. Cricothyrotomy is nearly always performed as a last resort in cases where orotracheal and nasotracheal intubation are impossible or contraindicated. Cricothyrotomy is easier and quicker to perform than tracheotomy, does not require manipulation of the cervical spine, and is associated with fewer complications. However, while cricothyrotomy may be life-saving in extreme circumstances, this technique is only intended to be a temporizing measure until a definitive airway can be established.

History

Asclepiades of Bithynia is credited with being the first person who proposed bronchotomy as a surgical procedure, though he never attempted to perform one. [2] Aretaeus of Cappadocia thought the procedure dangerous even as a remedy for choking, since the resulting incision "would not heal, as being cartilaginous "; Caelius Aurelianus also rejected its usefulness. [2]

Asclepiades of Bithynia 1st-century BC Greek physician

Asclepiades, sometimes called Asclepiades of Bithynia or Asclepiades of Prusa, was a Greek physician born at Prusias-on-Sea in Bithynia in Asia Minor and who flourished at Rome, where he established Greek medicine near the end of the 2nd century BC. He attempted to build a new theory of disease, based on the flow of atoms through pores in the body. His treatments sought to restore harmony through the use of diet, exercise, and bathing.

Aretaeus of Cappadocia Ancient Greek physician

Aretaeus is one of the most celebrated of the ancient Greek physicians, of whose life, however, few particulars are known. He presumably was a native or at least a citizen of Cappadocia, a Roman province in Asia Minor, and most likely lived around first century CE. He is generally styled "the Cappadocian" (Καππάδοξ).

Choking mechanical obstruction of the flow of air from the environment into the lungs

Choking is a life-threatening medical emergency characterized by the blockage of air passage into the lungs secondary to the inhalation or ingestion of food or another object. Choking is caused by a mechanical obstruction of the airway that prevents normal breathing. This obstruction can be partial or complete. The disruption of normal breathing by choking deprives oxygen delivery to the body, resulting in asphyxia. Although oxygen stored in the blood and lungs can keep a person alive for several minutes after breathing stops, this sequence of events is potentially fatal. Choking was the fourth most common cause of unintentional injury-related death in the US in 2011.

Cricothyrotomy

A cricothyrotomy is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive facial trauma. [3] A cricothyrotomy is nearly always performed as a last resort in cases where orotracheal and nasotracheal intubation are impossible or contraindicated. Cricothyrotomy is easier and quicker to perform than tracheotomy, does not require manipulation of the cervical spine and is associated with fewer complications. [4]

Cricothyroid ligament

The cricothyroid ligament is composed of two parts:

Angioedema skin disease characterized by the rapid swelling of the dermis, subcutaneous tissue, mucosa and submucosal tissues

Angioedema is an area of swelling of the lower layer of skin and tissue just under the skin or mucous membranes. The swelling may occur in the face, tongue, larynx, abdomen, or arms and legs. Often it is associated with hives, which are swelling within the upper skin. Onset is typically over minutes to hours.

Needle cricothyrotomy

Cricothyrotomy kit Kit de Cricothyroidotomie.JPG
Cricothyrotomy kit

A needle cricothyrotomy is similar to a cricothyrotomy, but instead of making a scalpel incision, a large over-the-needle catheter is inserted (10- to 14-gauge). This is considerably simpler, particularly if using specially designed kits. This technique provides very limited airflow. The delivery of oxygen to the lungs through an over-the-needle catheter inserted through the skin into the trachea using a high pressure gas source is considered a form of conventional ventilation called percutaneous transtracheal ventilation (PTV).

Percutaneous transtracheal ventilation is the delivery of oxygen to the lungs through an over-the-needle catheter inserted through the skin into the trachea using a high pressure gas source is considered a form of conventional ventilation.

Tracheotomy

A tracheotomy is a surgically created opening from the skin of the neck down to the trachea. [5] A tracheotomy may be considered where a person will need to be on a mechanical ventilator for a longer period. [5] The advantages of a tracheotomy include less risk of infection and damage to the trachea such as tracheal stenosis. [5]

See also

Related Research Articles

Trachea cartilaginous tube that connects the pharynx and larynx to the lungs

The trachea, colloquially called the windpipe, is a cartilaginous tube that connects the pharynx and larynx to the lungs, allowing the passage of air, and so is present in almost all air-breathing animals with lungs. The trachea extends from the larynx and branches into the two primary bronchi. At the top of the trachea the cricoid cartilage attaches it to the larynx. This is the only complete tracheal ring, the others being incomplete rings of reinforcing cartilage. The trachealis muscle joins the ends of the rings and these are joined vertically by bands of fibrous connective tissue – the annular ligaments of trachea. The epiglottis closes the opening to the larynx during swallowing.

Tracheal intubation

Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill, or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction.

Mechanical ventilation or assisted ventilation is the medical term for artificial ventilation where mechanical means is used to assist or replace spontaneous breathing. This may involve a machine called a ventilator, or the breathing may be assisted manually by a suitably qualified professional compressing a breathing system, bag valve mask device or set of bellows.

Tracheotomy temporary surgical incision into the trachea

Tracheotomy, or tracheostomy, is a surgical procedure which consists of making an incision (cut) on the anterior aspect of the neck and opening a direct airway through an incision in the trachea (windpipe). The resulting stoma (hole) can serve independently as an airway or as a site for a tracheal tube or tracheostomy tube to be inserted; this tube allows a person to breathe without the use of the nose or mouth.

A tracheal tube is a catheter that is inserted into the trachea for the primary purpose of establishing and maintaining a patent airway and to ensure the adequate exchange of oxygen and carbon dioxide.

Airway management medical procedure ensuring an unobstructed airway

Airway management includes a set of maneuvers and medical procedures performed to prevent and relieve airway obstruction. This ensures an open pathway for gas exchange between a patient's lungs and the atmosphere. This is accomplished by either clearing a previously obstructed airway; or by preventing airway obstruction in cases such as anaphylaxis, the obtunded patient, or medical sedation. Airway obstruction can be caused by the tongue, foreign objects, the tissues of the airway itself, and bodily fluids such as blood and gastric contents (aspiration).

Respiratory arrest is caused by apnea or respiratory dysfunction severe enough it will not sustain the body. Prolonged apnea refers to a patient who has stopped breathing for a long period of time. If the heart muscle contraction is intact, the condition is known as respiratory arrest. An abrupt stop of pulmonary gas exchange lasting for more than five minutes may damage vital organs especially the brain, possibly permanently. Lack of oxygen to the brain causes loss of consciousness. Brain injury is likely if respiratory arrest goes untreated for more than three minutes, and death is almost certain if more than five minutes.

Artificial ventilation Assisted breathing to support life

Artificial ventilation, is means of assisting or stimulating respiration, a metabolic process referring to the overall exchange of gases in the body by pulmonary ventilation, external respiration, and internal respiration. It may take the form of manually providing air for a person who is not breathing or is not making sufficient respiratory effort on their own, or it may be mechanical ventilation involving the use of a mechanical ventilator to move air in and out of the lungs when an individual is unable to breathe on their own, for example during surgery with general anesthesia or when an individual is in a coma.

Ludwigs angina human disease

Ludwig's angina is a type of severe cellulitis involving the floor of the mouth. Early on the floor of the mouth is raised and there is difficulty swallowing saliva, which may run from the person's mouth. As the condition worsens, the airway may be compromised with hardening of the spaces on both sides of the tongue. This condition has a rapid onset over hours.

High-frequency ventilation is a type of mechanical ventilation which utilizes a respiratory rate greater than 4 times the normal value. and very small tidal volumes. High frequency ventilation is thought to reduce ventilator-associated lung injury (VALI), especially in the context of ARDS and acute lung injury. This is commonly referred to as lung protective ventilation. There are different types of high-frequency ventilation. Each type has its own unique advantages and disadvantages. The types of HFV are characterized by the delivery system and the type of exhalation phase.

Bronchoscopy procedure allowing a physician to look at a patients airways through a thin viewing instrument called a bronchoscope

Bronchoscopy is an endoscopic technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. An instrument (bronchoscope) is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy. This allows the practitioner to examine the patient's airways for abnormalities such as foreign bodies, bleeding, tumors, or inflammation. Specimens may be taken from inside the lungs. The construction of bronchoscopes ranges from rigid metal tubes with attached lighting devices to flexible optical fiber instruments with realtime video equipment.

Subcutaneous emphysema

Subcutaneous emphysema is when gas or air is in the layer under the skin. Subcutaneous refers to the tissue beneath the skin, and emphysema refers to trapped air. Since the air generally comes from the chest cavity, subcutaneous emphysema usually occurs on the chest, neck and face, where it is able to travel from the chest cavity along the fascia. Subcutaneous emphysema has a characteristic crackling feel to the touch, a sensation that has been described as similar to touching Rice Krispies; this sensation of air under the skin is known as subcutaneous crepitation.

Bronchomalacia congenital disorder of respiratory system

Bronchomalacia is a term for weak cartilage in the walls of the bronchial tubes, often occurring in children under six months. Bronchomalacia means 'floppiness' of some part of the bronchi. Patients present with noisy breathing and/or wheezing. There is collapse of a main stem bronchus on exhalation. If the trachea is also involved the term tracheobronchomalacia (TBM) is used. If only the upper airway the trachea is involved it is called tracheomalacia (TM). There are two types of bronchomalacia. Primary bronchomalacia is due to a deficiency in the cartilaginous rings. Secondary bronchomalacia may occur by extrinsic compression from an enlarged vessel, a vascular ring or a bronchogenic cyst. Though uncommon, idiopathic tracheobronchomalacia has been described in older adults.

Tracheobronchial injury damage to the tracheobronchial tree

Tracheobronchial injury (TBI) is damage to the tracheobronchial tree. It can result from blunt or penetrating trauma to the neck or chest, inhalation of harmful fumes or smoke, or aspiration of liquids or objects.

A tracheotome is a medical instrument used to perform an incision in the trachea with a cutting blade operated by a powered cannula. It is often called a tracheostomy tube because once it enters the stoma in the trachea, a breathing tube is connected to a ventilator and oxygen is provided to the lungs.

Tracheal intubation, an invasive medical procedure, is the placement of a flexible plastic catheter into the trachea. For millennia, tracheotomy was considered the most reliable method of tracheal intubation. By the late 19th century, advances in the sciences of anatomy and physiology, as well as the beginnings of an appreciation of the germ theory of disease, had reduced the morbidity and mortality of this operation to a more acceptable rate. Also in the late 19th century, advances in endoscopic instrumentation had improved to such a degree that direct laryngoscopy had finally become a viable means to secure the airway by the non-surgical orotracheal route. Nasotracheal intubation was not widely practiced until the early 20th century. The 20th century saw the transformation of the practices of tracheotomy, endoscopy and non-surgical tracheal intubation from rarely employed procedures to essential components of the practices of anesthesia, critical care medicine, emergency medicine, gastroenterology, pulmonology and surgery.

Advanced airway management

Advanced airway management is the subset of airway management that involves advanced training, skill and invasiveness. It encompasses various techniques performed to create an open or patent airway - a clear path between a patient’s lungs and the outside world.

Tracheoinnominate fistula

Tracheoinnominate fistula is an abnormal connection (fistula) between the innominate artery and the trachea. A TIF is a rare but life-threatening iatrogenic injury, usually the sequela of a tracheotomy.

References

  1. Wikisource-logo.svg Chisholm, Hugh, ed. (1911). "Bronchotomy". Encyclopædia Britannica . 4 (11th ed.). Cambridge University Press. p. 636.
  2. 1 2 "Chirurgia". A Dictionary of Greek and Roman Antiquities. penelope.uchicago.edu. Retrieved 2012-09-20.
  3. Mohan, R; Iyer, R; Thaller, S (2009). "Airway management in patients with facial trauma". Journal of Craniofacial Surgery. 20 (1): 21–3. doi:10.1097/SCS.0b013e318190327a. PMID   19164982.
  4. Katos, MG; Goldenberg, D (2007). "Emergency cricothyrotomy". Operative Techniques in Otolaryngology. 18 (2): 110–4. doi:10.1016/j.otot.2007.05.002.
  5. 1 2 3 Gomes Silva, B. N.; Andriolo, R. G. B.; Saconato, H.; Atallah, Á. N.; Valente, O. (2012). Gomes Silva, Brenda Nazaré, ed. "Early versus late tracheostomy for critically ill patients". The Cochrane Library. doi:10.1002/14651858.CD007271.pub2.