ENT

Dr. Baseem N. Abdulhadi Fifth Year

Emergency Airway Procedures
Assessment of the critical airway
Simply looking and listening to the patient will give a lot of information about their
airway.
Emergency situations can be frightening for all concerned, but try not to panic, think
in logical patterns, appear confident, and try to reassure the patient – who will
undoubtedly be far more frightened than you.

Try to answer the following questions

✓ Does the patient require admission to hospital?
✓ Will admission and observation suffice, or is the clinical picture deteriorating
such that active intervention will be required?
✓ If intervention is required, do you have time to call an expert or do you need to
do something now? If so, consider oxygen with or without antibiotics,
nebulized adrenaline, intubate, laryngotomy and tracheostomy.

Start by looking at the patient

✓ What is their colour? Are they blue?
✓ Look for intercostal recession/tracheal tug.
✓ What is the respiratory rate?

Then listen to the patient

✓ Are they able to talk in sentences/in short phrases/in words only/not at all?
✓ Do they have inspiratory stridor (laryngeal) or expiratory wheeze
(tracheobronchial)?
✓ What is the history?

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Look at the observations chart and other investigations
• Respiratory rate: climbing?
• Pyrexial?
• Oxygen saturation: falling?

Endotracheal intubation
This is the first-line treatment for acute airway obstruction when experienced staff
are available and adequate equipment is at hand. All accident and emergency
departments and hospital wards will have an endotracheal intubation (ET) tube on
the resuscitation trolley.
Placement of an ET tube is a skill that all anaesthetists and emergency doctors attain
and practice regularly. All medical staff should at some point in their training be
instructed in intubation. On occasions, endotracheal intubation may not be possible
due to poor access, inadequate equipment or unskilled staff.
In this situation, other maneuvers are needed to establish an airway. Which of the
following methods are used will depend on the training and experience of the staff in
attendance and the equipment available.

Cricothyroidotomy
A hollow tube is introduced into the lumen of the larynx via a percutaneous route.
The easiest and most commonly available instrument, at least in the hospital setting,
is a wide-bore intravenous cannula. This is inserted into the neck in the midline
through the cricothyroid membrane.

Cricothyroidotomy involves the following steps:

1) Run a finger down the midline of the neck, feeling for the thyroid notch.
2) Continue down the neck for 2–4 cm until you feel the firm ring of the cricoid
cartilage.
3) Immediately above the cricoid you will feel the slightly spongy cricothyroid
membrane. Mark this spot in the midline.
4) Take a 10 mL syringe, draw up 5 mL of saline and attach the syringe to a large-
bore cannula or transtracheal ventilation needle.
5) At 90 degrees to the skin insert the needle, keeping some suction pressure on
the syringe.
6) When the tip of the needle passes into the airway a stream of bubbles will be
seen in the fluid in the syringe.
7) Now pull the needle trocar back 1 cm and advance the plastic cannula, angling
45 degrees downwards.
8) Remove the needle and fix the cannula in place.

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 9) Attach oxygen tubing with a Y-connector or cut a side hole in the tubing.
10) Using finger occlusion, give 1-second bursts of ventilation with 4-second gaps
to allow carbon dioxide to escape.
11) Remember this will buy you time and you will now have to plan your
definitive airway.
Custom-made kits are available for use in this procedure and are often available in
accident and emergency departments. However, in desperation, all manner of tubes
have been inserted through the cricothyroid membrane and saved lives as a result,
including a steak knife to make the incision and the hollow barrel of a ballpoint pen
to maintain the airway.

Tracheostomy
A hole is made in the front wall of the trachea and a tube maintains this air way.
Most commonly, this is performed as an elective procedure in patients who require
long-term assisted ventilation or as part of some head and neck or airway operation.

Indications of tracheostomy:
1) Airway obstruction:
a) Congenital (subglottic stenosis, laryngeal web, laryngeal cyst)
b) Trauma (foreign body, severe head and neck injury, swallowing corrosive,
inhalation of irritants)
c) Infection (acute epiglottitis, CROUP, diphtheria, Ludwig’s angina)
d) Tumor (tongue, larynx, pharynx, trachea, thyroid)
e) Vocal cord paralysis (thyroidectomy complications, bulbar palsy)

2) Protection of the tracheobronchial tree:

a) Neurological diseases (Polyneuritis, tetanus, mysthenia gravis, MS)
b) Trauma (burns of the face and neck, multiple facial fractures)
c) Coma (drug overdose, head injury, cerebrovascular accident)
d) Head and neck surgery (oral or oropharyngeal resections, supraglottic
laryngectomy)

3) Ventilatory insufficiency:
Tracheostomy reduces upper respiratory dead space by about 70%.
a) Pulmonary diseases
b) Neurological diseases
c) Severe chest injury (flail chest)

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It is important to have some knowledge of the basic steps in performing a
tracheostomy:
1) A 3 cm midline horizontal incision is made midway between the sternal notch
and cricoid cartilage.
2) Divide the subcutaneous tissues and platysma muscle
3) Separate the strap muscle in the midline.
4) Ligate and divide the thyroid isthmus.
5) Identify the three or four rings of the trachea.
6) In an adult, remove the anterior portion of one ring to create a tracheal
window (between 2nd and 3rd rings). In children, simply incise the trachea and
retract the cut edges.
7) Insert an appropriately sized tube and secure in place.
8) Attach ventilatory support where necessary.

In the emergency situation, a ‘crash’ tracheostomy may be required. Here, the

technique is modified somewhat: a scalpel blade is used to make a longitudinal
incision in the neck, while the other hand supports the larynx in the midline and
provides some pressure on the thyroid isthmus as it is divided in an attempt to
minimize bleeding.
The blade is plunged into the trachea and twisted sideways to keep the incision in the
trachea open. Then a tube may be inserted into the airway, which is then secured,
and haemorrhage dealt with.
In recent years, percutaneous tracheostomy has become popular, especially among
anaesthetists working in intensive treatment units. This technique involves passing a
needle into the tracheal lumen, through which is passed a guidewire. Dilators of
increasing size are passed over the wire until a tracheotomy tube can be inserted.

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