SURGICAL AIRWAY

Dr. sobhan aich

Department of anaesthesiology
Tata medical center
Algorithm
 Cannot intubate cannot ventilate OR
Cannot intubate cannot oxygenate
▶ Last but not the least scenario.

▶ Worst nightmare for anaesthesiologist.

 Definition

Complete Ventilation Failure

▶ According to AIDDA,

▶ A situation where intubation, ventilation using SAD and

face mask have all failed after giving the best attempt,
even if oxygenation may be maintained.

Indian Journal of Anaesthesia | Vol. 60 | Issue 12 | Dec 2016

 Points to remember
• Proceeding to emergency cricothyroidotomy when
there is CVF, while oxygenation is maintained .

• Nasal oxygen insufflation should continue.

• Before declaring CVF, a final attempt at mask

ventilation should be made.

• Ensuring complete muscle relaxation.

 Call for help
• The AIDAA recommends calling for additional help
when the final attempt at rescue mask ventilation
fails and emergency cricothyroidotomy is planned.
Surgical airway or front of neck
access technique
 TYPES

Emergency front of neck

access or surgical airway

Puncture Seldinger Surgical

cricothyroidotomy cricothyroidotomy cricothyroidotomy

Narrow bore cannula

Wide bore
a)Ravussian needle Melker’s
a)Quicktrach Scalpel bougie tube
b)Patil cricothyroidotomy
b)Surgicric II
cricothyroidotomy needle
 Anatomical landamrks

• The boundaries of the cricothyroid membrane .

• Thyroid cartilage superiorly, the cricoid cartilage

inferiorly and the cricothyroideus muscles laterally.

• The membrane is approximately 10 mm in height,

22 mm in width and is made up of dense
fibro-elastic tissue.
• The cricothyroid membrane is a superficial, easily
felt, less mobile structure held steadily in place.
• Relatively avascular structure.
• Placed away from thyroid gland, anterior jugular
veins and laryngeal nerves.
• Cricothyroidotomy is thus easier and faster to
perform than tracheostomy .
 Identification

‘Laryngeal handshake’ described by levitan.

 Hyoid and thyroid laminae are identified using the
non-dominant hand.

 Larynx is identified and stabilised between the thumb

and the middle finger.

 The neck should be moved down to palpate the

cricothyroid membrane with the index finger.
 Patient position

• Patient is positioned supine with the neck

extended.

• This can be provided using a pillow under the

shoulders or dropping the head over the
operating table.
 Surgical cricothyroidotomy

• One of the useful techniques uses ‘stab, twist,

bougie, tube’ steps sequentially.

• Only a scalpel with number 10 blade, a

gum-elastic bougie with angled tip and a
cuffed ET tube of size 6 mm are required.
• Nasal oxygenation at 15 L/min flow rate and
attempts to ventilate by face mask are continued.

• Keeping the blade perpendicular to the skin,

perform a transverse stab incision through the
skin and cricothyroid membrane (lower half of
the membrane).
• After stabbing, rotate the blade by 90° with sharp edge of the
blade facing caudally.

• Stabilise the blade with left hand, provide gentle traction

towards the operator .

• Insert the bougie 10–15 cm into the trachea.

• The blade must be removed, cuffed ET tube should be

railroaded over the bougie and the bougie must be
withdrawn gently.

• Inflate the cuff and confirm tube position using capnography.

• When cricothyroid membrane is not palpable scalpel–
finger–bougie technique may be attempted.
• A vertical midline skin incision of around 8–10 cm is
made and enlarged with blunt dissection using the
finger (scalpel handle, forceps or dilator may also be
used).
• Rest of the steps remain as mentioned above.
 Puncture Technique
Puncture may be:
1. Needle cricothyroidotomy(narrow
bore)
2. Wide bore (cannula over trocher)
3. Seldinger (wire guided )technique.
 Narrow bore cricothyroidotomy

▶ Cannula over needle

▶ ID <or = 4 mm

▶ Needs high pressure

▶ ventilation
 Manujet
▶ Colour coded pressure gauge.

▶ 100 cm connecting tube with luer

lock.

▶ Trigger.

▶ 4m pressure hose.

▶ Jet ventilation
catheter(13G,14G,16G).

▶ Endojet adaptor.

▶ 50 psi o2 source
• Narrow-bore cricothyrotomy requires jet ventilation
using a high-pressure ventilation source .
• Associated breath stacking, barotrauma
(pneumothorax, pneumomediastinum), catheter
kinking, malposition or dislodgement.
• In addition to not being a definitive airway, the risk of
aspiration is present.
• Requires a patent upper airway for exhalation.
 Wide bore cricothyroidotomy
• It can be used with standard ventilator and breathing circuits.

• Less invasive .

• Avoids the need for jet ventilation.

• Various devices require Seldinger technique/wide-bore

cannula-over-trocar technique or other techniques which rely on a
dilational step with or without wire guidance.

• May carry the risk of perforation of the trachea, due to force

required to insert it, leading to distortion of trachea.
 Seldinger cricothyroidotomy

▶ Melker emergency cricothyroidotomy set

Seldinger cricothyroidotomy
 Contraindications

• Children less than 12 years .

• Distorted anatomy.

• Laryngyotracheal injury.
 Complications
▶ Reported complications 0- 52%.

▶ Initial misplacement.

▶ Barotrauma (subcutaneous emphysema, pneumothorax,

pneumomediastinum, circulatory arrest).

▶ Bleeding.

▶ Laryngeal fracture.

▶ Long term – subglottic stenosis.

 Which technique?

Indian Journal of Anaesthesia | Vol. 60 | Issue 12 | Dec 2016

Difficult Airway Society 2015 Guidelines
Percutaneous dilatation tracheostomy

• Percutaneous dilatational tracheostomy (PDT)

over a guidewire was invented by Ciaglia in 1985.

• PDT involves blunt dissection of pretracheal

tissues followed by dilatation of trachea over the
guidewire and insertion of tracheal cannula using
Seldinger technique.
 Indication/contraindications
Indications
• PDT in ICU is classically
indicated
(1) to facilitate weaning in difficult
to wean patients,
(2) to aid in tracheobronchial
toileting,
(3) to protect airways in patients
at risk of aspiration,
(4) in anticipated prolonged
ventilator stay,
(5) to minimize sedation
requirement.
contraindications
• Infants.
• Enlarged thyroid glands.
• Infection at insertion site
Presence of pulsatile vessels at
the insertion site.
• Operator inexperience.
• Difficult anatomy (short neck,
morbid obesity, limited neck
extension, local malignancy,
tracheal deviation)
• Unstable cervical spine injuries.
• coagulopathy
Ciaglia’s multiple dilators.
Griggs Technique.
Portex Ultraperc single-stage dilator.
 Ventrain or expiratory ventilation
assistance

• Expiratory Ventilation Assistance (EVA®)

technology enables active expiration by suction.
• Shortens expiration time, increases the
achievable minute volume and reduces the risk
of air trapping and the associated risks of
barotrauma and circulatory collapse.
 Mechanism
▶ Special design optimizes a balance
between the Venturi effect and jet
entrainment.

▶ Gas flows via the inlet through a

very narrow nozzle and exhaust
pipe to the outside.

▶ It entrains gas from port, which is

connected to a catheter: active
expiration.

▶ Insufflation occurs by closing the

exhaust pipe.
Ventrain- A new era in ventilation

▶ Full ventilation through a 2

mm catheter .

▶ Active expiration.

▶ Up to 7 litres minute
volume.

▶ Connection for
capnometry.
 Post oxygenation
▶ Detailed report in patient’s chart.

▶ Detail the cause of difficulty.

▶ Mention the technique which succeeded.

▶ Mention the technique which failed.

▶ Inform the family and the patient.

▶ Medic alert bracelet.

▶ Support to the health care staff – depression, post – traumatic stress

disorder.
Thank you…