Airway obstruction

Presenters: Sam
Yoon Kok
Miao Fang
Jireh Tee
 Learning outcomes
• Define stertor, stridor, wheezing and snoring

• List causes of stertor

• List causes of stridor

• Describe the management of airway obstruction

 Define
• Stertor

• Stridor

• Snoring

• Wheezing
 Stertor
• Noisy breathing due to rattling or rumbling secretions in the pharynx and larynx

• Due to turbulent air flow through partially narrowed air passage above larynx

• Snoring –type sound

• Lower pitch

• Loudest over neck and cheek

• Generated at level of nasopharynx, oropharynx and occasionally supraglottis.

 Stridor
• High pitched

• Harsh , vibrating noice

• From turbulent flow through a partially obstructed segment of respiratory tract

• At level of supraglottis , glottis, subglottis and/or trachea.

{below larynx}

• Can be present due to inspiratory or expiratory phase or biphasic

 Snoring
• Turbulent airflow through the nasopharynx and oropharynx
while sleeping

• It is an undesirable disturbing sound that occurs during sleep. It

is estimated that 25% of adult males and 15% of adult females
snore.

• Its prevalence increases with age.

 Wheezing
• Continuous , “musical “sound

• Most often heard on expiration , but may occur in both phases

• Sound is result of flow limitation in large or medium sized airway

• Obstruction of airway may be due to intraluminal or

extraluminal causes
Causes of stertor
 Stridor
• abnormal, high-pitched sound produced by turbulent airflow through
a partially obstructed airway at the level of the supraglottis, glottis,
subglottis, or trachea
• a symptom, not a diagnosis or a disease
• Above the thoracic inlet, where the external pressure is atmospheric, the negative pressure within the airways leads
to a degree of inward collapse during inspiration
• during expiration, when the recoil pressure of the chest wall generates a positive intrathoracic pressure and pushes air
out from the alveoli to the upper airway compressing the intrathoracic airways but distending the extrathoracic airway
• These changes are exaggerated during any form of airway obstruction, since the pressures generated to overcome the
obstruction are even higher
• obstruction to the extrathoracic airways is worse during inspiration, whereas obstruction to the intrathoracic airways
is worse during expiration
1. Inspiratory stridor suggests a laryngeal obstruction
2. Expiratory stridor implies tracheobronchial obstruction
3. Biphasic stridor suggests a subglottic or glottic anomaly
Tracheostomy and Other Procedures for Airway
Management
• PROCEDURES FOR IMMEDIATE AIRWAY MANAGEMENT
1. Jaw thrust
2. Oropharyngeal airway
3. Nasopharyngeal airway (trumpet)
4. Laryngeal mask airway
5. Transtracheal jet ventilation
6. Endotracheal intubation
7. Cricothyrotomy or laryngotomy or mini tracheostomy
8. Emergency tracheostomy
Tracheostomy Learning Outcome
 Tracheostomy
is making an opening in the anterior wall of trachea and converting it into a stoma
on the skin surface.
Types of tracheostomy tube
1. Uncuffed and cuffed tubes.
2. Double cuff tube. Each cuff can be inflated alternately to prevent pressure necrosis at one site.
3. Suction-aid tracheostomy tubes. They have a small tube ending above the cuff to suck out
pharyngeal secretion and prevent their aspiration.
4. Single lumen tube. There is no inner cannula.
5. Double lumen tube. They have an inner cannula inside an outer cannula. It is easier to remove,
clean and replace the inner cannula, keeping outer cannula in place for breathing.
6. Fenestrated tube. Single or multiple holes are situated at the upper curvature. The hole(s) help in
speech production or in weaning from tracheostomy. Fenestrated tube is used in children for
decannulation.
7. Adjustable flange long tube. Extra length tracheostomy tubes are used when pretracheal tissues are
thick or swollen or to by-pass a growth or stenosis in trachea. Flange in these cases can be adjusted.
8. Tracheostomy with speaking valve. A valve is fitted at the outer end of tracheostomy tube. It allows
ingress of air when breathing in but closes when breathing out. In the latter situation air finds its
way to vocal cords to produce sound. It is used in long-term treatment of bilateral abductor
paralysis or laryngeal stenosis. Digital closure of tracheostomy tube to speak is thus avoided.
Indications of tracheostomy
Complications of tracheostomy
1. Immediate (at the time of operation):
• Haemorrhage.
• Apnoea. Pneumothorax due to injury to apical pleura.
• Injury to recurrent laryngeal nerves.
• Aspiration of blood.
• Injury to oesophagus.
2. Intermediate (during first few hours or days):
• Bleeding, reactionary or secondary.
• Displacement of tube.
• Blocking of tube.
• Subcutaneous emphysema.
• Tracheitis and tracheobronchitis with crusting in trachea.
• Atelectasis and lung abscess.
• Local wound infection and granulations.
3. Late (with prolonged use of tube for weeks and months):
• Haemorrhage, due to erosion of major vessel.
• Laryngeal stenosis, due to perichondritis of cricoid cartilage.
• Tracheal stenosis, due to tracheal ulceration and infection.
• Tracheo-oesophageal fistula, due to prolonged use of cuffed tube or erosion of trachea by the tip of tracheostomy tube.
• Problems of decannulation. Seen commonly in infants and children.
• Persistent tracheocutaneous fistula.
• Problems of tracheostomy scar. Keloid or unsightly scar.
• Corrosion of tracheostomy tube and aspiration of its fragments into the tracheobronchial tree.
Outline steps of
operation
Of Tracheaostomy
TECHNIQUE

• Whenever possible, endotracheal intubation should be done before

tracheostomy. This is specially important in infants and children.
• Position. Patient lies supine with a pillow under the shoulders so that
neck is extended. This brings the trachea forward.
• Anaesthesia. No anaesthesia is required in unconscious patients or
when it is an emergency procedure. In conscious patients, 1–2%
lignocaine with epinephrine is infiltrated in the line of incision and the
area of dissection. Sometimes, general anaesthesia with intubation is
used.
Procedures
1. A vertical incision is made in the midline of neck, extending from
cricoid cartilage to just above the sternal notch.
• This is the most favoured incision and can be used in emergency and
elective procedures.
• It gives rapid access with minimum of bleeding and tissue dissection.

• A transverse incision, 5 cm long, made two fingers’ breadth above the

sternal notch can be used in elective procedures.
• It has the advantage of a cosmetically better scar (Figure 64.1).
2. After incision, tissues are dissected in the midline. Dilated veins are
either displaced or ligated.
3. Strap muscles are separated in the midline and retracted laterally.
4. Thyroid isthmus is displaced upwards or divided between the clamps,
and suture ligated.
5. A few drops of 4% lignocaine are injected into the trachea to
suppress cough when trachea is incised.
6. Trachea is fixed with a hook and opened with a vertical incision in the
region of third and fourth or third and second rings. This is then
converted into a circular opening. The first tracheal ring is never divided
as perichondritis of cricoid cartilage with stenosis can result
7. Tracheostomy tube of appropriate size is inserted and secured by
tapes
8. Skin incision should not be sutured or packed tightly as it may lead to
development of subcutaneous emphysema.
9. Gauze dressing is placed between
POSTOPERATIVE CARE
1. Constant supervision.
• After tracheostomy, constant supervision of the patient for bleeding, displacement or
blocking of tube and removal of secretions is essential.
• A nurse or patient’s relative should be in attendance.
• Patient is given a bell or a paper pad and a pencil to communicate.
2. Suction.
• Depending on the amount of secretion, suction
may be required every half an hour or so; use
sterile catheters with a Y-connector to break
suction force.
• Suction injuries to tracheal mucosa should be
avoided. This is done by applying suction to the
catheter only when withdrawing it.
3. Prevention of crusting and tracheitis. This is achieved by
(a) Proper humidification, by use of humidifier, steam tent, ultrasonic nebulizer or keeping
a boiling kettle in the room.
(b) If crusting occurs, a few drops of normal or hypotonic saline or Ringer’s lactate are
instilled into the trachea every 2–3 h to loosen crusts. A mucolytic agent such as
acetylcysteine solution can be instilled to liquify tenacious secretions or to loosen the
crusts.

4. Care of tracheostomy tube.

• Inner cannula should be removed and cleaned as and when indicated for the first 3 days.
• Outer tube, unless blocked or displaced, should not be removed for 3–4 days to allow a
track to be formed when tube placement will become easy.
• After 3–4 days, outer tube can be removed and cleaned every day.
• If cuffed tube is used, it should be periodically deflated to prevent pressure necrosis or
dilatation of trachea.
Decannulation
• Tracheostomy tube should not be kept longer than necessary.
• Prolonged use of tube leads to tracheobronchial infections, tracheal
ulceration, granulations, stenosis and unsightly scars.
• To decannulate a patient, tracheostomy tube is plugged and the
patient closely observed.
• If the patient can tolerate it for 24 h, tube can be safely removed. In
children, the above procedure is done using a smaller tube.
• After tube removal, wound is taped and patient again closely
observed.