Five methods of surgical access to the airway will be outlined:
13.2.1 Can You Walk Me through Each Method…Step by Step?
126.96.36.199 Open Cricothyrotomy
- Equipment: The instruments required are a scalpel with a #11 blade; a tracheal hook; Armand Trousseau dilator; and a 5.0 mm ID cuffed endotracheal tube, or a small, cuffed tracheotomy tube (Figure 13-4).
- Technique: It should be clearly appreciated by the practitioner that the technique of emergency cricothyrotomy is primarily a tactile and not a visual technique. With the patient positioned and landmarks identified, the following are steps to a successful standard surgical cricothyrotomy technique:
A 4.0 cm vertical, midline skin incision (Figure 13-5)
A transverse incision of the CTM at the superior border of the cricoid cartilage
Retraction with a tracheal hook (Figure 13-6) either superiorly, with potential trauma to the vocal cords or thyroid cartilage, or inferiorly, with less risk and perhaps better exposure
Insertion of the Trousseau dilator (Figure 13-7)
Caudal placement of a 5.0 mm ID cuffed endotracheal tube, or a small, cuffed tracheotomy tube (Figure 13-8)
Inflation of the cuff, ensuring the proper position and removal of the hook and dilator
Equipment required for an open cricothyrotomy: a scalpel with a #11 blade; a tracheal hook; Armand Trousseau dilator; and a small, cuffed tracheal tube (or a cuffed tracheotomy tube).
Open cricothyrotomy in a cadaver: A 4 cm vertical, midline skin incision is made followed by a transverse incision of the CTM at the superior border of the cricoid cartilage.
Open cricothyrotomy in a cadaver: retraction with a tracheal hook superiorly.
Open cricothyrotomy in a cadaver: insertion of the Trousseau dilator.
Open cricothyrotomy in a cadaver: The tracheotomy tube is inserted into the trachea through the Trousseau dilator.
Prior to securing the tube, it is important to confirm proper placement by ETCO2 and/or by auscultation. A chest X-ray should be obtained, as soon as conveniently possible, to determine adequate tube position and to rule out any parenchymal lung injury, or pneumothorax. Current recommendations view a cricothyrotomy as a temporizing, lifesaving measure. The patient should undergo conversion to a traditional tracheotomy once stabilized.
188.8.131.52 Seldinger Cricothyrotomy Technique
The majority of practitioners are familiar with the Seldinger technique and most will be more comfortable with this approach.
- Equipment: There are several cricothyrotomy kits designed with this technique in mind and all with similar contents. They contain a scalpel blade, a syringe, an 18-gauge catheter over needle and/or a thin-walled introducer needle, a guidewire, a dilator, and a cuffed airway catheter (Figure 13-9).
- Technique: As access to the airway is achieved through the cricothyroid membrane, the anatomic considerations and patient positioning are the same as for open cricothyrotomy. The technique is summarized as follows:
Vertical midline stab incision through the skin overlying the CTM.
Caudal insertion of an 18-gauge needle attached to a syringe (Figure 13-10).
Confirmation of needle placement by aspirating air, followed by removal of the needle and syringe.
Insertion of the guidewire (Figure 13-11) and removal of the catheter, leaving the guidewire in the trachea.
After making a small cut of the CTM along the guidewire (Figure 13-12), the cuffed airway catheter loaded onto the dilator is advanced as a single unit, over the wire and into the airway (Figures 13-13 and 13-14).
Removal of the dilator and securement of the tube.
Confirmation of proper tube placement by ETCO2 and/or by auscultation.
Equipment for Seldinger cricothyrotomy: a scalpel blade, a syringe, an 18-gauge catheter over needle and/or a thin-walled introducer needle, a guidewire, a dilator, and a cuffed airway catheter.
Seldinger cricothyrotomy in a cadaver: Following a vertical midline stab incision through the skin overlying the CTM, an 18-gauge needle attached to a syringe is inserted through the CTM.
Seldinger cricothyrotomy in a cadaver: After confirming accurate needle placement by aspirating air, the needle and syringe are removed. A guidewire is inserted into the trachea through the catheter.
Seldinger cricothyrotomy in a cadaver: A small cut of the CTM is made along the guidewire.
The airway catheter loaded onto the dilator is advanced as a single unit through the guidewire.
The airway catheter loaded onto the dilator is advanced through the guidewire into the trachea.
It should be noted that the Universal Cook Critical Care Melker Cricothyrotomy kit contains equipment to perform both open and Seldinger techniques. Once again, current teaching recommends securing a formal tracheotomy, once the patient is stabilized.
184.108.40.206 Transtracheal Catheter Ventilation
The passage of a 12 to 14 gauge catheter through the CTM for the purposes of establishing an emergency airway is a temporizing method at best. It provides short-term oxygenation until a definitive airway can be established. Many variations of this technique have been used in general relation to availability of equipment. One such technique is summarized as follows:
Caudal insertion of 14 g IV catheter, with syringe attached, through the CTM
Confirmation of position by aspiration air, and advancement of the catheter to its hub, while removing the needle and syringe
Oxygenation utilizing one of several options
Ensuring that there is sufficient time for egress of gas, in order to prevent hypercapnea/hypoxia and air trapping
Options that are available for delivery of O2 include jet ventilation, the O2 flush valve on the anesthetic machine, and the anesthesia circuit itself. As mentioned, it is essential that there is sufficient time and an available route for egress of gas. An assistant should be instructed to manage the upper airway with all necessary maneuvers, including LMA, or other airway, and appropriate airway maneuvers.
Gaufberg and Workman recommend that ventilation with this technique should not exceed 20 minutes in adults and 40 minutes in children.26 It is also the only recommended emergency surgical airway, other than tracheotomy, in children under the age of 12 years.
220.127.116.11.1 Transtracheal Jet Ventilation
For the purposes of simplicity, only classic transtracheal jet ventilation (TTJV) and TTJV with the ENK modulator will be considered here.
Many operating rooms have access to a commercially available jet ventilator, consisting of a high-pressure connector, high-pressure hosing, an in-line regulator, a jet ventilation toggle switch, and a Luer-Lock connector. This device is powered by central wall oxygen at 50 psi (15 L·min−1) and subject to an in-line regulator. Activation of the toggle switch, in a controlled fashion, allows oxygen to be safely jetted through the transtracheal catheter into the airway.
An O2 tank regulator powers another form of TTJV system, with similar high-pressure hosing, jet injector, and Luer-Lock connector. A low flow tank regulator, as on the E cylinder O2 transport tanks, can achieve a maximum pressure of 120 psi with the flow meter set at 15 L·min−1. When the jet is activated briefly, very high flows are generated and can result in satisfactory tidal volumes through 14-gauge catheters over 0.5 second.27
For all systems, chest rise and fall, and the pulse oximeter response, are noted as a measure of ventilatory adequacy.
18.104.22.168.2 ENK Flow Modulator
The ENK flow modulator (Figure 13-15) permits transtracheal ventilation by tubing connected to the O2 flush valve on an anesthesia machine, or on a wall-mounted flow meter. The device is equipped with a series of five holes that can be occluded in a measured fashion to direct flow through the device to the patient. As with TTJV, chest rise and fall is noted as a measure of ventilatory adequacy.
The ENK flow modulator: The device is equipped with a series of five holes (arrow) that can be occluded in a measured fashion to direct flow through the device to the patient.
22.214.171.124 Percutaneous Dilational Tracheotomy
There is an increase in popularity of using percutaneous dilational tracheotomy (PDT) following Ciaglia's28 1985 publication. Limited to elective, bedside procedures, the current widespread use of this technique has revealed it to be safe, rapid, with minimal overall procedural morbidity.15 In fact, the overall complication rate is low and comparable to traditional surgical tracheotomy.29
The procedure was initially performed as a blind technique relying on knowledge of surface landmarks. Adjuncts, such as the lightwand30 (Trachlight™, Laerdal Medical Inc., Wappingers Falls, NY) and the flexible bronchoscope (FFB), can enhance the ease of performing the procedure while minimizing complications, such as paratracheal placement of the tracheotomy tube, pneumothorax, and loss of airway control upon withdrawal of the ETT.31
A summary of the Seldinger-based procedure with the Ciaglia Blue Rhino (Cook Inc., Bloomington, IN) is as follows:
Skin incision and palpation of cricoid and proximal tracheal rings
Flexible bronchoscopic (FB) visualization to retract the ETT and monitor insertion of a catheter over needle device between the second and third, or third and fourth, tracheal rings
Application of the Seldinger technique with J-guidewire and a single tapered dilator
Insertion of a size-appropriate tracheostomy tube
Confirmation of the intratracheal placement with the FB
PDT should be performed by a team of experienced practitioners familiar with the use of the FB and with the traditional surgical approach. Avoidance of the obese patient with poorly defined neck anatomy, acute laryngeal pathology, complete airway obstruction, previous neck surgery, or C-spine flexion deformity will increase the overall success rate of the procedure. For a complete review, and application of the technique, please refer to Chapter 31.