Introduction to Upper Airway and Olfaction by rt3463df

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									Upper Airway Obstruction and
  Tracheostomy Workshop
   Drs. Eric Henry, Shaun Kilty, Miklos
   Matyas, Laurie McLean, JP Vaccani
    Otolaryngology—Head and Neck
                Surgery
          University of Ottawa
                     OBJECTIVES
• Recognize how pathology in the upper airway may contribute
  to airway obstruction
• Recognize the presenting signs and symptoms of a patient
  with airway obstruction
• Explain how airway infections may lead to airway obstruction
• List three indications for placement of a tracheostomy tube
• Compare and contrast tracheostomy and cricothyroidotomy
• Identify the parts of a tracheostomy tube
                               CASE
• 50 year old male presents to the emergency room with a 1 week history of
  progressive difficulty breathing
• On examination:
   – Restless, looks unwell
   – Tachycardic, tachypnic
   – Abnormal voice
   – Respiratory exam:
       • Inspiratory stridor
       • Accessory muscle use
       • Tracheal tug
ABC’s
REVIEW OF RELEVANT ANATOMY: UPPER
        AIRWAY AND LUNGS
REVIEW OF RELEVANT ANATOMY:
       SAGITTAL VIEW
REVIEW OF RELEVANT ANATOMY: LARYNX
        LOOKING FROM ABOVE

                         Hypopharynx

                         Arytenoids

                         True Vocal Cords

                         Epiglottis

                         Vallecula
REVIEW OF RELEVANT ANATOMY:
       ANTERIOR NECK



 Cricothyroid membrane   Thyroid cartilage

 Cricoid cartilage
                         Thyroid gland


                             Trachea
WHAT ARE THE SYMPTOMS AND SIGNS
    OF AIRWAY OBSTRUCTION?
         PRESENTATION OF AIRWAY
              OBSTRUCTION
SYMPTOMS MAY INCLUDE:                    SIGNS MAY INCLUDE:
•   Difficulty breathing                 •   Looks unwell
     – Stridor: high pitched sound       •   Restlessness
         when breathing caused by        •   Cyanosis
         turbulent flow in the upper     •   Hoarseness or aphonia
         airway (can be inspiratory,
         expiratory or biphasic)         •   Drooling
     – Shortness of breath               •   Vital Signs:
•   Hoarseness                                – Tachycardia
•   Dysphagia (difficulty swallowing)         – Tachypnea
•   Odynophagia (pain with swallowing)   •   Respiratory exam:
                                              – Stridor
                                              – Tracheal Tug/Accessory muscles
                                              – Decreased breath sounds
DIFFERENTIAL DIAGNOSIS OF
   AIRWAY OBSTRUCTION




 THINK “IN” THE LARYNX AND
   “AROUND” THE LARYNX
    DIFFERENTIAL DIAGNOSIS OF
       AIRWAY OBSTRUCTION
• INFECTIOUS                        • TRAUMATIC
   – Supraglottitis, Epiglottitis      – Neck trauma
   – Parapharyngeal Space              – Foreign Body
     Infection                      • INFLAMMATORY/IMMUNE
   – Retropharyngeal Space            MEDIATED
     Infection                         – Angioedema
• NEOPLASM                          • IDIOPATHIC/DEGENERATIVE
   – Benign                            – Bilateral Vocal Cord Paralysis
   – Malignant
                       SUPRAGLOTTITIS
• Inflammation/infection of the larynx
  above the level of the true vocal
  cords
• Most common pathogens:
         •   Strep pneumoniae
         •   Grp A Strep
         •   H. influenza
         •   Staph aureus
         •   Viral
• Incidence of H. influenza
  SIGNIFICANTLY decreased since
  introduction of Hib vaccine
    – Health Canada Immunization Monitoring
      Program detected 99% fewer cases of H.
      influenza in 2000 vs 1985
                EPIGLOTTITIS
• Inflammation/infection
  of the epiglottis
• Can be a component of
  supraglottitis
• Pathogens the same as
  supraglottitis
      PARAPHARYNGEAL OR
RETROPHARYNGEAL SPACE INFECTION
                   • Parapharyngeal:
                      – Infection/inflammation of the
                         space BESIDE the
                         pharynx/larynx
                   • Retropharyngeal:
                      – Infection/inflammation of the
                         space BEHIND the
                         pharynx/larynx
                   • Causes airway obstruction
                     through compression and/or
                     edema




                   • Causes airway
                       NEOPLASM
• Inside Larynx:
   – Benign
   – Malignant:
      • Squamous Cell Carcinoma
        is most common
        malignant neoplasm of
        the larynx
• Beside Larynx
   – If large, may compress
     larynx/trachea
      • E.g. Large thyroid
        neoplasm
          BILATERAL VOCAL CORD PARALYSIS

• PARALYSED IN
  ADDUCTION:
  – Poor Airway
  – Good Voice


• PARALYSED IN
  ABDUCTION:
  – Good Airway
  – Poor, breathy voice
FOREIGN BODY
  MANAGEMENT OF AIRWAY
      OBSTRUCTION
• ESTABLISH AN AIRWAY
  – Remove foreign body when applicable (Heimlich)
  – Endotracheal intubation
  – Cricothyrotomy (AKA Cricothyroidotomy)
  – Tracheostomy
• TREAT THE CAUSE
QUESTIONS?
CRICOTHYROIDOTOMY AND
     TRACHEOSTOMY
      Small Groups
           CRICOTHYROIDOTOMY
• Temporary emergency airway
• Indications:
  – Airway obstruction above the level of the larynx
    and oral/nasal endotracheal intubation is not
    possible
• Types:
  – Needle
  – Surgical
           CRICOTHYROIDOTOMY
• Advantages:
   – Cricothyroid membrane is superficial and accessible
   – Minimal dissection required
   – Usually faster than tracheostomy
• Disadvantages:
   – Cricothyroid membrane is small (cannula may not fit)
   – Adjacent structures jeopardized
   – Cricoid damage may lead to perichondritis or stenosis
   – 32% complication rate if done emergently
  For Video Review of Procedure:

http://minasartopoulos.blogspot.com/search/l
            abel/DVD-CD-VIDEO
            TRACHEOSTOMY
• Opening into the trachea
• Indications:
  – Airway obstruction
  – Failure to wean from mechanical ventilation
  – Pulmonary toilet (copious secretions)
  – Long-term mechanical ventilation
  – Temporary airway for extensive head and neck
    procedures
PARTS OF A TRACHEOSTOMY TUBE
              • Be aware of “cuffed” vs
                “uncuffed”
                tracheostomy tubes
              • Parts:
                 –   Outer cannula
                 –   Inner cannula
                 –   Introducer or Obturator
                 –   Balloon/Cuff
                 –   Ties
                 –   Phalange indicating size
CAN A PT WITH A TRACHEOSTOMY
     TUBE SPEAK AND EAT?
• YES
• For a cuffed tracheostomy tube:
  – Cuff needs to be deflated for vocalization
• Can vocalize by:
  – Occluding tracheostomy with finger
  – Using Passy Muir Valve
 SPEAKING VALVES
(PASSY MUIR VALVE)

              • One way valve to
                allow for
                inspiration
                through trach tube
                but exhalation
                through larynx
SUCTIONING
CHANGING A TRACHEOSTOMY
          TUBE
          COMPLICATIONS OF A
            TRACHEOSTOMY
IMMEDIATE                         EARLY
• Bleeding                        • Mucous plugging
• Pneumothorax                    • Tracheitis
• Postobstructive pulmonary       • Displacement
  edema
• Injury to adjacent structures   LATE
                                  • Granulation tissue
                                  • Tracheoinnominate fistula
                                    (0.06%; 80% mortality rate)
CONSOLIDATING YOUR
   KNOWLEDGE
       TEST YOUR KNOWLEDGE
• What is the difference between a
  cricothyroidotomy and a tracheostomy?
• What are common causes of upper airway
  obstruction?
• Can a person vocalize if they have a
  tracheostomy tube in place?
• Can you cork or occlude a cuffed
  tracheostomy tube if the cuff is inflated?
QUESTIONS?

								
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