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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