Airway Emergencies: Pearls for the Anesthesiologist
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1 Airway Emergencies: Pearls for the Anesthesiologist Pavan S. Mallur, MD, FACS Division of Otolaryngology, Department of Surgery Beth Israel Deaconess Medical Center Department of Otology and Laryngology Harvard Medical School
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4 Cartilaginous Framework Fixed Spaces Post Cra Ant Cau Glottis (arytenoid to AC) Subglottis (cricoid) 2-4mm 1-2 cm Infraglottis (VF to cricoid)
5 Laryngeal Cartilages ABduction ADduction 3D Motion 1. Sliding (AP): VF tension 2. Rocking (Cranio-caudal): VF height 3. Twisting (Vertical Axis): VF ab / adduction
6 Innervation: RLN and SLN SLNiB CNX SLNeB RLN
7 Layered Microstructure: Phonation Cover Body
8 ABduction and ADuction
9 Lengthening
10 Laryngeal ADductor Reflex
11 Laryngospasm / PVFM
12 Post-Intubation Laryngospasm Immediate vs. Recurrent / Episodic Etiology: unknown Coexistent: RLN + / - SLN neuropathy LEMG: mononeuropathy 71% 14% intubation onset of sx Complex Interaction: Tachykinins Sensory Afferents NTS Cofactors: LPR, chronic irritants Lee and Woo. Ann Otol Rhinol Laryngol 114:
13 LEMG-Guided Botox Partial paralysis of ADductors à decrease strength LAR Affect on sensory afferent limb?
14 Laryngospasm: Post-Botox
15 Office VFI (Awake Unsedated) * Laryngoscope Inj Needle *Images from Mallur PS and Rosen CA. Otolaryngol Clin N Am 2013.
16 * Office VFI I m (Awake not actually Unsedated) screaming in pain. Office injections are welltolerated in >90% of patients (Young VN et al., Laryngoscope 2012) *Images from Mallur PS and Rosen CA. Otolaryngol Clin N Am 2013.
17 Office VFI (Awake Unsedated)
18 Office VFI (Awake Unsedated)
19 Bilateral Vocal Fold Paralysis
20 MSL: Paralysis vs. Fixation
21 BVFP: Acute Treatment Awake Tracheotomy Acute: safest Chronic: best function EMG Botox to TA-LCA ADductors: flaccidity Abductors: tone Andrade Filho PA and Rosen CA. Bilateral vocal fold paralysis: an usual treatment with botulinum toxin. J Voice (4):
22 BLVFP: Acute Treatment Lichtenberger G. Laryngorhinootologie (12): Woodson G and Weiss T. Ann Otol Rhinol Laryngol (7):
23 BLVFP: Long-Term Treatment 1. Transverse Cordotomy 2. Medial Arytenoidectomy 3. Total Arytenoidectomy
24 Airway Management for BLVFP or PGS *Choices for acute airway management: 1. Awake trach 2. *PGS Supraglottic mimics BLVFP Jet Ventillation flex laryngoscopy Hand-held 3. BLFP Subglottic à VF Jet splay Ventillation PGS à VF fixed Hunsaker Tube / Monsoon Ventillator 4. Rigid Bronchoscopy
25 MSL: Paralysis vs. Fixation
26 Airway Management for BLVFP or PGS *Choices for acute airway management: 1. Awake trach 2. Supraglottic Jet Ventilation Hand-held 3. Subglottic Jet Ventilation Hunsaker Tube / Monsoon Ventilator 4. Rigid Bronchoscopy
27 Subglottic JET Ventilation Hunsaker-Mon Tube + Monsoon Ventilator Sublesional Jet Pressure monitor: automatic / adjustable pressure ceiling Basket aligns tube with trachea Collapsible basket: diameter ~5mm
28 Subglottic Jet: Hunsaker-Mon Tube Basket Pressure / ETCO2 Luer Lock
29 Universal Modular Glottiscope (Endocraft LLC) Removable Baseplate Varying Sizes Hand Model
30 Bilateral Immobility from PGS / fixation CA Joint
31 BVFP: Distal JET Ventilation
32 BVFP: Distal JET Ventilation
33 BVFP: Medial Arytenoidectomy and Transverse Cordotomy
34 BVFP: MA and TC
35 BVFP: MA and TC
36 Posterior Glottic Stenosis: the Great Imitator ETT Pressure
37 Posterior Glottic Stenosis: the Great Imitator ETT Pressure Vocal Process Ulceration Vocal Process Granulation * * * *
38 Posterior Glottic Stenosis: the Great Imitator ETT Pressure Vocal Process Ulceration Vocal Process Granulation Posterior Glottic Scar
39 BVFP: MA and TC
40 Vocal Fold Laceration During Phonomicrosurgery 1. Right hypomobility 2. Right severe scar 3. Right vascular ectasia 4. Right ligamentous lesion (fibrous mass) Plan: KTP laser / Injection
41 Vocal Fold Laceration During Phonomicrosurgery
42 Vocal Fold Laceration During Phonomicrosurgery
43 Vocal Fold Laceration During Phonomicrosurgery
44 Vocal Fold Laceration During Phonomicrosurgery
45 Subglottic Stenosis
46 Airway Management for SGS: Supraglottic JET Subglottic (lumen > 4-5mm) Supraglottic (lumen < 4-5mm) Venturi catheter Mounted to laryngoscope Manual (hand-held) delivery Pro: delivery through narrow apeture, decrease risk of barotrauma (no pressure monitor required) Con: motion of tissues, drying of mucosa
47 Venturi Needle Supraglottic Jet
48 SGS: Treatment MSL / CO2 laser +/- balloon dilation 60% require more than one dilation Interval 9 months Maximum number: 4 Can be done without dilation Balloon / rigid dilation alone PCTR Anterior cricoid split (pediatric age group) Roediger FC, Orloff LA, Courey MS. Adult subglottic stenosis: management with laser incision and mitomycin-c. Laryngoscope (9):
49 SGS: CO2 Laser
50 SGS: Pre-Op vs. Post-Op
51 SGS: Adjuvant Treatment Extra-esophageal reflux Blumin et al.: 60% idiopathic SGS with pepsin in larynx / trachea Mitomycin-C Smith et al.: MMCx2 decreases recurrence year 1-2 Cotton et al.: MMC = isotonic saline in LTR Simpson et al.: 4.7% incidence emergent airway intervention post-op (fibrinous exudate)
52 Complications Related to Tracheotomy Intraop: Hemorrhage (anterior jugular / bridging v., thyroid isthmus, thyroid IMA a. / v., innominate a. injury) Failure of insertion / false tract creation Tracheal cartilage fracture Pneumothorax Early post-op: Dysphagia / dysphonia Hemorrhage Inadvertent decannulation Cellulitis Tracheostomy lumen occlusion
53 Less Common Complications Intraoperative death (failure of insertion or tube occlusion) Esophageal perforation Aortic arch laceration (1 case) Injury to common / internal carotid artery (esp if aberrant takeoff / anterior course) Injury to internal jugular v. Post-op subcutaneous emphysema / pneumomediastinum Stomal stenosis TI fistula TE fistula
54 Insertion Failure False tract (soft tissues / mediastinum / goose) Anatomy: large neck, kyphosis or scoliosis, short cricoid à sternal notch distance Tracheal stenosis H&N malignancy / XRT Diagnosis: Flexible suction and end tidal CO2 / tidal volumes Bronchoscopy (trach / peroral flex / rigid / MSL) Treatment: Ventilate through ETT (reintubate if necessary) Localization with syringe / needle / Seldinger tech Conversion to open
55 Suboptimal Tube Orientation * * Diagnosis: rigid bronch or suspension laryngoscopy Treatment: revision (open) or decannulation
56 Acute Hemorrhage Surrounding Vessels Anterior jugular v. (bridging v. common) Inferior thyroid v. Thyroid Ima a. and v. (13% of patients) Carotid / Jugular (RARE) Soft Tissue Thyroid Isthmus Malignant neck mass Treatment: Replace with cuffed ETT just above carina Compression (tube / digital) Open neck exploration à open trach
57 Laryngeal Cartilage Fracture L Cra Cau R * Treatment: open neck exploration, ORIF, open tracheostomy
58 Pneumothorax Apical injury Barotrauma Subcutaneous emphysema False tract / occluded tube Vigorous mechanical ventillation Peripheral bleb Pneumomediastinum Caudal dissection Treatment: Confirm placement CT chest Chest tube
59 Tracheal Stenosis (Suprastomal) and Tracheomalacia VF * VF
60 Tracheal Stenosis from Cartilage In-Fracture
61 Late Hemmorrahge: T.I. Fistula Exploration at Bedside Clot
62 Late Hemmorrahge: T.I. Fistula R Cau Cra Exposed Innominate A. L
63 T.I. Fistula Low placement à direct pressure à anterior / superior artery wall erosion Sentinal bleed common Treatment: Replace with cuffed ETT just above carina Digital compression Open exploration (preparation for sternotomy and vascular repair) or IR stent placement
64 Vert a. L. à R. CA Bypass R. SCA Innom a. w/ stents L. CCA RIMA Aortic Arch
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