Trachea Mark Perna Sunday, May 02, 2010

Introduction Anatomy Discuss emergent and elective surgical Airways Discuss complications of surgical airways Review repair of tracheal trauma Review tracheoinnominate fistula Discuss tracheoesophageal fistula Foreign Body

Emergent Surgical Airway When  Sooner than you think Usually three strikes and your out Knife, Clamp, 4 or 6 ET tube, Betadine Cricothyroidotomy Tracheotomy Crushed Larynx

Elective Surgical Airway When  Sooner than you think 7 days or less on ventilator Early weaning of vent Patient comfort Improved Pulmonary Toilet

Elective Surgical Airway Tracheostomy Percutaneous Blue Rhino Kit, Selindger Technique, Use Bronch Open Define anatomy visually, stay sutures, T incision in trach or Bjork flap Semi Open Define anatomy visually, Blue Rhino Kit

Early Complications Loss of Airway False Passage Decannulation Bleeding Mucus Plug Pneumomediasteum Pneumothorax Infection Negative Pressure Pulmonary Edema

Late Complications Tracheomalacia Stenosis Tracheoinnominate Fistula Dynamic obstruction Stenosis Obstructive symptoms Tracheoinnominate Fistula Herald Bleed Granulation Tissue Bleeding

Tracheal Trauma Tracheobronchial injury generally very appearent Blunt tracheal trauma 22% have concomitant esophageal injuries 16% have major vessel injury 40% have hemothorax

Repair of Tracheal Trauma Small defect - 3-0 or 4-0 absorbable sutures transversely including two tracheal rings Large anterior defect- Convert to tracheostomy Large lateral or posterior defect- Moblize and repair primarily and protect with tracheostomy Drains?  Only if esophageal injury

Tracheoinnominate Fistula Late complication of tracheostomy Low lying tracheal Rings 3-4 Herald Bleeds Bronch can rule out

Plan for initial management Decannulate Quickly reintubate from above Get ET past the bleeding site Blow up the cuff Insert finger and tamponade the innominate artery Call OR and for help

Definitive Management Sternotomy and likely neck incision Proximal and distal control Leave trachea alone Resect artery with autologous bypass Protect with sternohyoid flap

Tracheosophageal Fistula Classically pediatric surgery issue Enteral feeding access and electively repair Adults with prolong intubation High cuff pressures

Bronchoscopy (Rigid)

Esophagoscopy (Rigid or Flexible)

Bronchoscopy

Summary Anatomy  Complicated Emergent Airways  Be ready and do it quickly Elective Airways Be prepared Tracheal Trauma  Look for other injuries Tracheoinnomiate Fistula  Prevention is best treatment Tracheoesophageal Fistula  Close defects and protect with muscle flap Foreign Body - Think Rigid Scope