1. Trachea
Mark Perna
Sunday, May 02, 2010

2. 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

7. 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

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

9. 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

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

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

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

15. 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

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

17. 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

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

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

23. Bronchoscopy (Rigid)

25. Esophagoscopy (Rigid or Flexible)

27. Bronchoscopy

28. 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