Surgical Options in Airway Management

The greatest challenge for an airway manager is dealing with an apneic patient whom they cannot intubate or ventilate.
Before irreversible hypoxic injury occurs, the airway manager must be ready to establish a surgical airway.
The purpose of this chapter is to describe surgical airway management options for those not trained to perform a surgical tracheostomy.

The primary objective is to establish a route for oxygen delivery to the patient's lungs.
Oxygenation is life-saving, while ventilation is desirable.
The surgical airway creates a route for oxygen delivery when standard techniques fail.

Managing the surgical airway demands psychological, logistical, and clinical preparation.

The airway manager must be prepared to abandon standard techniques and undertake more invasive surgical interventions.

All surgical airway management equipment must be immediately available and functional.

The airway manager must establish a protocol or algorithm to deal with the difficult airway, including surgical options.

Objective: To insert a catheter into the trachea through which oxygen can be inspired or injected with low-pressure or high-pressure systems.
This is a temporary intervention until a more formal airway can be established.
Needles and catheters inserted percutaneously into the trachea through the cricothyroid or another tracheal membrane have been used to provide ventilation and oxygenation in both pediatric and adult patients.

Locate the cricothyroid ligament between the thyroid and cricoid cartilages.
Insert a needle through the ligament; suction with the syringe. Once the needle/catheter is in the trachea, air will flow into the syringe.
Insert the catheter into the trachea and remove the needle. At this point, you may try to oxygenate the patient through the catheter.
Merely pass a guide wire through the catheter. Remove the catheter leaving the wire in the trachea.
Make an incision along the wire into the trachea.
Pass a non-kinking dilator over the wire.
Insert the cannula and remove the wire. To avoid trauma do not pass the cannula more than a few inches into the trachea. Secure it by hand or with a suture.

Trauma (subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumopericardium)
Breakage or bending of the needle
Kinking, dislodgement, or breakage of the catheter
Perforation of the esophagus or other structures in the neck or thorax
Bleeding at the insertion site or into the trachea, causing obstruction
Expiratory obstruction
Hypoventilation with hypercapnia and acidosis
Sore throat
Infection

Objective: A retrograde wire or catheter passed from the trachea, through the glottis into the upper airway may be used to guide an endotracheal tube between the vocal cords into the trachea.

First described in 1984 for patients who did not require a formal tracheostomy.
- Formal tracheostomy = Stoma

Airway access is achieved by standard wire-guided (Seldinger) technique via the cricothyroid membrane.
Subsequent dilation of the tract and tracheal entrance site permits passage of the emergency airway.
Catheter is cuffed to protect and control airway once placed.
Airway catheter is radiopaque and has standard 15 mm connector.
passing a guide wire into the trachea (as described in the Technique of Needle/Catheter Cricothyroidotomy
making a small scalpel incision along the wire into the trachea
passing the dilator/airway catheter over the wire into the trachea. The dilator and wire are then removed
Once in place, the catheter distal port can be connected to standard airway equipment to provide oxygenation and ventilation

Difficult insertion
Misleading signs of tracheal positioning
Pneumothorax
Surgical emphysema
Bleeding
Respiratory difficulty – insufficient respiratory support after placement
Loss of the introducer into the pleural space
Esophageal perforation
Neck extension during insertion – may be contraindicated if underlying cervical spine injury is suspected

Contraindications are relative or absolute depending on many factors such as the experience of the operator, institutional standards, time constraints, and the stage of technical development and knowledge concerning a particular intervention.

Tracheal stenosis (1.85%)
Hemorrhage (0.8%)
Tracheo-cutaneous fistula (0.53%)
Infection (0.44%)
Tube decannulation/obstruction (0.35%)
Subcutaneous emphysema (0.08%)
Pneumothorax (0.26%)
Tracheoesophageal fistula (0.08%)

The complications associated with tracheostomy are similar for adult and pediatric patient populations.
Tracheostomy-related mortality is reportedly 0.5–5% in the pediatric population.

A rigid bronchoscopy can act as an airway by inserting a hollow metal tube with a light and camera into the throat and down the windpipe, allowing for visualization and intervention.
It can help to open the airway, remove obstructions, and perform procedures like stenting or tissue biopsies.
A rigid bronchoscope may be inserted to provide an airway during surgery involving the trachea, mediastinum, vascular rings, aberrant innominate artery, or the removal of foreign bodies.
- Vascular ring = from aorta around the trachea
In most circumstances an experienced surgeon will insert the bronchoscope.
The airway operator must be ready to assist the surgeon and to connect the bronchoscope to the anesthesia circuit to provide oxygen, ventilation, and/or anesthesia gases to the patient.