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Trachea

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.

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Trachea

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  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

  3. 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

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

  5. 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

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

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

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

  9. 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

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

  11. 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

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

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

  14. Bronchoscopy (Rigid)

  15. Esophagoscopy (Rigid or Flexible)

  16. Bronchoscopy

  17. 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

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