Surgical Airway Techniques

SURGICAL AIRWAY TECHNIQUES

“Invasive” airways are required when the “can’t intu-bate, can’t ventilate” scenario presents and may be performed in anticipation of such circumstances in selected patients. The options include: surgical cricothyrotomy, catheter or needle cricothyrotomy, transtracheal catheter with jet ventilation, and retro-grade intubation.

Surgical cricothyrotomy refers to surgical incision of the CTM and placement of a breath-ing tube. More recently, several needle/dilator cricothyrotomy kits have become available. Unlike surgical cricothyrotomy, where a horizontal inci-sion is made across the CTM, these kits utilize the Seldinger catheter/wire/dilator technique. A catheter attached to a syringe is inserted across the CTM (Figure 19–30). When air is aspirated, a guidewire is passed through the catheter into the trachea ( Figure 19–31). A dilator is then passed over the guidewire, and a breathing tube placed (Figure 19–32).

Catheter-based salvage procedures can also be performed. A 16- or 14-gauge intravenous cannula is attached to a syringe and passed through the CTM toward the carina. Air is aspirated. If a jet ventila-tion system is available, it can be attached. The cath-eter MUST be secured, otherwise the jet pressure will push the catheter out of the airway, leading to potentially disastrous subcutaneous emphysema. Short (1 s) bursts of oxygen ventilate the patient. Sufficient outflow of expired air must be assured to avoid barotrauma. Patients ventilated in this manner may develop subcutaneous or mediastinal emphysema and may become hypercapneic despite adequate oxygenation. Transtracheal jet ventilation will usually require conversion to a surgical airway or tracheal intubation.

Should a jet ventilation system not be available, a 3-mL syringe can be attached to the catheter and the syringe plunger removed. A 7.0-mm internal diameter TT connector can be inserted into the syringe and attached to a breathing circuit or an ambu bag. As with the jet ventilation system, ade-quate exhalation must occur to avoid barotraumas.

Retrograde intubation is another approach to secure an airway. A wire is passed via a catheter placed in the CTM. The wire is angulated cephalad and emerges either through the mouth or nose. The distal end of the wire is secured with a clamp to prevent it from passing through the CTM. The wire can then be threaded into an FOB with a loaded endotracheal tube to facilitate and confirm placement. Conversely, a small endotracheal tube can be guided by the wire into the trachea. Once placed, the wire is removed. Alternatively, an epidural catheter can be placed via an epidural needle in the CTM. After the distal end is retrieved from the mouth, an endotracheal tube may be passed over the catheter into the trachea.