Transcript UPPER AIRWAY OBSTRUCTION & TRACHEOTOMY

Babak Saedi MD
OTOLARYNGOLOGIST
TEHRAN UNIVERSITY OF MEDICAL SCIENSES
 Voice change
 Dyspnea
 Local pain
 Cough
 Stridor
 Hoarseness
 Retraction
(intercostal- suprasternal-supraclavicular)
 Drooling
- bleeding
- emphysema
 History
 Physical examination
 Fiber optic laryngoscopy
 Radiography
 Arterial blood gas
 C.T.Scan
(if general status of patient is stable)
 Simplest adequate form of control should be selected
 Lower level
 Other medical problems
 Trauma
 Inflammatory diseases
 Benign neoplasms
(intrinsic – extrinsic)
 Malignant neoplasms
(intrinsic – extrinsic)
 others
 External laryngeal injury
- blunt neck trauma
- penetrating wound
 Internal laryngeal injury
- prolonged endotracheal intubation
- post tracheotomy
- post surgical procedures
- post irradiation
- endotracheal burn
(thermal – chemical)
CROUP
AND
EPIGLOTTITIS
 Barking Cough
 Hoarse Voice
 Inspiratory Stridor
 Varying Degrees of
Respiratory Distress
Ages infancy [1-3]
(peak 2 years)
Para influenza viruses – most frequent
Influenza A and B – most severe (esp. A)
Adenovirus
Measles
Respiratory syncytial virus
Clinical Course:
 Recent URI several days before
 Mild cough, progressing to stridor, worsening cough,
retractions.
 Fever usually only slightly elevated
 Symptoms worse at night, better in day
 Most gradually recover over several days
Chest X-ray often shows
classic “steeple sign”
Management:
 Close observation until stable
 Warm or cool mist
 Steroids – oral or nebulized
 Racemic epinephrine
 Hospitalize hypoxic, worsening children
A dramatic, potentially life-threatening form of upper
airway obstruction characterized by:
 High fever
 Sore throat
 Dyspnea
 Rapidly progressive respiratory obstruction
Etiology:
Haemophilus
influenza organism
Clinical Course:
Quick onset of fever, dyspnea
Often sits leaning forward, drooling
Inspiratory stridor
Refuses to eat
Within hours may progress to respiratory
obstruction
Can occur at any age
Physical Findings:
Left picture: nearly completely blocked airway
Right picture: airway opened after intubation
Lateral soft
tissue
neck xray:
“thumbprint” sign
TREATMENT:
 MAINTAIN THE AIRWAY!!
 Empiric antibiotics (Ceftriaxone, cefuroxime, ampicillin
plus chloramphenicol) to cover most likely organisms (P
mirabilis, H influenzae, E coli, K pneumoniae, and M
catarrhalis)
 + or - Steroids
Characteristic
Age
Onset
Location
Temperature
Dysphagia
Dyspnea
Drooling
Cough
Position
Epiglottitis
Any age
Sudden
Supraglottic
High fever
Severe
Present
Present
Uncommon
Croup
6months-12yrs
Gradual
Subglottic
Leaning forward, mouth
open
comfortable
X-Ray
Thumb sign
Steeple sign
Low-grade fever
Mild or absent
Present
Present
Characteristic cough
 Prolonged intubation
 Ventilation support
 Manage bronchopulmonary secretion
 Upper airway obstruction
 Obstructive sleep apnea
 Bilateral vocal cord paralysis
 Inability to intubate
 Major head & neck surgery or trauma
Advantages
 lower risk of laryngotracheal injury
 improved comfort/mobility
 improve airway stabilization
 allows for oral nutrition
 improved secretion clearance
 Sternal notch
 Thyroid cartilage
 Cricoid cartilage
- cricothyroid membrane
- innominate artery
- thyroid gland (isthmus)
- recurrent laryngeal nerve
 Venous supply
 Superior and middle
thyroid v. drain into the
IJ
 Inferior thyroid v. drains
into the brachiocephalic
trunk
 Anatomy variant:
thyroid ima artery, in
1.5% to 12%, in front of
the trachea.
 Emergent (slash trach)
 Urgent (awake)
 Elective
 Optimally under general anesthesia
 Incision between sternal notch and cricoid
 Dissection in a vertical plane
 Thyroid isthmus (third and fourth ring)
 Entrance into trachea
 Tracheotomy tube insertion
 Hemorrhage
 False route
 Electrocautery fire
 Injury to adjacent structures
 Hemorrhage [most common ]
 Infection
 Subcutaneous emphysema
 Pneumomediastinum
 Pneumothorax [most common in infant ]
 Obstruction of tacheotomy tube
 Displacement of tube
 Hemorrhage
 Tracheoesophageal fistula
 Tracheal stenosis
 Tracheocutaneous fistula