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Chapter 21

Devices for Managing the Difficult Airway


Ensuri ng a pat ent ai rway wi t h adequate vent i l at ion and oxygenat i on is a pri mary
goal i n anesthesia and resusci t ati on. Al though death and brai n damage f rom t he
di ff i cul t ai rway have decl ined, i ts management remains a signi f i cant probl em (1).
The Ameri can Society of Anest hesi ol ogists (ASA) has devel oped an al gori thm to
hel p the anesthesi a provider recogni ze and deal wi t h pat i ents who have, or are
l ikel y to have, a di ff icul t ai rway (2, 3). If a di ff i cul t ai rway i s recogni zed bef orehand,
t he course i s l i kel y to be dif ferent f rom that whi ch occurs i f t hat probl em goes
unrecogni zed.
Vari ous aspects of ai rway preservat i on are deal t wi t h in other chapters, i ncl uding
masks and ai rways (Chapt er 16), t racheal intubat ion (Chapter 19), and use of the
supraglott ic ai rway devices (Chapter 17). When these techni ques are unsuccessf ul ,
ot her measures need to be consi dered.
Combitube
Description
The Combi tube (ETC, esophageal -tracheal doubl e lumen ai rway, ETLDA,
esophageal t racheal Combi t ube) (Fi g. 21.1) has t wo separat e l umens that are fused
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l ongi t udi nal l y and two i nf lat abl e cuf f s (4, 5,6). Each l umen i s l i nked by a short tube
t o a standard 15-mm connector at the breathi ng syst em end. The pharyngeal l umen
has an occl uded distal end and eight oval -shaped perf orat i ons (vent i lat i ng eyes)
bet ween t he cuff s. The tube and connector associated wi th t he pharyngeal lumen
may be colored bl ue. The other (tracheoesophageal , t racheal ) l umen has a patent
di stal end and a cl ear t ube. The smal l er di st al cuf f serves to seal ei ther t he
esophagus or t rachea, dependi ng on i ts pl acement . The l arger (pharyngeal ) cuf f
(bal l oon) i s above the perf orati ons. It serves to seal the pharynx by f i l l i ng t he space
bet ween t he base of t he tongue and sof t pal at e so that gas cannot escape through
t he mouth or nose. The pi l ot bal l oon f or t he pharyngeal cuf f is colored bl ue. If the
t i p i s i nsert ed i nt o the t rachea, the di stal cuf f is i nf lated and the t ube i s used as a
conventi onal tracheal tube. If t he t ip i s i nserted i nt o the esophagus, both cuf fs are
i nf l ated and vent i l at ion occurs through the hol es above the di st al cuf f .

View Figure

Figure 21.1 Combitube. Note the ventilating eyes between
the two cuffs. (Courtesy of Sherican Cather Corp.)

The Combi tube has a pronounced anteri or curve toward t he pati ent end. I t is
marked wi th t wo bl ack ri ngs at the machi ne end that help t o indicate t he i nsert i on
depth.
The Combi tube i s avai l abl e i n t wo si zes: the regul ar (41 French [ Fr]) f or adul t
mal es and t he smal l adul t (SA, 37 Fr) f or f emal es and smal l adul ts. The Combi tube
i s recommended f or pati ents wi th a hei ght greater than 5 feet (152 cm). The
Combi t ube SA is recommended f or use in pat i ents 4 to 6 feet tal l (120 t o 180 cm)
but has been used i n pat ients up to 6-1/2 f eet t al l (198 cm) (7,8,9). The Combi tube
i s not recommended f or pat i ents younger t han 12 years of age.
Use
I t i s i mportant to practi ce i nsert ing t he Combi tube under control l ed condi ti ons
before att empt i ng to use i t on a di f f i cul t ai rway. I f a cervi cal col lar i s i n pl ace, i t
shoul d be removed and t he cervi cal spi ne immobi l i zed manual l y whi l e the
Combi t ube i s i nsert ed (10, 11,12). Once the ETC has been inserted successf ul l y,
t he ant eri or port i on of the col l ar shoul d be reappl i ed before releasi ng the manual
stabi l izati on (6).
The Combi tube can be i nserted f rom any posi ti on. For bl i nd inserti on, the head
shoul d be in a neutral posi ti on wi th the occi put on the f l at surf ace on whi ch t he
pati ent i s posi t i oned, not the sni f fi ng posi t i on that is usual l y used f or t racheal
i ntubat ion. Bendi ng the Combi tube i n the port i on bet ween t he bal loons f or a f ew
seconds may f aci l i tate inserti on (6,13,14,15, 16). Sucti oni ng is not necessary, even
i n the presence of blood or vomi t us (4).
The Combi tube i s inserted wi t h one hand, whi le the ot her hand pul l s the t ongue
f orward and l i f ts the j aw (4, 17,18). I t shoul d be passed al ong the surface of the
t ongue, not the palate. It i s i mport ant to keep the Combi t ube mi dl ine duri ng
i nsert i on to avoi d bl ind pockets such as t he val l ecul a. The Combi tube is advanced
unti l the space bet ween the two bl ack rings l i es between the pati ent ' s teeth or gums
or unti l resi st ance i s f el t . Temporary release of cri coi d pressure (if used) may be
requi red (19). I f there i s di ff icul ty advancing t he ETC, rot ati ng t he tube may be
hel pf ul i n some pati ents (16). The use of a l aryngoscope may facil i tate successf ul
pl acement and lower the number of compl i cat i ons (7,20,21,22).
The pharyngeal bal l oon i s inf l ated wi t h 100 mL (85 cc f or t he Combi tube SA) of ai r.
The Combi tube of ten moves outward about 1 cm duri ng i nf l ati on (5). The di stal cuf f
shoul d be inf l ated wi t h 5 t o 12 mL of ai r (Combi tube 37 Fr) or 5 t o 15 cc of ai r
(Combi tube 41 Fr). It may be pref erabl e to i nf late the di stal cuf f f i rst i f t he pati ent i s
at ri sk for aspi rati on (23). The bl ue bal l oon shoul d not be visi bl e when l ooking i nto
t he pat ient' s oral cavi ty (16).
Af ter inserti on and ball oon i nf lati on, vent i l ati on is begun in order to determine
whether the distal lumen i s i n the esophagus or t rachea. Si nce most i nsert i ons
resul t i n esophageal pl acement , venti l ati on shoul d be attempted f i rst vi a the blue
l umen. Gas travel s down t he t ube, t hrough the l ateral wal l perforat ions, i nto the
pharynx, and on into the trachea. I t is prevent ed f rom enteri ng t he stomach by t he
di stal cuff i n t he esophagus and f rom escapi ng through the mouth and nose by the
pharyngeal cuf f . If no evi dence of venti lati on i s detected, a swi t ch shoul d be made
t o t he cl ear l umen wi t hout al t ering the Combi tube' s posi t i on. If venti l ati on i s
sati sf actory, t he devi ce i s then used as a t racheal tube. If venti l ati on conti nues to
be i nadequat e, the Combi tube shoul d be
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wi thdrawn 1 t o 3 cm af ter def l ati ng the cuf fs and venti lati on at tempted agai n wi t h
t he bl ue lumen (24). I f this thi rd at tempt at venti l at ion i s unsati sf actory, t he
Combi t ube shoul d be removed and vent i l at ion establ ished by usi ng another
t echni que.

View Figure

Figure 21.2 Combitube in place in the esophagus.
(Courtesy of Sherican Cather Corp.)

The esophageal detector devi ce and t he col ori met ric carbon dioxi de detect or
(Chapter 22) have been used to veri f y correct posi ti on (24,25, 26,27,28, 29,30,31).
I n anest hesi a sett i ngs, capnography can be used.
Af ter stabi l i zi ng the tube, the amount of ai r i n the cuff s should be reduced. I f the
Combi t ube i s i nsert ed i nt o the t rachea, i nf l ati on shoul d be to j ust seal i ng vol ume
(32). The vol ume i n the pharyngeal bal l oon shoul d be reduced t o the mi ni mum
requi red t o form an ef f ecti ve seal (7,22,33,34,35, 36). If venti l at i on is control led, a
sl i ght posi ti ve end-expi rat ory pressure may be present (21,37,38,39).
I n t he esophageal posi t ion (Fi g. 21.2), the unused tracheal l umen can be connected
t o sucti on to aspi rat e f l ui ds or a gastric tube can be i nserted (22). Epi nephri ne can
be i nsti l l ed through the esophageal lumen (40). The dose shoul d be ten ti mes that
admi ni stered through a t racheal tube.
The Combi tube i n the esophageal posi t i on may be exchanged for a standard
t racheal tube by usi ng a fl exi bl e fi berscope, ri gi d l aryngoscope, or ret rograde
i ntubat ion around the Combi tube (5, 7,9,41,42,43, 44).
Indi cati ons
The Combi tube i s useful for ai rway management in t he di ff icul t-to-i nt ubat e pat ient
(6,25,45,46,47,48, 49,50,51, 52,53,54, 55,56,57). Because i t can be pl aced wi t hout
having to vi sual i ze the larynx, i t may be especi al l y usef ul f or pati ents wi t h massive
ai rway bl eedi ng or regurgi tati on. I t can be used i n pat ients wi t h l i mi ted access to
t he ai rway and li mi t ed mout h opening and for pat i ents i n whom neck movement is
contrai ndi cat ed. It has been used successf ul l y i n pati ents i n a halo head f rame
(58,59), a pat i ent wi th excessive pharyngeal bl eedi ng (60), a hematoma causi ng
upper ai rway obst ruct ion (61), a pat i ent who had a wooden spli nter t hrough the
mouth parti al l y blocki ng the pharynx (62), respi ratory arrest secondary to an acute
asthmati c exacerbati on (63), a pat ient wi th f aci al burns (64), and a pati ent trapped
i n a car (65). It may be usef ul i n entert ai ners in whom i t i s import ant t o avoid vocal
cord damage (18). I t has been used for Cesarean sect ion (66). The ETC has been
used successful l y af ter f ai l ure wi th a l aryngeal mask ai rway (LMA) (54,59).
The ETC has an est abl i shed rol e i n cardi opul monary resusci tati on i n both
prehospi tal and i n-hospi t al sett ings (56,67,68,69, 70,71,72, 73). It i s i ncl uded i n t he
Gui del i nes f or Advanced Cardi ac Lif e Support of the Ameri can Heart Associ ati on,
Pract ice Guidel ines f or Management of the Di ff i cul t Ai rway of the ASA, the
Canadi an Ai rway Focus Group, and gui del i nes f or resusci tat ion of the European
Resusci t ati on Counci l as a sui t abl e al ternat i ve ai rway t o tracheal i ntubati on,
especi al l y i n the cannot vent il at e, cannot intubate si tuati on (2,45,74).
The Combi tube has been used successful l y for anesthesi a lasti ng up t o 6 hours,
i ncl udi ng gynecologic l aparoscopic surgery (5,21,22,38,41,75). Rel ativel y hi gh
ai rway pressures can be used (4,21,22). Whi l e i t is not recommended for routi ne
anesthesi a, i t may be a vi able opti on f or pati ents i n whom i t has been placed t o
secure a di f fi cul t ai rway (76,77). Usi ng i t i n el ect ive cases may
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i ncrease t he anesthesi a provi der' s comfort wi t h t he device. I t has been used i n the
esophageal posi ti on wi th mechani cal venti l ati on f or up t o 8 hours (38).
The Combi tube has been used during percut aneous di lat at ional t racheostomy (see
bel ow) (78) but may not be t he best choi ce f or ai rway management duri ng this
procedure (79). The t rachea i s f ree of any appl i ance, but i t does not al l ow a
f iberscope t o be used duri ng the procedure (80). It has al so been used for
venti l ati on duri ng tracheotomy (81).
Contraindications
Contrai ndi cat ions to using t he Combi t ube i ncl ude acti ve pharyngeal or l aryngeal
ref l exes; known esophageal t rauma or pathology; i ngesti on of corrosive agents; and
oropharyngeal , pharyngeal , or hypopharyngeal mass. It shoul d not be used i n
pati ents younger t han 12 years of age or i n those under 4 f eet tal l .
Advantages
Compared wi t h a t racheal tube, t he ti me needed f or inserti on i s si gni f i cantl y
short er, and l ess ski l l i s requi red (82). Because successf ul use does not requi re
di rect vi sual i zati on, the presence of blood and/or vomi tus does not prevent
successf ul pl acement . Once i n pl ace, the Combi tube provi des comparabl e
venti l ati on and i mproved oxygenat ion compared wi th t racheal i ntubati on
(37,38,41, 48, 67,68,71, 83). I t can be used by an anest hesi a provi der who has
l i mi ted use of t he l ef t arm (84).
Mi nimal trai ni ng is needed before use. The ski l l s requi red to i nsert a Combi tube do
not need to be rei nf orced as of ten as they do for tracheal i ntubat i on. The
Combi t ube can be used successf ul l y by non-anest hesi a personnel bot h as a f i rst-
l i ne t reatment and af ter f ai l ed t racheal i ntubat ion (71,72,73, 83,85,86,87,88). I t i s
of ten used by paramedi cs.
The Combi tube i n the esophageal posi t i on i s wel l t ol erated by t he pat i ent duri ng
emergence f rom anesthesi a (4). It s use i s not associ ated wi t h high l evels of trace
gases (89). There is no danger of bronchial i ntubati on i n the esophageal posi t ion.
The pharyngeal bal l oon anchors the devi ce i n place, l esseni ng the ri sk of
accident al extubat ion.
The Combi tube provides good but not compl et e protect i on f rom aspi rati on
(7,9,22,48,58,63,72,90, 91,92). Gast ri c di stent ion can occur wi th i ts use (36).
Disadvantages
Tracheal suct ioning or fi beropt i c bronchoscopy is not possi ble t hrough t he
Combi t ube i n t he esophageal posi t ion unless the Combi tube i s modi f ied (93).
I f inserted i nto the t rachea, the resul t i s a tube wi t h a rel at ivel y l arge out er
di ameter but smal l i nternal l umen. The ai rf low resi stance wi t h a smal l adul t
Combi t ube i s greater than that of a 7-mm t racheal tube but l ower t han t hat of a 6-
mm tube (94,95).
A case has been report ed where the pati ent coul d not be venti l at ed af ter the
Combi t ube was pl aced (96). The tube was found to be so deep that the upper cuf f
obstruct ed the tracheal l umen. Pul l i ng t he tube backward remedi ed the probl em. In
another case where vent il ati on was di ff icul t, f l exi bl e f i beroscopy showed a val vel i ke
mechani sm by the aryepi gl otti c f ol ds over the perf orat ions in t he tube (97).
I nserti on and removal of the Combi t ube may be associ ated wi th a hi gher st ress
response than that wi th a tracheal t ube or supragl ot ti c ai rway devi ce (22, 39).
I nserti on t akes l onger t han wi th t he LMA (72). The Combi tube may be insert ed
wi thout moving t he head or neck, but there may be more cervi cal spi ne moti on
duri ng ai rway management wi th a Combi tube than wi t h ot her devi ces (98,99).
Trauma t o the ai rway and esophagus may occur wi th t he Combi tube
(12,21,36, 71, 100, 101,102,103,104,105). It exerts rel ativel y hi gh pressure on t he
t racheal mucosa (106). Sore throat and dysphagi a are common af t er i ts use
(33,100). Trauma may be reduced by usi ng t he smal l adul t Combi tube when
appropri at e, gentl e inserti on, hal ti ng f urt her advancement i n t he presence of
resi st ance, usi ng a laryngoscope to ai d i nsert i on, adequate anesthetic depth, sl ow
cuff i nf lati on, and regul ar assessment of bot h cuf f pressures.
The proximal cuf f of t he Combi t ube is made of l atex, making i t unsui table f or use in
a pat i ent wi th l at ex al lergy (Chapt er 15).
The Combi tube i s expensi ve compared to other singl e use devi ces. This makes i t
uneconomical t o use for routi ne anesthet ics.
Retrograde Intubation
Ret rograde (t ransl aryngeal -gui ded, gui ded bl i nd) i ntubati on i s an el ecti ve or
emergency techni que f or securi ng a dif f i cul t ai rway, ei t her alone or i n conj uncti on
wi th ot her t echni ques (107,108,109). It should be consi dered part of t he
armament arium of every anesthesi a provider (2). Retrograde i ntubati on is a useful
opti on in pati ents who cannot be i nt ubated by usi ng tradi ti onal techni ques
(110, 111,112,113, 114, 115,116, 117, 118,119). It may not be sui tabl e for pat ients
who requi re i mmedi at e i ntubati on and venti l at ion, as the procedure can be expect ed
t o t ake 5 mi nut es or more for compl et ion.
A ret rograde i ntubati on set i s shown i n Figure 21.3. Af t er ski n preparati on, a
catheter-over-needl e device wi t h an attached syri nge is i nsert ed through the
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cricot hyroi d membrane i n a cephal ad di recti on (Fig. 21.4). Ent eri ng t he ai rway
l ower i n the ai rway (between the cri coi d cart i l age and t he f i rst t racheal ri ng or
bet ween t he f i rst and second tracheal rings) al l ows more room f or advanci ng the
t ube (107, 117, 120,121, 122, 123). Free ai r aspi rati on conf i rms the l ocati on. Local
anesthesi a shoul d be i nj ected t hrough t he syri nge. The needl e and syri nge are
removed, and a gui de wi re i s inserted t hrough the cathet er (124) (Fi g. 21.5).
Another device such as an epidural or central venous catheter may be used as a
gui de.

View Figure

Figure 21.3 Retrograde intubation set.

The guide i s advanced cephal ad unt i l i t emerges at the oral cavi t y or nares (Fi g.
21.5). I t may be necessary t o use a special device t o retrieve the gui de wi re
(123, 125,126). If nasot racheal intubat ion i s desi red, a catheter can be i nsert ed
nasal l y, brought out through t he mouth, and secured t o the guide wi re (127). The
catheter is t hen pul l ed out through the nose, bri ngi ng the guide wi re wi t h i t . The
catheter at the cri cothyroi d membrane i s removed and t he gui de cl amped at the
ski n.

View Figure

Figure 21.4 The catheter-over-needle with syringe attached
is inserted through the cricothyroid membrane in a cephalad
direction. Aspiration of air confirms placement within the
airway.

A larger devi ce such as an epidural catheter or ai r way exchange cat heter can be
sl i d over the gui de wi re and t he t racheal tube advanced over t he cat heter
(108, 123,128,129, 130, 131,132) (Fi gs. 21.6,21.7,21.8). Al ternatel y, t he t racheal
t ube can be t hreaded over the gui de wi re, wi t h the gui de wi re goi ng ei ther through
t he Murphy eye or mai n l umen.
The guide shoul d then be put under sl ight tensi on. The tracheal tube i s advanced
unti l i t reaches t he poi nt where the guide wi re enters the ai rway. The gui de wi re i s
removed f rom above and t he tracheal tube i nsert ed to t he proper dept h. If t he
t racheal tube cannot be advanced, i t may be helpf ul t o rotate i t 90 degrees
counterclockwi se, exchange i t f or a smal l er tube, rel ax the tension on the gui de, or
i nsert a f i berscope through the tracheal tube (112,123,133). The tracheal t ube may
al so be pul l ed i nto the trachea by tyi ng the retrograde guide t o the t racheal t ube
(108, 117,122,131, 134).
Al ternatel y, af ter t he gui de wi re i s ret ri eved through t he mouth or nose, i t may be
pl aced through the channel of a f l exi ble f i berscope wi t h a t racheal tube threaded
over i t (108,109, 111,114,123, 135, 136,137,138). The f i berscope i s advanced over
t he gui de and down to the poi nt of exi t of t he gui de wi re f rom the t rachea. At thi s
poi nt , the gui de wi re can be l oosened and the f i berscope advanced f urt her (139).
Af ter conf i rmati on that the f i berscope is i n the t rachea, the guide i s removed via the
proxi mal port of the fi berscope. The t racheal t ube i s t hen advanced i nto t he
t rachea.
Ret rograde intubati on i s a saf e, easy, and dependable method of i nt ubati on (117).
I t may be especi al l y usef ul i n pati ents wi th ai rway trauma or l i mi ted neck mobi l i ty
and i n the presence of oropharyngeal bl eedi ng, whi ch
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may obscure the f i eld of the f i berscope (108,113, 140). I t has been used i n infants
and chi l dren (112, 123,135). It has been used to pl ace a doubl e-lumen t ube (141).
Thi s met hod may be a useful means f or rei ntubat ion when a tracheal tube i s
removed (142). I t has been used to intubat e a pati ent wi t h a Combi tube i n pl ace
(143). I t i s i ncl uded i n the ASA Algori thm f or Management of t he Di ff icul t Ai rway
(3).

View Figure

Figure 21.5 A: Guide for retrograde intubation. B: The
guide is inserted through the catheter and advanced
cephalad until it emerges from the mouth.

Compl i cat i ons of ret rograde i nt ubati on i ncl ude sore throat, t rauma, barotrauma, and
pret racheal abscess (117, 119,138,144,145). The t racheal tube may i nadvertentl y
sl i p out as i t i s advanced (146).
Cricothyrotomy
Pl aci ng a device through t he cricothyroid membrane t o gai n control of t he ai rway i s
not a new procedure (147, 148, 149,150). In recent years, the t echnique has been
ref i ned and is now commonl y used by emergency medical servi ces (151,152). It i s
part of the ASA and Di f fi cul t Ai rway Soci ety di ff icul t ai rway al gori thms (2,3).
Cri cothyrotomy equi pment should be on every di f fi cul t ai rway cart.
General Considerations
The t hyroi d carti lage is promi nent and easi l y palpabl e i n most i ndivi duals,
especi al l y i n mal es. I t may be di f f i cul t to pal pat e i n obese pat i ents and infants. The
rel ativel y avascul ar cri cothyroi d membrane i s l ocated approxi mat el y 2 to 3 cm
bel ow t he thyroid notch i n adul ts. Thi s area i s usual l y t he most accessi bl e part of
t he respi rat ory tree bel ow the gl ot t is. Occasi onal l y, i t may be necessary t o choose
a si te l ower i n the ai rway between t he second and thi rd t racheal ri ngs (153,154).
Cri cothyrotomy can be performed by pl acing a smal l needl e or catheter (needl e
cricot hyrotomy), a l arge cannul a special l y designed for thi s purpose, or surgical l y
i nsert i ng a cuff ed tube (147,155). If ti me all ows, f i beropt i c gui dance may decrease
t he i nci dence of mal posi t ion (156).
Techniques
Needle Cricothyrotomy
Technique
The pati ent ' s head i s extended and the cri cothyroi d membrane i dent i fi ed. A needl e
or catheter-over-needl e uni t wi t h a syri nge att ached is i nsert ed i n
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t he midl i ne poi nt ing between 30 degrees and 45 degrees i n a caudal di rect ion. I f ai r
can be aspi rated f reel y i nto the syri nge, the needl e i s i nsi de the ai rway. A three-
way stopcock can be pl aced between the syri nge and needle wi th one li mb of the
stopcock connected to a capnograph (154,157). Aspi rat ing carbon di oxi de conf i rms
ai rway pl acement. The cannul a i s then sl ipped of f the needl e i nto the trachea and
t he needle removed.

View Figure

Figure 21.6 A: Airway exchange catheter. B: Airway
exchange catheter has been advanced over the guide wire
(after removal of the connection).

Smal l i nt ravenous cannulae are usual ly readi l y avai l abl e but are easi l y compressed
and prone to ki nki ng (158,159,160). Placing a small bend i n the end of the catheter
may decrease t he incidence of ki nki ng (159). Some
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i ntravenous catheters are not sui table, because a syri nge cannot be attached and
many are too short (161).

View Figure

Figure 21.7 The tracheal tube is advanced over the airway
exchange catheter.


View Figure

Figure 21.8 The guide wire and airway exchange catheter
are removed, and the tracheal tube is advanced into the
trachea.

Large-gauge i ntravenous catheters have been used successful l y (162). Most
authors recommend a 14-gauge or l arger catheter for adul t pati ents
(147, 163,164,165). Use of a catheter wi t h si de hol es may l essen the risk of t racheal
damage (163).
Catheter l ength i s import ant . If the catheter i s too short , i t may come out , and gas
wi l l be inj ected i nto the subcutaneous neck t i ssues. However, t he l onger the
catheter, t he great er the resistance to f l ow. For t he adul t pati ent, t he cat heter
shoul d be at l east 4 cm i n length. For t he pati ent wi t h a thi ck neck, a greater l ength
may be necessary (166).
Ot her devi ces used include a Tuohy needl e (167, 168), t he vessel di l ator of an
i ntravenous i nt roducer ki t (169,170), a tri ple-l umen central venous catheter (171),
and a suct ion catheter (172).
To connect the cri cothyrotomy device to a means of vent i lat i on, ei t her a Luer l ock
(Fi g. 21.9) or a 15-mm connector i s requi red. Many ki ts provide both. Some have
t he Luer l ock att achment i nsi de a 15-mm connector.
Ventilation Techniques
The catheter di amet er of ten does not al low an adequate t idal vol ume to be
del i vered at the pressures provided by conventi onal venti lat ors. A source of hi gh-
pressure oxygen and robust connect ions are requi red.
Jet Ventilation
I nject ion of hi gh-vel oci t y gas into the ai rway t hrough a narrow cannula wi thout a
seal i s termed j et venti l ati on. It can be performed automati cal l y or manual l y. Jet
venti l ati on i s convent i onal l y carri ed out at rat es up t o 60 cycles/mi nute. Above 60
cycl es/ mi nut e, the technique i s referred to hi gh-frequency j et vent i l at i on (173).

View Figure

Figure 21.9 This device is designed to deliver oxygen at a
high flow through a small tubing. The pressure tubing is
attached to a 50-psi oxygen source, such as the outlet of a
piped oxygen system. The pressure delivered can be
adjusted by turning the knob. The pressure is measured by
the pressure gauge at left. The flow is controlled by the
toggle switch downstream of the knob. The tubing end at
the top has a Luer lock connector and is attached to a large-
bore needle or catheter placed percutaneously through the
cricothyroid membrane.

P. 669


A means of jet venti lati on shoul d be avai labl e i n every anesthet i zing area (174).
Unf ortunatel y, not all locat i ons have the equipment readi l y avai labl e and ready for
use (175). Duri ng an emergency is not the ti me t o assembl e these devices. Al l
connecti ons must be correct f or t he mode of venti l at ion ant ici pated and robust
enough to wi t hstand the pressures t hat wi l l be used.
I n a smal l pat i ent, t he peak pressure shoul d be reduced to 5 pounds per square
i nch (psi ) and then i ncreased i n i ncrements of 5 psi unt i l adequate chest excursions
are observed (166,176, 177). I n adul ts, the j et vent il ati on devi ce shoul d be preset at
25 psi , t hen i ncreased or decreased as i ndicated by the cl i ni cal response (178).
The upper ai rway shoul d be made maxi mal ly patent during j et venti lat i on by put ti ng
t he pat ient i n an opt imal snif f posi ti on, by usi ng bi l ateral jaw t hrust and
oropharyngeal ai rways, and by avoi di ng j et venti l ati on duri ng phonat i on. If compl et e
ai rway obst ruction persists af ter j et venti lati on i s attempted, t he ai rway needs to be
converted to a tracheost omy as soon as possi bl e.
The pattern of jet venti l ati on i s import ant (142,162,179). The i nspi ratory volume
depends on t he gas f l ow rat e, i nj ecti on ti me, respi ratory system compl iance, and
ai rway resistance. The expi ratory vol ume wi l l depend on the exhal at i on ti me, el asti c
recoi l of the l ungs, and ai rway resi stance. Care must al ways be taken not i ni ti at e
i nspi rati on before the end of exhal at ion. End-t i dal carbon di oxi de can be moni tored
by pl acing a sample l i ne through t he mouth or nose (180). The i nspi red oxygen
concentrati on wi l l depend on the amount of ai r that i s ent rai ned, whi ch depends on
t he rati o of the cat heter t o t he t rachea and the st ructure of the catheter (number of
si de hol es).
I f too much gas escapes f rom the t rachea through the mouth or nose duri ng
i nspi rati on, the pati ent ' s mout h and nose shoul d be cl osed or the backfl ow bl ocked
wi th a throat pack (181).
Devices
A number of j et venti l at ion devi ces are commerci al l y avai labl e. One is shown i n
Fi gure 21. 9. They are connected to a pi ped oxygen outl et or an oxygen cyl i nder
wi th a regul at or. Some have a means to regul at e the deli vered pressure and/or an
al arm.
The j et may act as a Venturi and entrai n adj acent gas t o increase the vol ume
del i vered. The j et' s ef fi ci ency depends on a number of f actors (173). The amount of
gas del ivered i ncreases as the dri vi ng pressure i s raised.
Automatic Ventilator
Aut omat i c venti l at ors that can del iver a j et of gas automati cal l y whi l e moni tori ng
both del i very pressure and ai rway pressure are avai labl e and can be at t ached t o
t he cri cothyrotomy catheter (142,169,172,183,184,185,186). Some automat icall y
pause venti l ati on when t he end-expi rat ory pressure exceeds a preset l i mi t, enabl i ng
detecti on of outl et obst ructi on (171).
Manual J et Ventilation Device
A manual l y control led j et vent il at ion devi ce may be at tached to the cri cot hyrot omy
catheter and the pat ient venti lated by usi ng an i ntermi ttent j et of oxygen. Tidal
volume, inspi red oxygen concent rati on, and ai rway pressures are not easi l y
moni tored. A check must be made for compl et e exhalat i on af ter each del i vered ti dal
volume.
Flowmeter
Many anesthesia machi nes have an auxi l iary (courtesy) f lowmet er. This or a
f lowmeter attached di rectl y to a pi pi ng system outl et can be used as a source of
oxygen (186, 187). Noncompli ant tubi ng shoul d be used bet ween the f l owmet er and
t he cri cothyrotomy catheter. A three-way stopcock or other devi ce can be used at
t he pat ient end to convert the cont inuous f low of gas to i nt ermi t tent bursts, or a
hol e can be cut i n the tubi ng and the operat or' s f inger pl aced over the hole t o
del i ver a j et of oxygen.
Oxygen Flush
I t may be possi ble to suppl y oxygen f rom the anesthesi a machi ne by att achi ng
noncompl i ant tubi ng to the common gas outl et and i nt ermi t tentl y act ivati ng t he
oxygen f lush (188,189,190,191). Al ternativel y, i f there i s a port near the pati ent end
of t he t ubi ng, a second person can conti nuousl y depress the oxygen f l ush but ton
whi l e t he anesthesi a provi der i nt ermi t tentl y occludes t he port (192).
Not al l anesthesi a machi nes have a common gas out l et that can be accessed, and
not al l anesthesi a machi nes suppl y oxygen at a high enough pressure t o drive the
oxygen through the noncompl iant t ubi ng and a cricothyroid catheter (191, 192).
Bef ore rel yi ng on this means of vent i l at ion, t he anesthesi a depart ment shoul d
ascertai n what pressure wi l l be del i vered.
Anesthesia Breathing System
The 15-mm connect or f rom a ci rcle breat hi ng system can be connected to the
cricot hyroi d devi ce and t he oxygen f lush int ermi t tentl y acti vated. Because the
reservoi r bag and tubings absorb most of t he pressure, the l ungs wi l l probabl y not
be ef fect ivel y vent i l ated by this method al though adequate oxygenati on may be
achieved (188). Appl yi ng pressure t o the reservoi r bag wi l l i ncrease the del ivered
pressure.
Manual Resuscitation Bag
A manual resusci tat or (Chapt er 10) or a Mapl eson system (Chapter 8) may be
at tached t o the cri cothyrotomy device. These cannot provi de adequate venti l ati on
unl ess a very l arge cannul a is used (176,192, 197).
Percutaneous Di latational Cri cothyrotomy
The el ements of a percutaneous cricothyrotomy set are shown i n Figure 21.10. A
number of customi zed ki ts contai ni ng the necessary i t ems are avai labl e
(164, 175,198,199, 200, 201,202, 203, 204,205, 206,207,208,209). A needle-over-
cannul a or a si mpl e needl e wi th an at tached syri nge i s i nserted t hrough t he
cricot hyroi d membrane and ai r aspi rated (Fi g. 21.11). A guide wi re i s then inserted
t hrough the catheter.
P. 670


(Fi g. 21.12), and t he cat heter i s then removed. The hol e i n the ski n around t he
gui de wi re i s enl arged by using a scal pel (Fi g. 21.13). The t ract around the guide
wi re can be enl arged by usi ng a seri es of progressivel y l arger di l ators (introducers)
or a curved di l at or (Fi g. 21. 14). The ai rway device is then i nserted i nt o the t rachea
over the wi re gui de or di l ator, whi ch i s then removed (Fig. 21.15). A cri cothyrotomy
t ube may have a cuf f (Fi g. 21.16). The inserti on assembl y may di ff er (Fi g. 21.17).

View Figure

Figure 21.10 Elements of a cricothyrotomy set. At bottom
is a syringe with needle. Next is the guide wire, which is
advanced through the needle. The small scalpel is used to
enlarge the hole in the skin at the site of the guide wire. The
dilator is used to enlarge the opening into the airway. The
tube is advanced over the dilator. The guide wire and dilator
are then removed, and the tube is used to ventilate the
patient.

Thi s technique is f ast and usual l y easy t o perform, even i n t he pati ent wi t h a short
neck or spinal i njury. An advantage is that most anesthesi a provi ders are
experienced i n wi re-gui ded techni ques (210). Adequat e vent i l at ion can be achieved
by using a conventi onal breathi ng system i f the diameter of t he devi ce i s at l east 4
mm (147,208). However, i t may resul t i n more compl icati ons and less chance of
correct posi ti oni ng t han a catheter-over-needl e techni que (211, 212).
Surgical Cricothyrotomy
I n surgical cri cot hyrot omy, a t ransverse skin i nci si on i s made at t he level of the
cricot hyroi d membrane (147,151, 198, 213,214, 215, 216). I f t he neck i s edematous
and the l arynx cannot be pal pated, the i nci si on should be vert ical and then
deepened unt il t he l aryngeal cart i l ages are i denti f i ed. An i ncisi on i s then made i n
t he cri cothyroid membrane. A cat heter may be pl aced as a gui de. The i ncisi on i n
t he membrane is t hen spread, and a t racheal or t racheostomy t ube i s pl aced
t hrough the openi ng. A bougi e may f aci l i tate i nsert i on of a tracheal tube (217).
Surgi cal cri cothyrotomy i s more t ime consumi ng than the percutaneous methods
and requi res an experi enced surgeon but provi des a more def i ni ti ve ai rway
P. 671

t han the other met hods. However, if speed i s parti cularl y i mport ant and/or when
equipment f or l ess i nvasive techni ques is unavai l abl e, i t can be perf ormed qui te
rapi dl y.

View Figure

Figure 21.11 The needle-over-catheter is inserted through
the cricothyroid membrane in a caudal direction.


View Figure

Figure 21.12 A guide wire is inserted through the catheter.

Indications
Upper Airway Obstructi on with Inabilit y to Ventil ate or
Intubate
A pri me indi cati on f or cri cot hyrot omy is the i nabi l i ty to secure a patent ai rway by
conventi onal techni ques (154,170,194,218,219,220,221,222,223). These incl ude
f oreign body aspi rat ion and upper ai rway pathol ogy or when a person ski l led at
i ntubat ion i s not avai l abl e or cannot i nt ubate t he pat ient and a supragl ott i c devi ce
cannot be i nsert ed.
Anticipated Diffi cult Intubation
Cri cothyrotomy may be used as an adjunct t o fi beropt i c or other i ntubat i on
t echni ques where i t is anti ci pat ed that i ntubat ion may be dif f icul t to perf orm
(109, 166,174,224, 225, 226,227). It provides a means to venti lat e the pati ent if the
i ntubat ion procedure is prol onged. This may be especial l y useful f or pat ients who
cannot t ol erate an awake i ntubat ion. Jet venti lati on may make subsequent tracheal
i ntubat ion easi er because the hi gh t racheal pressure may open the col l apsed
P. 672

gl ot ti s (154, 228, 229). Leavi ng t he cri cothyrotomy devi ce in pl ace duri ng t he
recovery peri od al lows emergency oxygenati on at a ti me when rei ntubat ion may be
di ff i cul t or cont rai ndicated.

View Figure

Figure 21.13 The hole in the skin around the guide wire is
enlarged by using a scalpel.


View Figure

Figure 21.14 A: The tract around the guide wire is enlarged
by using a curved dilator (introducer). B: The
cricothyrotomy tube fits over the introducer and guide wire.

Procedures Involvi ng the Airway
Jet vent i lati on through a cri cothyrotomy devi ce can be used duri ng procedures
i nvol vi ng the upper ai rway (168,171,174,182,230). Thi s l eaves the ent i re ai rway
f rom the vocal cords to t he f ace accessible t o t he surgeon. Si nce there is no
t racheal tube, t here i s a reduced l i kel ihood of f i re (231) (Chapter 32). A
di sadvantage i s that t he ai rway i s not protected f rom contaminati on by bl ood and
surgi cal debri s. However, the cont i nuous egress of gas f rom the ai rway hel ps to
reduce contami nat ion.
Cervical Spi ne Inj ury
I f cervi cal spi ne inj ury has occurred or has not been rul ed out , cricot hyrotomy may
be a good way to establ i sh an ai rway. Ot her methods of securi ng an ai rway wi th
mi nimal neck movement are discussed in Chapters 17 and 19.
Contraindications
Intrathoracic Airway Obstructi on
Cri cothyrotomy i s onl y useful for obst ruct ions above t he cricoi d carti l age.
Obstruct ions at or bel ow thi s l evel may be pushed deeper. For obstruct i ons at or
bel ow t he level of the cri coi d, t racheotomy wi l l be necessary.
P. 673



View Figure

Figure 21.15 The introducer and guide wire are removed,
and the cricothyrotomy tube is left in place.

Inability to Locate the Cricothyroi d Membrane
Thi s procedure shoul d not be attempted i f there i s uncert ai nty about the l ocati on of
t he cri cothyroid membrane.
Complete Airway Obstructi on
I f there i s compl et e obst ruct ion above the cri cothy-rotomy cathet er, t here wi l l be no
exi t path f or exhal at ion. However, i f a f oreign body obst ructi on i n the mouth or
l arynx is preventi ng respi rati on, t here i s the possibi l i t y that t hi s coul d be bl own out
and the obstruct i on rel i eved. It may be possi ble to admi nister pressuri zed oxygen
saf el y to pati ents wi th complete upper ai rway obst ruct ion by usi ng a Y-adapt or
at tached t o the catheter hub (228). Oxygen can be administered t hrough one l imb
whi l e t he other l i mb i s used for passive expi rati on.

View Figure

Figure 21.16 Cuffed cricothyrotomy tube. (Courtesy of
Cook Critical Care.)

Pediatric Patients
Cri cothyrotomy i s techni call y di ff icul t in the pediat ric popul ati on and should be
perf ormed wi t h extreme cauti on i n chi ldren bel ow 10 years of age (155). Pediat ric
pati ents have a hi gher i nci dence of compl i cat i ons f rom cricothyrotomy than do
adul ts (232).
Laryngeal Pathology
Cri cothyrotomy shoul d not be used i n the presence of l aryngeal i nf l ammati on or
i nfect ion.
Decreased Compliance
Pat i ents wi t h condi t ions such as emphysema and chronic bronchi ti s of ten have
di minished compl i ance that may make venti l at ion l ess eff ect i ve.
Complications
Barotrauma
I f posi t ive pressure is appl ied below t he vocal cords, ai rway pressure may ri se t o a
hazardous l evel wi th resul tant barot rauma (175,182,183,228,230,233,234,235).
Caref ul l y moni tori ng chest movements, l i mi ti ng inspi ratory pressure and ti me, and
al l owi ng adequate t i me f or expi rati on wi l l decrease t he ri sk of barotrauma. Ai rway
pressure moni toring shoul d be performed, if f easi bl e. Some j et venti l ators
automati cal l y pause when a preset pressure i s reached (171,229).
Trauma
Pl aci ng a cricothyroid devi ce can resul t i n injury. Bl eedi ng, hematoma, l aryngeal
cart i l age i nj ury, mucosal ulcerati on, and perforat i on of t he post erior trachea and
esophagus have been reported (175,205,213, 220,236, 237, 238,239,240).
P. 674



View Figure

Figure 21.17 Cricothyrotomy set with the guide wire
attached to the needle and a side tubing through which air
can be aspirated.

I f the catheter i s i ncorrect l y pl aced or sli ps out of t he trachea or i f there i s a hol e i n
t he catheter near t he surface of the neck, oxygen may be i nj ected i nto the ti ssues,
resul ti ng i n subcutaneous or medi asti nal emphysema (183,228,241,242,243).
Subcutaneous emphysema al so may occur af t er decannul ati on (168,244). The
cricot hyrotomy devi ce shoul d be fi rml y secured t o prevent di sl odgment. Suturi ng
t he devi ce i n pl ace shoul d be considered i f t i me permi ts. Neck movement shoul d be
l i mi ted. Whippi ng of the catheter wi t h each breath can be mi ni mizing by keepi ng a
short l ength wi t hi n the trachea and using a l ow dri vi ng pressure (171).
Late compli cat i ons i ncl ude granul ati on at t he cuf f si t e, excessive procedure ti me,
t racheal stoma stenosi s, persistent stoma, hemorrhage, subgl ot ti c stenosis,
aspi rat ion of bl ood, dysphoni a, vocal cord paral ysi s or paresis, voi ce changes, and
wound i nfecti on (220,236,239,245,246).
Kinked Catheter
I f the catheter ki nks, venti l ati on may not be possible (158,168,247). Addi ng a smal l
curve to the t ip may help prevent ki nking (159). Precurved cathet ers are
commerci al l y avai l abl e (248). I f ki nking occurs, i t may be possi bl e to change t he
catheter for one more resi stant t o ki nki ng by using a guide wi re (168).
Fail ure to Cannulate the Trachea
The report ed fai l ure rate f or successf ul l y placing cathet ers i n the t rachea vari es
f rom 0% to 40% (151,200,213,214,219,220,236,238,239,240,249,250,251). Practi ce
wi th t he techni que duri ng el ecti ve cases or a si mul ator i ncreases f ami li ari t y wi th
t he method and f aci l i tates i ts use i n an emergency si tuat i on (156,247, 252,253).
Advantages and Disadvantages
Cri cothyrotomy i s relat i vel y si mpl e, saf e, easy to l earn, and qui ck. The success rate
i s high even i n inexperi enced hands (151,152,214,219,220,238, 239, 250).
Percutaneous j et vent i l at ion may f aci l i t ate tracheal i nt ubat i on by al lowi ng
i denti f i cat i on of t he gl ott i s openi ng (154,228). The pri nci pal di sadvantage i s that i t
does not establ ish a def i ni ti ve ai rway.
Percutaneous Dilatational Tracheostomy
Percutaneous di l atati onal tracheostomy entai l s i nserti on of a f ull -si zed
t racheostomy t ube i n the subcri coi d area (254). I t i s an al ternat ive to t radi t ional
surgi cal tracheostomy. It may be perf ormed at t he bedside i n a cri t ical care uni t .
Many i nsti tuti ons have adopted i t as the techni que of choice i n cri t i cal l y i ll pat ients
who requi re a t racheostomy (255,256, 257). I t i s most of ten perf ormed elect ively but
can be used i n an emergency si t uat i on (258).
Technique
Venti lati on can be mai ntai ned throughout t he procedure by using a t racheal t ube
pl aced above the si t e of the proposed t racheostomy, a supraglott ic ai rway device, a
Combi t ube, a mi crol aryngeal tube, an ai rway exchange cathet er, or a fl exi bl e or
ri gi d bronchoscope
(78,259,260,261,262,263,264,265,266,267,268,269,270,271,272,273,274,275,276).
The Combi tube may not be sui tabl e if t he l onger lumen is i n the t rachea (79).
Endoscopy i s of t en used duri ng t he procedure t o avoi d compl i cat i ons
(261, 265,275,277, 278, 279,280, 281, 282,283). An opt ical st yl et may also be used
(284). I t al lows conf i rmat ion of the posi ti on of t he t racheal tube as wel l as correct
pl acement of the needl e (i .e., whether i t is mi dl ine and
P. 675

at t he correct l evel ), gui de wi re, di lator, and f i nal l y the tracheostomy tube. More
severe compl icat ions occur when endoscopi c vi sual i zat i on is not used (285). I t al so
makes i t rel at ivel y easy t o perf orm a therapeuti c or di agnost ic bronchoscopy af t er
t he procedure i s compl eted (286,287). Di sadvantages of f i beroscopy i ncl ude an
i ncrease i n the t i me needed f or t he procedure, the need f or a separate ski l led
person, and the potent i al f or hypoventi l at i on (288). A l i ght wand may be used to
gui de the procedure (289,290).
A modi f i cat i on of thi s techni que i s to uti l i ze endoscopi c gui dance duri ng guide wi re
pl acement and then t o insert an ai rway exchanger cat heter (266, 291). Thi s
produces l ess ai rway resistance, al l ows venti l ati on and admi nistrati on of oxygen,
and f aci l i t ates rei ntubati on, if necessary.
The pati ent is pl aced in the supi ne posi ti on wi th t he neck extended unless there i s
known or suspected cervical spi ne i nstabi l i t y. Ul t rasound scanni ng can be used t o
i denti f y bl ood vessels and the correct l evel (269, 292,293,294, 295, 296).
I f the pati ent is i ntubated, the t racheal tube shoul d be wi t hdrawn to a poi nt above
t he i ntended si te of the t racheostomy. A bougi e or ai rway exchange cat heter may
be i nsert ed through the t racheal tube to f aci l i t ate rei ntubat ion i f t he tracheal t ube i s
di sl odged (291,297).
A short , shall ow ski n inci si on is made over t he trachea, between the f i rst and fourth
cart i l ages (259,298). If t he si tuat ion i s urgent , t he cricothyroi d membrane may be
punctured (202). A l arge gauge needl e is t hen i nt roduced i nto t he t racheal lumen
bet ween t wo ri ngs (Fi g. 21.18). Posi ti on wi thi n the t rachea i s conf i rmed by
aspi rat ion of ai r, di rect bronchoscopic vi sual i zati on (pref erred), or capnography
(299, 300). Local anestheti c can be i nj ected i nto t he lumen of the trachea. A gui de
i s i nt roduced through the needl e i nto the t rachea, and the needl e i s then removed.

View Figure

Figure 21.18 After the front of the trachea has been
exposed, the needle with syringe attached is inserted into
the trachea. Entry into the trachea is confirmed by the
appearance of air bubbles on aspiration. A guide wire is
then inserted through the needle, and the small dilator is
inserted.

Di ff erent techniques are used t o di l ate the openi ng i n the anteri or t racheal wal l
over the gui de (301, 302,303,304). The f i rst empl oys progressi vel y larger tapered
di l ators (Fig. 21.19) or one l arge t apered or screwl ike dil ator (Fi g. 21.20)
i ntroduced over the gui de (305,306,307,308, 309,310,311,312,313,314). Some
di l ators have a hydrophi l ic coat ing t hat hel ps to enlarge t he ent rance si te. Another
t echni que uses a di l ati ng f orceps (315, 316,317). Thi s techni que i s f aster and may
be
P. 676

associ ated wi th f ewer compl icati ons than sequenti al di l atat ion techni que (318,319).
Ki ts cont ai ni ng the necessary i t ems f or each method are avai l abl e
(254, 309,320,321, 322).

View Figure

Figure 21.19 Progressively larger dilators can be used to
enlarge the hole.


View Figure

Figure 21.20 A large dilator is passed over the guiding
catheter, which was passed over the guide wire.

The l ubri cated tracheost omy tube i s i nsert ed over the di l at ing devi ce or gui de,
whi ch i s then removed (323) (Fi g. 21. 21). Speci al t racheal cannul as wi t h obl iquel y
cut ti ps t hat f aci l i tate i nsert i on have been devel oped (259). Capnography shoul d be
used to confi rm correct placement (286,324).
Contraindications
Rel at ive cont raindicat ions to percut aneous tracheos-t omy i ncl ude i nf ect ion at the
si te, i nabi l i t y to extend the neck, anatomi cal f eat ures i nterf eri ng wi th i dent i f i cat i on
of anat omi c l andmarks, t racheomal aci a, and severe coagul opathi es. It s use i n
chil dren is cont roversial (259, 325, 326,327). However, percutaneous di l at ati onal
t racheostomy has been perf ormed in al l of these subgroups (255).
Advantages and Disadvantages
A maj or advantage of percut aneous tracheostomy i s t he abi l i t y to perf orm the
t echni que at the bedside. Thi s avoids del ays, ri sks, and l ogi stical probl ems of
t ransfer to t he operat i ng room. Compared wi th a surgi cal t racheostomy, i t i s less
expensive, f aster, easi er, and associat ed wi th l ess blood l oss and is l ess l i kel y to
resul t i n cosmeti c def ormi t y, i nf ect ion, or bacteri al contami nat ion of nei ghbori ng
st ructures (255,259,278,328,329,330,331,332,333,334,335,336, 337, 338). Short -
t erm compl i cati on rates are less than f or operat ive t racheostomy
(316, 329,331,334, 339, 340,341, 342, 343,344). It can be perf ormed i n most pati ents
who cannot undergo neck ext ensi on (345,346) and i n morbidl y obese pati ents
(306, 347,348,349, 350).
Complications
St udi es i ndi cate that there i s a l earni ng curve f or percutaneous di l atat ional
t racheostomy (351). The compl icat ion rat e may be hi gher i n obese pat i ents (350).
The use of ul trasound shoul d reduce the number of seri ous compl i cati ons
(295, 296).
Incorrect Placement
Some studi es show that a si gni f i cant number of t ubes have been pl aced i n an
i mproper l ocati on, usual l y hi gher i n the ai rway t han intended (352, 353). A t ube may
end up movi ng cephal ad rather t han caudall y (354).

View Figure

Figure 21.21 The tracheostomy tube is loaded over a small
dilator, which is in turn loaded over a guiding catheter,
which is then loaded onto a guide wire. After insertion into
the trachea, the dilator, guiding catheter, and guide wire are
removed.

P. 677


Trauma
Trauma resul ti ng f rom percutaneous t racheostomy can i ncl ude f ormat i on of a f alse
passage ei t her anteri or t o or beside the t rachea, inj ury to the posteri or tracheal
wal l or t racheal cart i l ages, hematoma, hemorrhage, esophageal perf orati on,
subcutaneous emphysema, medi ast i nal emphysema, pneumothorax, hemothorax,
t racheoesophageal fi st ul a, and tracheoi nnomi nate f i stul a have al l been reported
(286, 287,302,303, 310, 322,333, 334, 353,355, 356,357,358,359,360,361,362,363,364,
365,366,367,368,369,370,371,372,373,374,375,376,377,378,379,380,381,382).
Tracheal Tube Damage
Tracheal tube damage, i ncluding punct uring t he cuff , t ransfi xi ng t he tube, and
i nsert i ng the gui de wi re t hrough the Murphy eye, may occur during percutaneous
t racheostomy (301,383,384, 385, 386,387). Damage to the endoscope may al so
occur.
Tracheal Stenosis
The i nci dence of t racheal stenosis as a l ong-t erm compli cati on vari es f rom l ess
t han 1% to 10% (259,286,325,329,339,342,388,389,390,391). Thi ckening of the
l ateral tracheal wal l has been report ed (392).
Hypoventil ati on
Hypoventi l ati on can occur when t he tracheal l umen i s obst ructed f rom external
pressure, a di l at or, or t he endoscope (255,288). The ti dal volume and/or respi ratory
rate can be increased to compensate for the l eak created by t he hol e i n the
t rachea.
Forei gn Body in Trachea
Cases have been reported of a f ract ured gui de wi re and t he di lat or l odged in t he
t rachea f oll owi ng percutaneous di l at ati onal t racheostomy (393,394,395). A case
has been reported where t he bl ade of the f orceps broke away and entered the
t rachea (396).
Other Compli cations
Ot her compl icati ons report ed wi t h percut aneous t racheostomy i ncl ude i nadvertent
extubati on, persi stent stoma, cel luli t is, bacteremi a, a change in voi ce, ai rway
obstruct i on, dysphagi a, ongoi ng severe cough, and skin t etheri ng
(301, 321,342,388, 397, 398,399, 400). Damage to the endoscope may occur (401).
Translaryngeal Tracheostomy
Thi s technique is unl i ke others in t hi s chapter i n that the tracheal cannul a i s
i nsert ed f rom i nsi de the tracheal l umen t o the outside (402,403). A ki t based on t hi s
t echni que is avai lable. It may be advantageous i n pat i ents who have seri ous
hypoxemia and i n those who are considered dif f i cul t to intubat e or who have
cervi cal spi ne i nj uri es (177).
TABLE 21.1 Equipment for Difficult Airway Cart
Fiberscope
Fiberoptic light source
Video head
VCR
Defogging solution
Swivel fiberoptic adaptors
Local anesthetic spray
Endoscopic mask
Fiberoptic intubating airways (e.g., Ovassapian, Patil-Syracuse, Williams, Berman)
Fiberoptic stylet laryngoscope
Lighted intubation stylet
Rigid indirect laryngoscope (e.g., Bullard, WuScope, Upsher Scope)
Bougies
Flexible suction catheters
Yankauer suction catheter
Supraglottic devices (LMAs, etc.) and tracheal tubes suitable for insertion through the
supraglottic device
Cricothyrotomy device and device for jet ventilation
Combitubes
Retrograde intubation kit
Percutaneous dilatational tracheostomy kit
Binasal airway
Magill forceps
Water-soluble jelly and ointment
Airway exchange catheters
Difficult airway algorithm
Elevation pillow (Fig. 18.47)
Variety of face masks
Variety of rigid laryngoscope blades and handles
Nasal and oral airways
Tracheal tubes
Stylets

Under bronchoscopi c gui dance, a gui de wi re i s passed vi a a percut aneous needle
i n the t rachea (passed ret rograde i nto the mouth). The gui de wi re i s att ached to a
speci al ly desi gned cone that i s bonded to a tracheostomy t ube. The conal
di l ator/ tracheost omy t ube is threaded over the gui de wi re and pul led t hrough t he
oral cavi ty, l arynx, and t rachea and out through the ant erior tracheal wal l . The cone
i s then detached f rom the tracheost omy tube, whi ch is rotated f rom a cephal ad to a
caudal di rect i on by usi ng an obturator, then advanced caudal l y to i ts f inal posi t i on.
During the procedure, t he pati ent i s vent i lated vi a a thi n t racheal tube, the end of
whi ch i s posi t ioned di st al t o the t racheostomy si te. The t racheal t ube i s removed
af ter or j ust before t he tracheostomy t ube is rot ated and secured (404,405).
P. 678


The modif i ed Fanconi techni que invol ves t he use of a f i berscope, i nsert ion of a J-
shaped wi re, and t he use of a smal l -diameter tracheal t ube posi ti oned coaxi al l y to
t he ori gi nal ai rway t o vent i l ate the pat ient duri ng i nt roducti on of t he tracheostomy
t ube (177).
Thi s technique can be perf ormed at the bedsi de. Because di lati on i s achi eved by
t he tracheal cannula i tself , t he cannul a f i ts smugl y wi t h t he t racheostomy wound
edges. I t has been used in pati ents wi th severe respi ratory f ai l ure and
coagul opathy (177,406).
Thi s technique is technical l y more compl i cat ed than percutaneous tracheostomy. It
requi res three peopl e to perf orm properl y, one of whom i s concerned sol el y wi th
mai ntai ning t he ai rway and t he pat ient' s venti l ati on. Compl icati ons i ncl ude
bl eedi ng, barot rauma, t rauma, and mi spl acement of the t racheostomy tube
(332, 403,405,407, 408). A study comparing thi s techni que wi th f orceps di l at ati onal
percutaneous t racheostomy found a higher compl icati on rate and more technical
di ff i cul ti es wi th t he translaryngeal techni que (403). I t takes l onger than a
percutaneous t racheostomy.
Difficult Airway Cart
A cart containi ng equipment t hat i s usef ul when a di f f i cul t ai rway i s encountered
shoul d be i mmediat el y avail abl e in every l ocati on where anest hesi a is
admi ni stered. I t i s i mport ant t hat each cart be nearl y i dent i cal across al l l ocat i ons
so t hat when faced wi th an emergency, t he user i s f ami li ar wi t h the l ocati on and
operati on of al l t he equipment. The equipment on t hi s cart should f i t t he ski l l s and
pref erences of the anesthesia provi der. The l i st i n Tabl e 20-1 is gi ven onl y as an
exampl e and shoul d not be consi dered exhaust i ve.
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P. 684


Questions
For the f ol lowing quest ions, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i s D i s correct
i f A, B, C, and D are correct .
1. Whi ch statements concerni ng Combitube placement are true?
A. The pharyngeal bal l oon shoul d be i nf l at ed fi rst
B. The use of a l aryngoscope may l ower the number of compl i cat i ons
C. The t i p of the tube usual l y ends up i n the t rachea
D. The esophageal detector devi ce i s usef ul i n veri fyi ng tube posi t i on
Vi ew Answer2. Contraindications to usi ng a Combitube include
A. I ngesti on of corrosive agents
B. Known esophageal t rauma
C. Active pharyngeal and l aryngeal ref l exes
D. Pati ents younger t han 12 years of age
Vi ew Answer3. Advantages of the Combi tube include
A. I t can be used by non-anesthesia personnel
B. Neck movement i s not necessary
C. The pharyngeal ball oon anchors i t in pl ace
D. There i s no danger of bronchi al i ntubati on
Vi ew Answer4. Disadvantages of the Combitube include
A. Fi beropti c bronchoscopy is not possi bl e
B. I t i s not usef ul f or pat i ents wi t h lat ex al l ergy
C. There i s hi gher stress response t han t hat f rom a tracheal t ube duri ng i nsert i on
or removal
D. The presence of bl ood or vomi t us i n the pharynx precl udes i ts use
Vi ew Answer5. Situations that l end themsel ves to retrograde i ntubation
i ncl ude
A. Oropharyngeal bl eedi ng
B. I nf ant and chi ld i nt ubat i on
C. Li mi ted neck mobi l i t y
D. Pret racheal abscess
Vi ew Answer6. Condi ti ons where cricothyrotomy may be i ndi cated
i ncl ude
A. Cervi cal spi ne i nj ury
B. Surgery i nvol vi ng t he upper ai rway
C. Di ff i cul t i ntubat ion
D. Forei gn body aspi rati on
Vi ew Answer7. Contraindications to cricothyrotomy i ncl ude
A. Complete ai rway obst ruct ion above t he cri cothyroid membrane i n the l arynx
B. Decreased compl iance
C. Laryngeal i nfl ammat ion or i nfecti on
D. Obstructi ons bel ow t he thyroi d cart i l age
Vi ew Answer8. Complicati ons of cricothyrotomy include
A. Ki nked catheter
B. Tracheal stoma stenosi s
C. Subcutaneous or mediast inal emphysema
D. Esophageal perforat ion
Vi ew Answer9. Barotrauma can be reduced by which mechanisms?
A. Li mi ti ng i nspi ratory t ime
B. Usi ng ai rway maneuvers such as sni ff posi ti on and j aw t hrust
C. Watchi ng chest movements
D. Li mi ti ng the peak pressure to a maxi mum of 35 psi in adul ts
Vi ew Answer10. Relati ve contraindicati ons to percutaneous tracheostomy
i ncl ude
A. Severe coagul opat hi es
B. I nf ect ion at the si t e
C. Tracheomal acia
D. I nabi l i t y to extend the neck
Vi ew Answer11. Advantages of percutaneous tracheostomy i ncl ude
A. Fast er than surgi cal t racheost omy
B. Can be perf ormed on pati ents who cannot extend t hei r necks
C. Lower i nci dence of i nf ect ion
D. Fewer compli cati ons than surgi cal tracheost omy
Vi ew Answer12. Compl icati ons of percutaneous tracheostomy i ncl ude
A. Pneumothorax
B. Tracheal t ube damage
C. Ai rway obst ruct ion
D. Tracheal stenosi s in up to 15% of pati ents
Vi ew Answer