AIRWAY MANAGEMENT: TIPS AND TECHNIQUES
| PERCUTANEOUS TRACHEOSTOMY: A COLLABORATIVE APPROACH —David J. Terris, MD, Porubsky
Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia, Augusta
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| Percutaneous tracheostomy (PCT): indications—long-term or anticipated long-term intubations in intensive
care unit (ICU); hemodynamic stability with low positive inspiratory pressures (PIP); nonobese patient (unless
obese patient has easily palpated landmark neck structures); absence of coagulopathy; nonemergent case;
contraindications—large goiter or isthmus; ectopic or high-riding innominate artery; high PIP; inability to palpate
landmarks in neck; precautions—bedside tracheostomy set in case problems arise; easily available unopened
tracheostomy set in ICU
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 | Technique: patient in supine position with neck extension; pulmonary personnel at head of bed for bronchoscopy,
otolaryngologist at patient’s neck; tracheostomy set opened and spread out for easy access to items; sterile preparation
and draping of PCT site done while bronchoscopy in process; inject local anesthesia into site; localize puncture
site; endotracheal tube must be through vocal cords, but above where tracheostomy tube will be placed, usually between
first and second or second and third tracheal rings; transillumination technique—room lights darkened;
bronchoscope aimed anteriorly so structures transilluminated by light from bronchoscope; back endotracheal tube
up to level of bronchoscope; PCT incision made distal to tube; palpation technique—feel cricoid through neck incision;
palpate and blanch tracheal wall 1 to 2 rings below level of cricoid; pull endotracheal tube back to just
above point of entry; counting tracheal rings—desired location 1 to 2 rings below cricoid cartilage; go to carina
and count backwards to eighteenth ring (20 tracheal rings total); placing PCT tube—deflate cuff and slowly withdraw
endotracheal tube with periodic palpation; make sure incision large enough to accept tracheostomy tube; perform
gentle blunt dissection if incision not large enough to accommodate tube; use light from bronchoscope for
guidance; aim for midline and enter airway; avoid hitting posterior tracheal wall; withdraw needle and put
guidewire through angiocatheter toward carina; avoid puncturing posterior tracheal wall; use Blue Rhino dilator;
insert tracheostomy tube over introducer; take bronchoscope out of endotracheal tube and pass it through tracheostomy
tube to make sure location correct; confirm bronchoscopy before removal of endotracheal tube; speaker prefers
4-point restraints, suturing of face plate, or twill tapes to secure tracheostomy tube
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| PCT vs conventional procedure: advantages of PCT—bedside tracheostomy good patient care; easier than taking
operating room (OR) equipment to ICU; no need to transport patients back and forth to OR; uses smaller incision;
safer than open tracheostomy in patient at risk for bleeding; easier to do than conventional bedside tracheostomy; decreased
risk for cervical spine injury in physician performing procedure; PCT associated with convenience of scheduling,
less time, and cost savings; disadvantages of PCT—less-controlled procedure; cannot visualize anterior tracheal
wall; potential pitfalls in PCT—premature extubation; patient with thick neck challenging; cannot perform in patient
with calcified trachea; cuff of tracheostomy tube can rupture if dilation insufficient; calcified trachea can dull angiocatheter
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| Experience with PCT: 100 consecutive cases over 2 yr; prospectively assigned risk level to cases, starting with
low-risk patients, then including high-risk patients as experience gained; time of procedure ≈13 min; complications
included 3 cases of premature extubation, 2 ruptured cuffs, 1 case of bleeding (resulting from violation of
anterior communicating jugular vein) that required operative intervention; complications occurred early in experience;
no paratracheal insertions, pneumothorax, or posterior tracheal injuries; most complications occurred during
first 50 cases
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| Experience in high-risk patients: performed PCT in 16 high-risk patients; 7 patients morbidly obese with mean body
mass index (BMI) 64 and mean weight 184 kg; 9 patients had coagulopathic conditions; time to complete procedure
and blood loss similar in high- and low-risk patients; Acute Physiology and Chronic Health Evaluation (APACHE) 2
scores nearly double that of low-risk patients; no complications occurred in high-risk patient group
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| TRACHEAL STENOSIS IN THE NEWBORN: LIFE OR DEATH IN THE NICU—Kenneth Geller, MD, Associate
Professor of Clinical Otolaryngology, Keck School of Medicine at the University of Southern California, Los Angeles,
and Director, Division of Pediatric Otolaryngology, Childrens Hospital of Los Angeles
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| Pediatric tracheal stenosis
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| Classification: extrinsic congenital anomalies—innominate artery compression syndrome (most common vascular
anomaly; characterized by “brassy” cough); aberrant left pulmonary artery (pulmonary hypertension compresses
pulmonary artery onto trachea and left main bronchus and causes obstruction); aortic arch anomalies; right-sided origin
of left common carotid artery (mirror image of innominate artery compression syndrome); aberrant subclavian
artery (lies behind esophagus; look for sudden bouts of reflex apnea during feeding); anomalous azygous vein or
vena cava; mediastinal cysts or tumors (include bronchogenic or foregut cysts, lymphatic malformations, thymic
cysts, pericardial cysts, teratomas, soft tissue sarcomas, neurofibromatosis, and other vascular malformations and
tumors); megaesophagus; tracheoesophageal fistula (TEF); instrinsic congenital anomalies—tracheal agenesis;
hamartomas; hemangiomas; complete tracheal rings; tracheal webs; tracheomalacia (secondary to TEF; primary
tracheomalacia, anterior, posterior, or combined); acquired lesions—postintubation (membranous or thick circumferential
webs); posttracheotomy tracheal stenosis; chemical ingestion; burns (iatrogenic [eg, with laser] or community-acquired);
tumors; trauma; papilloma; post-lung transplantation; infectious adenopathy (eg, compression of
trachea in tuberculosis)
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| Pathophysiology and anatomy: problems with recurrent nerve coming around patent ductus arteriosus; thoracic
surgeons see nerve, but many patients come in with left cord out; pulmonary hypertension can occur in patients with
large ductus; if large enough, ductus can stretch nerve out and cause problems; innominate artery compression most
common vascular anomaly; double aortic arch most common vascular ring; posterior arch dominant arch; frequently 2
vascular rings; sometimes thoracic surgeon forgets about double ring and fails to solve second ring; second ring
formed by ligamentum arteriosum; aberrant right subclavian artery can compress esophagus from behind; pulmonary
artery sling vascular anomaly in which left pulmonary artery between trachea and esophagus, causing anterior compression
of esophagus; double aortic arch, subclavian, right aortic arch, all posterior compressions of esophagus; can
reimplant; 50% of children with pulmonary artery sling have complete tracheal rings (life threatening)
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| Diagnosis: history and physical examination—check for stridor to determine location of airway lesion (coarse or
fine, inspiratory, expiratory, or both); listen to patient’s voice quality (helps locate airway obstruction or lesion);
note type of cough (barky or brassy); check for feeding problems; tracheal stenosis profile—patient has high-
pitched, biphasic stridor; normal quality of voice; “brassy” and/or “wheezy” (bronchial stenosis) cough; with normal
feeding initially, progressing to abnormal feeding with worsening stenosis or increasing amount or size of food
intake; imaging studies—consider plain chest x-ray, barium swallow, computed tomography (CT), magnetic resonance
imaging (MRI; preferred for vascular anomalies), or combined imaging studies; diagnostic cases—on x-ray
of child, can make diagnosis of right descending aorta if tracheal shadow on left side of chest; on barium swallow,
see both anterior and posterior indentations of both limbs of double aortic arch; ratio of tracheal cartilage to muscular
wall 4.5:1; tracheomalacia occurs if ratio less than that (patients have problems clearing secretions); use bronchoscope
to clear tracheal web acquired from endotracheal tube
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| Treatment of tracheal stenosis: consider tracheal resection and end-to-end anastomosis if short segment; consider
pericardial patch for long-segment tracheal stenosis from complete tracheal rings (however, patch can collapse and
cause anterior tracheomalacia); tracheoplasty basic operation performed along with thoracic surgeon (otolaryngologist
marks proximal and distal ends of stenosis and makes v-shaped cut in front and back to shorten and widen trachea)
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| RECURRENT TRACHEOESOPHAGEAL FISTULAS: ENDOSCOPIC MANAGEMENT —Gresham T. Richter,
MD, Clinical Fellow, Cincinnati Children’s Hospital and Medical Center, Cincinnati, OH
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| Tracheoesophageal fistula: rare congenital anomaly; aberrant communication between trachea and esophagus;
incidence 1 in 3000 to 5000 individuals (majority of patients have esophageal atresia and distal esophageal fistula);
diagnosis—often occurs early, usually when choking and coughing episodes occur during feeding; chest x-
ray shows nasogastric tube stopped at site of esophageal atresia and stomach distention because of air collection;
treatment approaches—include transthoracic, transcervical, and thorascopic; successful, but associated with
complications, including recurrent TEF (RTEF) in 10% of patients
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| RTEF: diagnostic and therapeutic challenge; occurs 2 to 18 mo after primary repair; commonly found in pouch of
original TEF; often small; thought to result from persistent epithelial tract or recannulization; various techniques
associated with recurrence of TEF include double-layer closures, fistula ligation, excessive tension on closure
initially, and postoperative complications, eg, anastomotic leak, esophageal stricture, foreign body; diagnosis—
often difficult; may take several months before diagnosis established; clear signs and symptoms include coughing
and cyanosis with feeding; other symptoms include recurrent pneumonia; most patients present with persistent
pneumonitis despite antibiotic therapy and persistent wheezing; esophagography can aid in diagnosis, but
associated with ≈50% false-negative rate; endoscopy gold standard for diagnosis
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| Management and repair of RTEF: most often performed through open or transcervical approaches; associated
with significant morbidity and high recurrence rates (≤17%)
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| Endoscopic management: approaches include destruction of epithelial lining, tissue adhesive, and combined approach;
study data—3 patients with RTEF; ages 4, 16, and 18 mo; patients presented with coughing, wheezing,
and pneumonia; time to discovery of RTEF 5 mo; esophagography positive for RTEF in one patient; fistula identified
in all patients using bronchoscopy; size of fistulas 2 to 4 mm; approach used ventiliating bronchoscope
passed into airway; identify pouch, pass catheter and perform esophagoscopy, and identify emergence of catheter;
Bugbee diathermy used to cauterize and denude epithelium of fistula, then fibrin glue (Tisseel) applied to fistula;
all procedures successful; no recurrences; mean follow-up 2.1 yr; revision required in one patient; average operating
time 30 to 45 min; no complications occurred
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| Other experiences with endoscopic approach: study found 55% success rate; highest success found in patients
where sclerosant used to denude mucosa and then tissue adhesive used; tissue adhesive alone in 13 patients successful,
but multiple applications required; other case reports showed using destructive technique with tissue adhesive
uniformly effective; mean attempts 1.5; open approach recommended if RTEF cannot be repaired after 2
attempts; diathermy and tissue adhesive looked at specifically; one study abandoned technique because of significant
mucosal edema leading to airway obstruction after diathermy; 2 other reports using diathermy and tissue
adhesive achieved 100% success rate; key to control cautery so no mucosal necrosis or edema occurs (blanching
of tissue indicates epithelium removed); laser as effective as diathermy, but increases cost
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| Conclusions: 2- to 4- mm fistulas best for endoscopic procedure using diathermy and fibrin glue; external procedure
recommended for larger fistulas; endoscopic approach reduces morbidity and mortality associated with
open approach; can repeat procedure; fewer attempts at repair associated with diathermy and tissue adhesive; important
to have proximal fistula that allows placement of endotracheal tube beyond fistula for ≈48 hr after repair
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Suggested Reading
Blankenship DR et al: High-risk tracheostomy: exploring the limits of the percutaneous tracheostomy. Laryngoscope
115:987, 2005; Blankenship DR et al: Percutaneous tracheostomy: don't beat them, join them. Laryngoscope
114:1517, 2004; Devendra K et al: Recurrent tracheoesophageal fistula after foreign body impaction. Pediatr Surg
Int 19:214, 2003; Geller KA et al: Use of the Palmaz stent in the treatment of severe tracheomalacia. Ann Otol Rhinol
Laryngol 113:641, 2004; Hoelzer DJ et al: Successful long-term endoscopic closure of a recurrent tracheoesophageal
fistula with fibrin glue in a child. Int J Pediatr Otorhinolaryngol 48:259, 1999; Konkin DE et al: Outcomes in
esophageal atresia and tracheoesophageal fistula. J Pediatr Surg 38:1726, 2003; Lopes MF et al: Endoscopic obliteration
of a recurrent tracheoesophageal fistula with enbucrilate and polidocanol in a child. Surg Endosc 17:657, 2003;
Rangecroft L et al: Endoscopic diathermy obliteration of recurrent tracheoesophageal fistulae. J Pediatr Surg
19:41, 1984; Seybt MW et al: 100 consecutive collaborative percutaneous tracheostomies. Otolaryngol Head Neck
Surg 136:934, 2007; Sharma AK et al: Esophageal atresia and tracheoesophageal fistula: a review of 25 years' experience.
Pediatr Surg Int 16:478, 2000.
Educational Objectives
| The goal of this program is to improve the performance of percutaneous tracheostomy, management of tracheal
stenosis, and endoscopic management of recurrent tracheoesophageal fistulas. After hearing and assimilating this
program, the clinician will be better able to:
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| 1. List the indications for percutaneous tracheostomy.
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| 2. Describe the advantages of using percutaneous tracheostomy rather than conventional tracheostomy techniques.
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| 3. Discuss the classification of pediatric tracheal stenosis.
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| 4. Evaluate a newborn for tracheal stenosis.
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| 5. Describe the endoscopic management of recurrent tracheoesophageal fistulas.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the following has been disclosed: Dr. Terris is a consultant
for Medtronic-Xomed and Ethicon Endosurgery.
Acknowledgements
Dr. Terris was recorded at the Annual Clinical Conference of the Kansas City Society of Ophthalmology and Otolaryngology
, January 5-6, 2007, in Kansas City, MO. Dr. Geller was recorded at Clinical Frontiers in Otolaryngology, January 12-
13, 2007, in Los Angeles, CA, and sponsored by the Research Study Club of Los Angeles. Dr. Richter was recorded at the
34th Annual Meeting of the Society for Ear, Nose, and Throat Advances in Children (SENTAC), November 30 to December
3, 2006, in San Francisco, CA, and sponsored by SENTAC. The Audio-Digest Foundation thanks the speakers and the
sponsors for their cooperation in the production of this program.
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