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Airways Considerations in IR
5
Airway Considerations
in IR
By: McKenzie
Harrison, PA-C
Purpose of an Artificial Airway
Provide adequate ventilation
Maintain patent airway
Eliminate airway obstruction
Reduce potential for aspiration
Provide access for secretion clearance
Altered Airway
Altered
Airway
- Discoordinated care can result in dangerous, even potentially fatal situations
- Opportunity to better protect our patients
-Establish trust with the patient
Airway Incident Risk Factors
-Lack of staff education
-Poor chart documentation
-Confusion with anatomy
-Lack of equipment/resources
Picture of mucous plus
Purpose and Incidents
Artificial Airway
Incidents
Majority due to airway loss
-Displaced tracheostomy
-Tube occlusion from mucous plug (partial or complete)
-Airway obstruction/ stenosis
Mallampati 4 is
automatic
Anesthesia if patients requires
sedation
Airway
Classifications
Tracheostomy
Timeline
What is a "fresh"trach?
- A tracheostomy takes at least 3-4 weeks to develop a mature, well-established tract
- Following decannulation, re-insertion of a trach tube into a tract that is not mature can be very difficult and in some situations impossible
- Inpatient: For our purposes, the head and neck fellow should "cuff" the trach prior our procedure in the morning.
Tracheostomy Anatomy
Tracheostomy
Incision is made in the trachea, larynx is left intact.
Air can pass through both the oral cavity and the stoma in the neck.
Cricothyrotomy is emergency procedure that provides quick, temporary solution. Incision is made in the cricothyroid membraine. It's not used for a long term airway, Usually faster to perform with less bleeding than trach.
Epiglottis: Flap of tissue that sits beneath the tongue at the back of the throat. Function is to close over the trachea while you swallow to prevent food/water from enterinng the airway. AKA preventing aspiration,
Laryngectomy
Can these patients still swallow food?
Laryngectomy
NECK BREATHER: No patent connection between the oral cavity and the lungs.
Click here for
the
answer
Yes if the laryngectomy went well and heals with no issues + no further esophageal damage from cancer or radiation.
Visual Aids
Laryngectomy
(no inner cannula)
Tracheostomy
(inner cannula)
Heat and moisture exchanger (HME)
How do patients speak with a tracheostomy?
Speaking
Valve
Passy Muir Valve - Restores positive airway pressure and pushes air through vocal cords
-Patients should not sleep with this on or have moderate sedation with it on
Mandibulectomy
Maxillectomy
Patients can have patent natural airways after these surgeries, just always check to see if they can lay flat without any oral secretions.
Other common H&N
Surgical
Anatomy
Free Flap Recon
Obturator
These patients may only have a trach for a short duration while inpatient until swelling subsides.
How do laryngectomy patients speak?
Tracheoesophageal Puncture Site
A TEP site is a one way valve between the trachea and the esophagus.
The valve keeps food out of the trachea. After TEP, patients can cover their stoma with a finger, and force air into the esophagus through the valve.
TEP
What if the TEP gets dislodged and you can't find it?
-STAT CXR (some can only be seen on CT)
Electrolarynx
Electrolarynx
Tracheostomy
Airway
Emergency
First try anesthesia team
Contact Head and Neck Surgery Team
- MD Anderson intranet
- Type in "on call schedule"
*Don't remove trach, only inner cannula for our purposeses*
laryngeal mask
airway
Cuffed
vs
Uncuffed
Trach
Ventilation
Cuffed vs Uncuffed Trach
-Cuffed is for positive pressure ventilation
-Reduces amount of tracheal secretions aspirated into the lungs
- Many patients start with cuffed trach and then get switched to uncuffed trach as trach site heals
Lary
Ventilation
Remember laryngectomy patients are neck breathers!
Ventilating through their oral cavity will not work.
SCREENING
*This icon is not always accurate, you can click on the icon and open "airway audit" which will show you the encounters linked
Screening
These patients do not need ANES if it's a local only Procedure.
ANES
1. Always check for difficult airway icon.
- These patients have to be with ANES in PAVILLION.
- Some patients have severe trismus with no airway icon, these patients need ANES. *** Ask if they can bite an apple
-New Tracheostomies or laryngectomies (within 4 weeks)
2. History of sleep apnea with BMI> 35 = automatic ANES
3. History of sleep apnea with BMI> 45 = ANES in PAV only
5. New tracheostomies and laryngectomies need ANES (Within 4-6 weeks at a minimum)
Moderate Sedation Procedures
- Can patients lay flat?
- History of aspiration?
- Hospitalized for pneumonia in past year?
- Are they having a lot of tracheal secretions?
* Speech notes usually talk about modified barium swallow test and will discuss aspiration
-Can they drink water and swallow food?
Other guidelines:
-Prior head and neck radiation? Can't go to HALS.
Can a
total laryngectomy patient go to HALS????
When in doubt email Dr. Ruiz or Dr. Tan with ANES :)
Make sure the patient has a way to communicate. Communication is key with these patients. Provide pen and paper or allow them to text out what they want to say.
More Tips
Thank you so much!!!
THANK YOU!
Sources
https://onlinelibrary.wiley.com/doi/abs/10.1002/lary.23436
https://www.mdanderson.org/cancerwise/coping-with-a-laryngectomy-.h00-159145245.html
https://www.ncbi.nlm.nih.gov/books/NBK556041/
https://twitter.com/medictests/status/1495882281847857160
https://www.mountsinai.org/files/MSHealth/Assets/HS/Care/ENT/General/TracheostomyEducationPatientsCaregivers2019.pdf
http://blog.clinicalmonster.com/2021/04/23/troubleshooting-trach-complications/
https://www.youtube.com/watch?v=v55NAjqltEI
https://www.atosmedical.com/wp-content/uploads/2016/01/rescue-breathing.pdf
https://clinical.stjohnwa.com.au/clinical-practice-guidelines/respiratory/tracheostomy-laryngectomy-airway-emergencies
https://www.entnet.org/wp-content/uploads/files/LaryngectomeeGuide.pdf