V Ensuring an adequate airway is the first

priority in the primary survey.In general

patients who are conscious and have a
normal voice do not require early attention
to their airway.Patients who have an
abnormal voice or altered mental status
require further airway evaluation.
V Options for airway access include
nasotracheal,orotracheal and surgical.
áhe most widely used route is
i orotracheal, in which an endotracheal
tube is passed through oral cavity.
iIn a nasotracheal procedure, an
endotracheal tube is passed through the
nose.
i Other methods of intubation involve
surgery and include the
I. cricothyroidotomy
II. tracheostomy
áracheal intubation is indicated in patients with:

V Actual or impending airway obstruction due to

V Foreign body common in infants and toddlers.
V Severe blunt or penetrating injury to the face
or neck may be accompanied by swelling
and an expanding hematoma, or
V Injury to the larynx, trachea or bronchi.
V It is also common in people who have suffered
smoke inhalation or burns within or near the
airway.
V Sustained generalized seizure activity and
V angioedema
efined as decreased oxygen content and oxygen saturation of the blood
caused due to hypoventilation) suspended (apnea), or when the lungs
are unable to sufficiently transfer gasses to the blood.
V Examples of such conditions include
V cervical spine injury,
V multiple rib fractures,
V severe pneumonia,
V acute respiratory distress syndrome (ARS), or
V near-drowning.
V Specifically, intubation is considered if the arterial partial pressure of
oxygen (PaO2) is less than 60 millimeters of mercury (mm Hg) while
breathing an inspired O2 concentration (FIO2) of 50% or greater. In
patients with elevated arterial carbon dioxide, an arterial partial
pressure of CO2 (PaCO2) greater than 45 mm Hg in the setting of
acidemia would prompt intubation, especially if a series of
measurements demonstrate a worsening respiratory acidosis.
V epressed level of consciousness due to
a) Administration of general anaesthesia
b) Stroke
c) Non-penetrating head injuries
d) Poisoning
e) Intoxication
f) when depressed level of consciousness
becomes severe to the point of stupor or
coma (defined as a score on the Glasgow
Coma Scale of less than 8)
iagnostic or therapeutic manipulation of the
airway (such as bronchoscopy, laser
therapy or stenting of the bronchi) may
intermittently interfere with the ability to
breathe.
Relative contraindications include
maxillo facial trauma
laryngeal injury
cervical spine injuries
V PRE REQUISIáES
Pre oxygenation with a bag valve mask apparatus and
100%oxygen,suction,adequate sedation and muscle relaxation
an appropriately sized Eáá tube and a functional laryngoscope
are required

V With the physician at the patients head,the head is so positioned

that the pharyngeal and laryngeal axes are in alignment.
V áhe patients head and neck are fully extended.
V With the non dominant hand,the physician opens the mouth
with the thumb and index finger on pts lower and upper teeth.
V áhe oropharynx is inspected and foreign bodies or secretions are
removed,blade of the laryngoscope is introduced and
advanced with gentle traction upward and towards the patients
feet.
àOnce the epiglottis is visualized the tip
of the blade is positioned in the
valeculla.the glottic opening and
vocal cords are visualized, the Eá tube
is advanced under direct vision until
the cuff passes through the vocal
cords.

àCuff is inserted roughly 2cm past the

vocal cords and the patients incisors
should rest between the 19 and 23 cm
markings on the tube.

àáhe cuff is inflated and proper position

is confirmed by auscultating bilateral
breath sounds.An anteroposterior chest
x ray is obtained to confirm
position.Ideallly the tip of the Eá tube
should be 2 to 4 cm above the carina.
V Chipped teeth
V Emesis and aspiration
V Vocal cord injury
V Laryngospasm
V Soft tissue injury to the oropharynx
V Advantages include
irect visualization of the vocal cords
Ability to use larger diameter
endotracheal tubes
Applicability to apneic patients
Familiarity to most physicians
V emerits
require neuromuscular blockade or
deep sedation
V A cricothyrotomy is an incision made through the skin and
cricothyroid membrane to establish a patent airway

V INICAáIONS include

V Life-threatening situations, such as airway obstruction by a

foreign body, angioedema, or massive facial trauma.

V A cricothyrotomy is nearly always performed as a last

resort in cases where orotracheal and nasotracheal
intubation are impossible or contraindicated.
V Advantages include
V Cricothyrotomy is easier and quicker to perform than
tracheotomy, does not require manipulation of the
cervical spine and is associated with fewer complications.[
áhe thyroid cartilage is easily
identified in the midline of the
neck.áhe cricoid is the only
complete cartilaginous ring ,is
the first ring inferior to the
thyroid cartilage.áhe
cricothyroid membrane joins
these two cartilages and is an
avascular membrane.Inferior
to the cricoid and straddling
the trachea is the isthmus of
the thyroid gland.áhe thyroid
lobes lie lateral to the trachea
and the superior poles can
extend to the level of the
thyroid cartilage.
V If time permits the area is prepared,draped and anesthetized with 1%
lidocaine.
V A vertical skin incision is made. áhe cricoid is identified and held firmly and
circumferentially in the physician·s non dominant hand until the end of the
procedure.
V With a no.11 or 15 blade, a small 3 to 5 cm transverse incision is made over
the cricothyroid membrane.áhe incision is carried deep to the until the
airway is entered through the cricothyroid membrane.
V áhe tract is widened using a clamp ,tracheal dilator or end of the scalpel
handle.
V áhe tracheostomy tube is inserted along its curve into the trachea,the cuff is
inflated and bilateral breath sounds are confirmed.
V If breath sounds are confirmed ,the tracheostomy is secured to the skin by
suturing the tabs to the skin with heavy ,non absorbable,monofilament
suture.
V A chest x ray is obtained to document the location of the tracheostomy
tube.
V áraditionally cricothyroidotomy was converted to formal tracheostomy
.However it has been suggested that a cricothyroidotomy maybe used long
term without an increase in acute complications.
V Creation of a false passage when inserting tracheostomy
tube is most common complications. Others include
V Subcutaneous emphysema
V Pneumothorax
V Injury to surrounding structures such as
thyroid,parathyroids,esophagus,anterior jugular veins,and
recurrent laryngeal nerves can occur in situations of urgency.
V Subglottic stenosis and granuloma formation are potential
long term complications.
V Advantages include
simplicity and safety
V isadvantages include
inability to place a tube greater than 6mm
in diameter due to limited aperture of
cricothyroid space
relatively contraindicated in patients under
the age of 12 years because of the risk of
damage to the cricoid cartilage and the
subsequent risk of subglottic stenosis
V áracheotomy consists of making an incision
on the front of the neck and opening a
direct airway through an incision in the
trachea. áhe resulting opening can serve
independently as an airway or as a site for
a tracheostomy tube to be inserted; this
tube allows a person to breathe without the
use of their nose or mouth. áhe opening
may be made by a knife or a needle
(referred to as surgical and
percutaneous[72] techniques respectively)
and both techniques are widely used in
current practice.
V In the acute setting, indications for
tracheotomy are similar to those for
cricothyrotomy.
V In the chronic setting, indications for
tracheotomy include the
à need for long-term mechanical
ventilation and removal of tracheal
secretions (e.g., comatose patients, or
à extensive surgery involving the head
and neck).
V áhe patient is laid supine with padding placed under the
shoulders and neck extended.
V A vertical midline incision is made from the inferior aspect
of the thyroid cartilage to the suprasternal notch and
continued down between the infrahyoid muscles.
V In extreme urgency,a further vertical incision straight into
the trachea at the level of the second,third and fourth ring
should be made immediately without regard to the
presence of thyroid isthmus.
V áhe knife blade is rotated through 90 ,thus opening the
trachea.
V Any form of available tube is inserted into the trachea as
soon as possible and blood and secretion sucked out.
V Once an airway is established hemostasis is then
secured.With the emergency under control,the
tracheostomy should be refashioned as soon as possible.
V INáRAOPERAáIVE
Hemorrhage
Injury to para tracheal structures
injury to trachea
V EARLY POSá OP
Apnea caused by a fall in pCO2
Hemorrhage
Subcutaneous emphysema,pneumomediastinum and pneumothorax
accidental extubation
anterior displacement of the tube
obstruction of the tube lumen
occlusion against tracheal wall
V LAáE POSá OP
ifficult decannulation
áracheocutaneous fistula
áracheo-esophageal fistula
árachea stenosis
V Although emergent tracheostomy has fallen into disfavor because of its
technical difficulties it may still be necessary in cases of laryngotracheal
separation or laryngeal fractures,where cricothyroidotomy may cause further
damage or result in complete loss of the airway.