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Management Of Acute Airway Obstruction

  1. Heimlich Maneuver:
    1. Used when acute airway obstruction is produced by a food bolus or a foreign body
    2. Principle: Uses the residual air in the lungs to expel the foreign body
    3. Method: Rapid squeezing motion is applied against the xiphoid region of the Sternum
  2. Nasopharyngeal / Oropharyngeal Airway:
    To overcome problems due to relaxation or prolapse of the palate and the base of the tongue.
  3. Transtracheal needle ventilations:
    1. With a 16 G plastic sheathed needle
    2. 02 delivered at 161b/m2
    3. Can be given for 30 min
  4. MINI tracheostomy:
    Site: Through a vertical incision in the CRICOTHYROID MEMBRANE. A 4 mm cannula: Is inserted for ready access & delivery of 02
  5. Indications:
    1. For treatment of respiratory failure
    2. in obstructive sleep apnea
    3. For removal of secretions
  6. Percutaneous Tracheostomy:
    Site  : Trachea
    Methods  : Trachea is punctured at a particular site with a needle and cannula and a guide wire is passed through the opening over which dilators are passeD.
  7. Contraindications:
    1. A patient already in intense stridor.
    2. Laryngeal malignancies
    3. Short neck individuals
    4. When proper trained personal are not available
    5. Large thyoid gland
    6. When ultrasound reveals an abnormally large inferior thryoid vein.
  8. Cricothyroidotomy:
    1. Site: Cricothyroid membrane
    2. Using I.V. catheter(14 G i.v. needle is used)
    3. Using cricothyrotomy
    4. Formal surgical procedure
    5. Main problem: Subglottic stenosis
  9. Tracheostomy:
    1. Functions:
      1. Serves as an alternative pathway for breathing
      2. Improves alveolar ventilation (¯ es the dead space by 30-50%)
      3. For protection of the airway
      4. Permits removal of tracheobronchial secretions
      5. For I.P.P.V
      6. To administer anesthesia
    2. Indications:
      1. Respiratory obstruction:
        1. Infections
        2. Trauma
        3. Neoplasms
        4. Foreign body larynx
        5. Oedema; larynx
        6. B/L abductor paralysis larynx
        7. Congenital anomalies
      2. Children
        1. Mostly inflammatory or traumatic lesions
          1. Acute laryngo-tracheo-bronchitis
          2. Epiglottitis
          3. Diphtheria
          4. Laryngeal oedema (chemical/thermal injury)
          5. External laryngeal trauma
          6. Prolonged intubation
          7. Juvenile laryngeal papillomatosis
    3. Retained secretions:
      1. Inability to cough
      2. Painful cough (chest injuries) rib fractures
      3. Aspiration of pharyngeal secretions (bulbar polio, U/L laryngeal paralysis)
    4. Respiratory insufficiency:
      1. Chronic lung conditions
    5. Common indications of tracheostomy in infants and children
      1. Infants below 1 year (mostly congenital lesions)
        1. Subglottic hemangioma
        2. Subglottic stenosis
        3. Laryngeal cyst
        4. Glottic web
        5. Bilateral vocal cord paralysis
  10. Tracheostomy tubes
    1. Metallic:
      1. Silver - Jackson
      2. FU Hers                                                           
      3. Koenig’s (with extensive and low narrowing of the trachea)        
      4. Durham’s (adjustable flange - Can be used for thin and fat neck)
    2. Non- metallic (P.V.C Silastic)
      1. Portex                                                                                            
      2. Salpeker (has 2 cuffs, one above each other to prevent pressure necorsis)
      3. Shiley/ neonatal tube                                                                              
      4. Great Onnond street tube (has a beveled tip and is winged tube)
    3. Complications:
      Most common complication: Haemorrhage
  11. Immediate:
    1. Haemorrhage:
      Anterior jugular
      Thyroid vein
    2. Air embolism : If large veins opened in the neck
    3. Apnea: Due to sudden release of retained CO2
      Treatment: 5% O2 +95% CO2 (carbogen)
    4. Cardiac arrest: Excessive adrenaline production in anxious patient
      Rapid rise of pH
      Hyperkalemia- Due to respiratory alkalosis
    5. Local damage:
      Thyroid cartilage
      Cricoid cartilage
      Recurrent laryngeal nerve
    6. Intermediate:
      Dislodgment/Displacement of the tube
      Surgical emphysema-neck
      Tracheal necrosis
      Tracheoarterial fistula
      Tracheo-oesophageal fistula
    7. Late
      Stenosis of the trachea
      Difficulty with decannulation
      Tracheocutaneous fistula /scars
      P.S. The property of the cuffs in tracheostomy tubes should be: high volume low pressure cuffs

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