Obtaining a Surgical Airway
Encountering a patient in need of an emergent surgical airway is one of the most harrowing situations a surgeon faces. The surgeon is often called as the patient becomes hypoxic after multiple attempts at an airway. In these cases it is necessary to rapid
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Robert Ellis Southard
Encountering a patient in need of an emergent surgical airway is one of the most harrowing situations a surgeon faces. The surgeon is often called as the patient becomes hypoxic after multiple attempts at an airway. In these cases it is necessary to rapidly assess the situation and develop a plan. Therefore, the surgeon must possess an understanding of the indications for an emergent surgical airway, a detailed knowledge of the anatomy of the neck, procedural options available, and the potential complications. With this knowledge the acute care surgeon can be adequately prepared for this rare but challenging scenario.
Indications for a Surgical Airway Development of guidelines and algorithms related to placement of a surgical airway are complicated by the relative infrequency of these procedures. Also, the emergent nature of the scenarios in which these procedures are performed make it difficult to perform randomized trials or comparative effectiveness studies in actual clinical scenarios. There are many scenarios which may develop requiring the need for a surgical airway including a foreign body or mass in the upper airway; edema of the upper airway to infection, inflammation, or anaphylaxis; trauma and burns to the face or neck; or encountering an anatomically difficult airway during attempted intubation [1]. Signs which should prompt immediate consideration of obtaining a surgical airway include stridor and impending obstruction due to edema of the upper airway, particularly if signs of hypoxia are present. An obvious laryngeal injury particularly with respiratory compromise is also an indication for obtaining a surgical airway.
R.E. Southard (*) Baylor College of Medicine, One Baylor Plaza, MS BCM390, Houston, TX 77030, USA e-mail: [email protected]
The presence of a traumatic tracheocutaneous fistula may require emergent placement of an airway if there is a significant air leak. Outside of the setting of direct trauma and obstruction, the need for a surgical airway arises when a difficult airway preventsSurgical airway:indications: endotracheal intubation. The American Society of Anesthesiologists has published Practice Guidelines for Management of the Difficult Airway which contains a useful algorithm for approaching the potentially difficult airway [2]. There are a growing number of tools and modalities which allow rescue ventilation and intubation such as intubating laryngeal masks and video laryngoscopes. These adjuncts have proven useful, but still fail at times. The Practice Guidelines for Management of the Difficult Airway defines the difficult airway as “the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with tracheal intubation, or both.” Factors predictive of a potentially difficult airway are listed in Table 16.1, and should prompt preparation for a difficult airway, including calling for additional personnel and equipment and utilization of the difficult airway algorithm. Acut
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