Stridor and Airway Management

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Stridor and Airway Management

• Dr G Soo
• Division of Otorhinolaryngology

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Physical Mechanisms of Sound Production
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Laminar flow
Turbulence when flow velocity exceeds critical
velocity
Turbulence
Turbulence Noise Stridor Turbulence heat
local drying effect Inspissated mucus
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Why Inspiratory Stridor?
Inspiration smaller airway due to Venturi effect
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Why less expiratory stridor?
Expiration larger airway with nil or minimal
turbulence
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Biphasic stridor when inspiration and expiration
velocity gt critical velocity implying severe
obstruction
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Why expiratory wheeze, and not inspiratory?
Inspiration larger airway
Expiration smaller airway
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Aetiology of Stridor

• Congenital
• Infective
• Foreign Bodies
• Neoplasm
• Trauma
• Vocal Cord Paralysis (Bilateral)

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Stridor

• Management
• Maintain Airway
• Treat Underlying Causes

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Supraglottitis

• Bacterial Infection H. Influenza etc.
• Involves epiglottis, aryepiglottic folds,
  arytenoids, false vocal cords (hence
  supraglottitis)
• Sudden severe rapid sore throat, odynophagia and
  progressive dyspnoea
• Inspiratory stridor, tripod position
• Lateral neck X-ray - Thumb sign
• Laryngoscopy Odematous supraglottis

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Supraglottitis

• Airway protectionIntubation with standby
  tracheostomy in theatres with gas down technique
• Treatment IV antibiotics (Cefotaxime and
  Metronidazole)
• Extubate when airway patent

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Supraglottis
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Ca Larynx
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Bilateral vocal cord palsy
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Intubation or Tracheostomy
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Intubation

• Short term condition
• Condition allowing ET tube passage

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Factors that make intubation difficult

• Stiff Neck
• Trimus
• Long sharp teeth, crowns
• Bulky tongue
• Severe bleeding preventing visualisation (fr
  nose, maxilla and teeth sockets, pharynx, lung,
  GI)
• Any space occupying lesion in pharynx or larynx

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Tracheostomy

• Chronic condition
• Failed intubation
• Moses dictum when you think of it

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Indications for tracheostomy

• Acute upper airway obstruction
• Type 1 respiratory failure
• - reduce dead space by 10 - 50
• Prophylactic protection of the airway
• (pre-elective HN Surgery due to potential
  postop swelling, bleeding, aspiration,etc)
• Access for bronchopulmonary toilet

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Types of tracheostomy tubes

• Nonmetal/metal
• Cuff/uncuff
• Fenestrated/unfenestrated
• Short term/long term tubes
• Single/double lumen tubes

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Common Types of Tracheostomy Tube

• Portex (PVC) / Shiley (Silicone)
• Cuffed ( low pressure, high volume )
• Uncuffed
• Shiley - Inner tube and outer tube
• Silver - Negus / Chevalier Jackson
• Inert, Thin wall, larger inner diameter
• Inner tube Speaking Valve
• Outer tube
• Largest tube and tolerable should be used
• 3/4 diameter of trachea

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Portex Tracheostomy
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Tracheostomy (look in MS Word file)

• Indications
• Technique
• Complications
• Management

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Complications of Tracheostomy

• Immediate
• Haemorrhage - BCV
• Surgical Trauma
• Oesophagus
• Recurrent Laryngeal Nerve
• Trachea
• Pneumothorax
• Apnoea

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Complications of Tracheostomy

• Intermediate
• Tracheobronchitis - Dryness
• Tracheal Erosion and Haemorrhage
• Tube Displacement
• Tube Obstruction
• Subcutaneous Emphysema
• Aspiration

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Complications of Tracheostomy

• Late
• Persistent Tracheocutaneous Fistula
• Laryngeal and tracheal stenosis
• Tracheomalacia
• Difficult Decannulation
• Tracheo-oesophageal Fistula
• Tracheostomy Scar

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Mortality of Tracheostomy

• Adult
• 1.6
• Children
• 5

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Care of Tracheostomy

• Suction PRN
• Humidification continuous
• Chest physiotherapy
• Cleansing of Inner Tube
• Tracheal dilator standby

Do what the body does
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Decannulation Protocol

• See tracheostomy MS word file