Anesthesia management in patients with air dissection

Aerotomy, also known as tracheostomy, refers to the incision of the cervical trachea and the placement of a metal tracheal cannula or silicone cannula, which is a common surgery to relieve dyspnea caused by laryngeal dyspnea, respiratory dysfunction or lower respiratory tract secretion retention, and some patients who are about to undergo large-scale laryngeal and oral surgery can also undergo prophylactic tracheostomy
before or during surgery.
part.
1

Classification of aeroctomy Commonly used catheters

1.
Open tracheostomy

（Opentracheostomy,OT）

2.
Percutaneous tracheostomy

（Percutaneous dilatational tracheostomy, PDT）

3.
Ccricothyroid tracheostomy

（Cyclophated tracheotomy,CT）

Metal tubing tubing:

Merit:

Durable, with inner sleeve, can be disassembled at any time, easy to clean and care, not easy to block the pipe, can be used
for a long time.

Shortcoming:

(1) If used improperly, long-term compression of the tracheal mucosa can cause complications such as respiratory ulcers and strictures in patients;

(2) Long-term disinfection of the inner sleeve, metal easy to change color deformation, making it difficult to take and place;

(3) Mechanical ventilation cannot be connected;

(4) No hemostasis and prevent
secretions from entering the lower respiratory tract.

Polyvinyl chloride (PVC) or polyurethane materials:

(1) The material of the tracheal casing is light, there is an inner casing, it can be removed and cleaned, and it is not easy to block the pipe;

(2) There is an air bag at the end of the cannula with air bag, the capsule tube is integrated, the combination is firm and tight, and it can be directly connected to the ventilator for mechanical ventilation, and after the air bag is inflated, it can effectively stop bleeding and prevent secretions from entering the lower respiratory tract
.

PVC cannula in patients with air dissection

part.
2

Airway evaluation in patients with air resection

1.
Assess the patient's general condition, vital signs, disease status, physiological state and degree of cooperation;

2.
Assess whether there is dyspnea and hypoxia, whether the endotracheal tube is unobstructed, whether there is discharge, the color of the discharge and the amount of discharge;

3.
For patients who are in a coma and are in a tracheostomy, try to replace the metal catheter with a plastic catheter with a cuff before surgery, which can be connected to the anesthesia machine and prevent aspiration;

4.
For those with short incision time and difficulty in catheter insertion, the cannula can be removed and the endotracheal tube with cuff can be directly inserted;

5.
Before anesthesia, carefully check the patient's tracheostomy, strictly evaluate the difficulties and impacts that the patient may bring to anesthesia intubation, and make full preparations
from technology and equipment.

part.
3

Anesthesia management and catheter replacement in patients with air resection

1.
If it is difficult to inulate, barely intubation may cause bleeding caused by airway scar rupture, and it is difficult to stop bleeding, so anesthesia induction should be sufficient, avoid choking, never violently intubate, replace the small tube when the resistance cannot pass, and prepare a suction device;

2.
When the tracheostomy patient undergoes head and neck surgery, the surgeon occupies a favorable position for the anesthesiologist to manage breathing, and the anesthesiologist should always pay attention to the catheter and joint, and deal with possible accidents in the first time;

3.
Pay attention to respiratory resistance, if there is a change, check the pipeline in time to ensure that the airway is unobstructed, avoid carbon dioxide accumulation, and avoid the increase in intracranial pressure caused by hypercapnia;

4.
Awake tracheal intubation is mainly for patients who cannot maintain airway patency during anesthesia induction, but patients with increased intracranial pressure and severe tension pneumothorax should be used
with caution.

To replace the air stomy catheter:

The usual method of replacing the balloon catheter is to deflate the balloon after removing the balloon residue, pull out the balloon catheter, and insert a new aerostomy catheter
along the original path.
Once the tube change is difficult, if the patient has spontaneous breathing and good oxygenation, at this time, the pneumatic incision suture can be considered to be appropriately cut to expand the field of view and facilitate insertion
.
If spontaneous breathing is not available, emergency oral endotracheal intubation should be considered, and the tip of the catheter should be passed past the aerotracheal incision to prevent hypoxia and ensure oxygen supply
.

part.
4

Complications in patients with air dissection

(1) Subcutaneous emphysema

Subcutaneous emphysema mostly occurs in the neck, but can also affect the face, chest, abdomen, and even the perineum; Symptoms are localized swelling and, if present in the neck, thickening, a sensation of blood to the touch, and crepitations or small plosives on auscultation
.

(2) Pneumomediastinum

Mostly due to excessive removal of the anterior fascia of the trachea; The mild symptoms are not obvious, generally have chest pain, severe shortness of breath, auscultation heart sounds are low and far away; When emphysema is severe and mediastinal compression affects the respiratory circulation
, decompression should be performed to release gas.

(3) Bleeding

It can be divided into early bleeding and postoperative bleeding, because there are many blood vessels in the neck, so we must pay attention to prevent the possibility of heavy bleeding;

(4) Asphyxia or respiratory arrest

It is more common in children, the trachea is softer in children, and blunt peeling during surgery is easy to flatten the trachea, causing asphyxia;

(5) Tracheoesophageal fistula

Less common, it usually occurs within
two to ten weeks after surgery.

summary

The management of anesthesia in tracheostomy patients is challenging and requires adequate planning
.
The anesthesiologist should understand the indications for tracheostomy and the status of the trachea to develop an appropriate airway management plan
.
In addition, the causes and mechanisms of tracheostomy emergencies should be understood to provide effective first aid measures
.