The critical airway in adults: The facts

Abstract

An algorithm on the indications and timing for a surgical airway in emergency as such cannot be drawn due to the multiplicity of variables and the inapplicability in the context of life-threatening critical emergency, where human brain elaborates decisions better in cluster rather than in binary fashion. In particular, in emergency or urgent scenarios, there is no clear or established consensus as to specifically who should receive a tracheostomy as a life-saving procedure; and more importantly, when. The two classical indications for emergency tracheostomy (laryngeal injury and failure to secure airway with endotracheal intubation or cricothyroidotomy) are too generic and encompass a broad spectrum of possibilities. In literature, specific indications for emergency tracheostomy are scattered and are biased, partially comprehensive, not clearly described or not homogeneously gathered. The review highlights the indications and timing for an emergency surgical airway and gives recommendations on which surgical airway method to use in critical airway.

Urgent tracheostomy: four-year experience in a tertiary hospital

“…[8,9] However, acute airway obstruction [9] and/or impossible oral/nasotracheal intubation is one of the most important indications for tracheostomy because of the presence of volumous pharyngeal/laryngeal tumor, neck trauma or deep neck infection. [9][10][11] Cricothyrostomy is a fast and simple method for creating a surgical airway, [2,9,12] with a success rate of 88%-100%, [2] especially in adult patients with trauma. [9] Because subglottic stenosis has long-term morbidity, [9,12] this is why some doctors prefer to convert to tracheostomy.…”

Surgical airways for trauma patients in an emergency surgical setting: 11 years’ experience at a teaching hospital in Japan

“…Facial trauma can make it impossible to open the mouth fully, and makes face-mask ventilation very difficult. Face-mask ventilation in facial trauma cases can worsen hypoxia by pushing blood, debris, and tissue from the upper airway into the lower airway, and can cause further damage to facial structures [8]. Imprudent induction of general anesthesia can cause a CVCI situation, leading to a tragic outcome.…”

“…In some cases, such as in Case 3, it may be quicker and easier to introduce a tracheostomy cannula via a wound, or to surgically extend a wound rather than perform standard ESA procedures [8].…”

In Reply to Dr Jamshidi’s Letter

“…With this level of facial trauma, the use of a bag-valve mask is reported to worsen hypoxemia by pushing blood, debris, and tissue into the lower airways, and potentially compounds the damage to unstable facial structures. 4 Further, the need for a definitive airway in the austere setting ultimately comes from a different etiology than that seen in the normal civilian setting. Whereas primary cardiac arrest in adults and primary respiratory arrest in children form the bulk of airway problems in this setting, in the wilderness it can be expected that airway difficulty would primarily be secondary to trauma or to anaphylaxis.…”

“…With this level of facial trauma, the use of a bag-valve mask is reported to worsen hypoxemia by pushing blood, debris, and tissue into the lower airways, and potentially compounds the damage to unstable facial structures. 4…”