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356
Fig. 20 VividTrac
videolaryngoscope
R. Lima et al.
Fig. 21 Airtraq
videolaryngoscope
Dicult Intubation: How toAvoid aTracheostomy
Fig. 22 Ambu aScope3
357
the image. It has a high cost of purchase and maintenance, and the fragile glass
bers require care. A bite block must be used when it is introduced orally. Due to its
small diameter, it is possible to perform endotracheal intubations in patients with
spontaneous ventilation, with minimal discomfort after topical anesthesia. It is not
recommended to be used in patients under general anesthesia, because loss of tone
in pharyngeal muscles makes it more difcult to visualize the larynx. The presence
of excessive secretion or blood in the upper airway is also a difculty with the use
of the beroptic bronchoscope.
The Ambu aScope 3 (Ambu, Copenhagen, Denmark) is a device with the
same functionality as the beroptic bronchoscope (Fig.22). The lighting and
visualization are electronically generated, which allows the device to be more
resistant, portable, and affordable, since there are no beroptics. It is a disposable device.
Difficult-Airway Algorithms
A difcult airway can be caused by any clinical factor that complicates bag mask
ventilation or endotracheal intubation, preventing proper endotracheal tube placement by experienced professionals. Difcult bag mask ventilation can be dened
as impossible, inadequate, unstable, or requiring two providers to be effective.
Difcult intubation is the need for more than three attempts at intubation, or a
procedure that lasts longer than 10min. The need for more than one specialist, or
the need for blade changing or use of accessories, can also dene a difcult
intubation.
A difcult airway is not always predicted, so a strategy for the management of
unanticipated difculty is important. Several algorithms have been developed to
provide a structured response to this life-threatening situation. The most widely
used are the algorithms issued by the Difcult Airway Society [33] and by the
American Society of Anesthesiologists [34]. Implementation of a standardized
protocol has proved to signicantly reduce the need for emergency surgical airway [32].
358
R. Lima et al.
Difficult-Airway Algorithm fromtheDifficult Airway Society
This algorithm [33] has a simpler and more straightforward strategy for management of the airway. It does not go into details of different clinical situations such as
an uncooperative patient or one with a full stomach. It is of great help in an emergency situation, when an unexpected difculty is encountered (Fig.23).
Plan A: It is of fundamental importance to correctly position the patient for
endotracheal intubation. The appropriate equipment, such as a bougie and an oral
airway or a nasopharyngeal airway, must be readily available. A videolaryngoscope
must also be available and used if the attempts with a regular laryngoscope fail
(the maximum number of attempts recommended is three). Adequate neuromuscular blockade must be done.
Plan B: If attempts at endotracheal intubation fail, it is recommended to place a
supraglottic airway device. The guideline recommends second-generation devices
and a maximum of three attempts (changing devices or size at each attempt).
Different devices of different sizes must be available.
Fig. 23 Algorithm for unanticipated difcult tracheal intubation owchart from the Difcult
Airway Society (it includes all the information of the difcult airway algorithm of DAS)
Reproduced from [33]
Dicult Intubation: How toAvoid aTracheostomy
359
Plan C: If endotracheal intubation and ventilation through a supraglottic airway
device fails, face mask ventilation must be attempted. The guideline recommends
optimal positioning of the patient, the use of accessories (oral or nasopharyngeal
airway), and a two-person technique.
Plan D: This envisions a situation of difcult endotracheal intubation and difcult face mask ventilation—a life-threatening scenario. No further attempts with the
previous plans should be made. A cricothyroidotomy must be performed without
delay.
Difficult-Airway Algorithm fromtheAmerican Society
ofAnesthesiologists
The difcult-airway algorithm issued by the American Society of Anesthesiologists
[34] includes more details and clinical scenarios, which may not be optimal for
use by inexperienced professionals in an emergency situation. However, it must
be studied by anyone who might possibly have to manage a difcult airway
(Fig.24).
The algorithm emphasizes that oxygenation is more important than intubation.
Adequate preoxygenation must be offered to allow a longer apnea time before
hemoglobin desaturation. The use of noninvasive positive-pressure ventilation
prior to any attempt at airway management and a 20-degree upright position in
obese patients can delay critical desaturation. This has great importance in the case
of a postinduction endotracheal intubation attempt or if an emergency surgical
airway is needed.
Awake intubation is an option in those patients with known or high likelihood of
a difcult airway. With awake intubation, the patient maintains spontaneous ventilation, which provides a longer time and increased safety to manage the airway.
Possible limiting factors include an uncooperative patient or the presence of blood
or other liquids in the upper airway. In this case, a rapid sequence for endotracheal
intubation is required. The safety of maintaining spontaneous ventilation is lost;
however, a better laryngoscopy is gained by adequate neuromuscular blockade [35].
With the knowledge and the new devices available for clinical care, it is possible to
ensure safety and comfort for most patients.
360
R. Lima et al.
Fig. 24 Difcult-airway algorithm owchart from the American Society of Anesthesiologists
Dicult Intubation: How toAvoid aTracheostomy
Conclusion
361
Adequate airway management requires knowledge of a wide range of techniques
and skills to avoid complications. Understanding of anatomy, combined with
practical training, is of fundamental importance. Adequate assessment and prior
reference will allow optimal choice of equipment and appropriate techniques.
Whether the aim is to ensure the patency of the airway or to aid ventilation, the
professional must remain calm, focused, and attentive, avoiding waste of valu-
able time and preventing the situation from becoming chaotic in the face of the
challenge. There must always be a clear strategy, with the necessary equipment
available and pretested.
Disclosure
Many devices for airway management have been developed in recent years.
Omission of any such device from this chapter does not imply that it might not be
useful in clinical management.
None of the authors has any conict of interest.
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R. Lima et al.
Bronchoscopy Before and After Tracheostomy
Marcus Antônio de Mello Borba, André Leonardo de
Castro Costa, Daniela Silva Santos, and Terence Pires de
Farias
Introduction
Bronchoscopy, or direct examination of the respiratory tract, has been developed
over time. The rst person to create an instrument for endoscopic use was Hippocrates,
in 400BC. The term endoscopy is derived from the Greek words endo (meaning
“in”) and scopia (meaning “look”). But it was only on March 30, 1897, in Freiburg,
Germany, that the physician Gustav Killian performed the rst, still rudimentary,
procedure of what was to be called direct bronchoscopy. Gustav Killian performed
removal of a foreign body through visualization of the right main bronchus, where a
solid body (bone) was identied using a Kirstein laryngoscope. Because of this,
Johann Gustav Killian is considered the “father” of bronchoscopy [1].
M.A. de MelloBorba, Ph.D. (*)
Faculty of Medicine, Department of Experimental Surgery and Surgical Specialties,
Federal University of Bahia, Salvador, BA, Brazil
Department of Head and Neck Surgery, Portuguese Hospital, Salvador, BA, Brazil
Department of Head and Neck Surgery, Aristides Maltez Hospital, Salvador, BA, Brazil
e-mail: marcusmelloborba@gmail.com; marcus.borba@ufba.br
A.L. de CastroCosta
Department of Head and Neck Surgery, Portuguese Hospital, Salvador, Bahia, Brazil
Department of Head and Neck Surgery, Aristides Maltez Hospital, Salvador, Bahia, Brazil
D.S. Santos, M.D.
Department of Head and Neck Surgery, Portuguese Hospital, Salvador, BA, Brazil
T.P. de Farias, M.D., Ph.D., M.Sc., Researcher.
Department of Head and Neck Surgery, Brazilian National Cancer Institute—INCA,
Rio de Janeiro, RJ, Brazil
Department of Head and Neck Surgery, Pontical Catholic University,
Rio de Janeiro, RJ, Brazil
© Springer International Publishing AG 2018
T.P. de Farias (ed.), Tracheostomy, https://doi.org/10.1007/978-3-319-67867-2_21
363
364
Fig. 1 Tracheal exposure in conventional tracheostomy. (Adapted from Cheung et al. [7], with
permission)
M.A. de Mello Borba et al.
Over time, new devices were developed and adapted, which facilitated direct visualization of the respiratory tract. As well, the technique has been rened and expanded.
An exponent of great importance for the development of the endoscopic technique
was the physician Chevalier Jackson, who was responsible for the creation of a school
and abundant literature on the subject. His rst book—Tracheobronchoscopy,
Esophagoscopy and Bronchoscopy—was published in 1907 and reissued in 1914,
detailing the necessary instruments, technique, and indications for the procedure [1].
Similarly, tracheostomy—a term of Greek origin meaning “to expose the trachea
to the outside”—is a procedure known about 3500years ago and also developed
over time [2]. This exposure is maintained through the use of cannulae or through
suturing of the tracheal wall to the skin, as in the case of denitive postlaryngectomy tracheostomy [3]. Currently, tracheostomy is one of the most common procedures in intensive care units (ICUs), being performed in about 20% of patients
receiving mechanical ventilation, and is widely recommended in patients with prolonged orotracheal intubation [4–6].
The communication generated by the tracheostomy with the external environment reduces anatomical dead space by up to 50%, ultimately facilitating pulmonary mechanics, and is therefore strongly indicated in the ICU setting to help
patients with reduced pulmonary reserve. It also reduces the discomfort of mechanical ventilation and facilitates weaning when it is no longer needed, in addition to
reducing the complications generated by prolonged intubation.
The disadvantages of tracheostomy include changes in respiratory and digestive
physiology, leading to tracheobronchial hypersecretion and difculty in swallowing, which may increase the risk of airway infection and bleeding.
Conventional tracheostomy, which is the object of detailed study elsewhere in
this publication, involves dissection of the pretracheal tissues and insertion of a
tracheostomy tube into the trachea under direct vision, according to the representation schematically summarized in Fig.1 [7].
In 1955, Shelden etal. described the rst percutaneous tracheostomy technique
[8]. Percutaneous tracheostomy emerged as an alternative, facilitating the procedure
at the bedside in intensive care, and being faster and less expensive, with low risk and
results similar to those obtained with the traditional technique [9]. Unlike conventional tracheostomy, the percutaneous procedure is often still performed “blindly.” It
consists of a technique in which the airway is punctured with passage of a guide wire,
tracheal dilation, and introduction of the tracheostomy cannula, as shown in Fig.2 [7].
Bronchoscopy Before and After Tracheostomy
Fig. 2
Percutaneous
dilation
tracheostomy.
(Adapted from
Cheung et al.
[7], with
permission)
Table 1 Frequent indications for bronchoscopy
Diagnostic indication Therapeutic indication
Chronic cough, hemoptysis, and dysphonia Guidance during percutaneous
tracheostomy
Endobronchial masses/biopsies Hemoptysis
Respiratory infection Cleaning of the tracheobronchial tree
Staging of lung and esophageal cancer Foreign body
Tracheoesophageal stula Dilatation of stenosis
Cervical and thoracic trauma Tracheobronchial tree prosthesis placement
Evaluation of chronic patients with tracheostomy Drainage of pulmonary abscesses
Persistent or recurrent atelectasis Difcult intubation and/or extubation failure
Foreign body Bronchopleural stula
Airway burn Brachytherapy
365
General Bronchoscopy Indications
The use of bronchoscopy in the medical environment is extremely relevant and
increasingly common. One proof of this is that in the USA, nearly 500,000 bronchoscopies are done each year [10].
Bronchoscopy is a fundamental technique in the study of respiratory diseases. It
provides direct visualization of the upper airways and initial divisions of the tracheobronchial tree, and allows samples to be removed from the trachea, bronchi,
mediastinum, and pulmonary parenchyma [11].
In a summary form, and only for didactic reasons, we can divide the indications
for performing bronchoscopy into diagnostic and therapeutic indications. We can
group the main indications as described in Table1 [1].