Tracheostomy

Considerations

Preparation

• • Communication is critical - with your anesthesiologist, your assistant, your tech, and your circulator 

  • Setup is critical

    • Mayo - Lay out all the planned instruments for the tech, keep the backup instruments nearby on the back table

• • In case of suspected difficult airway

    1. Laryngoscopy tray 

       1. Make sure you have the correct light cord

       2. Jackson sliding laryngoscope 

       3. Dedo laryngoscope 

    2. Rigid Bronchoscopy tray

• • • 1. Make sure Hopkins rod is in the set

• • 3. Rigid bronchoscopes

• • • 1. Storz bronchoscopes (2): adult (6.5 & 7.5 x 43 cm; 8.5 available but in separate location), adolescent (5.0 & 6.0 diameter x 40 cm)

         1. If you can, try to use at least a 6.5 bronchoscope, because your optics will be much better (with the corresponding 5.5 mm telescope); if you need to use a 6.0 or smaller bronchoscope, you will unfortunately be forced to use a 2.8 mm telescope

      2. Adult Pilling bronchoscope (7.0 & 8.0 diameter x 40 cm)

• • • • 1. Mostly used for airway dilatations

        2. Key maneuver: At level of vocal cords, rotate bronchoscope clockwise 90 degrees, so that longer edge of bevel is on the right.  Advance scope w/ bevel tip in center of larynx and shorter edge of bevel sliding against left cord, to avoid catching and traumatizing right cord with bevel tip

        3. Two methods to place rigid bronchoscope: 1) Directly.  2) Use Jackson sliding or anesthesia laryngoscopes to guide bronchoscope to level of vocal cords

        4. Sample rigid bronchoscope:

        5. Single combo unit with eyepiece, rubber telescope adaptor, and suction port. Dr. Funk does not like this and uses the smaller individual unit

           1. A. (Direct view) Bridge adaptor for endoscope vs. glass eyepiece vs. rubber telescope adaptor (for quick transfer b/w endoscope & optical forceps)

           2. B. (Top) Prism with connection to light cable

           3. C. (Oblique) Instrument guide for flexible suction catheter vs. jet ventilation cannula (though we usually don’t jet through bronchs)

           4. D. (Bottom) Adaptor for respirator

• • • 3. It is important to note that there are 2 different proximal jet cannulas (adaptors that connect the laryngoscope to the jet ventilator), one for the Dedo laryngoscope and one for the Kleinsasser laryngoscope

      4. If the one you are given doesn’t seem to fit, ask for the other one!Picture (below, left) shows a Kleinsasser laryngoscope with (A) = light source adaptor and (B) = jet ventilation.  Note that the jet ventilation always goes off to the right because it always goes towards the side that anesthesia is on.