composed

of cartilaginous and membranous portions, beginning with the cricoid cartilage, the first complete cartilaginous ring of the airway and consists of an anterior arch and a posterior broad-based plate
cartilages - articulate with the posterior cricoid plate

arytenoid

 vocal

cords - originate from the arytenoid cartilages and then attach to the thyroid cartilage space - the narrowest part of the

subglottic

trachea

internal diameter: approximately 2 cm begins at the inferior surface of the vocal cords and extends to the first tracheal ring
The

remainder of the distal trachea is 10.0 to 13.0 cm long, consists of 18 to 22 rings, and has an internal diameter of 2.3 cm.

 enters

the airway near the junction of the membranous and cartilaginous portions of the airway is segmental
each entering small branch supplies a segment of 1.0 to 2.0 cm, which limits circumferential mobilization to that same distance.

It

The

vessels are interconnected along the lateral surface of the trachea by an important longitudinal vascular anastomosis that feeds transverse segmental vessels to the soft tissues between the cartilages.

 The

arteries supplying the trachea

inferior thyroid Subclavian supreme intercostal internal thoracic innominate, and superior and middle bronchial arteries

 postintubation

injuries

Collectively termed tracheal injuries

Injury secondary to endotracheal intubation is most commonly the result of overinflation of the cuff

Although high-volume/low-pressure cuffs are now ubiquitous, they can easily be overinflated, and pressures can be generated that are high enough to cause ischemia of the contiguous airway wall. In some patients, periods of ischemia as short as 4 hours may be all that is required to induce an ischemic event significant enough to lead to scarring and stricture. With prolonged overinflation and consequent full-thickness destruction of the airway, fistula development between the innominate artery and esophagus may ensue.

 Tracheal

stenosis is nearly always iatrogenic.

secondary to either endotracheal intubation or tracheostomy due to scarring and local injury Factors associated with an increased risk of tracheal stenosis
incorrect placement of the tracheostomy through the first tracheal ring or the cricothyroid membrane where the airway is narrowest use of a large tracheostomy tube, and transverse incision on the trachea

 even

a properly placed tracheostomy can lead to tracheal stenosis secondary to scarring and local injury mild ulceration and stenosis frequently are seen after tracheostomy removal. The rate of stomal stenosis can be minimized by using the smallest tracheostomy tube possible and downsizing as soon as the patient will tolerate it, and by using a vertical tracheal incision without removing cartilage.

 primary

symptoms of tracheal stenosis:

stridor dyspnea on exertion

The length of time to onset of symptoms after extubation or after tracheostomy decannulation varies, usually ranging from 2 to 12 weeks; however, symptoms can appear immediately or as long as 1 to 2 years later.

Frequently, patients are misdiagnosed as having asthma or bronchitis, and treatment for such illnesses can persist for some time before the correct diagnosis is discovered.

 In

nearly all postintubation injuries the injury is transmural, and significant portions of the cartilaginous structural support are destroyed

 treatment

of tracheal stenosis: resection and primary anastomosis

ablation temporizing

laser

dilation

using a rigid bronchoscope - useful to gain immediate relief of dyspnea and to allow full assessment of the lesion in the early phase of evaluating patients if ever, is a tracheostomy necessary.

Rarely,

 internal

stents, typically silicone T tubes useful for patients who are not operative candidates due to associated comorbidities
mesh stents - should not be used, given their known propensity to erode through the wall of the airway of balloon dilation and tracheoplasty also has been described, although their efficacy is marginal

Wire

use

Most intubation injuries are located in the upper third of the trachea, so tracheal resection usually is done through a collar incision. Resection typically involves 2 to 4 cm of trachea for benign stenosis. However, a primary anastomosis can still be performed without undue tension, even if up to one half of the trachea needs to be resected. When resection for a postintubation injury is performed, it is critical to fully resect all inflamed and scarred tissue. Tracheostomies and stents are not required postoperatively, and the patient often is extubated in the operating room or shortly thereafter.

 TRACHEOINNOMINATE
two

ARTERY FISTULA

causes 1. too low a placement of the tracheostomy

Tracheostomies should be placed through the second to fourth tracheal rings without reference to the location of the sternal notch. When they are placed below the fourth tracheal ring, the inner curve of the tracheostomy cannula will be positioned to exert pressure on the upper surface of the innominate artery, which will lead to arterial erosion.

2. hyperinflation of the tracheal cuff

the tracheal cuff, when hyperinflated, will cause ischemic injury to the airway and subsequent erosion into the artery and fistula development. Most cuff-induced fistulas develop within 2 weeks after placement of the tracheostomy.

present with bleeding, although it usually is not massive, it must not be ignored or simply attributed to general airway irritation or wound bleeding With significant bleeding, the tracheostomy cuff can be hyperinflated to temporarily occlude the arterial injury.

If such an effort is unsuccessful, the tracheostomy

incision should immediately be opened widely and a finger inserted to compress the artery against the manubrium.

The patient can then be orally intubated, and the airway suctioned free of blood. Emergent surgical resection of the involved segment of artery is performed, usually without reconstruction.

occur primarily in patients with an indwelling nasogastric tube who are also receiving prolonged mechanical ventilatory support. Cuff compression of the membranous trachea against the nasogastric tube leads to airway and esophageal injury and fistula development. Clinically, saliva, gastric contents, or tube feeding contents are noted in the material suctioned from the airway. Distention of the stomach secondary to positive pressure ventilation can occur.

 Diagnosis

of a suspected TEF is by bronchoscopy.

of the endotracheal tube with the bronchoscope inserted allows the fistula at the cuff site to be seen. Alternatively, esophagoscopy will enable visualization of the cuff of the endotracheal tube in the esophagus.

Withdrawal

 TREATMENT:

requires weaning the patient from the ventilator and then extubating as soon as possible. During the weaning period, the nasogastric tube should be removed, with attention given to ensuring that the cuff of the endotracheal tube is placed below the fistula and that it is not overinflated. Then a gastrostomy tube should be placed for aspiration (to prevent reflux) and a jejunostomy tube for feeding. If aspiration is relentless and is not managed by the aforementioned steps, esophageal diversion with esophagostomy can be performed.

 Once

the patient is weaned from the ventilator, a single-stage operation should be done, consisting of:

tracheal resection and primary anastomosis

repair of the esophageal defect, and interposition of a muscle flap between the trachea and esophagus

 The

most common primary tracheal neoplasms (approximately 65%):

squamous cell carcinomas (related to smoking) and, adenoid cystic carcinomas

The remaining 35%

small cell carcinomas, mucoepidermoid carcinomas, adenocarcinomas, lymphomas, and others

 Primary

tracheal neoplasms are exceedingly

rare
diagnosis present

frequently is delayed

with cough, dyspnea, hemoptysis, stridor, or symptoms of invasion of contiguous structures (such as the recurrent laryngeal nerve or the esophagus)

 tracheal

stenosis: most common radiologic finding of tracheal malignancy is, but it is seen in only 50% of cases

 Squamous

cell carcinomas

often present with regional lymph node metastases frequently not resectable at the time of presentation biologic behavior is similar to that of squamous cell carcinomas of the lung

 Adenoid

cystic carcinomas

a type of salivary gland tumor generally slow growing, spread submucosally, and tend to infiltrate along nerve sheaths and within the tracheal wall Spread to regional lymph nodes can occur Although indolent in nature, they are malignant and can spread to the lungs and bones

 Evaluation

and treatment of patients with tracheal tumors should include

neck and chest computed tomography (CT) and Bronchoscopy

Rigid

bronchoscopy

permits general assessment of the airway and tumor allows dbridement or laser ablation of the tumor to provide relief of dyspnea

If the tumor is judged to be completely resectable, primary resection and anastomosis is the treatment of choice. The length limit of tracheal resection is roughly 50% of the trachea. To prevent tension on the anastomosis postoperatively, specialized maneuvers are necessary

anterolateral tracheal mobilization, suturing of the chin to the sternum with the head flexed forward for 7 days, laryngeal release, and right hilar release

For most tracheal resections (which involve much less than 50% of the airway), anterolateral tracheal mobilization and suturing of the chin to the sternum for 7 days are done routinely. Radiotherapy is frequently given postoperatively after resection of both adenoid cystic carcinomas and squamous cell carcinomas, due to their radiosensitivity. recurrent airway compromise, stenting or laser therapies should be considered part of the treatment algorithm.

For