Tracheostomy class

TRACHEOSTOMY

Dr Tridip Dutta BaruahAsst Prof, General Surgery

MGMCRI, Pondicherry

TRACHEOSTOMY

Tracheostomy is a surgical procedure to create an opening through the neck into the trachea. A tube is placed through the opening to provide airway and to remove secretions from trachea and lungs.

Tracheotomy Indications (A) To bypass obstruction

Tracheotomy Indications(B) Prolonged intubation

Need for prolonged respiratory support, such as in Bronchopulmonary Dysplasia

To reduce anatomic dead space and increase the chance for mechanical ventilation withdrawal

To improve the patient`s quality of life (easier toilet, ability to speak and eat, increase the mobility)

Neuromuscular diseases paralyzing or weakening chest muscles and diaphragm

(C) Protection of Airway Neurological Diseases(Polyneuritis, GBS) Coma (GCS<8, risk of aspiration)

(D) Elective Tracheostomy as Adjunct to H&N surgeries <14 days on ETT(relative) >21 days on ETT

(E) Miscellaneous Congenital abnormalities. (Pierre Robin, Triecher Collins

syndromes)

Obstructive Sleep Apnea Syndrome.

Aspirations related to muscle or sensory problems.

Prophylaxis (as preparation for extensive H&N procedures, before radiotherapy for H&N CA)

Cervical spinal cord injuries with respiratory muscles paralysis.

Contraindications

No absolute contraindications exist to tracheostomy.

Relative contraindication is Laryngeal CA.

Anesthesia

General anesthesia is used, unless the situation is critical.

Local anesthesia with 2% lignocaine can be used in case of emergency.

Atropine is used to decrease secretions.

Pre Operative Informed consent explain about:

Operating procedures Loss of voices when tracheostomy canule still in the trachea Complication of operation

Should be done in the operating theatre as much as possible

Adequate lightning One assistant required Tracheostomy set

Cont’d Plastic or metal canule preparation Prophylactic antibiotic: Cefazolin. Anaesthetic preparation:

Local or general anasthesia local anasthesia with lidocain (max dose 7 mg/kgBW)

Patient’s position is supine with hyperextension of the head give a cushion below the shoulder trachea will be exposed to the anterior. Rest the head on a “doughnut” cushion

Types of Tracheostomy Tubes

Cuffed Tube with Disposable Inner CannulaUsed to obtain a closed circuit for ventilation

Cuffed Tube with Reusable Inner CannulaUsed to obtain a closed circuit for ventilation

Cuffless Tube with Disposable Inner CannulaUsed for patients with tracheal problems

Used for patients who are ready for decannulation

Cont’d

Cuffed Tube with Reusable Inner Cannula

Used for patients with tracheal problems

Used for patients who are ready for decannulation

Fenestrated Cuffed Tracheostomy TubeUsed for patients who are on the ventilator but are not able to tolerate a speaking valve to speak

Fenestrated Cuffless Tracheostomy TubeUsed for patients who have difficulty using a speaking valve

Cont’d

Not used as frequently anymore. Many of the patients who received a tracheostomy years ago still choose to continue using the metal tracheostomy tubes.

Metal Tracheostomy Tube

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Types of Tracheostomy

A) Open procedure a) High tracheostomy (Cricothyroidectomy) b) Low tracheostomy

B) Percutaneous procedure

Steps of Procedures1. Desinfection with povidone - iodine 10% (from lower lips

– chin – neck until ICS 2, left and right until the anterior border of trapezius muscle)

2. Operation area is narrowed by sterile linen3. Identification of trachea with palpation, starting from

thyroid cartilage to jugular notch4. Perform a local anasthesia with lidocain 1% or 2%

injection subcutaneously5. Vertical incision 3-4 cm (emergency case) or horizontal

or collar incision (elective case), incision is deepened by cutting subcutis, fascia of neck superficial at the midline on the incision site

Cont’d6. Hemostasis7. Put Langenbeck to the left and the right, balanced traction

to mantain trachea in the midline. 8. If the isthmus of the thyroid gland stand in the way, set

aside the isthmus to the caudal and hold it with blunt hook. 9. Identification of trachea, put sharp-one-tooth hook between

cricoid and 1st tracheal ring10.Tracheal ring was cut vertically using No. 11 knife blade with

a sharp edge facing up and direction of the incision to the cranial (2nd – 3rd ring for high tracheostomy; 4th – 5th ring for low tracheostomy)

Cont’d

11. Trachea maintained open with a blunt tooth hooks on the right and left side.

12. clean the existing secretions by using a suction cannula and alternating with oxygenation. Secretions were taken for culture and sensitivity test (for diphteria patients).

13. Insert the cannula tracheostomy carefully, at the time of inserting the tip, position of the axis perpendicular to the tracheal cannula, after entering surely turn the direction parallel to the axis of the trachea, proceed to thrust according the curve of cannula tracheostomy into the lumen of the trachea.

Cont’d14. check cannula into the lumen of the trachea, feel the breath of the hole cannula tracheostomy, or use the end of the string that vibrates at the blast of breath15. the whole latch is released, assistant hold the cannula, cannula is fixed with sutures at the right and left lobes of cannula to the skin of the neck and installing a ribbon strap around the neck.16. If the incision is too wide, skin is sutured loosely (don’t be too tight: can cause skin emphysem)17. Between cannula lobes and skin, put a sterile gauze cushion

Percutaneous Dilational Tracheostomy

elimination of need for operating room use or anesthesia.

significant reduction in cost.

Under fiber optic control

To be ready to switch to open procedure

PERCUTANEOUS DILATIONAL TRACHEOTOMY

Guidewire, guide catheter, and dilator unit are advanced together into the trachea to the skin positioning mark

PERCUTANEOUS DILATIONAL TRACHEOTOMY

The tracheotomy tube is loaded onto a dilator and advanced into the trachea over the guidewire and catheter. The guidewire and catheter are removed, leaving only the tracheostomy tube in the trachea

Post Operative Management Repeat X-Ray soft tissue neck,Strong Analgesia Antibiotics, IV fluid until able to tolerate orally Observation for the first 24 hours Treatment for primary disease Tracheostomy cannula management:

i. Suction of the secrete / hourii. Cleanse the smaller cannula / 6 hoursiii. Nebulizer with warm air for 15 minutes /6 hoursiv. Treat tracheostomy wound with gauze replacement every

treatment PCV check(pressure controlled ventilation)

Complications(A)Immediate Apnea due to loss of hypoxic respiratory drive. This is mainly

important in the awake patient. Ventilatory support must be available.

False track. Bleeding Pneumothorax or pneumomediastinum Damage to the vocal cords (direct) Injury to adjacent structures: recurrent laryngeal nerves, the

great vessels, and the esophagus. Post-obstructive pulmonary edema Hypotension Arrhythmia

Complications(B) Early Early bleeding: This is usually the result of increased blood

pressure as the patient emerges from anesthesia and begins to cough.

Plugging of the tube with mucus Tracheitis, Cellulitis Tube displacement Subcutaneous emphysema Atelectasis

Complications(C) Late Bleeding - tracheoinnominate fistula Tracheo- and laryngomalacia Stenosis Tracheoesophageal fistula Tracheocutaneous fistula Granulation Scarring Failure to decannulate

Post Procedure If the tracheostomy is temporary, the tube will eventually be

removed. Healing will occur quickly, leaving a minimal scar. Sometimes, a surgical procedure may be needed to close the

site (stoma). Occasionally a stricture, or tightening of the trachea may

develop, which may affect breathing. If the tracheostomy tube is permanent, the hole remains

open. Most people need 1 to 3 days to adapt to breathing through a

tracheostomy tube. It will take some time to learn how to communicate with

others.After training and practice, most people can learn to talk with a tracheostomy tube

Tracheostomy CareCaring for a tracheotomy includes suctioning to prevent occlusions and replacing tubes. Because of the lack of filtering and humidifying by the nose

and the ineffective cough mechanism, there is a buildup of secretions.

Suctioning is only performed when clinically necessary because there are many potential risks. The suction catheter is inserted no more than 1 cm past the length of the tube to avoid contact with tracheatissue. Suctioning is only done during withdrawing the catheter at least 1/2 inch.

Risks include hypoxia and so suctioning is limited to 10 to 20 seconds at a time and the patient is hyperoxygenated just before and after suctioning.

Risks also include atelectasis, or collapsing lung tissue from high suction pressure, and so pressure is limited to 80–120 mm Hg. Risks also include tissue damage.

Tracheostomy Care

Tube changes: Indications: soiled, cuff rupture. Complications: insertion into a false passage bleeding,

and patient discomfort. Avoid within 1st week. First tube change by surgeon. Difficult cases (obese, short and thick neck), be prepared

for endotracheal intubation.

Decanulation when?

Resolution of pathology that necessitated the tracheotomy (upper airway obstruction, pneumonia)

Normal protective laryngeal mechanisms (no aspirations during normal swallowing, good coughing)

No planned further interventions (radiotherapy, H&N operations)

No mechanical ventilation