Tracheostomy ppt

TRACHEOSTOMY

DR NEEMU HAGE

DEFINITIONTracheotomy Greek origin: ‘tom’- ‘to cut’ the

trachea Surgical opening of the trachea

Tracheostomy Greek origin: ‘stom’- ‘mouth’ Creation of a stoma between

trachea and cervical skin

HISTORY1st known reference- rig veda dated

2000 BC.Ebers papyrus (dated 1550 BC)-

Egyptian medical papyrus mentions tracheotomy

Alexander the GreatAntyllus (2 AD), Greek surgeon- performed tracheostomies in oral surgeriesTracheotomy well documented in Indian and Arabian literature in middle ages.

Tracheostomy gained popularity in 1800s

Two methods: High- by dividing cricoid Low- trachea entered directlySignificant problems associated with

high methodTill the end of 19th century

tracheostomy considered hazardousChevalier Jackson in 1923

established principles of tracheostomy

PHYSIOLOGICAL EFFECTS

Reduction in

respiratory dead space

Laryngeal bypass

Nasociliary clearance

and humidificat

ion lostRedundant

area between

stoma and larynx

Disruption of normal

swallowing mechanism

INDICATIONSUpper airway obstruction Congenital Laryngeal web/cysts, B/L choanal atresia,

Tracheo-esophageal fistula, Craniofacial anomalies, Subglottic/tracheal stenosis

Infective Acute epiglottitis, Diphtheria, Acute layngotracheobronchitis, Ludwig’s angina

Trauma External injury to larynx/trachea, maxillofacial injury, corrosive injury, inhalational injury

Neoplasm Tumours of larynx, pharynx, tongue, upper trachea

Foreign Body

Foreign body lodged in larynx

Vocal cords B/L abductor paralysis, Bulbar palsy

Removal of secretions and protection of tracheobronchial tree from aspiration

Neurological diseases- GBS, MS, Bulbar palsy

Coma- head injury, poisoning, tumour

In such situations- laryngeal/pharyngeal incompetence

Cuffed tube useful

Respiratory failure Tracheostomy- dead space, effort

of breathing, alveolar ventilation Ease of removal of secretions Pulmonary diseases- exacerbation of

chronic bronchitis, emphysema, severe pneumonia

Neurological diseases- MS, Motor neuron disease

Severe chest injury- flail chest

Prolonged ventilation T-tube more secure than ET tube;

easier to wean off vent >3wks of intubation length of ventilation and hospital

stay

As a part of another procedure Temporary tracheostomy in head

and neck surgeries

TYPESTEMPORARY/PERMANENT:Temporary tracheostomy- elective or

emergencyPermanent tracheostomy-as part of

operation involving removal of larynx

HIGH/MID/LOW: High- above isthmus via 1st tracheal

ring Mid- through 2nd-3rd tracheal ring,

preferred Low- below level of isthmus

PREOPERATIVE ASSESSMENT

Informed consent Coagulation profile adequate,

platelet count >50000/cumm Neck examination- to anticipate

difficulties in procedure as in enlarged thyroid, limited neck extension.

T-tube arranged, checked and prepared

Surgical tracheostomyMinitracheostomy Paediatric tracheostomyPercutaneous dilatational

tracheostomy

SURGICAL TRACHEOSTOMY

COMPLICATIONS Immediate Haemorrhage Local injury-cricoid cartilage, 1st tracheal ring, carotid artery recurrent laryngeal nerveAir embolismApnoeaCardiac arrest

Intermediate (1st few hours or days) Secondary haemorrhage

Tube displacement Tube blockage Subcutaneous emphysema Pneumothorax

InfectionTracheal necrosisLate complicationsHaemorrhageGranuloma formationTracheo-oesophageal fistulaTracheo-cutaneous fistulaLaryngotracheal stenosisDifficult decannulationTracheostomy scar

MINITRACHEOSTOMY OR CRICOTHYROTOMY

Procedure for opening airway through cricothyroid membrane

Minitracheostomy kits commercially available

PAEDIATRIC TRACHEOSTOMY

Anatomy of paediatric upper airway different from adults

Age of child critical when deciding appropriate size of tube

Standard of paediatric intensive care facilities have improved in last 2 decades

Reduced rate of tracheostomy in paediatric population

Speech development may be impaired in long term tracheostomies

INDICATIONSUpper airway obtruction

Oropharynx, Tongue base

Macroglossia, Treacher Collins syndrome, Goldenhar syndrome, Cystic hygroma, Diphtheria

Nose, Nasopharynx

B/L choanal atresia

Supraglottis Supraglottic cyst, Acute Epiglottitis Glottis Vocal cord palsy, Laryngeal oedema,

Physical trauma, Juvenile respiratoty papillomatosis

Subglottis Subglottic stenosis, Hemangioma Trachea Acute laryngotracheobronchitis,

Tracheomalacia, Tracheal stenosis

Prolonged intubation Indicated for patients requiring long term

PPV such as- PT neonate, CNS disease, severe burns

Long term intubation leads to complications and difficult decannulation

>3 weeks of intubation

Pulmonary toilet For intractable aspiration- decreases dead

space and eases work of pulmonary toilet

ANATOMICAL CONSIDERATIONS IN PAEDIATRIC TRACHEOSTOMY

Structures lie higher up

Soft and compressible airway

Structures from superior mediastinum pulled up during extension of neck

Small tracheal lumen Trachea, a

developing structure Funnel shaped larynx

with narrowest part being subglottis

TECHNIQUE

TRACHEOSTOMY CARESuction Regular suctioning Frequency depends on individual basis Indications Appropriate size of Suction catheter Method

Humidification Upper respiratory tract

bypassed, conditioning of inspired gas lost

Different preferences in diffirent set ups

Types: -cold water humidifiers -hot water humidifiers

-heat and moisture exchangers

-stoma protector Nebulization

Tracheostomy tube change 1st tube change- 5-7 days Frequency of tube change- no

standard interval ‘if you can hear a tube, you should

change it’ Bougies or guidewires

Wound care

TYPES OF TRACHEOSTOMY TUBES

cuffed or uncuffed

Single or double lumen tubes

Adjustable flange long tubeSuction aid tracheostomy tube

Tracheostomy with speaking valve

Types of tubes based on material: PVC Silicone Siliconed PVC Silastic Silver Armoured Fullers tube

PERCUTANEOUS DILATATIONAL TRACHEOSTOMY

1st described by Shelden & Pudenz (1957) Tracheostomy: Indications & complications Contraindications: Absolute: -cervical injury -coagulopathy -emergency airway Relative : -short fat neck/obesity -enlarged thyroid -inability to extend neck (cervical injury/prior tracheostomy)

DECANNULATIONConsidered when original condition

requiring tracheostomy has improved

Approached in a step-wise manner In paediatric group endoscopic

assessment prior to decannulation essential

Fenestrated tube> occlusion cap> occlusion cap for 12 hrs > 24 hrs>decannulation

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