Tracheostomy

TRACHEOSTOMYTRACHEOSTOMY

HistoryHistory

Tracheostomy is one of the oldest surgical Tracheostomy is one of the oldest surgical procedures. procedures.

A tracheotomy was portrayed on Egyptian A tracheotomy was portrayed on Egyptian tablets dated back to 3600 BC. tablets dated back to 3600 BC.

Asclepiades of Persia is credited as the first Asclepiades of Persia is credited as the first person to perform a tracheotomy in 100 BC. person to perform a tracheotomy in 100 BC.

The first successful tracheostomy was The first successful tracheostomy was performed by Brasovala in the 15th performed by Brasovala in the 15th

century.century.  

TracheostomyTracheostomy History and indications History and indications

1932 prevent pulmonary infection in 1932 prevent pulmonary infection in neurologically impair patients secondary to neurologically impair patients secondary to infections (poliomyelitis).infections (poliomyelitis).

1943 remove bronchial secretions in cases of 1943 remove bronchial secretions in cases of myasthenia gravis and tetanus.myasthenia gravis and tetanus.

1951 reduce the volume of dead space, use in 1951 reduce the volume of dead space, use in COPD and severe penumonia.COPD and severe penumonia.

1950 positive pressure through tracheostomy 1950 positive pressure through tracheostomy for patients with poliomyelitis.for patients with poliomyelitis.

1955 obstruction secondary to infection: 1955 obstruction secondary to infection: diphteria, Ludwig’s angina.diphteria, Ludwig’s angina.

1961 Obstructions secondary to tumour, 1961 Obstructions secondary to tumour, infectious disease and trauma.infectious disease and trauma.

INDICATIONS FOR TRACHEOSTOMYINDICATIONS FOR TRACHEOSTOMY

Prolonged intubation

Facilitation of ventilation support

Inability of patient to manage secretions

Upper airway obstruction

Inability to intubate

Adjunct to major head and neck surgery

Adjunct to management of major head and neck trauma

Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.2005.

Goldenberg D, et al Tracheotomy: changing indications and a review of 1,130 cases, J Otolaryngol 31:211–215, 2002

INDICATIONS FOR TRACHEOSTOMYINDICATIONS FOR TRACHEOSTOMY

The Lindholm Scale of Laryngotracheal Damage

Grade I erythema and edema without ulceration

Grade II superficial ulceration of the mucosa <1/3 airway circumference

Grade III continuous deep ulceration <1/3 airway circumference or superficial ulceration >1/3 airway circumference

Grade IV deep ulceration with exposed cartilage.

TRACHEOSTOMY VS TRANSLARYNGEAL TRACHEOSTOMY VS TRANSLARYNGEAL INTUBATIONINTUBATION

– Increased patient mobilityIncreased patient mobility– More secure airwayMore secure airway– Increased comfortIncreased comfort– Improved airway suctioningImproved airway suctioning– Early transfer of ventilator-dependent patients Early transfer of ventilator-dependent patients

from the intensive care unit (ICU)from the intensive care unit (ICU)– Less direct endolaryngeal injuryLess direct endolaryngeal injury– Enhanced oral nutritionEnhanced oral nutrition– Enhanced phonation and communicationEnhanced phonation and communication– Decreased airway resistance for promoting Decreased airway resistance for promoting

weaning from mechanical ventilationweaning from mechanical ventilation– Decreased risk for nosocomial pneumonia in Decreased risk for nosocomial pneumonia in

patient subgroupspatient subgroups

Heffner, Hess.Clinics in Chest Medicine 22 , 2001.

Incision 1 cm below the cricoid or halfway between the cricoid and the sternal notch.

Retractors are placed, the skin is retracted, and the strap muscles are visualized in the midline. The muscles are divided along the raphe, then retracted laterally

The thyroid isthmus lies in the field of the dissection.Typically, the isthmus is 5 to 10 mm in its vertical dimension, mobilize it away from the trachea and retract it, then place the tracheal incision in the second or third tracheal interspace

Shiley Shiley tracheostomy tracheostomy tube: #6tube: #6

Shiley Shiley tracheostomy tracheostomy tube: #8 for tube: #8 for bronchoscopy.bronchoscopy.

TRACHEOSTOMY TUBE CARETRACHEOSTOMY TUBE CARE

Securing tracheostomy Securing tracheostomy around patient’s neck.around patient’s neck.

TRACHEOSTOMY TRACHEOSTOMY

TUBE CARETUBE CARE Tube changes: Tube changes:

– Indications: soiled, cuff rupture.Indications: soiled, cuff rupture.– Complications: insertion into a false Complications: insertion into a false

passage bleeding, and patient passage bleeding, and patient discomfort.discomfort.

– Avoid within 1Avoid within 1stst week. week.– First tube change by surgeon.First tube change by surgeon.– Difficult cases (obese, short and thick Difficult cases (obese, short and thick

neck), be prepared for endotracheal neck), be prepared for endotracheal intubation.intubation.

TRACHEOSTOMY TUBE CARETRACHEOSTOMY TUBE CARE

TracheostomyTracheostomy tube cuff pressures in a range of 20 to tube cuff pressures in a range of 20 to 25 mm Hg. 25 mm Hg.

Overly low cuff pressures < 18 mm Hg, may cause the Overly low cuff pressures < 18 mm Hg, may cause the cuff to develop longitudinal folds, promote cuff to develop longitudinal folds, promote microaspiration of secretions collected above the cuff, microaspiration of secretions collected above the cuff, and increase the risk for nosocomial pneumonia.and increase the risk for nosocomial pneumonia.

Excessively high cuff pressures above 25 to 35 mm Hg Excessively high cuff pressures above 25 to 35 mm Hg exceed capillary perfusion pressure and can result in exceed capillary perfusion pressure and can result in compression of mucosal capillaries, which promotes compression of mucosal capillaries, which promotes mucosal ischemia and tracheal stenosis.mucosal ischemia and tracheal stenosis.

Cuff pressure should be measured with calibrated Cuff pressure should be measured with calibrated devices and recorded at least once every nursing shift devices and recorded at least once every nursing shift and after every manipulation of the and after every manipulation of the tracheostomytracheostomy tube.tube.

TRACHEOSTOMY TUBE CARETRACHEOSTOMY TUBE CARE

Chest Xray: Chest Xray:

cuff has a width cuff has a width greater than the greater than the caliber of the caliber of the trachea, which trachea, which suggests the suggests the presence of a presence of a hyperinflated cuff hyperinflated cuff and tracheal and tracheal

overdistentionoverdistention Heffner, Hess.Clinics in Chest Medicine 22 , 2001.

TRACHEOSTOMY TUBE TRACHEOSTOMY TUBE CARECARE

Humidification of the inspired gas Humidification of the inspired gas is a standard of care for is a standard of care for tracheostomized patients. tracheostomized patients.

Thermovent

•  Secretions in the trach •  Suspected aspiration of gastric or upper airway secretions •  Increase in peak airway pressures when on ventilator •  Increase in respirations or sustained cough or both •  Gradual or sudden decrease in ABG •  Sudden onset of respiratory distress when airway patency is questioned

Indications For Suctioning

Tracheostomies should Tracheostomies should be suctioned whenever be suctioned whenever physical physical examination reveals the examination reveals the presence of secretionspresence of secretions

CLEARANCE OF SECRETIONSCLEARANCE OF SECRETIONS

SPEECHSPEECH

SPEECHSPEECH

Tracheostomy Speaking Valve

Passy-Muir

A tracheostomy speaking valve is a one-way valve, allows air in, but not outforces air around the tracheostomy tube, through the vocal cords and out the mouth upon expiration, enabling the patient to vocalize

NUTRITIONNUTRITION

Tracheostomy tube prevents normal Tracheostomy tube prevents normal upward movement of the larynx during upward movement of the larynx during swallowing and hinders glottic closure.swallowing and hinders glottic closure.

Between 20% and 70% of patients with Between 20% and 70% of patients with a chronic a chronic tracheostomytracheostomy experience experience at least one episode of aspiration at least one episode of aspiration every 48 hours every 48 hours

Evaluation by speech therapistEvaluation by speech therapist Keep head elevated to 45° during Keep head elevated to 45° during

periods of tube feeding periods of tube feeding

Heffner, Hess.Clinics in Chest Medicine 22 , 2001.

WEANING FROM WEANING FROM

TRACHEOSTOMYTRACHEOSTOMY Demonstrate stability for 24 to 48 hours Demonstrate stability for 24 to 48 hours

after discontinuation of mechanical after discontinuation of mechanical ventilation. ventilation.

Tracheostomy stomas can narrow Tracheostomy stomas can narrow markedly or close within 48 to 72 hours markedly or close within 48 to 72 hours after tube removal. after tube removal.

Deflating the tracheostomy cuff and Deflating the tracheostomy cuff and capping the tube. capping the tube.

WEANING FROM WEANING FROM

TRACHEOTOMYTRACHEOTOMY The ability to breath and clear airway The ability to breath and clear airway

secretions around a small, capped tube secretions around a small, capped tube signifies readiness for decannulation signifies readiness for decannulation

Patients who fail breathing trials with Patients who fail breathing trials with capped tracheostomy tubes should be capped tracheostomy tubes should be evaluated by flexible fiberoptic endoscopy evaluated by flexible fiberoptic endoscopy for evidence of airway lesions and for evidence of airway lesions and adequacy of airway function. adequacy of airway function.

Complications of Complications of TracheostomyTracheostomy

Complications 5-40%Complications 5-40% Mortality <2%Mortality <2% Complications are more frequent Complications are more frequent

in emergency situations, severely in emergency situations, severely ill patients and small children.ill patients and small children.

Complications of Complications of TracheostomyTracheostomy

– StomaStoma Stoma site infectionStoma site infection Stomal hemorrhageStomal hemorrhage Poor stoma healing after Poor stoma healing after

decannulation with scar, decannulation with scar, keloid, or tracheocutaneous keloid, or tracheocutaneous fistulafistula

Complications of Complications of TracheostomyTracheostomy

– TracheaTracheaGranulomaGranulomaTracheoesophageal fistulaTracheoesophageal fistula

fewer than 1% of patients as a result of fewer than 1% of patients as a result of pressure necrosis of the tracheal and pressure necrosis of the tracheal and esophageal mucosa from the tube cuff esophageal mucosa from the tube cuff

risks: high cuff pressures, presence of a risks: high cuff pressures, presence of a nasogastric tube, excessive tube nasogastric tube, excessive tube movement, and underlying diabetes movement, and underlying diabetes mellitus mellitus

Complications of Complications of TracheostomyTracheostomy

Tracheoinnominate fistula:Tracheoinnominate fistula: 0.4% with mortality rate of 85% to 90%.0.4% with mortality rate of 85% to 90%.Major airway hemorrhage may occur first within Major airway hemorrhage may occur first within several days or as long as 7 months after several days or as long as 7 months after performance of a tracheostomy. performance of a tracheostomy. Risk factors : excessive tube movement, low Risk factors : excessive tube movement, low placement of the tracheostomy, sepsis, poor placement of the tracheostomy, sepsis, poor nutritional status, and corticosteroid therapy nutritional status, and corticosteroid therapy

Tracheal stenosis:Tracheal stenosis:can develop from 1 to 6 months after decannulation can develop from 1 to 6 months after decannulation risk for tracheal stenosis ranges between 0% and risk for tracheal stenosis ranges between 0% and 16% 16%

TracheomalaciaTracheomalacia

CONCLUSIONCONCLUSION

The most common indications for The most common indications for tracheostomy is mechanical ventilation tracheostomy is mechanical ventilation with prolonged tracheal intubation.with prolonged tracheal intubation.

Tracheostomy: emergency and Tracheostomy: emergency and elective, improve quality of life.elective, improve quality of life.

Meticulous surgical technique.Meticulous surgical technique. Appropriate postoperative Appropriate postoperative

tracheostomy care to reduce tracheostomy care to reduce complications.complications.

Guidewire and catheter are advanced together into the trachea as far as the skin positioning marks on the guide catheter to the skin.[

Guidewire introduction, with removal of sheath

PERCUTANEOUS DILATIONAL TRACHEOTOMY

PERCUTANEOUS DILATIONAL PERCUTANEOUS DILATIONAL TRACHEOTOMYTRACHEOTOMY

Guidewire and catheter are advanced together into the trachea as far as the skin positioning marks on the guide catheter to the skin

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

PERCUTANEOUS DILATIONAL PERCUTANEOUS DILATIONAL TRACHEOTOMYTRACHEOTOMY

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

PERCUTANEOUS PERCUTANEOUS DILATIONAL DILATIONAL TRACHEOTOMYTRACHEOTOMY

Cook Ciaglia percutaneous dilatational tracheostomy kit

TRACHEOSTOMY TUBE CARETRACHEOSTOMY TUBE CARE

Securing tracheostomy around patient’s Securing tracheostomy around patient’s neck.neck.

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

passage bleeding, and patient discomfort.passage bleeding, and patient discomfort.– Avoid within 1Avoid within 1stst week. week.– First tube change by surgeon.First tube change by surgeon.– Difficult cases (obese, short and thick neck), Difficult cases (obese, short and thick neck),

be prepared for endotracheal intubation.be prepared for endotracheal intubation.

TRACHEOTOMYTRACHEOTOMY