TRACHEOSTOMY

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Presentation Description

brief description on tracheostomy, indications, complications, post-op care and tracheostomy tubes

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RAM NAIK. M 7 th Sem

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Tracheostomy and tracheotomy Anatomy of trachea Aims and Functions of tracheostomy Indications in adults, children and infants. Types Technique and steps in adults, children and infants Types of tracheostomy tubes Post-operative care Complications

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Tracheotomy: Operative procedure that creates an artificial opening in the trachea. Latin “trachea”(wind pipe) and “ tomein ” (to make an opening). Tracheostomy: Creation of permanent or semi permanent opening in the anterior wall of trachea and connecting to the exterior . It provides an alternative airway, bypassing the upper passages .

Anatomy of trachea:

Anatomy of trachea Fibromuscular tube supported by 20 hyaline cartilages which are opened posteriorly. The soft tissue posterior wall is in contact with the oesophagus. Trachea lies in midline of the neck extending from cricoid cartilage (C 6 ) superiorly to the tracheal bifurcation at the level of sternal angle (T 5 ) In adults it is 12-16 cm long and 13-16 mm wide in women and 16-20 mm wide in men Blood Supply: Primarily supplied by the bracheocephalic artery and through the inferior thyroid and bronchial arteries. Nerve Supply: Sympathetic fibres and Parasympathetic(Recurrent Laryngeal Nerve of Vagus )

Aims and functions of tracheostomy:

Aims and functions of tracheostomy Relief of upper air way obstruction Bronchial toilet Dead space reduced by 30- 50% Reduces air way resistance Protection against aspiration Assisted ventilation Administration of general anesthesia Administration of drugs, humidified oxygen

Indications in adults:

Indications in adults

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Congenital: Laryngeal webs, stenosis, cysts, Vallecula Trachea oesophageal anomalies Choanal atresia Tumors- hemangioma Neoplasms: Benign: Multiple papilloma of larynx Malignant: Tumors of tongue, pharynx Neurological: b/l laryngeal nerve palsy following thyroidectomy or idiopathic Bulbar palsy Traumatic: Blows, cut throat injuries, corrosives ingestion, foreign bodies, inhaling irritatant fumes&gases Infections: Diptheria , Ludwig’s angina. Laryngo -tracheal-bronchitis . Acute retropharungeal and Parapharyngeal abscess Acute epiglottitis Misc : Angioneuritic edema 1. Relief from upper airway obstruction :

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For pulmonary ventilation: Tracheostomy should be performed in a patient requiring ventilation through an endotracheal tube for more than one week Lung diseases: Pulmonary edema, COPD, Post-op pneumonia Chest injuries Operations involving chest wall Neurological incoordination Poly neuritis Polio myelitis Tetanus Motor neuron disease

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For pulmonary toilet: For those who cannot cough and clear their chest To prevent aspiration by low pressure-high volume cuff tracheostomy tube Bulbar poliomyelitis Tetanus Coma Head injuries- CVA Renal hepatic poisoning Cerebral tumors Poly neuritis Multiple facial fractures Elective procedures: For major head and neck surgeries.

Indications in infants and children:

Indications in infants and children Infants below 1year (mostly congenital lesions) Subglottic hemangioma Subglottic stenosis Laryngeal cyst Glottic web B/l vocal cord paraysis Children (inflammatory/traumatic) Epiglottitis Acute laryngo -trachea-bronchitis Diphtheria Laryngeal oedema External laryngeal trauma Proonged intubation Juvenile laryngeal papillomatosis

Types of tracheostomy:

Types of tracheostomy Mini tracheostomy- Cricothyroidotomy - for emergency procedures Percutaneous Dilatational Tracheostomy- done in ICU bedside procedure Depending on timing Elective/Tranquil/Orderly/routine tracheostomy Emergency tracheostomy Depending on cause Temporary Permanent Depending on site High Mid Low

TECHNIQUE :

TECHNIQUE Whenever possible, endotracheal intubation is done. ( esp in infants, children) Position: Patient lies supine with pillow under shoulders (so that neck is extended) This brings the trachea forwards. Anesthesia: Not necessary if unconscious or in emergency tracheostomy. If conscious, 1-2% lignocaine+epinephrine is infiltrated in line of incision and area of dissection Sometimes general anesthesia with intubation is used.

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POSITION OF THE PATIENT Shoulders elevated , neck extended Local infiltration in the Jackson's triangle

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Steps in adult tracheostomy

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Incision- Elective: Transverse incision in the midline of neck(extending from cricoid cartilage to sternal notch Emergency: Vertical incision 5cm long * 2fingers breadth above sternal notch. Tissues are dissected in midline. Dilated veins are displaced or ligated Strap muscles are separated in midline and retracted laterally Thyroid isthumus is displaced upwards or divided between the clamps, suture-ligated 4% lignocaine is injected into trachea to suppress cough Trachea is fixed with a hook and opened with vertical incision in 3 rd & 4 th or 3 rd & 2 nd rings Appropriate sized tracheostomy tube is inserted and secured by tapes Skin incision should not be sutured or packed tightly(risk of subcutaneous empysema ) Gauze dressing is placed b/w skin and flange of the tube around stoma

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Thyroid isthmus elevated; Pretracheal veins separated; Window excised in trachea

Surgical steps:

Surgical steps

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TRACHEOSTOMY TUBE INSERTED AND TIED IN PLACE WITH UMBILICAL TAPE, CUFF INFLATED AFTER INTRODUCTION

Paediatric tracheostomy:

Paediatric tracheostomy

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Always use a endotracheal tube or a bronchoscope prior to operation . Trachea of infant, childream is soft and compressable and its identification may be difficult May be easily displaced and may injure recurrent laryngeal nerve and even carotid Prefer general anesthesia Donot extend the neck too much It pulls structures from chest into neck. Thus injures pleura, innominate vessels, thymus Before incising the trachea, silk sutures are placed on either side of trachea Donot insert knife too deep. Tracheal lumen is small. May injure posterior tracheal wall or even oesophagus Trachea is simply incised, without excising a circular piece of tracheal wall Avoid infolding of anterior tracheal wall while inserting tracheostomy tube Selection of tube is important Long tube may impinge on the carina or right bronchus With high curvature, lower end may impinge on the anterior tracheal wall, while upper part compressed tracheal rings or cricoid Use a soft sialistic or portex tube Metallic tubes cause more trauma Take post-op X-ray of neck and chest To ascertain position of tracheostomy tube.

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Tracheostomy Tubes Tracheostomy tubes are available in a variety of sizes and styles, from several manufacturers. Dimensions of tracheostomy tubes are given by their inner diameter (ID), outer diameter (OD), length, and curvature. Tracheostomy tubes can be angled or curved, a feature that can be used to improve the fit of the tube in the trachea. Cuffs on tracheostomy tubes include high-volume low-pressure cuffs, tight-to shaft cuffs, and foam cuffs. Tracheostomy tubes which have an inner cannula are called dual cannula tracheostomy tubes.

Types of tracheostomy tubes:

Types of tracheostomy tubes Tracheostomy tubes can be of either metal or plastic. Metal tubes are constructed of silver or stainless steel. Metal tubes are not used commonly because they are → expenseive , → rigid construction → uncuffed → lack a 15 mm connector for attachment to a ventilator Plastic tubes are most commonly used and are made from polyvinyl chloride or silicone. Polyvinyl chloride softens at body temperature ( thermolabile ), conforming to patient’s tracheal anatomy and centering the distal tip in the trachea

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Synthetic Tubes

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Metal ( Silver) Tubes NEGUS TRACHEOSTOMY TUBE JACKSON’S METALLIC TRACHEOSTOMY TUBE FULLER’S BIFLANGED TRACHEOSTOMY TUBE EDINBURGH PATTERN TRACHEOSTOMY TUBE

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While selecting a tracheostomy tube, the ID and OD, its curvature and proximal and distal length must be considered . If the ID is too small, it will → increase the resistance through the tube, → make airway clearance difficult, → increase the cuff pressure required to create a seal If the OD is too large, → Difficulty in speech → difficult to pass through the stoma. → may not conform to the shape of the trachea, → compression of the membranous trachea,

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Tracheostomy tubes are available in standard length or extra length. Extra length tubes are constructed with either extra proximal length (horizontal extra length) or with extra distal length (vertical extra length) Extra proximal length facilitates tracheostomy tube placement in patients with a large neck ( eg , obese patients). Extra distal length facilitates placement in patients with tracheaomalacia or tracheal anomalies. Care must be taken to avoid inappropriate use of these tubes, which may induce distal obstruction of the tube

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Cuffed Tracheostomy tube Cuffed tracheostomy tubes → allow airway clearance, → protection from aspiration → positive pressure ventilation It is recommended that cuff pressure be maintained at 20–25 mmHg (25–35 cm H2O) to minimize the risks for both tracheal wall injury and aspiration.

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Fenestrated tracheostomy tubes The fenestrated tracheostomy tube is similar in construction to standard tracheostomy tubes, with the addition of an opening in the posterior portion of the tube above the cuff. With the inner cannula removed, the cuff deflated, and the tracheostomy air passage occluded, the patient can inhale and exhale through the fenestration and around the tube. This allows for assessment of the patient’s ability to breathe through the normal oral/nasal route → preparing the patient for decannulation → allowing phonation Supplemental oxygen administration to the upper airway ( eg , nasal cannula) may be necessary if the tube is capped.

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Anatomical positioning of a tracheostomy tube

Post-op care:

Post-op care Aseptic precautions, barrier nursing Tube position and patency checked regularly (prevents decubitus of trachea) Cuff should be deflated for 5min per 1hour (prevents tracheal stenosis) Inner tube care - Remove once or more daily and clean. Attention on crusts First change of tube is done only after tract formation(3 days) In emergency within 72hours .(neck extended and tube is changed with tracheal dilator) Subsequently, tube should be changed once 7days (prevent granulomas in stoma) Wound dressing is needed (prevents macerations from secretions and skin erosions from tube straps) Trachebronchial toilet (using suction tube with Y-connector) Antibiotics, analgesics, mucolytics

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COMPLICATIONS

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Risk factors for complications Age: infants and adults over 75 Obesity Smoking Poor nutrition Recent illness, especially an upper-respiratory infection Alcoholism Chronic illness Diabetes

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Peri -operative complications of tracheostomy Haemorrhage Surgical emphysema Pneumothorax Air embolism Cricoid cartilage damage Nerve damage

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Complications associated with tracheostomy tube placement Tracheal stenosis Ulceration Fibrosis Tracheo-malacia Loss of normal humidifying and warming mechanisms Loss of physiological peep Increased risk of nosocomial pneumonia

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Immediate Complications Apnea due to loss of hypoxic respiratory drive. This is mainly important in the awake patient. Ventilatory support must be available . 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

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Early Complications Early bleeding: d/t increased blood pressure as the patient emerges from anesthesia and begins to cough. Plugging with mucus Tracheitis Cellulitis Tube displacement Accidental decannulation Subcutaneous emphysema Atelectasis Dysphagea

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Late Complications Bleeding - tracheoinnominate fistula Tracheo - and laryngomalatia Stenosis Tracheoesophageal fistula Tracheocutaneous fistula Granulation Scarring Wound breakdown Aspiration of components of tracheostomy tube due to corrosion Failure to decannulate

Late Complications:

Late Complications

Wound breakdown :

Wound breakdown Common in ‘chubby’ babies with a short neck Avoid drag of ventilator tubing on trach tube Wound care

Suprastomal/Tracheal granuloma:

Suprastomal/Tracheal granuloma

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Other Methods Of Tracheostomy For Airway Management

Cricothyrotomy/mini tracheostomy :

Cricothyrotomy/mini tracheostomy Transverse incision over the cricothyroid membrane. Keep only for 3-5 days ANATOMY

Cricothyrotomy:

Cricothyrotomy

Cricothyrotomy:

Cricothyrotomy

Percutaneous tracheotomy:

Percutaneous tracheotomy ICU Bed Side Tracheostomy Should be done in carefully selected patients Use of guide wire and Dilators Under the vision of fibro optic Bronchoscope through endotracheal tube Less time , Less Expensive Not suitable for thick neck and in emergency To be ready to switch to open procedure

Cook Ciaglia percutaneous dilatational tracheostomy kit :

Cook Ciaglia percutaneous dilatational tracheostomy kit

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1cm transverse incision between 1 st and 3 rd tracheal rings Dissection of pretracheal tissue with curved artery forceps Trachea is reached 14 guaze iv canula with needles is inserted below 2 nd tracheal ring. (aspirated to confirm position) Needle is removed Sledinger guide wire is introduced through the canula Canula is removed 30F Teflon wire is passed over wire followed by 20F Once a asuitable stoma is created after dilating, a tracheostomy tube is advanced and guide wire with dilator is removed STEPS IN PDT

Surgical technique of percutaneous procedure:

Surgical technique of percutaneous procedure Guidewire introduction, with removal of sheath

Percutaneous dilatational tracheostomy:

Percutaneous dilatational tracheostomy 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 dilatational tracheostomy:

Percutaneous dilatational tracheostomy 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

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