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Tracheotomy

Dr J A Anderson MD MSc. FRCS(C)Chief Department of Otolaryngology HNS

St Michael’s HospitalUniversity of TorontoPOS November 2012

Tracheotomy

Indications Technique

Open and percutaneous Complications Physiology of a tracheotomy Troubleshooting Decannulation

Tracheotomy

Creation of communication between the trachea and the cervical skin with insertion of a tube

Indications

Airway obstruction Pulmonary Secretions Ventilation Prolonged mechanical ventilation

May assist in weaning from mechanical ventilation

Prevention of glottic stenosis/complication of prolonged ett

Fixed Airway Obstruction

Tumours of upper aero digestive tract Chronic airway obstruction up to 80% lumen

External compression by tumour Anaplastic thyroid, massive lymphadenopathy

Foreign Body Glottic Stenosis/tracheal stenosis Trauma upper airway

Non-Fixed Airway Obstruction

Trauma Expanding neck hematoma Maxillofacial trauma Laryngeal fracture

Inflammatory Inhalation injury Anaphylaxis Epiglottitis Ludwig’s Angina/Deep Neck space infection

Bilateral vocal cord paralysis

Fiberoptic Intubation can be successful

Pulmonary Secretion Clearance

Aspiration / dysphagia COPD Bronchiectesis Stasis of secretions

Poor cough Poor respiratory reserve

Ventilation Neuromuscular disorder affecting respiratory

muscles Reduced respiratory effort

Limited pulmonary reserve COPD, Scoliosis, bronchiectesis

Central respiratory depression Reduced LOC

Severe obstructive sleep apnea Cor pulmonale, failure CPAP

Prolonged Intubation

7-10 days ett Risk Factors for Glottic

Stenosis Diabetes Female Size ETT and # ett Hemodynamic

instability Incidence glottic

stenosis: 5% over 10 days (Whited 1984)

Example 1 Subglottic Stenosis

Example 3Combined Glottic/Tracheal Stenosis

Prolonged Intubation

Weaning from ventilator Relative indication for tracheotomy Modest gains in respiratory function after

tracheotomy may be enough to increase chance of successful weaning from ventilator

Trend of patients ventilator requirements 5 day reversibility of common ICU admitting

diagnoses

Tracheotomy

Decision made patient requires tracheotomy Open or percutaneous technique 75% of tracheotomies done at SMH are done

percutaneously in ICU at bedside Variations of open tracheotomy technique General principles are the same

External approach through neck soft tissue Creation of opening in trachea Placement of tube to maintain airway

Technique

Diagrams from Lore, Surgical Atlas 1988

Equipment

Tracheotomy set Right angles, cricoid hook, trach spreader

Tracheotomy tube Shiley most common Select size (6, 8 most common) Cuffed non-fenestrated for most ICU patients Fenestrated if voicing expected (use non-fen

inner cannula during procedure)

Open Tracheotomy

1. Position the patient Neck extended Roll under shoulders Arms tucked On OR bed

2. Palpate landmarks

3. Transverse incision half way between cricoid and sternal notch

4. Retraction

5. Divide strap muscles in midline

Technique

Diagrams from Lore, Surgical Atlas 1988

Technique cont’d

6. Thyroid isthmus

7. Divide or retract

8. Identify cricoid and upper tracheal rings using blunt dissection

9. Blunt cricoid hook helpful

10. Retract cricoid in superior direction

10. Tracheotomy tube cuff checked and obturator in

11. Deflate cuff of endotracheal tube

12. Horizontal incision between tracheal rings (below the second ring)

13. Suction lumen if necessary

14. Spread rings apart with spreader or scissors

Technique 2

DO NOT use cautery on the trachea

FIRE!

Technique 3

Technique

15. Endotracheal tube withdrawn until just above the open tracheal site

16. Tracheotomy tube with obturator, pushed into mid lumen of trachea, then directed inferiorly

17. Obturator withdrawn and inner cannula placed

18. Anaesthetic connector tubing passed over and connected

19. Cuff inflated

20. DO NOT LET GO OF THE TUBE

Final

21. Anaesthesia: Check CO2, good breath sounds

22. Sew in the trach tube shield to skin

23. Loosely approximate incision

24. Trach ties

Contraindications

Medically well enough for GA PEEP < 20 mm Hg Uncontrolled coagulopathy Airway pathology below tracheotomy site

Percutaneous Tracheotomy

Bedside tracheotomy in ICU patients An alternative not replacement for open trach General anaesthesia and paralysis for procedure Fiberoptic broncoscopic guidance Ciaglia ‘Blue Rhino” by Cooke $200 Bronchoscopic guidance Experienced personnel

Anaesthesia Respiratory therapist Surgeon

Selection of Patients

Must be able to palpate landmarks adequately

Cricoid above sternal notch Low larynx/cricoid

High innominate artery problematic

PEEP > 20 contraindication

AdvantagesAdvantages Smaller wound, less

dissection ICU setting Set uptime 20 minutes Procedures time less

than 10 minutes

Percutaneous Tracheotomy

DisadvantagesDisadvantages Not for everyone Must ventilate with ETT in high position

Maybe an air leak during procedure Must use Shiley tube Experienced personnel Contraindications same as open and

Anatomic limitations

Technique

1. Identify landmarks

2. Local anaesthetic

3. Small incision midline

4. ETT moved superiorly until cuff at cords

5. Bronchoscope with connector in ETT

6. Needle in midline into trachea

8. Guide wire passed inferiorly

9. Small calibre dilator

10. Wire sheath and ‘blue rhino’ dilator pushed along wire into trachea

11. Trach tube with fitted introducer passed over wire into trachea

Video Percutaneous Tracheotomy

Tracheotomy Tubes

Portex and Shiley common brands of trach tubes.

Shiley used as standard tube at St Michael’s Hospital.

Tracheotomy Tubes

Tracheotomy Tubes

Bivona or foam cuff Tracoe Cuffless

Speaking valve

Complications: Intraoperative

Bleeding 2.8%* Recurrent laryngeal nerve injury Tracheoesophageal fistula Pneumothorax: rare False passage

Anterior dissection most common Incidence <1%

*Kost et al 1994

Odd Things That Can Happen

Trach tube place upside down No CO2 tracing despite surgeon positive tube is in the

airway Cut the pilot tube of the cuff while cutting the sutures Trach tube coughed across table after correct

placement Difficulty with air leak

Cuff leak/tube too short or not large enough /position tube

Blocked tube secondary to secretions/blood

Tracheotomy: Early Complications

Bleeding Minor common Major tracheoinnominate fistula (<0.2%)*

Obstruction of tube (2.5%)* Dislodgement (1.4%)* Pneumothorax (1 - 2.5%)* Wound Infection

Local care, antibiotics (staph/pseudomonas)

Late Complications

Tracheal stenosis Tracheal chondritis Subglottis stenosis- high tracheotomy Tracheomalacia Tracheoesophageal fistula Failure of stoma closure when decannulated

Overall complication rate 15-30% in ICU patients largely minor with no long term morbidity

Tracheoinnominate Fistula

More than 10 days post tracheotomy (as early as 5 days)

Sentinel bleed Angiogram/CTA for diagnosis Surgical exploration Interventional radiology-stent Associated with low tracheotomy placement,

wound infection or aberrant artery

Late Complications/Stoma

Minor amount of bleeding common due to granulation tissue /dry mucosa

Stoma and Inferior View Vocal Folds

Physiology of Tracheotomy

Neck breathing Bypass upper airway and nasal function Loss of humidification/heat airflow Dryness, thick secretions Voicing possible with speaking valve Loss of smell /reduced taste Loss glottic closure function for cough

Physiology of Tracheotomy Respiration

AdvantagesAdvantages Lower work of breathing (30%) c/w normal airway Facilitates secretion clearance

Aspiration or thick secretions Less dead space (100 mL) Reduced airway resistance Assists in patient independence from mechanical

ventilation Patient comfort (better than ett)

Epstein 2005 Respiratory Care

Physiology of Tracheotomy Respiration

Disadvantages Tube diameter and shape

increases turbulent airflow, secretions adhere inside tube Loss of humidification/heat function of upper airway

Ciliary function affected Biofilm colonization

Diminish cough/loss glottic closure Reduce laryngeal elevation during swallow Patient comfort (better no tube at all)

Dysphagia

Common issue in neurological impaired pt Tube required for secretion management

particularly in patient with florid aspirate Tube presence associated with limitation of

the cephalad excursion of larynx during swallow and can contribute to dysphagia/aspiration

Endoscopic / fluoroscopic assessment

Speech Therapy assessment!Speech Therapy assessment!

Postoperative Tracheotomy Care

Humidification via trach mask/Instill saline Clear secretions, prevent crust Inner cannula cleaning tid at least If non-ventilated, change cuffed tube to non-

cuffed at 5-7 days Ties changed 2 people if possible Most hospital have nursing/RT protocol Teach everyone trach care including patient,

family

Inner Cannula Care

Frequently done tid or more Saline and hydrogen peroxide (1:1) and trach

brush Rinse with sterile water/saline and reinsert Spare inner cannula and store in clean

covered container Ties should be one finger tight and square

knot

Respiratory Therapy Protocol SMH

Troubleshooting Dislodgement

Causes Ties too loose Cough cuff deflated tube too short/wrong size for patient

Clinical signs Difficulty in ventilating patient Increased airway pressure Suction catheter obstructed Non Ventilated Patient

Poor cough Sudden voice change Stridor, SOB Suction catheter blocked

What to do: Dislodgement

Extend neck Remove inner cannula Use obturator to redirect tracheotomy tube

into lumen If patient in distress and does not have fixed If patient in distress and does not have fixed

obstruction above, pull out trach tubeobstruction above, pull out trach tube Ventilate with mask/intubate Use flex bronchoscope or replace/OR

Troubleshooting Tube Obstructed

Mucous plug or blood clot most likely Granulation tissue, particularly fenestrated

tubes Remove inner cannula, suction, instill saline Bronchoscopy If no other recourse, pull out trach tube and if

necessary, replace new tube with obturator Intubate/ventilate from above

Troubleshooting: Bleeding

Bleeding aroundaround trach stoma Minor bleeding immediately

post-op Moderate bleeding/venous

oozing often related to thyroid Examine wound

Pack, surgicel, if not controlled, take back to OR

Bleeding from withinwithin lumen Often related to suctioning Broncoscopy exam Dry mucosa Granulation tissue Coagulopathy Rare innominate fistula

Decannulation

Goal is to ensure patient can tolerate increasedincreased airway resistance/work of breathing and secretion clearance

30% increase WOB transition from trach breathing to upper airway breathing

Decannulation

Indication for tracheotomy has resolved/improved

Patient able to cope with secretions Upper airway patent - examined if necessary Appropriate vocal cord function Good respiratory reserve/overall respiratory

status Gag reflex present (5-10% no gag)

Decannulation

Stable clinical condition Hemodynamic stability Absence of fever, sepsis infection

Adequate swallowing Gag reflex, bedside swallowing assessment,

video fluoscopy

Maximum expiratory pressure > 40 cm H2O

Ceriana et al 2003

Decannulation Protocol

Downsize tube to either 4 or 6 Shiley Cuffless fenestrated tube

Gradually increase corking/cap of trach Corked 24-48 hours before decannulation Remove tracheostomy tube Occlusive dressing for stoma Persistent patent stoma

Occasionally requires local flap to close Outpatient procedure under local, infection common

Difficult to Decannulate

Granulation tissue Fenestra obstructed

Tracheal mucosal edema/supraglottic edema NG, aspiration

Laryngeal pathology Glottic stenosis, cord paralysis

Pulmonary secretions Increase airway resistance not tolerated

Tracheotomy: Summary

Safe method of airway management Open versus percutaneous technique

available Complications largely minor Mortality rare from procedure directly

0.3%* in last 30 years (grouped data)

Summary

Advantages/risks of a tracheotomy for that individual patient must outweigh the disadvantages/risks without one. Indication for Tracheotomy Medical comorbidities Respiratory /deglutition function Ability to cope with secretions Trial of corking/decannulation

Cricothyroidotomy

Open versus percutaneous technique Prep and position as for trach Identify landmarks Local anaesthetic Incision over cricothyroid membrane Placement of small tracheotomy tube, ETT or

large bore needle with attachment for ventilation

Cricothyroidotomy

Advantages Quick c/w open trach No laryngeal injury Failure of intubation

attempts in emergency situation

Disadvantages Can cause laryngeal

injury Must be sure of

landmarks Small tube required

Cricothyroidotomy