Tracheostomy

By Ussana Promyothin MD.

Tracheostomy

• Surgical opening in the trachea for ventilation

Indication• Bypass upper airway obstruction• Clearance secretion at lower respiratory• Prevent aspiration gastric content in absent of laryngeal reflex

Other indication

• Prolong intubation(1-3wks) children more prolong

• Laryngeal injury

• Fracture face neck area

• Also

• Improved oral hygiene

• Oral movement for communication

• Reduction damage larynx,nose ,mouth

Contraindication

• Prolong bleeding

• On anti-coag, anti-pletlet medication

• Elective tracheostomy• Emergency tracheostomy:

should avoid, expertised surgeon,team• In children: perform only with a secured airway

either from ET tube or bronchoscope in OR• Emergent tracheostomy should be avoided if

possible• Risk to vascular,lung and uncontrolled airway

Hyperextend the neck,

2 FB above thyroid notch ring 2,3

Skin incision,horizontal /vertical

Find white line,Test tracheostomy cuff

Clean trachea,aspirate air then push xylocaine

Stay suture,open trachea by inverted U flap,cross,vertical (in children stay suture on both sides of incision)

Standby tracheal dilator,suction,

Post operation care

• Irrigation with saline and suction q 15 mins

• Suction not exceed 15 seconds (block airway and suck Oxygen out)

• Humidification Oxygen (decrease thick mucus)

• Observe bleeding and subcutaneous emphysema

• Off packing 24-48hrs

• Left tube in place 5-7 days

• Stitch off and off stay suture 7th day

• Blow Cuff when on ventilation or prevent aspiration

• Not exceed 25 cm H2O

• Clean inner tube

• analgesic

Complication

Immediate• Apnea :loss hypoxic drive,COPD ventilator• Post obstructive pulmonary edemaPEEP• Pneumothorax chest x-ray post op• Injury to adjacent organ:thyroid ,vessel,

esophagus,recurrent laryngeal nerve

Pneumothorax

Early

• Bleeding HT, skin,thyroid,soft tissue• Mucus inner tube• Tracheitis humidification, minimize FiO2,

Stabilize tracheostomy• Cellulitis: wound care,antibiotic• Displacement: pass E-T tube, NG tube

LateBleeding -innominate vessel:usually in 2wks,high mortality

(low tracheostomy,mobilized tracheostomy tube,high pressure cuff,local infection)

-granulation( stroma, tip of tube)

Tracheoesophageal fistula:risk in retain NG tube

Type of TracheostomyType/description

permanent ventilator Inner tube

size

jackson yes no yes 4-5

shiley yes yes yes 4-6-8

portex no(7-14days) yes no 7-8

blueline no(1month) yes yes 7-8

Cricothyrodotomy:maneuver to buy time

Advantage• Near skin and less dissection

Disadvatage• Trauma to subglottic area• Contraindication:children<12 yrs,infection at

larynx,laryngeal trauma and risk transecting tumor

Tracheostomy care

• Clean skin around stroma

• Change gauze

• Clean inner tube

• Aware obstruction or slip out of tube

Weaning tracheostomy tube

• Reason for tracheostomy has resolved

• Stable lung status(O2<40%)

• Effective swallow,gag,and cough reflex

• Adequate nutrition, sleep, psychososial suppor

• Cuff deflate trial

Method

• Flexible bronchoscope or IDL

• Assess cord movement,granulation,stenosis area

• Admit,size tube down

• Plug tube day,all day night

• Off tube,observe before discharge

Epistaxis

Abnormal bleeding per nose

• Cause• Trauma ,nose picking ,nose blowing• URI, allergic rhinitis• Septum deviation• Decongestant ,nasal spray• Foreign body• Tumor• Post surgery

• Hypertension, artherosclerosis

• Anticoagulation drug,ASA,NSAID

• Decrease plt

• Liver function disease

Site of bleeding

MANAGEMENT

• Immediate evaluation :vital sign,airway

• Stop bleeding

• Compress nose,cold pack

Anterior epistaxis

• Little’s area region

• Ephridine or adrenaline pack (vasoconstrict agent)

• Beware in HT

• CAUTERIZATION

• 30%TCA,silver nitrate, electrical cautery

• Gel foam

Anterior nasal packing

Nasal speculum

Headlight

Suction

Anterior nasal packing

• Vasaline gauze or coated with antibiotic ointment

• Apneanaso-vagal reflex bradycardia,hypotension

• Remove packing 2-4 days later

• Antibiotic and decongestant

Posterior nasal packing

Foley catheter

Posterior nasal packing

Anterior and posterior nasal packing

• Posterior packing :oxygen face mask

• Elevate head 30 degree

• Antibiotic cover Staph aureus

• Liquid diet

• Remove packing 3-5 day later

• If high fever ,hypotension, remind toxic shock syndrome

• Surgery • Ligation artery• Endoscopy

•Angiogram and embolization

Sinusitis

Anatomy and function

• Resonance to voice• Humidify and warm air• Increase the area of olfactory • Absorb shock to head• Keep nasal chamber moist• Protect thermal to brain• Contribute facial growth• Lighten bone of skull

Acute bacterial sinusitis

• Cause

• URI,AR

• Dental infection

• Obtruction ostium: structure,tumor

• Immotile cilia

• Foreign body: NG tube

Symptom

• Fever

• Maxillofacial pain

• Dental pain

• Otalgia

• Posterior nasal drip

• Nasal congestion

• Causative agent

• viral

• S.pneumoniae

• H.influenzae

• M.catarrhalis

• Other bacteria

• Fungus

FILM SINUS

Management

• Proper antibiotic• Systemic decongestant:maxiphed• Beware: HT, Heart disease, urinary retention• Topical decongestant: not exceed 3 days• Mucolytic agent• Antihistamine if suspected allergy• Normal saline irrigation

• If failure medication• Antral puncture• For drainage and C/S• CHRONIC BACTERIAL SINUSITIS• Greater than 12 wks duration symptom• Treatment: antibiotic 4-6 wks• CT scan• Surgery : ESS (endoscopic sinus surgery)

ESS

Complication sinusitis

• Mucocele

• Orbital complication: cellulitis abscess

• Intracranial complication: meningitis brain abscess