TRACHEOSTOMY & TRACHEOSTOMY & CRICOTHYROIDOTOMYCRICOTHYROIDOTOMY

DR FRANK EDWINDR FRANK EDWIN

INTRODUCTIONINTRODUCTION

Tracheostomy is an operative Tracheostomy is an operative procedure that creates a surgical procedure that creates a surgical airway in the cervical trachea airway in the cervical trachea

It is considered synonymous with It is considered synonymous with tracheotomy tracheotomy

LARYNX & TRACHEALARYNX & TRACHEA

ANATOMY IANATOMY I

ANATOMY IIANATOMY II

ANATOMY IIIANATOMY III

ANATOMY IVANATOMY IV

UPPER AIRWAY OBSTRUCTION -UPPER AIRWAY OBSTRUCTION -RECOGNITIONRECOGNITION

Dyspnea Dyspnea Stridor Stridor Voice change Voice change Decreased or absent breath sounds Decreased or absent breath sounds Restlessness Restlessness Hemodynamic instability (late) Hemodynamic instability (late) Loss of consciousness (very late) Loss of consciousness (very late)

INDICATIONS FOR INDICATIONS FOR TRACHEOSTOMYTRACHEOSTOMY

To bypass obstruction To bypass obstruction Long-term Mechanical ventilationLong-term Mechanical ventilation Pulmonary toilettingPulmonary toiletting Neck trauma Neck trauma Tumor Tumor Bilateral vocal cord paralysis Bilateral vocal cord paralysis Laryngeal EdemaLaryngeal Edema Respiratory failureRespiratory failure

FORMS OF TRACHEOSTOMYFORMS OF TRACHEOSTOMY

Emergency tracheostomyEmergency tracheostomy

Urgent tracheostomyUrgent tracheostomy

Elective tracheostomyElective tracheostomy

INTRAOPERATIVE DETAILS:INTRAOPERATIVE DETAILS:TRACHEOSTOMYTRACHEOSTOMY

TRACHEOSTOMYTRACHEOSTOMY

TRACHY TUBESTRACHY TUBES

TUBE PARTSTUBE PARTS

METALIC TUBESMETALIC TUBES

PLASTIC TUBESPLASTIC TUBES

USE OF FENESTRATED TUBEUSE OF FENESTRATED TUBE

Chest X-ray Chest X-ray after trachyafter trachy

POSTOPERATIVE DETAILSPOSTOPERATIVE DETAILS

Postoperative care is critical. Postoperative care is critical.

Copious secretions is the normCopious secretions is the norm

Suctioning every 15 minutes may be Suctioning every 15 minutes may be requiredrequired

Suctioning should be shallow initially Suctioning should be shallow initially

Suctioning should be limited to no more Suctioning should be limited to no more than 15 secondsthan 15 seconds

POSTOPERATIVE DETAILS 2POSTOPERATIVE DETAILS 2

Humidified oxygen helps prevent Humidified oxygen helps prevent inspissation of the secretions.inspissation of the secretions.

Mucolytic agents may be employed.Mucolytic agents may be employed.

If uncorrected, mucus plugging of the If uncorrected, mucus plugging of the

inner cannula can cause a life-inner cannula can cause a life-threatening obstruction. threatening obstruction.

POSTOPERATIVE DETAILS 3POSTOPERATIVE DETAILS 3

The original tube is left sutured in place The original tube is left sutured in place for 5-7 days to allow the tract to heal. for 5-7 days to allow the tract to heal.

Then the sutures are removed, and the Then the sutures are removed, and the tube is replaced. tube is replaced.

The site should be kept clean and dry to The site should be kept clean and dry to minimize infectionminimize infection

Patient and family education should begin Patient and family education should begin ASAPASAP

FOLLOW-UP CAREFOLLOW-UP CARE Speaking: should be encouraged when Speaking: should be encouraged when

cuff is deflated cuff is deflated

Swallowing: Swallowing is more difficultSwallowing: Swallowing is more difficult

Evaluate risk of aspiration before feedingEvaluate risk of aspiration before feeding

Educate: both patient and familyEducate: both patient and family

Equipment: for dischargeEquipment: for discharge

SUCTIONINGSUCTIONING "STERILE TECHNIQUE" - the use of a "STERILE TECHNIQUE" - the use of a

sterile catheter and sterile gloves for sterile catheter and sterile gloves for each suctioning procedure. each suctioning procedure.

"CLEAN TECHNIQUE" - the use of a clean "CLEAN TECHNIQUE" - the use of a clean catheter and nonsterile, disposable catheter and nonsterile, disposable gloves or freshly washed, clean hands for gloves or freshly washed, clean hands for the procedure. the procedure.

““MODIFIED CLEAN TECHNIQUE" - MODIFIED CLEAN TECHNIQUE" - nonsterile gloves and sterile catheters). nonsterile gloves and sterile catheters).

SUCTIONING DEPTHSUCTIONING DEPTH

SHALLOW SUCTIONING – suctioning at the hub SHALLOW SUCTIONING – suctioning at the hub of the tracheostomy tube to remove secretions of the tracheostomy tube to remove secretions coughed up to the opening of the tracheostomy coughed up to the opening of the tracheostomy tube. tube.

The PRE-MEASURED TECHNIQUE - the catheter The PRE-MEASURED TECHNIQUE - the catheter is inserted to a pre-measured depth, with the is inserted to a pre-measured depth, with the most distal side holes just exiting the tip of the most distal side holes just exiting the tip of the tracheostomy tube. tracheostomy tube.

DEEP SUCTIONING - the insertion of the DEEP SUCTIONING - the insertion of the catheter until resistance is met, withdrawing catheter until resistance is met, withdrawing the catheter slightly before suction is applied. the catheter slightly before suction is applied.

WHEN IS SUCTIONING WHEN IS SUCTIONING REQUIRED?REQUIRED?

Whenever patient is unable to clear Whenever patient is unable to clear secretions by coughingsecretions by coughing

Bleeding down the airwayBleeding down the airway

WHEN TO SUCTION 1WHEN TO SUCTION 1

Mucus bubbling in trachy tube Mucus bubbling in trachy tube Audible gargling soundsAudible gargling sounds Laboured breathingLaboured breathing RestlessnessRestlessness Gurgles heard on auscultation Gurgles heard on auscultation Low SpOLow SpO22

WHEN T SUCTION 2WHEN T SUCTION 2 Stridor or changes in breathing Stridor or changes in breathing

Cyanosis Cyanosis

Increased ventilator inspiratory pressure Increased ventilator inspiratory pressure (for patient on ventilator, a high pressure (for patient on ventilator, a high pressure alarm may sound) alarm may sound)

Patient request Patient request

INSTILLINGINSTILLING Introduction of normal saline into the Introduction of normal saline into the

airway to aid removal of thick, tenacious airway to aid removal of thick, tenacious secretions. secretions.

TENACIOUS SECRETIONSTENACIOUS SECRETIONS Systemic hydration Systemic hydration

Humidification Humidification

Chest physiotherapy Chest physiotherapy

Suctioning, coughs and assisted coughs Suctioning, coughs and assisted coughs

Mucolytic agents Mucolytic agents

COMPLICATIONSCOMPLICATIONS

IMMEDIATEIMMEDIATE

EARLYEARLY

LATELATE

COMPLICATIONS 1COMPLICATIONS 1

IMMEDIATEIMMEDIATE

BleedingBleeding

Pneumothorax/PneumomediastinumPneumothorax/Pneumomediastinum

Injury to adjacent structuresInjury to adjacent structures

COMPLICATIONS 2COMPLICATIONS 2

EARLYEARLY

BleedingBleeding

Tube obstructionTube obstruction

Tube displacement/dislodgementTube displacement/dislodgement

Subcutaneous EmphysemaSubcutaneous Emphysema

AtelectasisAtelectasis

COMPLICATIONS 3COMPLICATIONS 3 LATELATE

BleedingBleeding

Tracheal stenosisTracheal stenosis

TracheomalaciaTracheomalacia

Tracheo-esophageal fistulaTracheo-esophageal fistula

Failure to de-cannulateFailure to de-cannulate