TRACHEOSTOMYDONE BY

P.SHRAVANCRI

DEFINITION :-

Tracheotomy : Surgical opening of the trachea.

Tracheostomy : Creation of a stoma at the skin surface which leads into the trachea.

It is a surgically created airway fashioned by making a hole in the anterior wall of the trachea.

TRACHEOSTOMA

HISTORY :-

Tracheostomy is one of the oldest surgical procedures.

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

In 1909, Chevalier Jackson : Guidelines for safe tracheostomy.

CURRENT TRENDS :

CURRENT TRENDS :

TEMPORARY TRACHEOSTOMY

Temporary tracheostomy may be either elective or emergency.

An elective temporary tracheostomy may be part of a planned procedure, such as a major head and neck operation.

An emergency temporary tracheostomy is a rare procedure and is indicative in some certain conditions.

PERMANENT TRACHEOSTOMY

Permanent tracheostomy is an elective procedure carried out as part of an operation involving larynx or trachea.

The trachea is permanently disconnected from the pharynx and the proximal end of the trachea is sutured to the skin.

In a permanent tracheostomy the only access to the lower airway is via the tracheostome.

Tracheotomy Indications To bypass obstruction

Tracheotomy Indications

- Need for prolonged respiratory support, such as in Bronchopulmonary Dysplasia

- To reduce anatomic dead space and increase the chance for mechanical ventilation withdrawal

- To improve the patient`s quality of life (easier toilet, ability to speak and eat, increase the mobility)

- Neuromuscular diseases paralyzing or weakening chest muscles and diaphragm

Tracheotomy IndicationsMiscellaneous

-Congenital abnormalities. (Pierre Robin, Triecher Collins syndromes)

- Obstructive Sleep Apnea Syndrome.

- Aspirations related to muscle or sensory problems.-Prophylaxis (as preparation for extensive H&N procedures, before radiotherapy for H&N CA)

-Cervical spinal cord injuries with respiratory muscles paralysis.

Contraindications No absolute contraindications exist to

tracheostomy

RELATIVE Laryngeal CA(strong)

it may lead to increased incidence of stomal recurrence(a diffuse infiltrate of neoplastic tissue at the junction of the amputated trachea and skin )

Cricothyroidectomy

Cricothyroid membrane

Crycoid cartilageThyroid cartilage

Landmark

CRICOTHYROIDOTOMY / MINITRACHEOSTOMY

The patient lies supine with the neck extended over a pillow.

Ascertain the correct anatomical landmarks by palpation.

The thyroid cartilage is gripped between the thumb and middle finger of the left hand; in this position the index finger can be used to palpate the cricothyroid membrane.

Airway is entered using a needle and cannula attached to a 10 ml syringe half full of saline.

The needle is angled in a caudal direction and the cannula is passed over the needle into the trachea.

CRICOTHYROIDOTOMY / MINITRACHEOSTOMY

Connect the cannula to an ambu bag using a syringe with a 7-mm endotracheal tube adaptor.

CO2 is not cleared effectively.

SURGICAL TRACHEOSTOMY

Surgical tracheostomy (ST) is usually performed in the operating room on a patient under general anesthesia, but it may be performed at the bedside in the intensive care unit.

The patient’s shoulders are elevated with head extension (unless cervical disease or injury is present), elevating the larynx and exposing more of the upper trachea.

Local anesthesia with a vasoconstrictor is usually infiltrated into the skin and deeper tissues

SURGICAL TRACHEOSTOMY

The skin of the neck over the 2nd tracheal ring is identified, and a vertical

incision about 2–3 cm in length is created.

Sharp dissection following the skin incision is used to cut across the platysma muscle, and bleeding controlled by hemostats and ties or electocautery.

SURGICAL TRACHEOSTOMY Blunt dissection parallel

to the long axis of the trachea is then used to spread the submuscular tissues until the thyroid isthmus is identified

If the gland lies superior to the 3rd tracheal ring, it can be bluntly undermined and retracted superiorly to gain access to the trachea

SURGICAL TRACHEOSTOMY There are 2 basic approaches

to tracheal entry.

the 2nd tracheal ring is divided laterally and the anterior portion removed.

Lateral sutures are used to provide counter traction during tracheostomy-tube insertion.

These are left uncut to provide assistance if the tube is accidentally dislodged later.

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.

Cuffs on tracheostomy tubes include high-volume low-pressure cuffs, tight-to shaft cuffs, and foam cuffs.

TRACHEOSTOMY TUBES

Metal Vs Plastic 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

→ rigid construction → uncuffed →lack a 15 mm connector for attachment to a

ventillator

Metal Vs Plastic Tracheostomy Tubes

Plastic tubes are most commonly used and are made from polyvinyl chloride or silicone.

Polyvinyl chloride softens at body temperature (thermolabile), adjustable to patient’s tracheal anatomy and centering the distal tip in the trachea.

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.

CUFFED TRACHEOSTOMY TUBE

Post-Op Managment

Repeat X-Ray soft tissue neck

Strong Analgesia

Antibiotics

IV fluid until able to tolerate orally

COMPLICATIONS :-

IMMEDIATE:-

anesthetic complications. air embolism. apnoea. cardiac arrest.

Hemorrhage- thyroid veins; jugular veins; arteries.

local damage- thyroid cartilage; cricoid cartilage; recurrent laryngeal nerve.

COMPLICATIONS :-

INTERMEDIATE:

- displacement of the tube. - surgical emphysema. - pneumothorax /pneumomediastinum. - infection: perichondritis. - tube obstruction by secretions or crusts. - tracheal necrosis. - tracheoarterial fistula. - tracheo-oesophageal fistula. - dysphagia.

COMPLICATIONS :-

LONG TERM:

- stenosis.

- decannulation problems.

- tracheocutaneous fistula.

- disfiguring scar.

•  Secretions in the trachea

•  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

Tube exchange After the track is formed – 4-5 days

after the operation.

Rate of exchange depends on clinical situation of the specific patient – type of discharge, type of tube, medical status, age..

Usually every 14 days.

Should be done by experienced staff.

SPEECH WITH TRACHEOSTOMY

A tracheostomy speaking valve is a one-way valve, allows air in, but not out.

This forces air around the tracheostomy tube, through the vocal cords and the mouth upon expiration, enabling the patient to vocalize .

DECANNULATION

Decannulation should be approached in a stepwise fashion.

if the initial cuffed tube has been changed there should be enough airflow around the tube to allow the patient to breath easily with the tube lumen occluded.

Block the tube during the daytime initially, and then for a full 24 hours, followed by decannulation.

DECANNULATION

Once the tube has been removed the stoma must be occluded with an airtight dressing.

Change the dressing whenever an air leak becomes apparent to avoid a persistent tracheocutaneous fistula.

Psychologically dependent patients require longer duration for decannulation.