13.tracheostomy (50) Dr Rahul Tiwari OMFS SIBAR Institute of Dental Sciences, Guntur, Andhra Pradesh

05/02/2023 12:14:06 AM RT/13/TRACHEOSTOMY/50 1

TRACHEOSTOMY

Dr. Rahul TiwariFinal Yr. PG

OMFS - SIDS

Good Morning


CONTENTS• INTRODUCTION• INDICATIONS• CONTRAINDICATIONS• EFFECTS• TIMINGS• TYPES• FEATURES

• TECHNIQUES• CARE • DECANULATION• COMPLICATIONS• CONCLUSION• REFERENCES


INTRODUCTION

• Tracheotomy refers to the surgical opening of the trachea.

• Tracheostomy refers to the creation of a stoma at the skin surface,

which leads to the trachea.

• Chevalier jackson described the principles of tracheostomy at the

beginning of the 20th century.


INDICATIONS FOR TRACHEOSTOMY

• 1. Upper airway obstruction.

• 2. Prolonged ventilation.

• 3. To provide pulmonary toilet and/or to protect the airway

• 4. As part of another procedure, for example, head and neck surgery.

• 5. Emergency airway access


CAUTIONS AND RELATIVE CONTRAINDICATIONS FOR TRACHEOSTOMY

1. Difficult anatomy – obese, spine injury, tracheal pathology, short neck.

2. Moderate coagulopathy – platelets<50000/ml.

• Prothrombin time or activated partial thromboplastin time >1.5

3. Significant gas exchange problems: e.G. PEEP > 10 cm H2O

4. Evidence of infection in the soft tissues of the neck at the insertion site

5. Age less than 12 years.

EFFECTS OF A TRACHEOSTOMY

• Larynx is by passed - unable to phonate (unless a valved device is used).

• Anatomical and respiratory dead space - breathing.

• Loss of the humidification and filtration function of the nasal mucosa.

• Increased risk of respiratory tract infection.

• Redundant area above the tracheal opening and below the larynx in which

mucus can accumulate and fall back into the lungs.

• A foreign body reaction can occur causing local inflammation.



TIMING OF TRACHEOSTOMY FOR PROLONGED VENTILATION CASES

• Timing - issue of debate.

• Terragni et al - no difference – intubated case- ventilator-associated pneumonia

with early (6-8 days) versus late (13-15 days).

• Tracman study was carried out in the united kingdom to assess the impact of

early (day 1-4 of icu admission) versus late (day 10 or later) tracheostomy - no

significant difference in mortality in icu or hospital length.

TUBES AVAILABLE• Metallic

• Fuller• Jackson• Alder hey

• Nonmetallic• Portex – cuffed and noncuffed

• Others• Portex paediatric• Shiley paediatric• Rusch • Franklin• Edinburgh• Negus• Durhams lobster tail

- Parker- Aberdeen- Cole’s- Patterson- King college- Holinger- Salpekar

- KCH pattern- Koenig’s- Bivona foam- Pit speaking- Mc Ginnis- Desaut- Molyncke


Silver Tube


Synthetic cuffed tube Synthetic uncuffed tube


Fenestrated tube Passy Muir speaking valve


FEATURES OF TRACHEOSTOMY TUBES1. Diameter: internal diameter (ID) - 5.0mm to 9.0mm in adult

practice. 2. Cuff: reduces aspiration and leakage of air.


FEATURES OF TRACHEOSTOMY TUBES

3. Inner tube:

• The inner tube has the safety advantage of being easily and quickly removed

to relieve life threatening obstruction due to blood clots or secretions.

• It is recommended that dual cannula tubes should be used whenever

possible because of the safety advantage.


FEATURES OF TRACHEOSTOMY TUBES

4. Fenestration:

• Phonation

• Simply deflating the cuff

may be an alternative

approach in patients who

do not require positive

pressure respiratory

support


FEATURES OF TRACHEOSTOMY TUBES5. Flexibility6. Adjustable flange:


FEATURES OF TRACHEOSTOMY TUBES7. Subglottic suction: reduce the incidence of ventilator-associated pneumonia.8. Speaking valve: speaking valves (like the passy muir valve)- phonation.


The Blue Rhino single stage dilator

This hydrophilically coated, curved

dilator allows progressive dilatation

of the tracheal stoma in a single step,

reducing the risk of posterior tracheal

wall injury, intraoperative bleeding

and the adverse effect on

oxygenation during repeated airway

obstruction by sequential dilators.


ANATOMY


TECHNIQUES FOR INSERTION• Percutaneous & open surgical technique.• Percutaneous tracheostomy - anaesthesiologist - fibreoptic bronchoscopic

guidance. • Open surgical tracheostomies - ENT surgeons & Trauma surgeons.• Percutaneous tracheostomy was first described in the late 1950s and 1960s.

Two initial techniques were described – • A serial dilatational technique described by ciaglia et al in 1985• A guidewire dilating forceps (GWDF) method described by griggs and

colleagues in 1990. • In 2000, byhahn et al modified the ciaglia technique by introducing the blue

rhino.


Percutaneous Tracheostomy Insertion1.Indication reviewed.

2. Consent .

3. Platelet and coagulation assays, blood grouping,

ultrasound

4. Nasogastric tube feeding - stop for 2 hours – aspirate &

check.


Percutaneous Tracheostomy Insertion5. Equipment- percutaneous tracheostomy set, a fibreoptic bronchoscope,

drapes and sterile skin preparation, LA.

6. Two clinicians - bronchoscope and tracheostomy insertion, nurse

7. Sedation, analgesia and muscle relaxation - propofol, fentanyl and

atracurium.

8. Position - neck extended- monitored and ventilated with 100% oxygen during

the procedure.


Percutaneous Tracheostomy Insertion9. ET Tube cuff deflated - tube withdrawn – till tip is distal to the patient’s vocal cords – clears site.

10. Mark anatomy - 2nd & 3rd Tracheal rings

Insertion above - tracheal stenosis

Insertion below - erosion of thoracic inlet great vessels.

11. Aseptic technique - gown, gloves, and mask and eye protection. patient’s skin - antiseptic

cleaning solution


Percutaneous Tracheostomy Insertion

12. LA - Small transverse skin incision - Blunt

dissection with forceps until the tracheal rings are

felt – Cannulization – Conform via Bronchoscope.

13. Next steps - bronchoscope. Guidewire is passed

into the trachea - intermediate rigid dilator is

passed over the guidewire - curved dilator - as far

as the thick black line, in one smooth movement.


Percutaneous Tracheostomy Insertion

14. Curved dilator removed – insert introducer - tracheostomy tube.

15. Introducer is removed - cuff is inflated - ventilation connected – confirm

(capnography).

16. Secure via supplied tapes – document the procedure.

17. A chest X-ray to exclude pneumothorax.


STANDARD OPEN TRACHEOSTOMY TECHNIQUE

• GA – Operating room.

• Supine - maximal neck extension.

(History of an unstable cervical spine, spinal stenosis, kyphosis, or

severe cervical osteophyte disease may preclude extension of the neck)


The patient is positioned supine with the neck extended. A transverse incision is fashioned about 2cm above the suprasternal notch and below the cricoid cartilage.

The subcutaneous tissue and platysma muscle are divided transversly entering the sub platysmal plane.


• Sterile surgical preparation - 2 cm to 3 cm transverse incision crossing the midline - about 2

cm above the suprasternal notch.

• Subcutaneous tissue & platysma – enter subplatysmal plane

• Longitudinal dissection – superficvial cervical fascia & strap muscles (midline)

• Anterior jugular veins - lateral to the dissection - rarely require ligation.

• Lateral retraction of the sternohyoid and sternothyroid muscles helps to develop the midline -

thyroid gland into view.



• The pretracheal fascia & fibrofatty tissue incised inferior to thyroid isthmus.

• Retract beneath the strap muscles - catch edge of isthmus - under surface of

the thyroid lobes - tracheal rings.

• Avoid avulsing small veins that may drain directly into the innominate vein,

and if present, the thyroid ima artery needs to be ligated.



Gentle lateral retraction of the strap muscles helps develop the midline and expose the underlying thyroid gland and trachea. Rarely it is necessary to ligate anterior jugular veins

The thyroid isthmus is retracted cephalad and lateral traction sutures placed around the 2nd or 3rd tracheal ring.


• Complete homeostasis - insertion of the tracheostomy tube

• The cuff is inflated, checked for leaks and deflated.

• Care should be taken to fully deflate and lubricate the cuff to avoid its getting caught and torn

by the cut edge of a calcified tracheal ring.

• A #15 knife blade, tracheal hook, and tracheal dilators should be readily available.

• The midline is identified, the tracheal rings carefully counted, and lateral traction sutures are

placed around the second or third tracheal ring



• A vertical linear tracheostomy is created in the midline, ideally between rings 2 and 4, and

gently dilated.

• The tracheostomy tube is passed into the airway, the cuff inflated, and ventilation

resumed.

• The skin is sutured loosely around the tube with absorbable suture and the flange of the

tracheostomy secured to the skin in all four quadrants.

• Finally the tube is further secured by the passage of a tracheal tie around the neck.



#15 blade scapel is used to create longitudinal tracheostomy. The laterally placed traction sutures provide enough. Distraction to allow for tracheostomy tube placement without excessive dilation. After confirming tube placement the traction sutures are removed.


Comparison - Types of Tracheostomy

Surgical tracheostomy

Percutaneous dilation

CricoThyroidotomy

Site 2nd – 3rd or 3rd – 4th

1st and 2nd or2nd – 3rd

Cricothyroid membrane

Method •Surgical dissection •Cut the trachea

Puncture and dilatation

Puncture with needle

Elective or emergency

Always elective (in OT or ICU setting)

For emergency access to airway


CARE OF THE TRACHEOSTOMY

1.Changing tracheostomy tubes:

• Without inner tubes every 7-14 days

• With inner tubes - thirty days.

• First change -72 hours (infection, reliable track)

• Emergency airway equipment – keep during the change.


2. Method of suctioning & the interval in between the two suctions

The interval in adults is 10 to 15 sec.

The duration of suctioning should also be the same.

In children there should be 3 to 4 breaths in between the two suctions even if the child is drowning in secretions.


3.Humidification:

• Cold and unfiltered air is an irritant - cause tracheal mucosal keratinisation.

• Viscous secretions - difficult to clear, can be life threatening if blocked.

• Inhaled oxygen is appropriately humidified using heat and moisture exchange

(HME) filters or heated water baths.


4.Nutrition:

• Via a nasogastric or nasojejunal tube.

• Patients may be fed orally, with the cuff inflated or partially deflated, but staff

must be alert to signs of aspiration, such as coughing, increased secretions and

impaired gas exchange.


COMPLICATIONS OF TRACHEOSTOMYImmediate :

aspiration

Haemorrhage

Air embolism

Failure of procedure

Structural damage to tracheal rings

Injury to recurrent laryngeal nerve

Injury to esophagus


COMPLICATIONS OF TRACHEOSTOMY• Intermediate complications :

• Delayed haemorrhage • Tube displacement • Surgical emphysema • Pneumomediastinum • Pneumothorax • Infection • Tracheal necrosis • Tracheoarterial fistula • Tracheoesophageal fistula • Dysphagia

Massive hemorrhage 1 to 6 weeks caused by tracheoinnominate artery fistula.


COMPLICATIONS OF TRACHEOSTOMY

• Management of tracheoinnominate artery fistula hemorrhage :

1.Overinflate the tracheostomy cuff to tamponade the hemorrhage

2.Replace the tracheostomy tube with an oral endotracheal tube. Position the cuff with

fiberoptic bronchoscopic guidance just above the carina.

3.Use digital compression of the innominate artery against the posterior sternum using a

finger passed through the tracheostomy stoma

4.Slowly withdraw the endotracheal tube and overinflate the cuff to tamponade

5.Then proceed with definitive therapy: sternotomy and ligation of the innominate artery.


COMPLICATIONS OF TRACHEOSTOMY

• Delayed complications :

• Tracheal stenosis - due to collapse of the cartilaginous ring - fibrosis.

• Decannulation problem

• Tracheocutaneous fistula – tracheal granuloma.

• Disfiguring scar


WEANING AND DECANNULATION

• Removal as Required.

• Decannulation - Resume breathing

• Patients can be trialled cuff deflation – swallowing and cleaning

• Decannulation - Not dependent on ventilatory support & able to

cough and clear his secretion


WEANING AND DECANNULATION

• Decannulation done in morning so to review their progress the whole day.

• Tube is removed and the stoma is covered with a semi-permeable dressing.

• Encourage to gently press over this defect with whilst speaking or coughing.

• Subsequent monitoring for signs of respiratory distress.


Is a hollow, 16- or 20-French, silicone tube

that has a one-way flap valve positioned

within its proximal tip - used in phonation

& prevents aspiration.


Complications of Bloom-Singer valve:

• Candida infection in and around the prosthesis

• Leakage through the valve due to defective one-way valve

• Peri-prosthetic leakage

• Occlusion of the prosthesis

• Inadvertent displacement and aspiration


REFERENCES• 1. Tracheostomy–a Multiprofessional Handbook Claudia Russel & Basil Matta–1st Ed

• 2. Tracheostomy - Eliana Soto, Downstate Medical Center.

• 3. Bailey & Love’s Short Practice Of Surgery 23rd Edition.

• 4. An Atlas Of Head & Neck Surgery-lore’ 3rd Edition.

• 5. Operative Otolaryngeo, Head & Neck Surgery- Myers,vol I.

13.tracheostomy (50) Dr Rahul Tiwari OMFS SIBAR Institute of Dental Sciences, Guntur, Andhra Pradesh

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Transcript of 13.tracheostomy (50) Dr Rahul Tiwari OMFS SIBAR Institute of Dental Sciences, Guntur, Andhra Pradesh