TracheostomyTracheostomyMay 4May 4thth /05 /05

HistoryHistory

• Greek tracheo plus stoma (mouth) creation of a opening in the trachea by suturing the

skin of the neck to the tracheal mucosa the placement of a tube through the anterior neck

into a tracheotomy

• Asclepiades in the first century BC described their use for of upper airway obstruction relief

Clin Chest Med 2003

HistoryHistory• 18th & 19th centuries Trousseau diphtheria epidemic surge in the tracheostomy performance & technique improvements but Still mortality 73%

• 1909 Jackson modern tracheostomy description

• 1969 Toy & Weinstein the percutaneous tracheostomy

• 1985 Ciaglia percutaneous dilatational tracheostomy Clin Chest Med 2003

IndicationsIndications

• Permanent tracheostomy post laryngectomy

• Relief of upper airway obstruction

• Rx uncontrolled tracheobronchial secretions

• Prolonged mechanical ventilation Clin Chest Med 2003

Advantage of Trach over ETTAdvantage of Trach over ETT• Stable airway • Minimize laryngeal injury• Improved pulmonary toilet and oral hygiene• improved patient comfort• potential for speech and oral feeding• Decreased requirement for sedation or restraints • Facilitated ventilator weaning• Shorter intensive care unit stay Clin Chest Med 2003

Physiological changesPhysiological changes

• Loss of warming ,humidifying & filtering Loss of warming ,humidifying & filtering function of upper airway function of upper airway thick secretions thick secretions

• Defective cough & ciliary function Defective cough & ciliary function Tube induced mucus production Tube induced mucus production increased risk of atelectasis increased risk of atelectasis

Loss of smelling Loss of smelling decreased appetitedecreased appetite

AnatomyAnatomy• Adult trachea 10 -13 cm larynx to carina

• trachea slides easily in the cephalo-caudal direction tremendous variability

• With neck extension half the length is above the thoracic inlet

AnatomyAnatomy• Incomplete rings with post membrane

• At thoracic inlet

trachea dives from anterior to posterior

behind the thymus, innominate vein & artery

• In the elderly this angle can approach 90 degrees

AnatomyAnatomy• Approaching the trachea anteriorly in the midline encounters : superficial cervical fascia, crossing branches of the ant. jugular veins sternohyoid and sternothyroid muscles thyroid isthmus 2nd ring level pretracheal fat pad inferior thyroid veins & occasionally a thyroid ima artery

Percutaneous Dilatational TarchPercutaneous Dilatational Tarch• Selection Criteria

Uncomplicated translaryngeal intubation

Palpable cricoid cartilage at least 3 cm above

the sternal angle

Appropriate neck extension

Hemodynamically stable

FIO2 < below 60%

PEEP < 10 cm H2O Clin Chest Med 2003

Percutaneous Dilatational TarchPercutaneous Dilatational Tarch

• Exclusion criteria

Distorted neck anatomy

head and neck tumors, thyromegaly or scarring Refractory coagulopathy

Tracheomalacia

Neck soft tissues infection

Inability to extend the neck

cervical fusion, fracture, or arthritis Clin Chest Med 2003

Cricothyroidotomy• Emergency situationEmergency situation

• Most reliable landmark laryngeal prominence

• Palpation along the midline inferiorly toward the sternal notch

the cricothyroid membrane

immediately above the cricoid cartilage. Clin Chest Med 2003

Cricothyroidotomy

• The cricothyroid membrane is identified and incised along its inferior border transversely

• Tracheal hook is inserted under the thyroid cartilage.

• Gentle vertical dilation is to allow passage of a 6 mm or 7 mm tube Clin Chest Med 2003

Tube-free tracheostomy• Alternative to tracheostomy tube when it is expected

to remain for months to years

• To avoid the morbidity associated with an indwelling tube

• horizontal omega-shaped skin incision extending beyond the margins of the sternocleidomastoid & arching to the level of the cricoidcartilage

• Creation of a muscle & tracheal flap Clin Chest Med 2003

Tube-free tracheostomy

• Subplatysmal flaps

inferiorly manubrium

laterally beyond the sternocleidomastoid

superiorly hyoid bone.

• Thyroid isthmus is divided

the two lobes mobilized to be sutured gathering the accompanying strap muscles & tendons

Clin Chest Med 2003

Tube-free tracheostomy

• Anterior tracheal flap

elevating the 2nd & 3rd tracheal rings

• The stoma is intubated until the patient is

stable and breathing spontaneously

decannulated. Clin Chest Med 2003

MinitarcheostomyMinitarcheostomy• Matthews and Hopkinson in 1984

• novel, minimally invasive method to facilitate endotracheal suctioning and clear secretions

• 4 mm cannula through cricothyroid membrane

• trachea can be stimulated by a catheter to produce a cough to clear secretions.

Clin Chest Med 2003

MinitarcheostomyMinitarcheostomy

• preservation of glottic function, secretions can be coughed up via the normal route

• Speech and swallowing are unaffected.

• The cannula is capped when not in use Clin Chest Med 2003

Minitarcheostomy IndicationsMinitarcheostomy Indications

• Prophylactic Prophylactic Postop major thoracic or upper abdom Sx Extubated pts with expected poor cough

Therapeutic Therapeutic sputum retention pneumonia, COPD exacerbations major atelectasis (usually postoperative), depressed LOC thoracic trauma Respiratory muscle weakness. Clin Chest Med

2003

MinitarcheostomyMinitarcheostomy• The success rate 96% to 100%

• The average duration of use 1 week

• There were no late complication 1-4 y

• 2 small RCT post pulmonary Sx 30 & 25 Pts Decrease in post op atelectasis & pneumonia & need of bronch J Thorac Cardiovasc Surg 1991 Eur J Surg 1991

Trach Tube selection• DiameterThe smallest outer diameter tube will minimize the risk of tracheal stenosisThe widest inner diameter decrease airflow resistanceSize 8 men & 6 women.

• Inner cannula safe & simple cleaning Clin Chest Med 2003

Trach Tube selection

• Cuffed tube mechanical ventilation

• Uncuffed tube off ventilator to decrease work of breathing

• Wire-reinforced tube enforced security & position tube

Clin Chest Med 2003

Trach Tube selection

• The fenestrated tube spontaneously breathing pt for easy phonation with the tube capped can be blocked with cannula for ventilation

High chance to be blocked by secretion , blood or granulation tissue needs changing frequently Clin Chest Med 2003

Trach Tube selection

• Tight-to-shaft Bivona tube intermittent ventilation high pressure, saline filled balloon when deflated is flush with the tube without inner cannula• One way speaking valve Allow phonation exhalation through vocal cord Clin Chest Med 2003

DecanulationDecanulation• Fenestrated tube Fenestrated tube cuff deflated cuff deflated cuffless tube cuffless tube

• Downsizing progressively smaller size tubesDownsizing progressively smaller size tubes

Allows the stoma to gradually fill in around the tube. Allows the stoma to gradually fill in around the tube.

• Decannulation plugDecannulation plug

• Tube removal Tube removal dry, sterile dressingdry, sterile dressing

ComplicationsComplications• Early Early Bleeding , pneumothorax, Bleeding , pneumothorax, SC emphysema pneumonia , SC emphysema pneumonia , Injury to recurrent laryngeal nerve Injury to recurrent laryngeal nerve Trachoesophageal fistulaTrachoesophageal fistula Accidental extubationAccidental extubation

• LateLate Tracheal stenosis , Tracheomalacia Tracheal stenosis , Tracheomalacia Skin breakdownSkin breakdown Cuff rupture or herniationCuff rupture or herniation

Should we trach more Pts ?Should we trach more Pts ?• A lot of studies A lot of studies still no solid answerstill no solid answer

• Different patient populationsDifferent patient populations

• Different timing of tracheostomyDifferent timing of tracheostomy

• Different surgical techniques & experienceDifferent surgical techniques & experience

Early Vs late Trach in Burn PtEarly Vs late Trach in Burn Pt

• Prospective Randomized controlled Prospective Randomized controlled 1996199620002000

• 21 pt early Trach ET Vs 23 trach D 1421 pt early Trach ET Vs 23 trach D 14• Predicted probability of prolonged ventilation Predicted probability of prolonged ventilation

formulaformula• 1ry outcome 1ry outcome hospital stay & mortality hospital stay & mortality• 2ry outcome 2ry outcome extubation rate , oxygenation extubation rate , oxygenation & pneumonia rate& pneumonia rate Jr of Burn Care & Rehab 2002Jr of Burn Care & Rehab 2002

Early Vs late Trach in SICU PtEarly Vs late Trach in SICU Pt

• Retrospective 2000 Retrospective 2000 20022002

• Early trach < 7 Vs late > 7 daysEarly trach < 7 Vs late > 7 days

• Outcomes mechanical ventilation ,VAP ,Outcomes mechanical ventilation ,VAP ,

ICU & hospital stayICU & hospital stay Am Jr of Surgery 2005Am Jr of Surgery 2005

Early Vs Late Trach in Head Injury PtsEarly Vs Late Trach in Head Injury Pts

• 2 y prospective randomized study 2 y prospective randomized study • Early 5Early 5thth or 6 or 6thth day Vs late day Vs late • Isolated severe head injury• Admission GCS < 8• Cerebral contusion on CT scan• GCS score 8 on the fifth day without any

sedation• Outcomes : ventilation , VAP , ICU & hospital stay Trauma 2004

Surgical Vs Percutaneous TrachSurgical Vs Percutaneous Trach• Few RCTFew RCT

• No mortality difference No mortality difference

• Time advantage for PT Time advantage for PT less prep time less prep time

• Shorter time from required to be doneShorter time from required to be done

• PT may have lower bleeding ratePT may have lower bleeding rate Anaesth Intensive Care 1999 Chest 2000

LMA instead of ETT in TrachLMA instead of ETT in Trach

• Randomized prospective 60 ptsRandomized prospective 60 pts

• Bedside trach with brocoscopic aidBedside trach with brocoscopic aid

• Outcomes : procedure timeOutcomes : procedure time oxygenation & ventilationoxygenation & ventilation complicationscomplications Intensive care med 2002Intensive care med 2002

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