Download Tracheotomy

Upper air way obstruction
&
Tracheotomy
Dr. Lamia AlMaghrabi
Consultant ENT
King Saud Medical City
Malignant tumours Trauma
Congenital
Bilateral laryngealInfections
paralysis
1 Advanced malignant
disease of
1 endotracheal
Subglottic
the tongue,orlarynx,
upper tracheal stenosis.
1 Prolonged
intubation.
1 Following thyroidectomy.
1 Acute epiglottitis
pharynx or upper trachea.
2 Laryngeal
web.throat, laryngeal
2 Gunshot wounds
and cut
2 Bulbar palsy. 2 Laryngotracheobronchitis.
2 As part of a surgical
procedure
Laryngeal
the treatment
and vallecular
of
cysts.
Foreign
body 3 for
fracture.
3 Following oesophageal
3 Diphtheria.
or heart
laryngeal cancer. 3 Inhalation4ofTracheo-oesophageal
steam or hot vapour. anomalies.
surgery.
4 Ludwig’s angina.
3 Carcinoma of thyroid.
5 Haemangioma
of larynx.
4 Swallowing
of corrosive fluids.
5 Radiotherapy
LIFE THREATENING AIRWAY
OBSTRUCTION
 Cricothyroidotomy.
 Indication:

Failure of
endotracheal
intubation, and
no time for
tracheostomy.
Tracheotomy
 Indications
 Technique

Open and percutaneous
 Complications
 Physiology of a tracheotomy
 Decannulation
Tracheotomy
 Creation of communication between the
trachea and the cervical skin with insertion of
a tube.
TRACHEOSTOMY
TRACHEOSTOMY
EMERGENCY
OPEN
ELECTIVE
PERCUTANOUS
Indications
 Upper Airway obstruction.
 Pulmonary Secretions.
 Ventilation.
 Prolonged mechanical ventilation.


May assist in weaning from mechanical
ventilation.
Prevention of glottic stenosis/complication of
prolonged endotracheal tube.
Pulmonary Secretion Clearance
 Aspiration / dysphagia
 COPD
 Bronchiectesis
 Stasis of secretions

Poor cough
 Poor respiratory reserve
Ventilation
 Neuromuscular disorder affecting respiratory
muscles

Reduced respiratory effort
 Limited pulmonary reserve

COPD, Scoliosis, bronchiectesis
 Central respiratory depression

Reduced level of consciousness
 Severe obstructive sleep apnea

Cor pulmonale, failure CPAP
Prolonged Intubation
 7-10 days ett
 Risk Factors for Glottic
Stenosis



Diabetes
Female
Size ETT and # ett
 Incidence glottic
stenosis: 5% over 10
days (Whited 1984)
Tracheotomy
 Decision made patient requires tracheotomy.
 Open or percutaneous technique.
 75% of tracheotomies done are done percutaneously
in ICU at bedside.
 General principles:
 External approach through neck soft tissue.
 Creation of opening in trachea.
 Placement of tube to maintain airway.
Types of tubes
 Cuffed and uncuffed
 Fenestrated and unfenestrated
 Single and double lumen
 Various diameters
Cuffs
 To protect airway
 To allow ventilation
Uncuffed
Cuffed
fenestrations
 Allow patient to
ventilate past tube via
upper airway
 Allow speech
Single/Double lumen
 Double lumen allows
easy cleaning
 Single lumen has a
greater internal
diameter
Procedure
 Skin
 Dissection
 Separate straps
 Divide thyroid isthmus
 Window in trachea
 Below 1st ring
 Stitch in place
Incision=bad
Hole=good
Contraindications
 Medically well enough for GA
 Uncontrolled coagulopathy
 Airway pathology below tracheotomy site
Tracheotomy Tubes
Portex and Shiley common brands of trach tubes.
Shiley used as standard tube at St Michael’s Hospital.
Tracheotomy Tubes
Tracheotomy Tubes
Bivona or foam cuff
Tracoe Cuffless
Speaking valve
Complications: Intraoperative
 Bleeding 2.8%*
 Recurrent laryngeal nerve injury
 Tracheoesophageal fistula
 Pneumothorax: rare
 False passage


Anterior dissection most common
Incidence <1%
*Kost et al 1994
Tracheotomy: Early Complications
 Bleeding


Minor common
Major tracheoinnominate fistula (<0.2%)*
 Obstruction of tube (2.5%)*
 Dislodgement (1.4%)*
 Pneumothorax (1 - 2.5%)*
 Wound Infection

Local care, antibiotics (staph/pseudomonas)
Late Complications






Tracheal stenosis
Tracheal chondritis
Subglottis stenosis- high tracheotomy
Tracheomalacia
Tracheoesophageal fistula
Failure of stoma closure when decannulated
 Overall complication rate 15-30% in ICU patients
 largely minor with no long term morbidity
Physiology of Tracheotomy
 Neck breathing
 Bypass upper airway and nasal function
 Loss of humidification/heat airflow
 Dryness, thick secretions
 Voicing possible with speaking valve
 Loss of smell /reduced taste
 Loss glottic closure function for cough
Physiology of Tracheotomy
Respiration
Advantages
 Lower work of breathing (30%) c/w normal
airway
 Facilitates secretion clearance

Aspiration or thick secretions
 Less dead space (100 mL)
 Reduced airway resistance
 Assists in patient independence from
mechanical ventilation
 Patient comfort (better than ett)
 Epstein 2005 Respiratory Care
Physiology of Tracheotomy
Respiration
Disadvantages
 Tube diameter and shape

increases turbulent airflow, secretions adhere inside tube
 Loss of humidification/heat function of upper airway
 Ciliary function affected
 Biofilm colonization
 Diminish cough/loss glottic closure
 Reduce laryngeal elevation during swallow
 Patient comfort (better no tube at all)
Postoperative Tracheotomy Care




Humidification via trach mask/Instill saline
Clear secretions, prevent crust
Inner cannula cleaning tid at least
If non-ventilated, change cuffed tube to noncuffed at 5-7 days
 Ties changed 2 people if possible
 Most hospital have nursing/RT protocol
 Teach everyone trach care including patient,
family
Decannulation
Decannulation
Goal is to ensure patient can tolerate increased
airway resistance/work of breathing and
secretion clearance
 30% increase WOB transition from trach
breathing to upper airway breathing
Decannulation
 Indication for tracheotomy has
resolved/improved
 Patient able to cope with secretions
 Upper airway patent - examined if necessary
 Appropriate vocal cord function
 Good respiratory reserve/overall respiratory
status
 Gag reflex present (5-10% no gag)
Decannulation
 Stable clinical condition


Hemodynamic stability
Absence of fever, sepsis infection
 Adequate swallowing

Gag reflex, bedside swallowing assessment,
video fluoscopy
 Maximum expiratory pressure > 40 cm H2O
Ceriana et al 2003