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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