Transcript 2. Stedman`s Medical Dictionary

Components of a standard tracheostomy tube
Following Successful Liberation From Prolonged Mechanical
Ventilation

Absence of distress and stable arterial blood gases on prolonged
mechanical ventilation for 5 days
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Stable clinical condition indicated by factors such as:
1Hemodynamic stability
2Absence of fever, sepsis, or active infection
3PaCO2 60 mm Hg
4
Normal endoscopic examination or revealing stenotic lesions
occupying 30% of the airway
5
Absence of delirium or psychiatric disorders
6
Adequate swallowing evaluated by gag reflex, blue dye, and
video fluoroscopy
7
Patient able to expectorate on request
8
Maximum expiratory pressure 40 cm H2O
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ComplicationsNo. ofcasesPercent ofTotal Outcome
Tracheal stenosis
21
1.85
Hemorrhage
9
0.87
Tracheocutaneous fistula
6
0.53
Infection
5
0.44
Pneumothorax
3
0.26
Tube decannulation/obstruction 1
0.08
Subcutaneous emphysema
1
0.08
Tracheoesophageal fistula
1
0.08
directly proportional to length
 inversely proportional to the radius of the tube
raised to the 4th power (when flow is laminar)
 When flow becomes turbulent, airways resistance
becomes inversely proportional to the radius of the
tube raised to the 5th power.
 small reductions in tube radius result in large
increases in resistance.
 Turbulent flow occurs when flow rates are high,
when secretions adhere to the inside of the tube
and because of tube curvature.
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The word tracheostomy is derived from 2
Greek words
meaning “I cut the trachea.”
ENDOTRACHEAL
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Size ID length
6
6
31
7
7
34
8
8
35
8.5
8.5 36
mm cm
TRACH
Vd
11
15
18
24
ml
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Size
4
6
8
10
ID
5
7
8.5
9
mm
length Vd
10
3
12
5
12
6
12
8
cm
ml
Tracheostomy tubes have an
important effect on respiratory
physiology. The most recent
and methodological
robust studies indicate that
these tubes reduce resistive and
elastic WOB when compared to
ETTs. This is a result of
tracheostomy tubes lessening
inspiratory and expiratory
airways resistance and intrinsic
PEEP.
Before tracheostomy
Vt ml
329
Ve l/m
9.2
F b/m
28
PEEPi cm/h20
2.9
PTP cm/h20xs/min 236
WOB J/L
.97
WOB J/min
8.9
Exp RAW
9.4
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After tracheostomy p
312
0.47
8.1
0.26
26
0.51
1.6
0.02
155
0.09
.81
0.09
6.6
0.04
6.3
0.07
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20 surgical patients
14 men
Mean age 58
Acute lung injury
Ventilate mean 16
days
Met extubation
criteria
Failed extubation
twice before trach
decision
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80% had #8 ETT
20% #7 ETT
Measurements: 6-8
hours before and 12
hours after surgical
trach.
THE 2ND TRACHEAL RING IS DIVIDED
LATERALLY AND THE ANTERIOR PORTION
REMOVED
INSTEAD OF RESECTING AND REMOVING
THE TRACHEAL RING, IT CAN BE USED TO CREATE A
FLAP, WHICH CAN
BE ATTACHED TO THE SKIN. THIS METHOD, DESCRIBED
BY BJORK.,
FIBEROPIC BRONCHOSCOPY IS USED TO HELP
PLACE THE GUIDE
WIRE CORRECTLY FOR PDT. HERE THE WIRE IS
SEEN IN THE ANTERIOR PART OR
THE TRACHEA, PASSING BETWEEN THE 2ND AND
3RD TRACHEAL RINGS.
HERE IS THE BRONCHOSCOPIC VIEW OF THE TIP
OF A DILATOR ENTERING
THE TRACHEA OVER THE GUIDE WIRE DURING
PLACEMENT OF A PERCUTANEOUS
DILATIONAL TRACHEOSTOMY.
A SERIES OF TAPERED DILATORS ARE
SEQUENTIALLY INSERTED OVER THE GUIDE WIRE
TO CREATE THE STOMA FOR
PLACEMENT OF THE TRACHEOTOMY TUBE.
THE BLUE RHINO IS A SINGLE DILATOR THAT
CAN BE USED INSTEAD OF THE SEQUENTIAL
DILATORS OF THE CIAGLIA METHOD
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The Rig Veda,
sacred book of Hindu medicine, written between
2000 and 1000 BC.
The Ebers Papyrus, dating from about 1550
BC. The Ebers Papyrus is written in hieratic
Egyptian writing and preserves for us the most
voluminous record of ancient Egyptian medicine
known.
The ancient Chinese text Huang Ti Nei Ching Su
Wen contains no reference to any surgical
procedure.
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In the 8th century BC, Homer is said to have
described the relief of choking persons on
cutting into the trachea.
Hippocrates (4th century BC) may have
referred to tracheal cannulation as a treatment
for quinsy (peritonsillar abscess).
Alexander the Great, in
the 4th century BC, “punctured the trachea of a
soldier with the point of his sword when he
saw the man choking from a bone lodged in his
throat.”
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Both Aretaeus and Galen, in the 2nd Century
AD, wrote that Asclepiades of Bithynia
performed elective tracheostomy in around 100
BC. McClelland RM
Galen, the most eminent Greek physician after Hippocrates.
Antyllus of Rome told in AD 340 of making a
transverse incision between the 3rd and 4th
tracheal rings, drawing the cartilages apart
with hooks, and subsequently sewing the
edges of the wound together once the patient
could breathe more freely. Frost EA
Antyllus', a 4th century Roman physician.
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The first account of the procedure to be written by the
surgeon who performed it
was by Brasavola in 1546, who used it to relieve airway
obstruction from enlarged tonsils. McClelland RM
Antonio Musa Brassavola (variously spelled Brasavoli, Brasavola, or Brasavoli, born January 16,
1500 in Ferrara) was an Italian physician and one of the most famous of his time.
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At about the same time , Fabricius ab Aquadependente
is said to have performed a tracheostomy on a patient
with a foreign body in the larynx , as well as on several
other occasions. Frost
EA
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The first step towards percutaneous tracheotomy was made by the famous Italian anatomist and surgeon Fabricius of Aquapendente ( 1537-1619).
Sanatorius , in 1590, first used a trocar for
tracheostomy, and reported leaving a cannula in place
for 3 days. Frost EA
The Italian surgeon Sanctorio Sanctorius (1561-1636) was probably the first surgeon to describe
percutaneous tracheotomy (Sanctorius, 1626).
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The word tracheostomy was first used by Heister
in 1739 (German surgeon Laurentius
Heister(1683-1758).
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George Washington, who died in 1799,
developed progressive upper-airway
obstruction, the cause of which is thought most
likely to have been acute epiglottitis. Scheidemandel HH.
Did George Washington die of quinsy? Arch Otolaryngol 1976;102(9):519–521.5.
Witt CB Jr. The health and controversial death of George Washington. Ear Nose Throat J 2001;80(2):102–105.
The prominent physician Elisha C Dick, who
examined the former president, recommended
tracheostomy, but was overruled by the other
physicians in attendance. Frost EA. Tracing the tracheostomy . Ann
OtolRhinol Laryngol 1976;85(5 Pt 1):618–624.
Witt CB Jr. The health and controversial death of George Washington Ear Nose Throat J 2001;80(2):102–105.
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In the early 19th century, performance of the
procedure became more widespread and there
were multiple reports in the medical literature.
Trousseau reported in 1869 on 215 patients in
whom tracheostomy was performed in the
treatment of diphtheria (with 47 survivors), his
series having begun during the 1830s.
The 1860 yearbook of the New Sydenham
Society contained some 38 papers devoted to
indications and techniques of tracheostomy.
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In this country,the famous surgeon Chevalier
Jackson refined the technical aspects of the
procedure and described them in detail in 1909.
Chevalier Jackson standardized the indications
for tracheostomy, the technique itself, and the
instruments used, around the turn of the 20th
century. He developed anatomically correct
tracheostomy tubes, recommended a“high”
tracheostomy location (ring 2 or 3).
1.
Merriam-Webster Online Dictionary:
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• Tracheostomy: the surgical formation of an opening into
the trachea through the neck especially to allow the passage
of air
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• Tracheotomy: the surgical operation of cutting into the
trachea especially through the skin
2. Stedman’s Medical Dictionary:
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• Tracheostomy: An operation to make an opening into
the trachea.
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• Tracheotomy: The operation of incising the trachea, usually
intended to be temporary
3. Oxford English Dictionary:• Tracheostomy: The operation of making an
opening in
the trachea near its upper end, so that the patient can
breathe through it; also, the opening so made
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• Tracheotomy: = tracheostomy
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administer positive-pressure ventilation
provide a patent airway
provide protection from aspiration
Airway protection in head injured or comatose
patient
and in postoperative neurosurgical patients
provide access to the lower respiratory tract
for
airway clearance
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1.
2.
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1.
2.
3.
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1.
a)
b)
1.
2.
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ID
OD
Curve
Angled
Curved
Length
Xl proximal
Xl distal
normal
Cuffed
Low pressure
Fenestrated
Non-fenestrated
Tight to shaft
Foam
Uncuffed
Shiley uses the Jackson scale most of the time
(xl and SCT uses ISO)
w/IC #4 = ID= 5.0, #6= ID 6.4, #8= ID 7.6 , #10=
ID 8.9mm.
 Portex uses the International Standards
Organization (ISO) scale. Median –measure at
shaft.
The functional internal diameter size. Subtract
1mm for inner cannula.
w/o IC #6= ID 6mm, #7 =ID 7mm, #8= ID 8mm
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the rigid cricoid cartilage encases a 1.5–2.0-cm
region known as the subglottic space.
Inferior to cricoid is the trachea, a cylindrical
tube that extends inferiorly and slightly
posteriorly.
The trachea is made up of 18–22 C-shaped
rings consisting of rigid cartilage anteriorly and
laterally, and a membranous posterior portion.
In the average adult, the distance from cricoid
to carina is approximately 11 cm in length, with
a range of 10–13 cm.
#4
11.47 cm H2O/L/s
 #6
3.96 “
 #8
1.75 “
 #10
0.69
Mullins JB, Templer JW, Kong J, Davis WE, Hinson J.
Airway
resistance and work of breathing in tracheostomy tubes.
Laryngoscope 1993;103(12):1367–1372
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SHAPE
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C
U
D
E
T
O
#MALE
14
33
16
21
16
0
#FEMALE
38
 10
 6
 45
 0
 1
The tone of the trachealis
muscle that bridges the
gaps posteriorly between
rings is responsible for the
shape differences.
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1.Reduced dead space
2.Less airway resistance
3.Decreased work of breathing
4.Better secretion removal with suctioning
5.Less likelihood of tube obstruction
6.Improved patient comfort
7.Less need for sedation
8.Better glottic function, with less risk of
aspiration
9.Ability to move patient out of the
intensive care unit
10.Changes in clinician behavior
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Inner Diameter
6
7
7.5
8
8.5
9
Outer Diameter
9.2
10.5
11.3
11.9
12.6
13.3
Length
64.5
70
73
75.5
78
81
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Can be used with Perc kit. Markings line up.
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1.
2.
3.
4.
5.
Pathologic correlates for hypoxemia
Low inspired O2: high altitude, smoke inhalation.
Alveolar hypoventilation: COPD acute
exacerbation, Acute asthma exacerbation,
neuromuscular weakness.
Ventilation-perfusion mismatch: COPD
exacerbation, asthma exacerbation, mild CHF,
mild pna, mild atelectasis.
Shunt, right to left: severe exacerbation
COPD/asthma, severe
CHF/pneumonia/atelectasis, ARDS.
Diffusion defect: acts a a V/Q mismatch.
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Work this table back and forth to determine
FIO2 change and device change.
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Low flow vs high flow; aka variable O2 devices
vs fixed O2 devices.
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A)The amount of oxygen (FiO2) desired (*This
is the fundamental consideration.)
B)The degree of FiO2 precision required.
(*The Venturi mask is the mask of choice for
“CO2 retainers”.)
C)Patient comfort and compliance.
D)The need for aerosol mist.
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1) Most commonly used device because of
excellent patient tolerance.
2) The delivered oxygen at any flow setting
depends primarily on the patient’s ventilatory
pattern.
3) Can deliver from 24 – 40% oxygen and is
ordered at flows of ¼ to 6 liters per minute.
4) Humidification should be used for flows greater
than 4L/minute.
(*Exceptions: Humidification for flow rates
<4L/min may be considered if the patient requests
it, if the patient experiences epistaxis, or if the
patient complains of a dry nose, dry secretions,
and/or a sore throat.)
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1) A reservoir bag is added to the simple mask
design to deliver over 60% oxygen (from 60-80%
oxygen).
2) A Non-Rebreather Mask is used and the 2 flaps
are removed to create a Partial Non-Rebreather
Mask.
3) The system allows the first part of the patient’s
exhalation to enter the bag (anatomic dead space
gas).
4) The reservoir bag should NOT deflate
completely on inspiration. If this occurs, the
patient may rebreathe his or her own CO2.
5) Partial rebreathers should always run at about
10 liter/minute to prevent total collapse.
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1) The use of valves in the non-rebreather mask
allows for one way flow of 100% oxygen into the
reservoir bag and then out to the patient with no
rebreathing of expired gas.
2) This delivery system is used when one needs to
deliver a high percentage of oxygen quickly.
3) Flow rates of 10 – 15 liters per minute
theoretically provide the patient’s entire inspired
volume.
4) Increased respiratory drive along with improper
seal of the mask may all for room air to be
inspired.
6) The non rebreather mask contains 2 valves.
Check labeling to be sure valves are latex free.