Transcript CHOO CHOO
Tracheostomy
By Ussana Promyothin MD.
Tracheostomy
• Surgical opening in the trachea for ventilation
Indication
• Bypass upper airway obstruction • Clearance secretion at lower respiratory • Prevent aspiration gastric content in absent of laryngeal reflex
Other indication
• Prolong intubation(1-3wks) children more prolong • Laryngeal injury • Fracture face neck area
• Also • Improved oral hygiene • Oral movement for communication • Reduction damage larynx,nose ,mouth
Contraindication
• Prolong bleeding • On anti-coag, anti-pletlet medication
•
Elective tracheostomy
•
Emergency tracheostomy
: should avoid, expertised surgeon,team •
In children
: perform only with a secured airway either from ET tube or bronchoscope in OR • Emergent tracheostomy should be avoided if possible • Risk to vascular,lung and uncontrolled airway
Hyperextend the neck,
2 FB above thyroid notch ring 2,3
Skin incision,horizontal /vertical
Find white line,Test tracheostomy cuff
Clean trachea,aspirate air then push xylocaine
Stay suture,open trachea by inverted U flap,cross,vertical ( in children stay suture on both sides of incision)
Standby tracheal dilator,suction,
Post operation care
• Irrigation with saline and suction q 15 mins • Suction not exceed 15 seconds (block airway and suck Oxygen out) • Humidification Oxygen (decrease thick mucus)
• Observe bleeding and subcutaneous emphysema • Off packing 24-48hrs • Left tube in place 5-7 days • Stitch off and off stay suture 7 th day
• Blow Cuff when on ventilation or prevent aspiration • Not exceed 25 cm H2O • Clean inner tube • analgesic
Complication
Immediate
• Apnea :loss hypoxic drive,COPD ventilator • Post obstructive pulmonary edema PEEP • Pneumothorax chest x-ray post op • Injury to adjacent organ:thyroid ,vessel, esophagus,recurrent laryngeal nerve
Pneumothorax
Early
• Bleeding HT, skin,thyroid,soft tissue • Mucus inner tube • Tracheitis humidification, minimize FiO 2 , Stabilize tracheostomy • Cellulitis: wound care,antibiotic • Displacement: pass E-T tube, NG tube
Late
Bleeding -innominate vessel:usually in 2wks,high mortality ( low tracheostomy,mobilized tracheostomy tube,high pressure cuff,local infection) -granulation( stroma, tip of tube) Tracheoesophageal fistula:risk in retain NG tube
Type of Tracheostomy
Type/descr iption permanent jackson yes ventilator Inner tube no yes shiley portex blueline yes no(1month) yes no(7-14days) yes yes yes no yes size 4-5 4-6-8 7-8 7-8
Cricothyrodotomy:maneuver to buy time
Advantage • Near skin and less dissection Disadvatage • Trauma to subglottic area • Contraindication:children<12 yrs,infection at larynx,laryngeal trauma and risk transecting tumor
Tracheostomy care
• Clean skin around stroma • Change gauze • Clean inner tube • Aware obstruction or slip out of tube
Weaning tracheostomy tube
• Reason for tracheostomy has resolved • Stable lung status(O 2 <40%) • Effective swallow,gag,and cough reflex • Adequate nutrition, sleep, psychososial suppor • Cuff deflate trial
Method
• Flexible bronchoscope or IDL • Assess cord movement,granulation,stenosis area • Admit,size tube down • Plug tube day,all day night • Off tube,observe before discharge
Epistaxis
Abnormal bleeding per nose •
Cause
• Trauma ,nose picking ,nose blowing • URI, allergic rhinitis • Septum deviation • Decongestant ,nasal spray • Foreign body • Tumor • Post surgery
• Hypertension, artherosclerosis • Anticoagulation drug,ASA,NSAID • Decrease plt • Liver function disease
Site of bleeding
MANAGEMENT
• Immediate evaluation :vital sign,airway • Stop bleeding • Compress nose,cold pack
Anterior epistaxis
•
Little’s area region
•
Ephridine or adrenaline pack (vasoconstrict agent)
•
Beware in HT
•
CAUTERIZATION
•
30%TCA,silver nitrate, electrical cautery
•
Gel foam
Anterior nasal packing
Nasal speculum
Headlight
Suction
Anterior nasal packing
• Vasaline gauze or coated with antibiotic ointment • Apnea naso-vagal reflex bradycardia,hypotension • Remove packing 2-4 days later • Antibiotic and decongestant
Posterior nasal packing
Foley catheter
Posterior nasal packing
Anterior and posterior nasal packing
•
Posterior packing :oxygen face mask
•
Elevate head 30 degree
•
Antibiotic cover Staph aureus
•
Liquid diet
•
Remove packing 3-5 day later
•
If high fever ,hypotension, remind toxic shock syndrome
•
Surgery
• Ligation artery • Endoscopy •Angiogram and embolization
Sinusitis
Anatomy and function
• Resonance to voice • Humidify and warm air • Increase the area of olfactory • Absorb shock to head • Keep nasal chamber moist • Protect thermal to brain • Contribute facial growth • Lighten bone of skull
Acute bacterial sinusitis
•
Cause
• URI,AR • Dental infection • Obtruction ostium: structure,tumor • Immotile cilia • Foreign body: NG tube
Symptom • Fever • Maxillofacial pain • Dental pain • Otalgia • Posterior nasal drip • Nasal congestion
•
Causative agent
• viral • S.pneumoniae
• H.influenzae
• M.catarrhalis
• Other bacteria • Fungus
FILM SINUS
Management
• Proper antibiotic • Systemic decongestant:maxiphed • Beware: HT, Heart disease, urinary retention • Topical decongestant: not exceed 3 days • Mucolytic agent • Antihistamine if suspected allergy • Normal saline irrigation
• If failure medication • Antral puncture • • For drainage and C/S
CHRONIC BACTERIAL SINUSITIS
• Greater than 12 wks duration symptom • Treatment: antibiotic 4-6 wks • CT scan • Surgery : ESS (endoscopic sinus surgery)
ESS
Complication sinusitis •
Mucocele
•
Orbital complication:
cellulitis abscess •
Intracranial complication:
meningitis brain abscess