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