Transcript Tracheostomy - The Medical Post

Tracheostomy
Dr. Vishal Sharma
Jackson’s metallic tube
Jackson’s metallic tube
Jackson’s metallic tube
• Made of German silver (alloy of Ag + Cu + P)
• Has obturator (pilot), inner tube & outer tube
• Inner tube is longer than outer tube for its
removal & cleaning. Outer tube maintains
patency. Pilot is inserted into outer tube for
smooth & non-traumatic insertion of tube
• Lock prevents expulsion of tube during cough
Fuller’s bivalved metallic tube
I
O
Fuller’s metallic tube
• Outer tube bi-valved. The 2 blades when
pressed together, help in smooth entry of tube.
• Inner tube is longer & has a vent for phonation
• Pt phonates by closing main tube opening
• Vent also helps in decannulation of tube
Phonation via vent
Portex cuffed tube
Portex cuffed tube
• Made of siliconized PolyVinylChloride. It is
thermolabile & prevents crusting.
• Low pressure high volume cuff maintains an
air-tight seal required for:
• Prevention of aspiration of secretions
• Positive pressure ventilation
Cuffed double lumen tube
Cuffed fenestrated tube
Portex uncuffed tube
For tracheostomy patient receiving radiation
Uncuffed double lumen
fenestrated tube
Hands free speaking valve
Mechanism of speaking valve
Adjustable flange tube
Used in obese neck, oedema neck
Salpekar double cuff tube
Prevents ischemic necrosis of tracheal cartilage
Cold & hot water humidifiers
Heat & moisture exchanger
Nebulization attachment
Metallic Tubes
Plastic Tubes
Easily cleaned without
suction
Cleaning requires
suction
Cuff is absent
Cuff is present
Cannot be connected to
ventilator
Can be connected
Rigid & less comfortable
to patient
Soft & more
comfortable
Concomitant radiotherapy is to be avoided
Can be given
Age of pt
Tracheostomy tube size
Portex (I.D. in mm)
Metallic (Fg)
1 – 3 yrs
4.0 – 4.5
16
4 – 6 yrs
5.0
18
7 – 9 yrs
5.5
20, 22
10 – 12 yrs
6.0
24, 26
13 – 18 yrs
7.0 – 7.5
28, 30
Adult
8.0 – 9.0
32, 34, 36
Functions of Tracheostomy
1. Relieves upper airway obstruction
2. Improves alveolar ventilation by ing dead
space by 30-50% & ing airflow resistance
3. Prevention of aspiration of blood & secretions
4. Removal of airway secretions in patient with
inability to cough or with painful cough
5. Administration of anesthesia
Indications for
Tracheostomy
A. Respiratory obstruction
 Trauma to airway : external, endoscopic
 Infection: epiglottitis, croup, Ludwig’s angina,
para-pharyngeal /retro-pharyngeal abscess
 Neoplasm: laryngo-tracheal, pharyngeal
 Foreign body in airway
 Oedema of larynx: irritant, allergic, irradiation
 Paralysis of larynx: B/L abductor palsy
 Congenital: laryngeal web, cyst, choanal atresia
B. Retained airway secretions
 Inability to cough: coma, respiratory muscle
palsy or spasm, laryngectomy
 Painful cough: chest injuries, pneumonia
 Excessive secretions: pulmonary oedema
C. Respiratory insufficiency
 Chronic bronchitis, bronchiectasis, atelectasis,
reatined airway secretions
D. Anesthesia administration in:
 Laryngo-pharyngeal growths
 Maxillo-facial trauma
 Trismus
 Severe Ludwig’s angina
 Positive pressure ventilation for > 72 hrs
Types of Tracheostomy
 Emergency
 Elective
 Temporary
 Permanent
 Therapeutic
 Prophylactic
 High (1st ring): above thyroid isthmus
 Mid (2nd – 4th ring): behind thyroid isthmus
 Low (below 4th ring): below thyroid isthmus
Mid tracheostomy preferred
High tracheostomy leads to subglottic stenosis
Low tracheostomy is avoided as:
 Trachea is deeper
 Displacement of tracheostomy tube is common
 Proximity to great vessels
 Surgical emphysema is common
 Tracheostoma is close to tracheal bifurcation
Steps of Tracheostomy
Positioning
Supine position with extension of neck. General
anesthesia with endotracheal intubation.
Infiltration
 Cricoid palpated & a 5
cm horizontal incision
marked 2 cm below it
 2 % lignocaine & 1 in 2
lakh adrenaline injected
into incision line
Horizontal Incision
A 5 cm horizontal incision made with # 15 blade &
deepened below subcutaneous tissue
Vertical Incision
A 5 cm midline vertical incision can be made
below cricoid in emergency tracheostomy.
This avoids injury to blood vessels.
Exposure of strap muscles
Investing layer of deep
cervical fascia opened
vertically with artery
forceps. Palpation for
tracheal rings done
regularly during the
dissection.
Retraction of strap muscles
Exposure of thyroid isthmus
Strap muscles
retracted laterally with
Langenbeck retractors
to expose the trachea
& thyroid isthmus
Isthmus separation from trachea
Thyroid isthmus detached from tracheal
surface & retracted with blunt tracheal hook.
Isthmus retraction to expose
pre-tracheal fascia
Division of thyroid isthmus
If required, thyroid
isthmus is divided
between clamps.
Transfixion sutures
applied at the ends.
Confirmation of trachea
• 5 ml syringe containing 4 % Lignocaine taken,
its needle inserted into trachea & aspirated. Air
bubbles confirm presence of needle in trachea.
• 2 ml of solution injected into trachea & needle
removed quickly to avoid breaking of needle
during violent cough movements.
Creation of tracheal window
Sharp cricoid hook inserted below cricoid to
steady trachea. Tracheal window created by
excising anterior 1/3rd of 2nd & 3rd tracheal ring
with No. 11 blade & Allis tissue forceps.
Cautery assisted window
Holding cartilage with Allis forceps
Tracheal window
Other options
Bjork flap
Inferiorly based tracheal flap made & sutured
to lower skin edge
Insertion of tracheostomy tube
• Endotracheal tube
withdrawn into larynx
• Lubricated tracheostomy
tube inserted into trachea
• Confirm presence of tube
in trachea with help of
ambu bag & auscultation
Suturing of flanges
• Cuff inflated with 5 ml of
air & anesthetic circuit
connected to the tube
• Neck extension released
& flanges of tube
sutured to skin to avoid
tube movement
Tying the tapes
• Tapes of tracheostomy
tube tied around the neck
keeping a space for 1
finger. Neck kept flexed.
• Skin incision closed
loosely to avoid surgical
emphysema.
Padded tapes
Insertion of medicated gauze
Betadine soaked gauze or Sofratulle put
around the tracheostomy opening.
Shower collar
Shower guard
Tracheostomy locket
Immediate Complications
Occurs during operation
• Primary Haemorrhage
 Air embolism
• Cardiac Arrest
 Aspiration of blood
• CO2 withdrawal Apnoea
• Injury to: Apical pleura (pneumothorax),
recurrent laryngeal nerve, oesophagus
Intermediate Complications
Occurs within first few days
• Reactionary & secondary haemorrhage
• Blocking or displacement of tube
• Subcutaneous emphysema, pneumothorax
• Tracheitis & crusting
• Atelectasis & lung abscess
• Wound infection & granulation tissue
Surgical emphysema
Causes of surgical emphysema
after tracheostomy
• Dissection into many tissue planes in neck
• Use of smaller tracheostomy tube
• Tight closing of skin incision
• Excessive struggling & coughing of pt during
extubation
Tracheostomy site granulation
Late Complications
Occurs after weeks / months
• Subglottic stenosis, tracheal stenosis
• Tracheo-arterial or Tracheo-venous fistula
• Tracheo-oesophageal fistula
• Persistent tracheo-cutaneous fistula
• Decannulation difficulty
• Tracheostomy wound scar / keloid
• Metallic tube corrosion & fragment aspiration
Anatomy of tracheal fistulae
Tube fragment aspiration
Tracheostomy care
• Pt given 100 % oxygen. Deflate the tube cuff.
• Suction catheter with negative suction
pressure (10 -15 mmHg) used
• Catheter diameter should be < 1/3rd of
internal diameter of tracheostomy tube
• Catheter length introduced just enough to go
beyond inner tube (10 cm)
Tracheostomy care
• Multiple-eyed catheters produce less trauma
than whistle tip catheters
• Lubricated catheter tip inserted (with suction
off) as pt is inspiring. At end inspiration, suction
put on & catheter withdrawn in rotating motion.
• Each suction procedure should last for 10-15
seconds. Instill 0.5 ml NaHCO3 to liquefy crusts.
Tracheostomy care
• Chest auscultated for confirmation of adequate
suctioning. Re-inflate cuff to a pressure of 25
mmHg. Patient oxygenated again.
• Tracheostomy wound dressing done BID
• Steam inhalation TID. Moist gauze piece placed
over tracheostomy tube opening. Regular chest
physiotherapy, expectorants & mucolytics given.
Wall suction
Portable suction
Closed-system Multiple-use
Suction Unit (CMSU)
Communication chart for pt
Electronic communication
Hand bells
Tracheostomy tube changing
• Inner tube is removed & cleaned when blocked
• Outer tube never removed before 72 hrs to
allow formation of tracheo-cutaneous tract
• Cuff of Portex tube deflated for 10 minutes
every 2 hours to prevent pressure necrosis &
dilatation of trachea
Pt position in tube changing
Cleaning of inner tube
Tube removal over bougie
Obturator guide wire insertion
Decannulation
• Adult: plug or seal tube opening & if tolerated
for 24 hrs, remove tube.
• Child: Sequentially reduce size of tube.
• After tube removal  close wound. Healing
occurs within 1 week. Secondary closure after
freshening the wound margin is required rarely.
Capping of tube opening
Decannulation difficulty
Organic causes:
• Persistence of cause requiring tracheostomy
• Obstructing tracheal granulations
• Tracheal oedema
• Subglottic stenosis
• Collapse of tracheal wall (tracheomalacia)
Decannulation difficulty
Non-organic causes:
• Emotional dependence in children
• Inability to tolerate upper airway resistance
• In-coordination of laryngeal opening reflex
• Long-standing tube leads to impaired
laryngeal development
Tracheostomy
Intubation
Invasive
Non-invasive
Complications are more
Less
Can be kept for > 7 days
Should not be kept
Pt can speak
Cannot speak
Tracheo-bronchial toilet is easy
Difficult
Decreases dead space by 30-50%
Does not
Disadvantages of Tracheostomy
• Anosmia: no nasal air entry
• Aphonia: avoided by phonatory vent
• Aspiration: avoided by cuffed tube
• Inability to lift heavy weight
• Inability to perform strenuous exercise
• Inability to swim
Percutaneous Tracheostomy
Insertion of cannula
Insertion of guide wire
Tracheal dilator over guide wire
Insertion of tracheal dilator
Tracheostomy tube
Insertion of tracheostomy tube
Percutaneous Tracheostomy
• Trachea punctured with needle & cannula
• Needle removed & a guide wire passed into
trachea via cannula
• Cannula removed & graded dilators passed
over guide wire till the opening can admit a
tracheostomy tube
Cricothyrotomy
Cricothyrotomy
1. Midline vertical skin incision made to identify
cricothyroid notch. 2. Cricothyroid membrane
incised horizontally, with # 11 blade, close to
cricoid. 3. Knife handle inserted & rotated by 900,
to widen the horizontal opening or tracheostomy
tube is inserted. 4. Elective tracheostomy done
as soon as possible to avoid subglottic stenosis.
Tracheal fenestration
Tracheal fenestration
Tracheal fenestration
Tracheal fenestration
• Indicated for C.O.P.D. where tracheal opening is
required for mechanical cleaning.
• Bilateral medial based skin flaps elevated &
tracheal opening made.
• Distal edges of flaps sutured to margins of
tracheal window.
• Lateral edges of 2 flaps sutured to each other to
create watertight skin buttons.
Thank You