Tracheostomy; When to
Perform and How to
Manage
Gamal Rabie Agmy, MD,FCCP
Professor of Chest Diseases
,Assiut University
Tracheostomy History
The Tracheostomy is
one of the oldest
surgical procedures.
It can be traced back
to Egyptian tablets
...
Who famous person died of
an upper airway obstruction
because their M.D. was
unwilling to perform his 1st
tracheostomy on ...
*George Washington
toured his estate on
horseback one cold
and rainy day in 179

9.

*The next day he had
severe upper air...
Antonio Musa Brasavola, an Italian
physician,
performed
the
first
documented case of a successful
tracheotomy. He publishe...
Evolution of Mechanical Ventilation in
Response to Clinical Research
Esteban A et al. Am J Respir Crit Care Med 2008; 177:...
WHY ?
WHEN ?
WHICH ?
WHO and HOW?
INDICATIONS FOR TRACHEOSTOMY
•
•
•
•
•
•
•

Prolonged intubation
Facilitation of ventilation support
Inability of patient ...
Why Tracheostomy
Pelosi P et al Crit Care 2004; 8:322-324

Facilitate prolonged assisted ventilation
- Coma
• Major Head i...
Why Tracheostomy
Pelosi P et al Crit Care 2004; 8:322-324

Inability to prevent pulmonary
aspiration
- Posterior fossa/inf...
Why Tracheostomy
Pelosi P et al Crit Care 2004; 8:322-324

Upper airway obstruction
- Maxillofacial surgery or trauma
- Co...
Predictors of Outcome for Patients With COPD
Requiring Invasive Mechanical Ventilation
Nevins ML et al Chest 2001;119;1840...
TRACHEOSTOMY VS
TRANSLARYNGEAL INTUBATION
–
–
–
–
–
–
–
–
–
–

Increased patient mobility
More secure airway
Increased com...
Disadvantages of Tracheostomy
Pelosi P et al Crit Care 2004; 8:322-324
Blot F et al. Chest 2005; 127:1347–1352

- Tracheal...
Contraindications for tracheostomy (?)
Groves DS et al Curr Opin Crit Care 2007, 13:90–97

Absolute contraindications (rar...
Postulated
Direct effects

Indirect effects

Reduction of dead space
Reduction of airway
resistance and dead space

Less n...
Tracheostomy: WOB and PEEPi
Diehl JL et al.Am J Respir Crit Care Med 1999, 159:383-388
Is tracheostomy associated with better
outcomes for patients requiring long-term
MV ?
Combes A et al. Crit Care Med 2007; ...
Tracheostomy does not improve the outcome of
patients requiring prolonged MV: A propensity
analysis
Clec’h C et al Crit Ca...
Indications for tracheostomy
Plummer AL, Gracey DR. Consensus conference on artificial
airways in patients receiving mecha...
Indications for tracheostomy
Chastre J, Bedock B, Clair B, et al. Which tracheal route
should be used for mechanical venti...
Indications for tracheostomy
MacIntyre NR, Cook DJ, Ely EW Jr, et al. Evidence-based guidelines for
weaning and discontinu...
Tracheostomy in the critically ill:
indications, timing and techniques
Groves DS et al Curr Opin Crit Care 2007, 13:90–97
...
How Is Mechanical Ventilation Employed
in the Intensive Care Unit ?

Esteban A et al Am J Respir Crit Care Med 2000; 161; ...
Outcome of mechanically ventilated
patients who require a tracheostomy
Frutos-Vivar F et al. Crit Care Med 2005;
33:290 –2...
Incision 1 cm below the cricoid or
halfway between the cricoid and the
sternal notch.

Retractors are placed, the skin is
...
The thyroid isthmus lies in the field of the dissection.
Typically, the isthmus is 5 to 10 mm in its vertical dimension,
m...
• Shiley
tracheostomy tube:
#6
• Shiley
tracheostomy tube:
#8 for
bronchoscopy.
PERCUTANEOUS DILATIONAL TRACHEOTOMY

Guidewire introduction, with removal
of sheath

Guidewire and catheter are advanced
t...
PERCUTANEOUS DILATIONAL TRACHEOTOMY

Guidewire and catheter are
advanced together into the
trachea as far as the skin
posi...
PERCUTANEOUS DILATIONAL TRACHEOTOMY

The tracheotomy tube is loaded onto a dilator
and advanced into the trachea over the
...
PERCUTANEOUS DILATIONAL
TRACHEOTOMY

Cook Ciaglia percutaneous dilatational tracheostomy kit
Percutaneous trachesotomy techniques
"classical" Ciaglia technique
Ciaglia P, Firsching R, Syniec C.
Elective percutaneous...
Technical approach

Criggs
Ciaglia
Frova
Blue Rhino
T-Dagger
Blue Dolphin
Seldinger guide wire  Carina
Management
LONG-TERM MANAGEMENT
•
•
•
•
•
•
•
•

CHOICE OF CANNULA
CUFF MANAGEMENT
MALPOSITION
REPLACEMENT
HUMIDIFICATION
DYSPHAGIA
P...
LONG-TERM MANAGEMENT
•
•
•
•
•
•
•
•

CHOICE OF CANNULA
CUFF MANAGEMENT
MALPOSITION
REPLACEMENT
HUMIDIFICATION
DYSPHAGIA
P...
ANGLED

CURVE
Specific case of thorax deformity
INNER CANNULA
Jackson ID with inner
ID without
size
cannula
inner cannula

ED

4

5.0 mm

6.7 mm

9.4 mm

6

6.4 mm

8.1 mm

8

7.6 mm

...
LONG-TERM MANAGEMENT
•
•
•
•
•
•
•
•

CHOICE OF CANNULA
CUFF MANAGEMENT
MALPOSITION
REPLACEMENT
HUMIDIFICATION
DYSPHAGIA
P...
20-30 cmH20
DEFLATED CUFF

INFLATED CUFF
INFLATED

DEFLATED
DEFLATED CUFF

INFLATED CUFF
LONG-TERM MANAGEMENT
•
•
•
•
•
•
•
•

CHOICE OF CANNULA
CUFF MANAGEMENT
MALPOSITION
REPLACEMENT
HUMIDIFICATION
DYSPHAGIA
P...
LONG-TERM MANAGEMENT
•
•
•
•
•
•
•
•

CHOICE OF CANNULA
CUFF MANAGEMENT
MALPOSITION
REPLACEMENT
HUMIDIFICATION
DYSPHAGIA
P...
TUBE REPLACEMENT
• FIRST CHANGE ADVISABLE > 10-15
DAYS AFTER TRACHEOSTOMY
• NO FIXED SCHEDULE FOR
REPLACEMENT BUT HIGHLY
D...
LONG-TERM MANAGEMENT
•
•
•
•
•
•
•
•

CHOICE OF CANNULA
CUFF MANAGEMENT
MALPOSITION
REPLACEMENT
HUMIDIFICATION
DYSPHAGIA
P...
PHYSIOLOGIC CHANGES
AFTER TRACHEOTOMY
LONG-TERM MANAGEMENT
•
•
•
•
•
•
•
•

CHOICE OF CANNULA
CUFF MANAGEMENT
MALPOSITION
REPLACEMENT
HUMIDIFICATION
DYSPHAGIA
P...
RESPIRATORY INTENSIVE CARE UNIT
PAVIA 2000-2008 (710 patients)

Tracheotomy and dysphagia

16%
OF
NGP
26%

58%

PEG
TRACHEOSTOMY AND
DYSPHAGIA
•
•
•
•
•
•
•

EPIGL. BACKWARD FOLDING 80%
RETENTION IN VALLECULAE 70%
LARYNX ELEVATION
40%
GAG...
LONG-TERM MANAGEMENT
•
•
•
•
•
•
•
•

CHOICE OF CANNULA
CUFF MANAGEMENT
MALPOSITION
REPLACEMENT
HUMIDIFICATION
DYSPHAGIA
P...
PHONATION
• REQUIRED A SUBGLOTTIS
PRESSURE OF AT LEAST 2-3
cmH2O
• REQUIRED A FLOW THROUGH THE
UPPER AIRWAY > 3 L/min
Speaking during spontaneous breathing
One way Passy Muir
Valve to speak under
mechanical ventilation
INSPIRATION

ESPIRATION - ZEEP
ESPIRATION
+ PEEP
LONG-TERM MANAGEMENT
•
•
•
•
•
•
•
•

CHOICE OF CANNULA
CUFF MANAGEMENT
MALPOSITION
REPLACEMENT
HUMIDIFICATION
DYSPHAGIA
P...
RESPIRATORY INTENSIVE CARE UNIT
PAVIA 2000-2008 (618 patients)

Tracheotomy at discharge

43%
NO
YES
57%
RESPIRATORY INTENSIVE CARE UNIT
PAVIA 2000-2008 (352 patients)

Patients weaned from tracheotomy
5%
29%
34%

NM
PA
PC
PO

...
CONCLUSIONS
Complications of
Tracheostomy
• Complications 5-40%
• Mortality <2%
• Complications are more frequent in
emergency situati...
Complications of
Tracheostomy
– Stoma
• Stoma site infection
• Stomal hemorrhage
• Poor stoma healing after
decannulation ...
Complications of
Tracheostomy
– Trachea
• Granuloma
• Tracheoesophageal fistula
fewer than 1% of patients as a result of
p...
Complications of
Tracheostomy
• Tracheoinnominate fistula:
0.4% with mortality rate of 85% to 90%.
Major airway hemorrhage...
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
Tracheostomy:When to perform and How to manage?
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Tracheostomy:When to perform and How to manage?

  1. 1. Tracheostomy; When to Perform and How to Manage Gamal Rabie Agmy, MD,FCCP Professor of Chest Diseases ,Assiut University
  2. 2. Tracheostomy History The Tracheostomy is one of the oldest surgical procedures. It can be traced back to Egyptian tablets from 3600 B.C.
  3. 3. Who famous person died of an upper airway obstruction because their M.D. was unwilling to perform his 1st tracheostomy on a person of such stature??
  4. 4. *George Washington toured his estate on horseback one cold and rainy day in 179 9. *The next day he had severe upper airway swelling.
  5. 5. Antonio Musa Brasavola, an Italian physician, performed the first documented case of a successful tracheotomy. He published his account in 1546. The patient, who suffered from a laryngeal abscess and recovered from the procedure
  6. 6. Evolution of Mechanical Ventilation in Response to Clinical Research Esteban A et al. Am J Respir Crit Care Med 2008; 177: 170–177 26% 25% 27% 20% Rate of Tracheostomy 1998 vs 2004 11% vs 12.5%
  7. 7. WHY ? WHEN ? WHICH ? WHO and HOW?
  8. 8. INDICATIONS FOR TRACHEOSTOMY • • • • • • • Prolonged intubation Facilitation of ventilation support Inability of patient to manage secretions Upper airway obstruction Inability to intubate Adjunct to major head and neck surgery Adjunct to management of major head and neck trauma
  9. 9. Why Tracheostomy Pelosi P et al Crit Care 2004; 8:322-324 Facilitate prolonged assisted ventilation - Coma • Major Head injury • Cerebral bleed/infarct/lesion • Encephalitis - High spinal cord injury - Neuromuscular disorder • Guillain-Barre syndrome • Critical Care Polyneuropathy - COPD
  10. 10. Why Tracheostomy Pelosi P et al Crit Care 2004; 8:322-324 Inability to prevent pulmonary aspiration - Posterior fossa/infratentorial lesions • Cerebellum/brain stem • Basilar/posterior cerebral artery • Encephalitis - Cranial nerve dysfunction
  11. 11. Why Tracheostomy Pelosi P et al Crit Care 2004; 8:322-324 Upper airway obstruction - Maxillofacial surgery or trauma - Congenital malformation - Facilitate upper cervical surgery - Vocal cord paralysis
  12. 12. Predictors of Outcome for Patients With COPD Requiring Invasive Mechanical Ventilation Nevins ML et al Chest 2001;119;1840-1849 - Previous Mechanical Ventilation - FEV1/FVC < 30% predicted - COPD Exacerbation - Low Ht (< 35%) and Albumin (< 2.5 g/dL) - APACHE (> 15, 6 hrs after MV) - Active Malignacy
  13. 13. TRACHEOSTOMY VS TRANSLARYNGEAL INTUBATION – – – – – – – – – – Increased patient mobility More secure airway Increased comfort Improved airway suctioning Early transfer of ventilator-dependent patients from the intensive care unit (ICU) Less direct endolaryngeal injury Enhanced oral nutrition Enhanced phonation and communication Decreased airway resistance for promoting weaning from mechanical ventilation Decreased risk for nosocomial pneumonia in patient subgroups Heffner, Hess.Clinics in Chest Medicine 22 , 2001.
  14. 14. Disadvantages of Tracheostomy Pelosi P et al Crit Care 2004; 8:322-324 Blot F et al. Chest 2005; 127:1347–1352 - Tracheal complications - Aggressive procedure - Risk of stomal infection - Esthetic sequelae - Bleeding - Psychological trauma - Delayed ICU discharge - Organizational difficulties - Increased risk in ward
  15. 15. Contraindications for tracheostomy (?) Groves DS et al Curr Opin Crit Care 2007, 13:90–97 Absolute contraindications (rare): - Soft tissue infections of the neck - Anatomic aberrations Relative controindications: - Severe respiratory distress with refractory hypoxemia and hypercapnia - Hematologic and coagulation disorders
  16. 16. Postulated Direct effects Indirect effects Reduction of dead space Reduction of airway resistance and dead space Less need for sedation Reduced rate of VAP Shortened weaning period Shortened ICU stay Lower mortality
  17. 17. Tracheostomy: WOB and PEEPi Diehl JL et al.Am J Respir Crit Care Med 1999, 159:383-388
  18. 18. Is tracheostomy associated with better outcomes for patients requiring long-term MV ? Combes A et al. Crit Care Med 2007; 35:802–807
  19. 19. Tracheostomy does not improve the outcome of patients requiring prolonged MV: A propensity analysis Clec’h C et al Crit Care Med 2007; 35:132–138 Odds ratios for post-intensive care unit mortality associated with tracheostomy in patients matched on propensity scores OR - All patients - Patients decannulated before discharge - Patients not decannulated before discharge 95% CI p Value 2.57 1.20-5.48 0.01 1.43 0.42-4.90 0.56 3.73 1.41-9.83 0.008
  20. 20. Indications for tracheostomy Plummer AL, Gracey DR. Consensus conference on artificial airways in patients receiving mechanical ventilation. Chest 1989; 96:178–180 - If the need for an artificial airway is anticipated to be greater than 21 days
  21. 21. Indications for tracheostomy Chastre J, Bedock B, Clair B, et al. Which tracheal route should be used for mechanical ventilation in the critically ill? Thirteenth consensus conference on resuscitation and emergency medicine. Rean Urg 1998; 7:435–442 - Mechanical ventilation anticipated to last between 10 and 21 days - The decision left to the attending MD - Daily assessment was recommended as to the need for continued intubation
  22. 22. Indications for tracheostomy MacIntyre NR, Cook DJ, Ely EW Jr, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitatedby the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001; 120 (6 Suppl):375S–395S. - After an initial period of stabilization on the ventilator (generally, within 3–7 days) - When apparent that the patient will require prolonged ventilator assistance
  23. 23. Tracheostomy in the critically ill: indications, timing and techniques Groves DS et al Curr Opin Crit Care 2007, 13:90–97 Prolonged Mechanical Ventilation
  24. 24. How Is Mechanical Ventilation Employed in the Intensive Care Unit ? Esteban A et al Am J Respir Crit Care Med 2000; 161; 1450–1458 Percentage of pts with tracheostomy
  25. 25. Outcome of mechanically ventilated patients who require a tracheostomy Frutos-Vivar F et al. Crit Care Med 2005; 33:290 –298 Tracheostomy performed at a median time of 12 days (7–17) from beginning mechanical ventilation.
  26. 26. Incision 1 cm below the cricoid or halfway between the cricoid and the sternal notch. Retractors are placed, the skin is retracted, and the strap muscles are visualized in the midline. The muscles are divided along the raphe, then retracted laterally
  27. 27. The thyroid isthmus lies in the field of the dissection. Typically, the isthmus is 5 to 10 mm in its vertical dimension, mobilize it away from the trachea and retract it, then place the tracheal incision in the second or third tracheal interspace
  28. 28. • Shiley tracheostomy tube: #6 • Shiley tracheostomy tube: #8 for bronchoscopy.
  29. 29. PERCUTANEOUS DILATIONAL TRACHEOTOMY Guidewire introduction, with removal of sheath Guidewire and catheter are advanced together into the trachea as far as the skin positioning marks on the guide catheter to the skin.[
  30. 30. PERCUTANEOUS DILATIONAL TRACHEOTOMY Guidewire and catheter are advanced together into the trachea as far as the skin positioning marks on the guide catheter to the skin Guidewire, guide catheter, and dilator unit are advanced together into the trachea to the skin positioning mark
  31. 31. PERCUTANEOUS DILATIONAL TRACHEOTOMY The tracheotomy tube is loaded onto a dilator and advanced into the trachea over the guidewire and catheter. The guidewire and catheter are removed, leaving only the tracheostomy tube in the trachea
  32. 32. PERCUTANEOUS DILATIONAL TRACHEOTOMY Cook Ciaglia percutaneous dilatational tracheostomy kit
  33. 33. Percutaneous trachesotomy techniques "classical" Ciaglia technique Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy a new simple bedside procedure: preliminary report. Chest 1985; 87:715-719 Griggs forceps technique Griggs WM, Gilligan JE, Myburg JA. A simple percutaneous tracheostomy technique Surgery 1990; 170:543-544 Fantoni - translaryngeal technique Fantoni A, Ripamonti D. A non-derivative, non surgical tracheostomy: the translaryngeal method. Intensive Care Med 1997; 27:386-392 PercuTwist Frova G, Quintel M. A new simple method for percutaneous tracheostomy: controlled rotating dilation Intensive Care Med 2002; 28:299-303
  34. 34. Technical approach Criggs Ciaglia Frova Blue Rhino T-Dagger Blue Dolphin Seldinger guide wire  Carina
  35. 35. Management
  36. 36. LONG-TERM MANAGEMENT • • • • • • • • CHOICE OF CANNULA CUFF MANAGEMENT MALPOSITION REPLACEMENT HUMIDIFICATION DYSPHAGIA PHONATION WEANING
  37. 37. LONG-TERM MANAGEMENT • • • • • • • • CHOICE OF CANNULA CUFF MANAGEMENT MALPOSITION REPLACEMENT HUMIDIFICATION DYSPHAGIA PHONATION WEANING
  38. 38. ANGLED CURVE
  39. 39. Specific case of thorax deformity
  40. 40. INNER CANNULA
  41. 41. Jackson ID with inner ID without size cannula inner cannula ED 4 5.0 mm 6.7 mm 9.4 mm 6 6.4 mm 8.1 mm 8 7.6 mm 9.1 mm 10 8.9 mm 10.7 mm 10.8 mm 12.2 mm 13.8 mm
  42. 42. LONG-TERM MANAGEMENT • • • • • • • • CHOICE OF CANNULA CUFF MANAGEMENT MALPOSITION REPLACEMENT HUMIDIFICATION DYSPHAGIA PHONATION WEANING
  43. 43. 20-30 cmH20
  44. 44. DEFLATED CUFF INFLATED CUFF
  45. 45. INFLATED DEFLATED
  46. 46. DEFLATED CUFF INFLATED CUFF
  47. 47. LONG-TERM MANAGEMENT • • • • • • • • CHOICE OF CANNULA CUFF MANAGEMENT MALPOSITION REPLACEMENT HUMIDIFICATION DYSPHAGIA PHONATION WEANING
  48. 48. LONG-TERM MANAGEMENT • • • • • • • • CHOICE OF CANNULA CUFF MANAGEMENT MALPOSITION REPLACEMENT HUMIDIFICATION DYSPHAGIA PHONATION WEANING
  49. 49. TUBE REPLACEMENT • FIRST CHANGE ADVISABLE > 10-15 DAYS AFTER TRACHEOSTOMY • NO FIXED SCHEDULE FOR REPLACEMENT BUT HIGHLY DEPENDENT ON LOCAL POLICY • CLOSELY LINKED TO THE TYPE OF CANNULA (INNER CANNULA etc) AND TO THE QUALITY OF DOMICILIARY MANAGEMENT
  50. 50. LONG-TERM MANAGEMENT • • • • • • • • CHOICE OF CANNULA CUFF MANAGEMENT MALPOSITION REPLACEMENT HUMIDIFICATION DYSPHAGIA PHONATION WEANING
  51. 51. PHYSIOLOGIC CHANGES AFTER TRACHEOTOMY
  52. 52. LONG-TERM MANAGEMENT • • • • • • • • CHOICE OF CANNULA CUFF MANAGEMENT MALPOSITION REPLACEMENT HUMIDIFICATION DYSPHAGIA PHONATION WEANING
  53. 53. RESPIRATORY INTENSIVE CARE UNIT PAVIA 2000-2008 (710 patients) Tracheotomy and dysphagia 16% OF NGP 26% 58% PEG
  54. 54. TRACHEOSTOMY AND DYSPHAGIA • • • • • • • EPIGL. BACKWARD FOLDING 80% RETENTION IN VALLECULAE 70% LARYNX ELEVATION 40% GAG REFLEX 30% VOCAL CORDS ADDUCTION 30% ORAL TRANSPORT PHASE 20% COUGH REFLEX 20%
  55. 55. LONG-TERM MANAGEMENT • • • • • • • • CHOICE OF CANNULA CUFF MANAGEMENT MALPOSITION REPLACEMENT HUMIDIFICATION DYSPHAGIA PHONATION WEANING
  56. 56. PHONATION • REQUIRED A SUBGLOTTIS PRESSURE OF AT LEAST 2-3 cmH2O • REQUIRED A FLOW THROUGH THE UPPER AIRWAY > 3 L/min
  57. 57. Speaking during spontaneous breathing
  58. 58. One way Passy Muir Valve to speak under mechanical ventilation
  59. 59. INSPIRATION ESPIRATION - ZEEP
  60. 60. ESPIRATION + PEEP
  61. 61. LONG-TERM MANAGEMENT • • • • • • • • CHOICE OF CANNULA CUFF MANAGEMENT MALPOSITION REPLACEMENT HUMIDIFICATION DYSPHAGIA PHONATION WEANING
  62. 62. RESPIRATORY INTENSIVE CARE UNIT PAVIA 2000-2008 (618 patients) Tracheotomy at discharge 43% NO YES 57%
  63. 63. RESPIRATORY INTENSIVE CARE UNIT PAVIA 2000-2008 (352 patients) Patients weaned from tracheotomy 5% 29% 34% NM PA PC PO 32%
  64. 64. CONCLUSIONS
  65. 65. Complications of Tracheostomy • Complications 5-40% • Mortality <2% • Complications are more frequent in emergency situations, severely ill patients and small children.
  66. 66. Complications of Tracheostomy – Stoma • Stoma site infection • Stomal hemorrhage • Poor stoma healing after decannulation with scar, keloid, or tracheocutaneous fistula
  67. 67. Complications of Tracheostomy – Trachea • Granuloma • Tracheoesophageal fistula fewer than 1% of patients as a result of pressure necrosis of the tracheal and esophageal mucosa from the tube cuff risks: high cuff pressures, presence of a nasogastric tube, excessive tube movement, and underlying diabetes mellitus
  68. 68. Complications of Tracheostomy • Tracheoinnominate fistula: 0.4% with mortality rate of 85% to 90%. Major airway hemorrhage may occur first within several days or as long as 7 months after performance of a tracheostomy. Risk factors : excessive tube movement, low placement of the tracheostomy, sepsis, poor nutritional status, and corticosteroid therapy • Tracheal stenosis: can develop from 1 to 6 months after decannulation risk for tracheal stenosis ranges between 0% and 16% • Tracheomalacia
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