Percutaneous tracheostomy

Dr Nor Hidayah Zainool Abidin
Supervisor: Dr Noryani
Percutaneous Tracheostomy
11/3/2015prepared by Anor Hidayah

OUTLINES
• History of Tracheostomy
• Definitions
• Indications
• Complications
• Tracheostomy Tubes & Components
• procedure
• Inner Cannula & Stoma Site Care
• Flange and Stay Suture Care
• Suctioning
• Cuffed Tracheostomy Care
• Changing a Tracheostomy Tube
• Tracheostomy weaning and removal

History of tracheostomy
• Tracheotomy was first depicted
on Egyptian artifacts in 3600 BC
• It was described in the Rigveda,
a Sanskrit text, circa 2000 BC

Ibnu Sina (980-1037)
• Described tracheal intubation in The Canon of
Medicine in order to facilitate breathing.
Ibn Zuhr (1091–1161) in the 12th century
• The first correct description of the tracheotomy
operation for treatment of asphyxiation

• Tracheotomies were used in the early 1800's for
airway inflammation in children due to Diphtheria.
The first documented successful tracheotomy
performed on a child was reported in 1808.

• In 1965, McDonald and Stocks describe the use of
intubation and respiratory support in neonate.
• Many more children surviving with tracheostomies
due to subglottic stenosis

• The percutaneous dilatational tracheostomy (PDT)
introduced by Ciaglia et al. in 1985, which involves
progressive dilatation with blunt-tipped dilators, is
the most frequently used and evaluated in the
literature.
• In 1989, Schachner et al. introduced a rapid PT
technique, Rapitrac, which did not get
considerable acceptance because of
complications associated with, and reservations
towards, the sharp edges of the dilating forceps.

Basic tracheal anatomy
• Trachea lies midline of the
neck
• Extending from cricoid
cartilage (C6) superiorly
• To the tracheal bifurcation
(level of sternal angle T5)
• Comprises of 16 – 20 C
shaped cartilage ring
• Length about 10 -12cm

Definitions
Word tracheostomy is derived from two words meaning “I cut trachea” in Greek
Tracheotomy
• Incision made below the cricoid cartilage through the
2nd – 4th tracheal ring
Tracheostomy
•The opening or stoma made by this incision.
Tracheostomy Tube
• Artificial airway inserted into the trachea during
tracheotomy.

Tracheostomy Tube
Components

Indications of Tracheostomy
• Acute upper airway obstruction
• Chronic upper airway obstruction
• Injury or post head and neck surgery  To obtain and
maintain a patent airway when compromised
• To facilitate weaning from mechanical ventilation
• To prevent and /or treat retained tracheobronchial
secretions
• To reduce the risk of pulmonary aspiration

Timing of Tracheostomy
<3weeks
Early
> 3 weeks
Late
• Early tracheostomy was associated :
o Similar survival at one month
o Improve short term clinical outcome
o early tracheostomy did not change any outcomes at one year

Adverse events occurred in 39%
hypoxemia
stoma
inflammation
stoma
infection
bleeding
•A higher likelihood of weaning from the ventilator77 vs 68 %
• A higher likelihood of being discharged from the ICU within 28
days48 vs 39%
• A trend towards a lower rate of pneumonia14 vs 21%
Multicenter trial (419 patients) that randomly early (mean 7 days) VS late
tracheostomy (mean 14 days)

observational
series
randomized
trials
meta-
analyses
terms of
mortality
mechanical
ventilation days
length of
stay
The timing of tracheostomy did not appear to impact 30 day or 2 year
mortality or ICU length of stay
Does not appear to impact the rate of nosocomial pneumonia
following tracheostomy

Decision for tracheostomy
• Mechanical ventilation anticipated to last between 10 and 21 days
• After an initial period of stabilization on the ventilator (generally,
within 3–7 days)
• Daily assessment for ventilatory weaning
o need for continued intubation
o readiness to wean
o When apparent that the patient will require prolonged ventilator
assistance
• Individualized according to the clinical circumstances and the patient's
preference
• The decision left to the attending Specialist/Intensivist

Advantages of tracheostomy
1. Reduced laryngeal damage
Reduced laryngeal stenosis
Less voice damage
2. Better secretion removal with suctioning
3. Lower incidence of tube obstruction
4. Less oral injury (tongue, teeth, palate)
5. Improved patient comfort
Less sedation/analgesia required
6. Better oral hygiene
7. Enhance nursing care

1. Improved ability to communicate  lip reading
2. Preservation of glottic competence
1. Less aspiration risk
3. Better preserved swallowing,  earlier oral feeding
4. Lower resistance to gas flow
5. Less tube dead space  better weaning from
mechanical ventilation
6. Ease of reinsertion if displaced
7. Allows less skilled care
Advantages of tracheostomy

Disadvantages of Tracheostomy
• Tracheal complications
• Aggressive procedure
• Risk of stomal infection
• Esthetic sequelae
• Bleeding
• Psychological trauma
• Organizational difficulties
• Increased risk in ward

Nosocomial pneumonia
• A retrospective study of 137 patients who underwent
tracheostomy
• significant bacterial colonization
(>100,000 cfu/mL)
• fever on the day of tracheostomy
• the need for sedation beyond 24
hours after tracheostomy
There was a 26% incidence of pneumonia in the study population, occurring
at a mean of 9 days after the tracheostomy.
Nosocomial pneumonia

Study reports – Nosocomial
infection
Lower
rate
six-fold
increase
Prospective cohort study of over
800 mechanically ventilated
Case-control study of 354 patients
who were mechanically
ventilated for more than seven
days
The timing of tracheostomy (early versus late) does not appear
to impact the rate of nosocomial pneumonia following
tracheostomy 11/3/2015prepared by Anor Hidayah

Associated Clinical
Complications
Immediate:
•Haemorrhage
• Pneumothorax
• Accidental
displacement of the
tube
Intermediate:
•Tube occlusion by
secretions and/or blood
•Infection
•Cuff over/under
inflation
Late:
Tracheal ulceration
•Tracheo-cutaneous
fistula
• Granulation tissue
(skin/tracheal)
• Tracheal stenosis
•Scar formation

Advantages of Percutaneous
Dilatation Technique
• Simple technique
• Can be done at the bedside in ICU
• Reduces the risks associated with the possible need to
transfer a critically ill patient out of the ICU
• Does not require operating theatre  less expensive in
terms of human and material resources
• Possibly less waiting time for patient
• Early tracheostomy
• Associated with less peristomal bleeding

Contraindications
• Age < 15 yrs
• Gross distortion of the neck due to haematoma, tumor,
thyromegaly or scarring from previous neck surgery
• Un-correctable bleeding diathesis
• Obese, short or bull neck that obscures the anatomical
landmarks in the neck
• Inability to extend the neck because of cervical fusion,
rheumatoid arthritis, or other cervical spine instability

Percutaneous Insertion
• Procedure to be done in ICU
Landmark
Needle
injection
Guidewire
insertion
Introducer Dilatation
Trachy tube
insertion

Patient preparation
• Take GSH, Latest FBC, BUSE and Coagulation profile
• Withhold anticoagulants
• Draw bedside curtains
• The procedure is explained in full to the patient and/or
significant others.
• Consent obtained. Record in the medical notes.
• Fast patient for 6 hours
• Discontinue deeding 6 hours prior to the procedure
• Aspirate the nasogastric tube again immediately prior to the
procedure.
• Prepare all required equipment
• Proper position the patient supine
• Ensure the head of the bed area is free from obstruction

Patient preparation
• To facilitate the procedure the patient is administered a
combination of Propofol and +/- an opioid via an IV
infusion.
• Full monitoring is instituted, and ventilatory parameters
altered
• Fio2 increased to 100%
• Tidal volume increased to compensate for airleak
around deflated ETT cuff
• Adjust peak airway pressure alarm to allow for the
raised pressures during ETT manipulation.
• The patient’s eyes are taped closed

Inner Cannula & Stoma Site
Care
• To help maintain a patent airway
To prevent infection
To maintain skin integrity
To help prevent tube displacement
Objective
•Inner cannula must be checked at least every 4hrs
•Stoma site must be checked at least daily or when
attending cannula. Site must be kept clean and dry
•Ties: ensure they are clean and dry
Frequency

Securing Tracheostomy Ties
Velcro Ties
• Bring longer piece
o (B) around neck and underneath section
o (A) Leave 1 finger space between ties and
patients neck.

Securing Tracheostomy Ties
Cotton Ties
• Bring one long end around the neck and tie to short end
in single knot.
• Repeat on the other side ensuring that 1 finger space is
remaining between the ties and the patient’s neck
• Tracheostomy ties  changed when wet or soiled and
routinely at least once a week.
• 2 person involve

Flange and Stay Suture Care
• Most surgically inserted tracheostomy tubes and
occasionally percutaneous tubes are secured in position
with silk sutures
• Removal time:
o at the time of the first tube change
o i.e. approximately 5 - 7 days post insertion
Observe suture sites for signs of infection
and treat accordingly

Suctioning
• to remove endotracheal secretions  maintain patent
airway
• as needed  pulmonary secretions
• Selecting appropriate catheter size.
o ensure the suction catheter is < /= 1/2 the internal diameter of
tracheostomy tube.
Tube
size
4
8 + 4
=12
(Tube size x 3)
/ 2
8 x 3 /2
= 12

Suctioning Procedure
1. vacuum pressure is > 20Kpa’s / 100- 150mmHg
2. Ventilated patient hyper-oxygenated (i.e. increase FiO2 to
100%) for > 30 seconds prior to suctioning, to minimise
hypoxia during and after the suctioning event.
3. Maintaining sterility
4. Insert the suction catheter to approximately 15cm without
applying suctioning
5. Smoothly withdraw catheter from the airway applying
continuous suction.
6. = / < 15secs.
7. 3 times per-session.
The Nurse must undertake the following:
Explain the procedure to the patient
Perform hand hygiene and apply sterile gloves
Apply apron and fluid shield mask

Cuffed Tracheostomy Care
• Indications for Cuffed Tube Use:
o The patient required mechanically ventilation
o Less than 24/48hours post insertion.
o high risk aspiration from gastric or oral secretions
o Unstable condition
• Stabilises the tracheostomy tube in the trachea.
Indications for cuff re-inflation:
1. Desaturation (must check inner cannula first)
2. Respiratory or cardiovascular distress
3. Constant oral drooling
4. No swallows observed

Cuff Pressure Measurement
• An underinflated cuff i.e. pressure too low, can lead
to
o inadequate seal around the cuff
o increasing risk of aspiration
o causing loss of positive pressure where the patient is
ventilated
• The recommended cuff pressure  25cmH2O
• Cuff pressures should not exceed 32cmH20.
• If leak present  increase tube size
• Palpation of the external balloon is not an
adequate method of pressure estimation

• Cuff deflation procedure:
o Explain procedure to the patients.
o Suction oropharynx to remove any secretions
o With the assistance of a 2nd nurse, suction via
tracheostomy tube while the second nurse slowly
aspirates air from air inlet port.
o Once deflated, expiratory noises may be heard as air
passes up around the tracheostomy tube  reassure
the patient that this is normal and will settle

Stoma Care
• At least once a day or more frequently  reduce the risk
of skin irritation and peri-stomal infection.
Stoma Cleaning Procedure
• Remove and dispose of any soiled dressings
• Using aseptic technique, clean the stoma site using
gauze and normal saline
• apply a skin barrier cream on patient’s skin is excoriated
 i.e. soft paraffin

Changing a Tracheostomy
Tube
• The recommended minimum time before the first tube
change or decannulation is
o 5-7days following surgical tracheostomy
o 7- 10days following percutaneous tracheostomy.
Rationale: To enable the tract to become established and minimise risk of occlusion.
• Changed every 28-30 days
• For weaning purposes i.e. downsizing,
change to cuffless or fenestrated.
Elective
Indications
• Tube dislodgement or accidental removal
• Tube obstruction (decreased risk when
using double lumen tubes).
Emergency
Elective

• Document the type of tube, size, the date it was
performed and last changed
• Ventilated patient fast patient for 4 hours before tube
changed.
• Emergency equipment
1st Tube
change
•must always be carried out by a doctor
•The track from the skin to the trachea may not be
well formed
Subsequent
tube changes
• Registered competent nurse

Tracheostomy weaning and
removal
o Medically stable
o The primary indication for tracheostomy has been resolved.
o Spontaneously breathing off the ventilator for 24-48 hours.
o Effective cough reflex
o Free from serious bronchopulmonary infection
o Minimal pulmonary secretions (suctioning < 4-6 hourly)
o O2 Therapy is less that 40% (FiO2 < .4)
o Successfully tolerating cuff deflation.
o Adequate nutritional intake

Weaning Procedure
Stage 4
Patient tolerance to Decannulation cap (not routine)
Stage 3
Patient tolerance to use of Passy Muir Speaking Valve
Stage 2
Patient tolerance to Downsizing the Tracheostomy tube (not routine at present)
Stage 1
Patient tolerance for Cuff deflation

Stage 1- Cuff Deflation
• This is usually carried out 24 – 48 hrs after tube insertion
Why?
• To assess if patient can manage their own airway and
manage their own oral secretions despite alteration in
tracheal airflow.

Stage 2- Downsizing
• Usually undertaken 5-7 days after the original tube
insertion
• Rationale: Airflow is increased either around or through
the tracheostomy tube and this reduces the work of
breathing for the patient.

Stage 3- Speaking valve
• at least 48-72 hours post
tracheostomy, prior to the initial
placement
• allowing air in through the valve
on inspiration, but closing on
expiration
• Where speaking valve is tolerated
the patient and valve:
o Ensure Cuff is deflated prior to applying / using
the speaking valve
o Do Not Leave the Speaking Valve on overnight
unless specifically ordered

Stage 4 - Decannulation
• Decannulation Cap
•  blocks the tracheostomy tube
•  patient breathe through nose and mouth
Rationale
• The use of a decannulation cap increases patient
confidence and gradually increases respiratory muscle
strength and avoids over exertion.
• Capping is tolerated for at least 24 consecutive hours

Stage 5
• Decannulation
(Removal of the Tracheostomy Tube)
INDICATION
• The decision to decannulation / remove tube is based on
the ability of the patient to maintain their own airway
without the tracheostomy tube insitu.

Stage 5
• Decannulation Predictors
o Patient has successfully completed the latter 4 stages
of weaning. (not all patients will go through each stage of
the process)
o Patient is able to expectorate pulmonary secretions
effectively
o Patient is not myopathic

Summaries
• 2 methods of Tracheostomy – surgical open
tracheostomy and percutaneous tracheostomy
• Percutaneous tracheostomy offer many benefits and a
good alternative
• Timing of tracheostomy does not have clear association
with better outcome but its clearly have many benefit in
term of patient comfort and nursing care
• Percutaneous tracheostomy does not have clear
association with nosocomial pneumonia
• Tracheostomy care knowledge and skills is important for
both doctors and nurses
• 4 stages of weaning and decanulation of tracheostomy

References
• St. James’s Hospital : Nursing Tracheostomy Care
Guidelines - Guidelines Number: SJH:N(G):009
• Uptodate - Overview of tracheostomy

Percutaneous tracheostomy

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