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Tracheostomy /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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  • 1. TRACHEOSTOMY INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  • 2. Contents • • • • History Introduction Cricothyrotomy Tracheostomy • • • • • • • Indications Armamentarium Surgical anatomy Procedure Tracheostomy care & maintainance Decannulation Complications & their management . • Percutaneous tracheostomy • References www.indiandentalacademy.com
  • 3. Introduction • Trachea is a passage between the upper airways and lungs. Any blockage or pathology above this level can impede air entry. At these times making an opening in the trachea is a safe technique in restoring air entry. www.indiandentalacademy.com
  • 4. History • 2000 BC :RigVeda • 1000 BC : Ebers papyrus • 400 BC: Hippocrates condemned tracheostomy, citing threat to carotid arteries • 1546 : first well-documented tracheostomy Antonius Musa Brasavola, • 1921: Chevaliar Jackson – standardized the technique - warned against high tracheostomy • 1957: Shelden - Percutaneous tracheostomy www.indiandentalacademy.com
  • 5. • 124 BC : Asclepiades – first tracheostomy • 1620 : Nicholos Habicot – 4 successful tracheostmies • 1718 :Lorenz Heister -tracheotomy, Negus –tracheostomy • 1730 : George Martin – inner cannula • 1833 : Trousseau – 200 cases of - diphtheria • 1969:Toy and Weinstein - the guidewire approach PT. • 1985 : Ciaglia et al – Percutaneous Dilatation Tracheostomy. www.indiandentalacademy.com
  • 6. CRICOTHYROTOMY Synonyms Tracheotomy , laryngotomy, high tracheostomy, low laryngotomy and coniotomy. www.indiandentalacademy.com
  • 7. History • Vicq d' Azyr - first description of cricothyrotomy. • 1921: Chevalier Jackson “ It should never be taught ,even in life threatening situatins” • 1976: Brantigan and Grow – 655 cricothyroidotomies - complication rate 6.1% www.indiandentalacademy.com
  • 8. Types • Surgical cricothyrotomy • Needle cricothyrotomy with translaryngeal jet ventilation • Percutaneous cricothyrotomy www.indiandentalacademy.com
  • 9. Indications • Severe Maxillofacial trauma with upper airway obstruction. • Oropharyngeal obstruction. • Respiratory failure, sleep apnea syndrome • Conditions in which tracheal intubation from above is either contraindicated or unsuccessful. www.indiandentalacademy.com
  • 10. Contraindications • Children < 11 yrs. • Elderly patients • Crush injury to the larynx • Preexisting laryngeal or tracheal pathology. • Laryngeal inflammation • After prolonged intubation www.indiandentalacademy.com
  • 11. Surgical anatomy www.indiandentalacademy.com
  • 12. Procedure www.indiandentalacademy.com
  • 13. Cricothyrotomy vs tracheostomy • Faster, less than 2mins • Easier, with less instrumentation • Less dissection • Fewer surgical complications and less bleeding • Can be taught to those with little surgical training  Space narrow for tube  Perichondritis, laryngeal stenosis, voice changes www.indiandentalacademy.com
  • 14. Complications Acute complications • Improper tube placement (emergency-36%, elective-1.3%) • Hemorrhage & hematoma • Posterior tracheal wall perforation • Subcutaneous &/or mediastinal emphysema • Thyroid perforation Chronic complications • Granulomas • Perichondritis • Subglottic stenosis (1.2% to 2.6%) • Dysphonia(40%) www.indiandentalacademy.com
  • 15. NEEDLE CRICOTHYROTOMY • first described by Sanders in 1967 • Spoerel et al (1971) and Klain&Smith(1977) defined the indications and technique. AdvCan be very quickly performed with fewer complications. DisadvCan provide oxygen for short period, not a definitive airway. www.indiandentalacademy.com
  • 16. Percutaneous Cricothyrotomy www.indiandentalacademy.com
  • 17. Tracheostomy • The surgical creation of an opening into the trachea to bypass obstructions that are interfering with breathing,& insertion of a tube into the opening to allow for normal breathing. www.indiandentalacademy.com
  • 18. Indications - Head and Neck Surgery- Otolaryngology: Byron J. Bailey 1.To bypass upper airway obstruction 2. To assist respiration over prolonged periods 3. To assist with clearance of lower respiratory secretions 4. To prevent aspiration of oral and gastric secretions www.indiandentalacademy.com
  • 19. Rowe & Williams Absolute indications for tracheostomy, for conditions other than impending respiratory obstruction (IPPV): • When injuries are severe enough to cause hypercarbia and/or hypoxaemia from the outset- flail chest, lung contusion or aspiration; or developing later due to 'shock lung' (ARDS) or fat embolism. • Control of cerebral oedema (by controlling blood gases) in severe head injuries www.indiandentalacademy.com
  • 20. Indications for tracheostomy in maxillofacial trauma • When prolonged artificial ventilation is necessary esp severe associated head and chest injuries • To facilitate anaesthesia for surgical repair in major injuries • To ensure a safe postoperative recovery after extensive reparative surgery • Following obstruction of the airway from laryngeal oedema or occasional direct injury to the base of the tongue and oropharynx • Serious haemorrhage into the airway particularly when a further secondary haemorrhage is a possibility www.indiandentalacademy.com - Synopsis of Otorhinolaryngology – Zakir Hussain
  • 21. Timing of Tracheostomy • The best time to do tracheostomy is the time when it is first felt necessary, Tracheostomy has been recommended within 3 days of intubation. (damage to the larynx & vocal cords is max b/w 3–7 days, if removed within this period, complete healing). - RESPIRATORY CARE • APRIL 2005 VOL50 No 4 (483-487) • The procedure is delayed long enough to allow extubation if possible but is performed early enough to avoid complications of long term intubation. - Byron J. Bailey www.indiandentalacademy.com
  • 22. Advantages • Decreases the amount of dead space by 70-100 ml • Reduces resistance to airflow and increases compliance • Provides Protection against aspiration. • Enables pt to swallow without reflex apnea. • Provides access to trachea for removing the secretions. • Delivery of medication & humidification to the tracheobroncheal tree. www.indiandentalacademy.com
  • 23. Adverse effects • Loss of heat & moisture exchange. • Desiccation of tracheal epithelium leading to loss or metaplasia of ciliated cells • Increased mucus production • Increase in viscid mucin, formation of thick crusts, blockage of the tube particularly in children. www.indiandentalacademy.com
  • 24. Types of Tracheostomy. • Elective Emergency • High Tracheostomy Mid Tracheostomy Low Tracheostomy • Temporary Permanent www.indiandentalacademy.com
  • 25. Various techniques • Surgical/open method. • Percutaneous dilatation. www.indiandentalacademy.com
  • 26. SURGICAL ANATOMY www.indiandentalacademy.com
  • 27. Surgical Anatomy www.indiandentalacademy.com
  • 28. Tube selection • Length • Diameter • Curvature • Material • Other features – cuff, fenestration, speaking valve, tracheal button www.indiandentalacademy.com
  • 29. Tubes available • Metallic – Fuller – Jackson – Alder hey • Nonmetallic – Portex – cuffed and noncuffed • Others – – – – – – – Portex paediatric Shiley paediatric Rusch Franklin Edinburgh Negus Durhams lobster tail - Parker - Aberdeen - Cole’s - Patterson - King college - Holinger - Salpekar www.indiandentalacademy.com - KCH pattern - Koenig’s - Bivona foam - Pit speaking - Mc Ginnis - Desaut - Molyncke
  • 30. www.indiandentalacademy.com
  • 31. STEPS 1.Airway control 2.Patient position 3. Anesthesia www.indiandentalacademy.com
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  • 41. Bjork flap www.indiandentalacademy.com
  • 42. Tracheostomy: Pediatric • Bronchoscope • Vertical skin incision • Retraction sutures • Margins of tracheal incision sutured to skin www.indiandentalacademy.com
  • 43. Tracheostomy care Guidelines • Bedside equipment. • Care of the inner cannula,stoma site & ties. • Suctioning of the tube. • Humidification of inspired gases. • Care for cuffed tube • Decannulation: removal of tracheostomy tube. • Dealing with emergencies. www.indiandentalacademy.com
  • 44. Bedside equipment • Spare tubes of Same / smaller size. • Tracheal dilator. • Suctioning equipment -Ensure everyday equipment is assembled and working. • Humidification unit -Ensure everyday equipment is working properly. • Container to hold speaking valve, occlusive cap/button or spare inner cannula. www.indiandentalacademy.com
  • 45. Care of the inner cannula, stoma site & ties. AIM: 1. To maintain a patent airway 2. To maintain skin integrity. 3. To prevent infection. 4. To prevent tube displacement www.indiandentalacademy.com
  • 46. Suctioning www.indiandentalacademy.com
  • 47. Humidification Aims: • To prevent drying of pulmonary secretions (tracheitis & crust formation). • To preserve muco-ciliary function. Various methods of humidification A) HEATED HUMIDIFIERS. B) HEAT MOISTURE EXCHANGE FILTERS. C) NEBULIZERS. www.indiandentalacademy.com
  • 48. CARE OF CUFFED TRACHEOSTOMY TUBE • When to inflate the cuff • Immediately post-operatively - to prevent aspiration of blood or serous fluid from the wound • To seal the trachea during mechanical ventilation • To prevent aspiration of leakage from tracheooesophageal fistula • To prevent aspiration due to laryngeal incompetence •Deflate: • first suction the oropharynx. • Cuff should be deflated atleast 5mins every hr. www.indiandentalacademy.com
  • 49. Tracheostomy decannulation • Should be left in place no longer than necessary • As soon as the patient's condition permits, reduced the size of tube to avoid physiologic dependence on a large tube, • Check for adequacy of the airway, ability to swallow and handle secretions for 24 hrs and then plug the tube. • Occlusion tolerated for 8-12 hrs, the tube is removed & the tracheocutaneous fistula is taped shut. • Bronchoscopy before decannulation in the pediatric patient, • Immediately after decannulation, the patient must be closely observed, www.indiandentalacademy.com and means for reestablishing the airway must be at hand.
  • 50. Complications of Tracheostomy • Immediate – – – – Apnea Bleeding Pneumothorax Damage to surrounding structures – – – – Dislodgement Blocked tube Tracheitis Subcutaneous emphysema – – – – – – Tracheal stenosis Tracheo-oesophageal fistula Exuberant granulations Scar Tracheomalacia Necrotising fascitis • Intermediate • Late www.indiandentalacademy.com
  • 51. Immediate 1.Apnea- physiologic denervation of the peripheral chemoreceptors by the sudden increase of p02; ventilatory assistance may be required. 2.Hemorrhage- raise in venous BP due to coughing associated with insertion of the tube. 3.Pneumothorax i. Respiratory obstruction - increased respiratory effort - air sucked in mediastinum. ii. secondary to laceration of the apex of pleural space (common in children). 4.Injury of adjacent structures- dissection lateral & deep to the trachea. www.indiandentalacademy.com
  • 52. www.indiandentalacademy.com
  • 53. Intermediate 1.Tracheitis and tracheobronchitis- severe in infants -necrotizing tracheo-bronchitis is frequent. -Humidification, nebulization & instillation of fluid/mucolytics. 2. Improper tube – Too long -partial tracheal obstruction & possible rupture of the innominate artery. - extend in one bronchus, atelectasis of the opp lung Too short- displacement of the tube out of the trachea, 3.Obstruction of the tube- mucus plug/ blood clot due to lack of care. - suction no relief in obstructive symptoms, change the tube www.indiandentalacademy.com
  • 54. . 4.Subcutaneous emphysema- tight suturing or packing. - Emphysema localized in the neck & upper chest but may involve the whole body and progress to pneumomediastinum and pneumothorax. pneumothorax -chest drain with an underwater seal. - Any constricting force around the tube b/w the skin& trachea must be removed to prevent progression. www.indiandentalacademy.com
  • 55. Late 1.Stenosis- injury and perichondritis of the cricoid cartilage. - can occur at -Cuff level -Tracheostomy level -Subglottic level www.indiandentalacademy.com
  • 56. 2.Exuberant granulations -anterior tracheal wall result of delayed epithelialization in case of large defects ,causing obstruction and bleeding. 3.Localized tracheomalacia- immediately superior& posteriorly to the healed opening. -Use of large & sharply angled tube, -avoided by using a more flexible tube of Teflon or Silastic. 4. Scar -vertical skin incision. -longer duration of tracheostomy -Vertical contracture,hypertrophic scar require a Z plasty. 5.Tracheocutaneous fistula-wound must be revised and closed with careful approximation of tissue layers. www.indiandentalacademy.com
  • 57. Tracheocutaneous fistula www.indiandentalacademy.com
  • 58. Tracheoesophageal fistula www.indiandentalacademy.com
  • 59. Percutaneous Tracheostomy Shelden described a needle-guided trocar for access into the trachea. Ciaglia et al described PDT based on the Seldinger technique, using sequential dilators of increasing diameter. INDICATIONS Percutaneous tracheostomy has been proposed as an alternative to open/surgical tech. www.indiandentalacademy.com
  • 60. Extended Indications for Percutaneous Tracheostomy • patients with short, fat neck; • inability to perform neck extension; • enlarged isthmus of thyroid; • previous tracheostomy; or • coagulopathy and anti-coagulation therapy. www.indiandentalacademy.com
  • 61. www.indiandentalacademy.com
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  • 63. www.indiandentalacademy.com
  • 64. Complications of Percutaneous Tracheostomy • false passage of the tracheostomy tube, • pneumothorax, • delayed bleeding, • puncture of the posterior tracheal wall, • premature extubation during the procedure and loss of the airway. www.indiandentalacademy.com
  • 65. Comparison of safety and cost of percutaneous versus surgical tracheostomy - Bowen, Whitney et all - Division of Surgical Oncology, University of Virginia Medical Center - Am Surg. 2001 Jan;67(1):54-60. Links Percutaneous Surgical Cases Complication rate 74 6.76% (4.1%) 139 2.2% Cost $1750 %2600 - PDT costs less and requires less time but carries more risk of complications. Careful patient selection and adequate experience will www.indiandentalacademy.com reduce comlications
  • 66. Endoscopic percutaneous dilatational tracheotomy: a prospective evaluation of 500 consecutive cases - Kost K.M. -Department of Otolaryngology, McGill University, Canada -Laryngoscope. 2005 Oct;115(10 Pt 2):1-30.   Links -Total complication rate was 9.2% (13.6% in the multiple dilator group, and 6.5% in the single dilator group) - most common complications were oxygen desaturation (in 14 cases) and bleeding (in 12 cases) - absence of serious complications such as pneumothorax and pneumomediastinum were attributable to the use of bronchoscopy -Endoscopic PDT is associated with a low complication rate and is at least as safe as surgical www.indiandentalacademy.com tracheotomy in the ICU setting
  • 67. Percutaneous dilatational tracheostomy versus open tracheostomy--a prospective, randomized, controlled trial. - Wu J.J., Huang et all - Division of Trauma, Taipei Veterans General Hospital, - J Chin Med Assoc. 2003 Aug;66(8):467-73 - 83 tracheostomies - Procedure time was 22.0 +/- 12.1 minutes in PDT group, and 41.5 +/- 5.9 minutes in OT group, - incidences of complications were not different between both groups - simple, safe and time-saving bedside procedure and can be recommended when an elective tracheostomy is needed in a critical patient. www.indiandentalacademy.com
  • 68. Conclusion www.indiandentalacademy.com
  • 69. References  Rowe &William’s Maxillofacial injuries 2nd edition-vol I  Oral & maxillofacial trauma :Fonseca-3rd edition-vol I  Bailey & love’s short practice of surgery 23rd edition.  Schwartz principles of surgery -8th edition .  Lange’s current diagnosis&treatment in otolaryngeology-head&neck surgery.  Clinical &operative methods in ENT, head & neck surgery-A systemic approach: Hazarica Nayak.  An atlas of head & neck surgery-Lore’ 3rd edition.  www.indiandentalacademy.com Operative otolaryngeo,head & neck surgery-Myers,vol I.
  • 70. Thank www.indiandentalacademy.com