TRACHEOSTOMY www.hi-dentfinishingschool.blogspot.com
History <ul><li>Tracheostomy is one of the oldest surgical procedures.  </li></ul><ul><li>A tracheotomy was portrayed on E...
Tracheostomy  History and indications <ul><li>1932 prevent pulmonary infection in neurologically impair patients secondary...
INDICATIONS FOR TRACHEOSTOMY Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.2005.  Goldenberg D, et al Tracheotomy:...
INDICATIONS FOR TRACHEOSTOMY The Lindholm Scale of  Laryngotracheal Damage  Grade I erythema and edema without ulceration ...
TRACHEOSTOMY VS TRANSLARYNGEAL INTUBATION <ul><ul><li>Increased patient mobility </li></ul></ul><ul><ul><li>More secure ai...
Incision 1 cm below the cricoid or halfway between the cricoid and the sternal notch. Retractors are placed, the skin is r...
The thyroid isthmus lies in the field of the dissection. Typically, the isthmus is 5 to 10 mm in its vertical dimension,  ...
<ul><li>Shiley tracheostomy tube: #6 </li></ul><ul><li>Shiley tracheostomy tube: #8  for bronchoscopy. </li></ul>
TRACHEOSTOMY TUBE CARE   <ul><li>Securing tracheostomy around patient’s neck. </li></ul>Use of this content is subject to ...
TRACHEOSTOMY TUBE CARE   <ul><li>Tube changes:  </li></ul><ul><ul><li>Indications: soiled, cuff rupture. </li></ul></ul><u...
TRACHEOSTOMY TUBE CARE <ul><li>Tracheostomy  tube cuff pressures in a range of 20 to 25 mm Hg.  </li></ul><ul><li>Overly l...
TRACHEOSTOMY TUBE CARE <ul><li>Chest Xray:  </li></ul><ul><li>cuff has a width greater than the caliber of the trachea, wh...
TRACHEOSTOMY TUBE CARE <ul><li>Humidification of the inspired gas is a standard of care for tracheostomized patients.  </l...
•   Secretions in the trach  •   Suspected aspiration of gastric or upper airway secretions  •   Increase in peak airway p...
Tracheostomies should be suctioned whenever physical  examination reveals the presence of secretions CLEARANCE OF SECRETIONS
SPEECH
SPEECH Tracheostomy Speaking Valve  Passy-Muir A tracheostomy speaking valve is a one-way valve,  allows air in, but not o...
NUTRITION <ul><li>Tracheostomy tube prevents normal upward movement of the larynx during swallowing and hinders glottic cl...
WEANING FROM TRACHEOSTOMY   <ul><li>Demonstrate stability for 24 to 48 hours after discontinuation of mechanical ventilati...
WEANING FROM TRACHEOTOMY   <ul><li>The ability to breath and clear airway secretions around a small, capped tube signifies...
Complications of Tracheostomy <ul><li>Complications 5-40% </li></ul><ul><li>Mortality <2% </li></ul><ul><li>Complications ...
Complications of Tracheostomy <ul><ul><li>Stoma </li></ul></ul><ul><ul><ul><li>Stoma site infection </li></ul></ul></ul><u...
Complications of Tracheostomy <ul><ul><li>Trachea </li></ul></ul><ul><ul><ul><li>Granuloma </li></ul></ul></ul><ul><ul><ul...
Complications of Tracheostomy <ul><ul><ul><li>Tracheoinnominate fistula:   </li></ul></ul></ul><ul><ul><ul><li>0.4% with m...
CONCLUSION <ul><li>The most common indications for tracheostomy is mechanical ventilation with prolonged tracheal intubati...
 
Guidewire and catheter are advanced together into the trachea as far as the skin positioning marks on the guide catheter t...
PERCUTANEOUS DILATIONAL TRACHEOTOMY Guidewire and catheter are advanced together into the trachea as far as the skin posit...
PERCUTANEOUS DILATIONAL TRACHEOTOMY The tracheotomy tube is loaded onto a dilator and advanced into the trachea over the g...
PERCUTANEOUS DILATIONAL TRACHEOTOMY Cook Ciaglia percutaneous dilatational tracheostomy kit
 
 
 
 
TRACHEOSTOMY TUBE CARE   <ul><li>Securing tracheostomy around patient’s neck. </li></ul><ul><li>Tube changes:  </li></ul><...
 
TRACHEOTOMY
 
 
Upcoming SlideShare
Loading in...5
×

Tracheostomy

17,685

Published on

Published in: Education
2 Comments
17 Likes
Statistics
Notes
  • TRACHEOSTOMY CARE FOR OLD AGED PEOPLE

    Tracheostomy means creating an artificial opening in the windpipe ( trachea ) by a surgical procedure. It is done to facilitate breathing in patients where normal breathing is not possible or in patients who have to be weaned off from the ventilator. Air goes in and out through this opening and whatever secretions the lungs produce can be removed from this opening.



    INDICATIONS

    There are many indications, few of them are

    Congenital conditions affecting wind pipe and larynx.

    2. Tumours affecting the wind pipe.

    3. Injury affecting respiration.

    4. Fractures affecting head and neck

    5. As a precaution in major head and neck surgeries.

    6. In certain patients requiring long term convalescence.



    CARE OF TRACHEOSTOMY



    Care of tracheostomy differs in patients who can do self care or in bed ridden patients who have to be helped with tracheostomy care.



    The basic principle is to keep the air moist as the natural organs that is the mouth and the nose which moisten the air before it enters the wind pipe are bypassed because of tracheostomy. Few tips to keep the air moist are

    1. Drinking lots of water if not contraindicated medically.

    2. Saline wash as advised by doctor.

    3. Humidifying the air in the room by humidifiers.

    4. Care of skin around the tracheostomy

    a. Special care of skin around the tracheostomy should be done in such a way that the water and soap does not enter the tracheostomy. It is best to clean it with sterile piece of gauze. Any secretion or mucus which gathers near the skin should be dislodged gently without disturbing the tracheostomy. Any redness or soreness on the skin should be noted and reported.

    b. If mucoid secretions tend to collect around the tracheostomy then plain gauze can be kept around the opening.

    5. Suction :- it is required time to time to bring out secretions from the lungs. In a patient who is able to take care of the tracheostomy himself it is easy for him to bring it out and the patient will know when to do suction if the chest feels heavy. In bed ridden patients the attendant has to be taught to do gentle suction as and when the secretions can be heard in the chest or when they are coming out.

    6. Few tips for doing suction

    a. Keep the machine off while inserting the suction tube.

    b. Don’t insert the catheter inside for more than 10 seconds specially in patients requiring oxygen.

    c. After insertion of the tube pull out tube a little before switching on the machine.

    d. Rinse the catheter with water or saline in between suctions.

    e. Keep the head up.

    f. Wipe out whatever secretions accumulate around the tracheostomy or in the mouth.

    These are few tips regarding tracheostomy care but ALWAYS CONSULT your Doctor or a senior nursing attendant before doing tracheostomy care by yourself.
    For More Consultation
    Please Visit
    http://www.vardaanhealthcare.com/contactus.php
    or call us on
    012046018201
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • good presentation
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total Views
17,685
On Slideshare
0
From Embeds
0
Number of Embeds
6
Actions
Shares
0
Downloads
974
Comments
2
Likes
17
Embeds 0
No embeds

No notes for slide
  • 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
  • INDICATIONS FOR TRACHEOTOMY Current indications for tracheotomy are: prolonged intubation and mechanical ventilation, bypass of an upper airway obstruction, easier management of secretions, as an adjunct to chest or head and neck surgery in which ventilation problems or prolonged intubation are anticipated ( Table 106-2 ). The earliest indication for the procedure was upper airway obstruction resulting from trauma or infection. As late as the 1950s, the major indication for 2444 Other causes of upper airway obstruction necessitating tracheotomy include obstruction due to neoplastic processes, or functional obstruction such as bilateral vocal cord paralysis or edema secondary to smoke inhalation or caustic agent ingestion. In such cases, patients are usually stabilized by tracheal intubation or with a cricothyrotomy and tracheotomy later. Although facial fractures in and of them selves are not an indication for tracheotomy, in cases of severe maxillo-facial trauma, tracheotomy is sometimes used to secure an airway where intubation would be difficult or damaging. Today, the most common indication for tracheotomy is prolonged tracheal intubation, usually with mechanical ventilation. A recent review of more than 1000 consecutive tracheotomies found that 76% were performed to facilitate mechanical ventilation.[ 21
  • Mentally alert patients tolerate a tracheostomy better than an endotracheal tube and experience less facial and oral discomfort.[ 6 ] Enhanced comfort may decrease the need for sedation that has been associated with an increased risk for nosocomial pneumonia.[ 80 ] Tracheostomy also allows greater mobility, including moving to a chair. Early transfer from the ICU is facilitated with performance of a tracheotomy for patients who are not ready for weaning from mechanical ventilation Ventilator-dependent patients have opportunities for articulated speech after placement of a tracheostomy . Speech and an ability to communicate spontaneously enhance patients&apos; well-being and sense of control.[ 47 ] [ 61 ] [ 86 ] The inability to communicate has been identified by patients as one of their most significant sources of psychologic stress during ventilator dependency Recent studies suggest that mechanically ventilated patients who receive a tracheostomy have a lower risk for nosocomial pneumonia Lower airway resistance with a tracheostomy decreases ventilatory load and provides an opportunity for accelerating weaning from mechanical ventilation in patients with borderline lung function. Lower airway resistance may explain why trauma patients who undergo early tracheotomy have a shorter period of mechanical ventilation and ICU stay than patients managed with prolonged translaryngeal intubation and delayed tracheotomy . Endotracheal tubes have a higher resistance in vivo than predicted by their manufactured caliber because inspissated secretions decrease the luminal diameter and promote turbulent airflow .
  • There is no evidence to guide the frequency of tracheostomy tube changes. It is a common practice to change the tracheostomy tube when it is grossly soiled, if it malfunctions (e.g., cuff rupture), or if a tube of another design is needed (e.g., fenestrated tube). Changing the tracheostomy tube is not a benign procedure. Complications include inability to insert the replacement tube, insertion of the replacement tube into a false passage[ 74 ] (soft tissue of the neck or mediastinum), bleeding, and patient discomfort. The risk for these complications decreases with the age of the tracheal stoma. For this reason, it is recommended that changing the tracheostomy tube be avoided for at least 1 week after surgical creation of the stoma and that the first tube change is performed by the surgeon who performed the tracheotomy. If a difficult tracheostomy tube change is anticipated (e.g., obese patient, airway anomaly, short and thick neck), a clinician experienced in endotracheal intubation should be present.
  • There is no evidence to guide the frequency of tracheostomy tube changes. It is a common practice to change the tracheostomy tube when it is grossly soiled, if it malfunctions (e.g., cuff rupture), or if a tube of another design is needed (e.g., fenestrated tube). Changing the tracheostomy tube is not a benign procedure. Complications include inability to insert the replacement tube, insertion of the replacement tube into a false passage[ 74 ] (soft tissue of the neck or mediastinum), bleeding, and patient discomfort. The risk for these complications decreases with the age of the tracheal stoma. For this reason, it is recommended that changing the tracheostomy tube be avoided for at least 1 week after surgical creation of the stoma and that the first tube change is performed by the surgeon who performed the tracheotomy. If a difficult tracheostomy tube change is anticipated (e.g., obese patient, airway anomaly, short and thick neck), a clinician experienced in endotracheal intubation should be present.
  • Cuff pressures also can increase when patients undergo anesthesia with volatile gases. Diffusion of volatile gases into a cuff inflated with air increases cuff pressures to critical levels above mucosal capillary perfusion pressure within 2 hours of a surgical procedure.[ 112 ] Anesthesiologists should monitor cuff pressures during prolonged procedures or inflate cuffs with the anesthetic gas mixture at the start of surgery. The latter approach requires reinflation of the cuff with air at the end of the procedure
  • Because suctioning is uncomfortable, it should be performed only when indicated and not at a fixed frequency.[130] The upper airway also should be suctioned periodically to remove oral secretions. Hyperinflation and hyperoxygenation generally are recommended before suctioning to prevent suction-related hypoxemia The effectiveness of secretion clearance is similar for closed-system catheters and that of the conventional suction technique.[140]
  • Patients who can breathe spontaneously during intervals of weaning from mechanical ventilation may speak spontaneously with the use of a fenestrated tracheostomy tube.[59] After removal from mechanical ventilation, the inner cannula of the fenestrated tube is removed, allowing expiratory airflow through the larynx when the external end of the tracheostomy tube is occluded transiently. Deflation of the tracheostomy tube cuff during periods of spontaneous breathing can enhance expiratory airflow further across the vocal cords. Application of a one-way valve (e.g., Passy-Muir valve, Passy and Passy, Irvine, CA; Phonate Speaking Valve, Mallinckrodt Medical, St Louis, MO) (Fig. 4) (Figure Not Available) permits inspiratory airflow through the tracheostomy tube during inspiration but closes during expiration promoting airflow through the tube fenestrations and around a deflated cuff.[75] [96] [106] [107] Patients managed with a Passy-Muir valve require careful evaluation to be certain that the airway resistance during exhalation with breathing through a fenestrated tube does not interfere with weaning.[34]
  • Normally speech is obtained by a steady stream of air that comes from the lungs and passes by the vocal cords as we exhale. This air is modified by the vocal cords which vibrate as the air passes through to produce sound A tracheostomy speaking valve is a one-way valve that allows air in, but not out. This forces air around the tracheostomy tube, through the vocal cords and out the mouth upon expiration, enabling the patient to vocalize
  • tracheostomy tube provides opportunities for oral nutrition but also complicates alimentation because of tube interference with normal swallowing and airway control A.[ 18 ] An inflated tracheostomy cuff does not protect patients from aspirating into the lower airway oral contents that pass through an incompetent glottis. Tracheostomy tube prevents normal upward movement of the larynx during swallowing and hinder glottic closure. Speech therapists should evaluate oral motor strength, swallowing, and the adequacy of volitional and reflex coughing and the gag reflex. The presence of a gag reflex, however, does not ensure that pharyngeal contents will not be aspirated during refeeding The first feeding attempts should begin with ice chips to accustom patients to swallowing, followed by soft foods, such as gelatins, that would not have important consequences if aspirated into the airway
  • Patients can be evaluated for decannulation after they demonstrate stability for 24 to 48 hours after discontinuation of mechanical ventilation. The patient&apos;s ability to protect the airway should be assessed for 24 hours by deflating the tracheostomy cuff and observing for signs of aspiration.[ 48 ] Evidence of moderate to severe aspiration warrants laryngoscopic inspection of the glottis before further weaning efforts.
  • Patients can be evaluated for decannulation after they demonstrate stability for 24 to 48 hours after discontinuation of mechanical ventilation. The patient&apos;s ability to protect the airway should be assessed for 24 hours by deflating the tracheostomy cuff and observing for signs of aspiration.[ 48 ] Evidence of moderate to severe aspiration warrants laryngoscopic inspection of the glottis before further weaning efforts.
  • Tracheostomy can cause tracheal stenosis adjacent to the tube cuff or at the level of the tracheostomy stoma site.[ 4 ] [ 5 ] [ 51 ] [ 52 ] High-volume, low-pressure cuffs have decreased markedly the incidence of stenosis at the cuff site.[ 24 ] Tracheal stenosis at the stoma site, however, continues to be an important clinical problem that can develop from 1 to 6 months after decannulation .[ 60 ] The incidence of tracheal stenosis after tracheotomy in patients who require long-term ventilation is unknown because of the absence of longitudinal studies with adequate follow-up. Published studies of patients in a critical care managed setting with a tracheostomy suggest that the risk for tracheal stenosis ranges between 0% and 16% (Table 1). [ 25 ] [ 29 ] [ 85 ] [ 116 ] [ 135 ] [ 136 ] Most patients, however, lose only 10% to 40% of their tracheal caliber, which usually does not compromise ventilatory function. Tracheomalacia with dynamic airway narrowing during spontaneous expiration also occurs. Randomized studies comparing the long-term outcome of patients managed with standard surgical tracheotomy compared with percutaneous dilational tracheostomy have not been performed. Synonyms and related keywords: tracheomalacia, flaccidity of supporting tracheal cartilage, widening of the posterior membranous wall, reduced anterior-posterior airway caliber, tracheal collapse, structural abnormality of the tracheal cartilage, airway obstruction, abnormally increased compliance of the trachea, percutaneous tracheostomy, aortopexy
  • There is no evidence to guide the frequency of tracheostomy tube changes. It is a common practice to change the tracheostomy tube when it is grossly soiled, if it malfunctions (e.g., cuff rupture), or if a tube of another design is needed (e.g., fenestrated tube). Changing the tracheostomy tube is not a benign procedure. Complications include inability to insert the replacement tube, insertion of the replacement tube into a false passage[ 74 ] (soft tissue of the neck or mediastinum), bleeding, and patient discomfort. The risk for these complications decreases with the age of the tracheal stoma. For this reason, it is recommended that changing the tracheostomy tube be avoided for at least 1 week after surgical creation of the stoma and that the first tube change is performed by the surgeon who performed the tracheotomy. If a difficult tracheostomy tube change is anticipated (e.g., obese patient, airway anomaly, short and thick neck), a clinician experienced in endotracheal intubation should be present.
  • Tracheostomy

    1. 1. TRACHEOSTOMY www.hi-dentfinishingschool.blogspot.com
    2. 2. History <ul><li>Tracheostomy is one of the oldest surgical procedures. </li></ul><ul><li>A tracheotomy was portrayed on Egyptian tablets dated back to 3600 BC. </li></ul><ul><li>Asclepiades of Persia is credited as the first person to perform a tracheotomy in 100 BC. </li></ul><ul><li>The first successful tracheostomy was performed by Brasovala in the 15th century.   </li></ul>
    3. 3. Tracheostomy History and indications <ul><li>1932 prevent pulmonary infection in neurologically impair patients secondary to infections (poliomyelitis). </li></ul><ul><li>1943 remove bronchial secretions in cases of myasthenia gravis and tetanus. </li></ul><ul><li>1951 reduce the volume of dead space, use in COPD and severe penumonia. </li></ul><ul><li>1950 positive pressure through tracheostomy for patients with poliomyelitis. </li></ul><ul><li>1955 obstruction secondary to infection: diphteria, Ludwig’s angina. </li></ul><ul><li>1961 Obstructions secondary to tumour, infectious disease and trauma. </li></ul>
    4. 4. INDICATIONS FOR TRACHEOSTOMY Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.2005. Goldenberg D, et al Tracheotomy: changing indications and a review of 1,130 cases, J Otolaryngol 31:211–215, 2002 Adjunct to management of major head and neck trauma Adjunct to major head and neck surgery Inability to intubate Upper airway obstruction Inability of patient to manage secretions Facilitation of ventilation support Prolonged intubation
    5. 5. INDICATIONS FOR TRACHEOSTOMY The Lindholm Scale of Laryngotracheal Damage Grade I erythema and edema without ulceration Grade II superficial ulceration of the mucosa <1/3 airway circumference Grade III continuous deep ulceration <1/3 airway circumference or superficial ulceration >1/3 airway circumference Grade IV deep ulceration with exposed cartilage.
    6. 6. TRACHEOSTOMY VS TRANSLARYNGEAL INTUBATION <ul><ul><li>Increased patient mobility </li></ul></ul><ul><ul><li>More secure airway </li></ul></ul><ul><ul><li>Increased comfort </li></ul></ul><ul><ul><li>Improved airway suctioning </li></ul></ul><ul><ul><li>Early transfer of ventilator-dependent patients from the intensive care unit (ICU) </li></ul></ul><ul><ul><li>Less direct endolaryngeal injury </li></ul></ul><ul><ul><li>Enhanced oral nutrition </li></ul></ul><ul><ul><li>Enhanced phonation and communication </li></ul></ul><ul><ul><li>Decreased airway resistance for promoting weaning from mechanical ventilation </li></ul></ul><ul><ul><li>Decreased risk for nosocomial pneumonia in patient subgroups </li></ul></ul>Heffner, Hess.Clinics in Chest Medicine 22 , 2001.
    7. 7. 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
    8. 8. 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
    9. 9. <ul><li>Shiley tracheostomy tube: #6 </li></ul><ul><li>Shiley tracheostomy tube: #8 for bronchoscopy. </li></ul>
    10. 10. TRACHEOSTOMY TUBE CARE <ul><li>Securing tracheostomy around patient’s neck. </li></ul>Use of this content is subject to the Terms and Conditions of the MD Consult web site. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed. , Copyright © 2005 Mosby, Inc. INDICATIONS FOR TRACHEOTOMY Current indications for tracheotomy are: prolonged intubation and mechanical ventilation, bypass of an upper airway obstruction, easier management of secretions, as an adjunct to chest or head and neck surgery in which ventilation problems or prolonged intubation are anticipated ( Table 106-2 ). The earliest indication for the procedure was upper airway obstruction resulting from trauma or infection. As late as the 1950s, the major indication for 2444 TABLE 106-2 -- RELATIVE CONTRAINDICATIONS TO PERFORM PERCUTANEOUS DILATIONAL TRACHEOTOMY tracheotomy was upper airway obstruction because of infectious disease including diphtheria, polio, Ludwig's angina, tetanus, and laryngotracheobronchitis. [ 29 ] [ 41 ] [ 49 ] Other causes of upper airway obstruction necessitating tracheotomy include obstruction due to neoplastic processes, or functional obstruction such as bilateral vocal cord paralysis or edema secondary to smoke inhalation or caustic agent ingestion. In such cases, patients are usually stabilized by tracheal intubation or with a cricothyrotomy and tracheotomy later. Although facial fractures in and of them selves are not an indication for tracheotomy, in cases of severe maxillo-facial trauma, tracheotomy is sometimes used to secure an airway where intubation would be difficult or damaging. Today, the most common indication for tracheotomy is prolonged tracheal intubation, usually with mechanical ventilation. A recent review of more than 1000 consecutive tracheotomies found that 76% were performed to facilitate mechanical ventilation. [ 21 ] Surgical Technique Tracheotomy is optimally performed under general anesthesia in the operating room. If necessary, the procedure may be performed under local anesthesia or in an intensive care setting. [ 29 ] In case a tracheotomy is being performed under local anesthesia, the surgeon and the anesthetist have to work in tandem to keep the patient maximally reassured. On most occasions the anesthetist may use minimal sedation to achieve patient comfort without compromising the ability to breathe spontaneously. Another critical precaution to keep in mind is to avoid the use of Bovie cautery. The surgical field may be getting the oxygenrich gas mixture from the nasal cannula or the ventilating mask. This simple precautionary measure will avert the risk of igniting fire in the surgical field. The basic technique consists of either a vertical incision from the cricoid cartilage, 1.5 inches inferiorly or a horizontal incision midway between the sternal notch and the cricoid cartilage ( Figure 106-1 ). The incision is carried down through the skin, subcutaneous tissue, and platysma to reveal the strap muscles. If the patient is obese and the adipose tissue obtrusive, a minimal cervical lipectomy may be performed. [ 23 ] At this level, the dissection should be in a vertical plane regardless of the skin incision chosen. The strap muscles are separated by a vertical incision through the bloodless midline raphe (linea Alba) and retracted from one another revealing the thyroid isthmus which typically lies over the third and fourth tracheal ring ( Figure 106-2 ). The isthmus may be dealt with in a number of ways. This decision is based on the position of the isthmus relative to the wound and the surgeon's personal preference. It may be superiorly retracted, transected, and suture-ligated ( Figure 106-3 ), transected slowly using a monopolar cautery (Bovie) [ 10 ] [ 28 ] ( Figure 106-4 ), or inferiorly retracted (least commonly used method). [ 28 ] The trachea is revealed and the third and fourth tracheal rings are identified using the cricoid as a landmark. As with the skin incision, there are equally reasonable choices for the entrance into the trachea. An inferiorly based trap door flap (Bjork flap) can be created using a Mayo scissor and sutured to the subcutaneous tissue using 3-0 chromic suture. Alternatively the anterior section of a single tracheal ring can be resected or a round or vertical oval window spanning two tracheal rings be excised [ 15 ] [ 29 ] [ 47 ] using a scalpel, curved Mayo scissor, or a tracheotomy punch ( Figure 106-5 and Figure 106-6 ). The endotracheal tube cuff is deflated and the tube slowly withdrawn by the anesthesiologist until the inferior tip of the tube is lined up with the superior border of the newly formed tracheal opening. A tracheotomy tube is then inserted through the tracheotomy into the airway and the patient is ventilated. Tracheotomy Complications The complications of tracheotomy may be categorized by the interval from the procedure to the onset of the complication and are thus divided into intraoperative, early, and late postoperative. It should be noted that there may be an overlap in the timeframe in which early, intermediate, and late complications present. It is important to note that specific patient populations, such as the pediatric, post head trauma, obese, burn patient, or seriously debilitated are more susceptible to complications related to tracheotomy. [ 20 ] 2445                                                       Figure 106-1 A, Surface anatomy of the neck with skin incision for the tracheotomy ( left ) and cricothyrotomy ( right ). B, A vertical skin incision is made between the cricoid and second tracheal ring as assessed by palpation through the skin. Tracheotomy holds a complication rate of between 5% to 40% depending on study design, patient follow-up, and the definition of the different complications. [ 46 ] In a recent study of 1130 surgical tracheotomies, the major complication rate for surgical tracheotomy was found to be as low as 4.3%, with a mortality rate of 0.7%. [ 20 ] Death from tracheotomy is caused most often by hemorrhage or tube displacement. It is important to note that the incidence of complications in emergency tracheotomy is 2 to 5 times that found in an elective procedure. The most common complication has classically been hemorrhage (3.7%), followed by tube obstruction (2.7%), and tube displacement (1.5%) The incidence 2446                                                     Figure 106-2 The strap muscles are separated through the bloodless midline raphe to reveal the underlying thyroid isthmus.                              Figure 106-3 The thyroid isthmus may be retracted or suture ligated. of pneumothorax, tracheal stenosis, and tracheoesophageal fistula is less than 1%. Immediate Complications Immediate complications of tracheotomy include those present during or at the termination of the operation. Although these complications are usually caused during surgery, they may appear hours or days after the tracheotomy is performed. Bleeding during the performance of a tracheotomy is most commonly the result of errors in surgical technique. Frequent sites of bleeding are the anterior jugular veins, the thyroid isthmus, and vascular variants such as the thyroid ima artery. [ 36 ] Other immediate complications include insertion of the tracheotomy tube into a false route, electrocautery-induced intraoperative fire, [ 1 ] and surgical injury to adjacent structures. Intermediate Complications Intermediate complications develop during the first hours to days after surgery. Again, hemorrhage may be a frequent postoperative complication of tracheotomy. 2447                                                         Figure 106-4 The thyroid isthmus may be safely transected slowly using a monopolar cautery (Bovie) when it obscures the proposed entrance site into the trachea.                              Figure 106-5 A horizontal incision can be made in the intracartilaginous space. Because many of these patients are hypotensive, bleeding does not occur until arterial blood pressure is restored or venous pressure is increased by coughing associated with canula placement. Minor oozing may be managed by light packing with oxidized cellulose, microfibrillar collagen, or tranexamic acid-soaked gauze packs. [ 27 ] Transient tracheitis and stomal cellulitis may occur, and all fresh tracheotomies should be attended to with strict local hygiene. Severe infection such as mediastinitis, clavicular osteomyelitis, and necrotizing fasciitis are rare, but have been reported after tracheostomy and must be treated aggressively. [ 48 ] Other known early postoperative complications include subcutaneous emphysema, pneumomediastinum,                              Figure 106-6 A tracheotomy punch is then used to make a circular window in the anterior wall of the trachea. and pneumothorax. All of these may result from excessive dissection of tissue planes at the time of tracheostomy , blockage of the cannula, or assisted ventilation with excessive pressure, causing dissection of air along the pretracheal fascia. The incidence of subcutaneous emphysema is 0% to 9% and the incidence of pneumothorax is 0% to 4% in adults. [ 43 ] Obstruction of the tracheotomy tube on the first few postoperative days is likely to result from blood clot, partial displacement, or tube impingement on the posterior tracheal wall. The incidence of tube obstruction is 2.5%. [ 43 ] Routine postoperative care including observation, humidification, and frequent gentle suctioning prevents tube obstruction. Dislodgment of the tracheotomy tube may be a fatal complication in the first few days after tracheotomy. Several factors that play a role in tube dislodgment are the length of the tube, thickness of the neck, site of tracheostomy , postoperative swelling, and method of securing the tube. As a general rule, the ties should be secured snugly, yet allow passage one finger between the ties and the neck to prevent neck constriction. We suture the flanges to the skin with monofilament suture in addition to the ties. In an emergent situation of accidental decannulation during the initial 48 hours after the tube placement, one failed attempt at replacement must be followed with orotracheal intubation. This often-neglected intervention can save many unnecessary mishaps. Late Complications A late complication such as delayed hemorrhage may be a result of traction on granulation tissue or from innominate artery erosion. Immediate investigation 2448 into the cause of bleeding is thus mandatory. Trachea-innominate fistula with massive hemorrhage occurs in 0.4% of tracheotomies. [ 14 ] Long-term tracheal intubation and ventilation with a cuffed tracheotomy tube may result in cartilage necrosis of the tracheal wall. Erosion may also occur with a cuffless tube if the tip of the tube is lodged anteriorly, the innominate artery is high in the neck, or the tracheostomy is placed too low. This complication may be heralded by a &quot;sentinel&quot; bleed that may occur 3 days to 3 weeks before massive hemorrhage and should prompt an immediate fiberoptic tracheal examination. [ 26 ] If there is evidence of erosion or necrosis, the patient must be immediately evaluated in the operating room under general anesthesia, with the patient prepared for mediastinal exploration and thoracotomy. In instances of massive hemorrhage, direct digital pressure on the anterior wall of the stoma tract (posterior wall of the vessel) has been effective in controlling bleeding. Tracheal-innominate artery blowout carries a mortality rate of 85% to 90%. [ 7 ] [ 8 ] [ 37 ] Tracheoesophageal fistula is rare, with a reported incidence of 0.01% to 1%. [ 51 ] Tracheoesophageal fistula is thought to result from incidental damage to the posterior tracheal wall at the time of surgery or to be the product of two factors: an over inflated and improperly fitted cuffed tube, which places pressure on the posterior tracheal wall, together with an indwelling nasogastric tube in the esophagus. The diagnosis should be suspected clinically by coughing during eating, chronic cough on swallowing saliva, recurrent aspiration, and pneumonia. Barium swallow or methylene blue instilled into the esophagus and flexible fiberoptic evaluation may be diagnostic; however, generally a combination of these studies, with endoscopic evaluation, is often necessary. Once the diagnosis is confirmed, definitive surgical repair is undertaken. [ 22 ] [ 40 ] Tracheal stenosis and subglottic stenosis are complications predisposed by previous endotracheal tube intubation, high tracheostomy or cricothyroidotomy, and trauma to the airway. Patients at increased risk for tracheal stenosis include children and patients tracheotomized for closed head trauma. Meticulous surgical technique, aggressive treatment of postoperative infections, and the use of the high-volume, low-pressure cuffed tube help minimize the risk of tracheal stenosis. Tracheocutaneous fistula is a late complication, which is more common as the stomal tract is epithelialized with long-term cannulation. A persistent fistula causes continual tracheal secretions with skin irritation, disturbed phonation, and frequent infections. Infection and granulation tissue may play a role in persistent stomal fistulas. Persistent fistulas require excision of the fistula tract. Contraindications No absolute contraindications exist to open surgical tracheostomy . Bookmark URL: /das/book/view/59514421-2/1263/983.html/top History of difficult intubation Limited ability to extend the cervical spine Prothrombin time or partial thromboplastin time >1.5 times control Bleeding time >10 min Platelet count <40,000/mm 3 Positive end-expiratory pressure >15 cm H 2 O Short or obese neck Occluding thyroid mass or goiter over the tracheotomy site Active infection over the tracheotomy site Pulsating palpable blood vessel over the tracheotomy site Anatomic abnormality of the trachea Children younger than 12 years of age   About MD Consult  |  Contact Us  |  Terms and Conditions  |  Privacy Policy  |  Registered User Agreement                           www.mdconsult.com       Copyright © 2006 Elsevier Inc . All rights reserved.
    11. 11. TRACHEOSTOMY TUBE CARE <ul><li>Tube changes: </li></ul><ul><ul><li>Indications: soiled, cuff rupture. </li></ul></ul><ul><ul><li>Complications: insertion into a false passage bleeding, and patient discomfort. </li></ul></ul><ul><ul><li>Avoid within 1 st week. </li></ul></ul><ul><ul><li>First tube change by surgeon. </li></ul></ul><ul><ul><li>Difficult cases (obese, short and thick neck), be prepared for endotracheal intubation. </li></ul></ul>Use of this content is subject to the Terms and Conditions of the MD Consult web site. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed. , Copyright © 2005 Mosby, Inc. INDICATIONS FOR TRACHEOTOMY Current indications for tracheotomy are: prolonged intubation and mechanical ventilation, bypass of an upper airway obstruction, easier management of secretions, as an adjunct to chest or head and neck surgery in which ventilation problems or prolonged intubation are anticipated ( Table 106-2 ). The earliest indication for the procedure was upper airway obstruction resulting from trauma or infection. As late as the 1950s, the major indication for 2444 TABLE 106-2 -- RELATIVE CONTRAINDICATIONS TO PERFORM PERCUTANEOUS DILATIONAL TRACHEOTOMY tracheotomy was upper airway obstruction because of infectious disease including diphtheria, polio, Ludwig's angina, tetanus, and laryngotracheobronchitis. [ 29 ] [ 41 ] [ 49 ] Other causes of upper airway obstruction necessitating tracheotomy include obstruction due to neoplastic processes, or functional obstruction such as bilateral vocal cord paralysis or edema secondary to smoke inhalation or caustic agent ingestion. In such cases, patients are usually stabilized by tracheal intubation or with a cricothyrotomy and tracheotomy later. Although facial fractures in and of them selves are not an indication for tracheotomy, in cases of severe maxillo-facial trauma, tracheotomy is sometimes used to secure an airway where intubation would be difficult or damaging. Today, the most common indication for tracheotomy is prolonged tracheal intubation, usually with mechanical ventilation. A recent review of more than 1000 consecutive tracheotomies found that 76% were performed to facilitate mechanical ventilation. [ 21 ] Surgical Technique Tracheotomy is optimally performed under general anesthesia in the operating room. If necessary, the procedure may be performed under local anesthesia or in an intensive care setting. [ 29 ] In case a tracheotomy is being performed under local anesthesia, the surgeon and the anesthetist have to work in tandem to keep the patient maximally reassured. On most occasions the anesthetist may use minimal sedation to achieve patient comfort without compromising the ability to breathe spontaneously. Another critical precaution to keep in mind is to avoid the use of Bovie cautery. The surgical field may be getting the oxygenrich gas mixture from the nasal cannula or the ventilating mask. This simple precautionary measure will avert the risk of igniting fire in the surgical field. The basic technique consists of either a vertical incision from the cricoid cartilage, 1.5 inches inferiorly or a horizontal incision midway between the sternal notch and the cricoid cartilage ( Figure 106-1 ). The incision is carried down through the skin, subcutaneous tissue, and platysma to reveal the strap muscles. If the patient is obese and the adipose tissue obtrusive, a minimal cervical lipectomy may be performed. [ 23 ] At this level, the dissection should be in a vertical plane regardless of the skin incision chosen. The strap muscles are separated by a vertical incision through the bloodless midline raphe (linea Alba) and retracted from one another revealing the thyroid isthmus which typically lies over the third and fourth tracheal ring ( Figure 106-2 ). The isthmus may be dealt with in a number of ways. This decision is based on the position of the isthmus relative to the wound and the surgeon's personal preference. It may be superiorly retracted, transected, and suture-ligated ( Figure 106-3 ), transected slowly using a monopolar cautery (Bovie) [ 10 ] [ 28 ] ( Figure 106-4 ), or inferiorly retracted (least commonly used method). [ 28 ] The trachea is revealed and the third and fourth tracheal rings are identified using the cricoid as a landmark. As with the skin incision, there are equally reasonable choices for the entrance into the trachea. An inferiorly based trap door flap (Bjork flap) can be created using a Mayo scissor and sutured to the subcutaneous tissue using 3-0 chromic suture. Alternatively the anterior section of a single tracheal ring can be resected or a round or vertical oval window spanning two tracheal rings be excised [ 15 ] [ 29 ] [ 47 ] using a scalpel, curved Mayo scissor, or a tracheotomy punch ( Figure 106-5 and Figure 106-6 ). The endotracheal tube cuff is deflated and the tube slowly withdrawn by the anesthesiologist until the inferior tip of the tube is lined up with the superior border of the newly formed tracheal opening. A tracheotomy tube is then inserted through the tracheotomy into the airway and the patient is ventilated. Tracheotomy Complications The complications of tracheotomy may be categorized by the interval from the procedure to the onset of the complication and are thus divided into intraoperative, early, and late postoperative. It should be noted that there may be an overlap in the timeframe in which early, intermediate, and late complications present. It is important to note that specific patient populations, such as the pediatric, post head trauma, obese, burn patient, or seriously debilitated are more susceptible to complications related to tracheotomy. [ 20 ] 2445                                                       Figure 106-1 A, Surface anatomy of the neck with skin incision for the tracheotomy ( left ) and cricothyrotomy ( right ). B, A vertical skin incision is made between the cricoid and second tracheal ring as assessed by palpation through the skin. Tracheotomy holds a complication rate of between 5% to 40% depending on study design, patient follow-up, and the definition of the different complications. [ 46 ] In a recent study of 1130 surgical tracheotomies, the major complication rate for surgical tracheotomy was found to be as low as 4.3%, with a mortality rate of 0.7%. [ 20 ] Death from tracheotomy is caused most often by hemorrhage or tube displacement. It is important to note that the incidence of complications in emergency tracheotomy is 2 to 5 times that found in an elective procedure. The most common complication has classically been hemorrhage (3.7%), followed by tube obstruction (2.7%), and tube displacement (1.5%) The incidence 2446                                                     Figure 106-2 The strap muscles are separated through the bloodless midline raphe to reveal the underlying thyroid isthmus.                              Figure 106-3 The thyroid isthmus may be retracted or suture ligated. of pneumothorax, tracheal stenosis, and tracheoesophageal fistula is less than 1%. Immediate Complications Immediate complications of tracheotomy include those present during or at the termination of the operation. Although these complications are usually caused during surgery, they may appear hours or days after the tracheotomy is performed. Bleeding during the performance of a tracheotomy is most commonly the result of errors in surgical technique. Frequent sites of bleeding are the anterior jugular veins, the thyroid isthmus, and vascular variants such as the thyroid ima artery. [ 36 ] Other immediate complications include insertion of the tracheotomy tube into a false route, electrocautery-induced intraoperative fire, [ 1 ] and surgical injury to adjacent structures. Intermediate Complications Intermediate complications develop during the first hours to days after surgery. Again, hemorrhage may be a frequent postoperative complication of tracheotomy. 2447                                                         Figure 106-4 The thyroid isthmus may be safely transected slowly using a monopolar cautery (Bovie) when it obscures the proposed entrance site into the trachea.                              Figure 106-5 A horizontal incision can be made in the intracartilaginous space. Because many of these patients are hypotensive, bleeding does not occur until arterial blood pressure is restored or venous pressure is increased by coughing associated with canula placement. Minor oozing may be managed by light packing with oxidized cellulose, microfibrillar collagen, or tranexamic acid-soaked gauze packs. [ 27 ] Transient tracheitis and stomal cellulitis may occur, and all fresh tracheotomies should be attended to with strict local hygiene. Severe infection such as mediastinitis, clavicular osteomyelitis, and necrotizing fasciitis are rare, but have been reported after tracheostomy and must be treated aggressively. [ 48 ] Other known early postoperative complications include subcutaneous emphysema, pneumomediastinum,                              Figure 106-6 A tracheotomy punch is then used to make a circular window in the anterior wall of the trachea. and pneumothorax. All of these may result from excessive dissection of tissue planes at the time of tracheostomy , blockage of the cannula, or assisted ventilation with excessive pressure, causing dissection of air along the pretracheal fascia. The incidence of subcutaneous emphysema is 0% to 9% and the incidence of pneumothorax is 0% to 4% in adults. [ 43 ] Obstruction of the tracheotomy tube on the first few postoperative days is likely to result from blood clot, partial displacement, or tube impingement on the posterior tracheal wall. The incidence of tube obstruction is 2.5%. [ 43 ] Routine postoperative care including observation, humidification, and frequent gentle suctioning prevents tube obstruction. Dislodgment of the tracheotomy tube may be a fatal complication in the first few days after tracheotomy. Several factors that play a role in tube dislodgment are the length of the tube, thickness of the neck, site of tracheostomy , postoperative swelling, and method of securing the tube. As a general rule, the ties should be secured snugly, yet allow passage one finger between the ties and the neck to prevent neck constriction. We suture the flanges to the skin with monofilament suture in addition to the ties. In an emergent situation of accidental decannulation during the initial 48 hours after the tube placement, one failed attempt at replacement must be followed with orotracheal intubation. This often-neglected intervention can save many unnecessary mishaps. Late Complications A late complication such as delayed hemorrhage may be a result of traction on granulation tissue or from innominate artery erosion. Immediate investigation 2448 into the cause of bleeding is thus mandatory. Trachea-innominate fistula with massive hemorrhage occurs in 0.4% of tracheotomies. [ 14 ] Long-term tracheal intubation and ventilation with a cuffed tracheotomy tube may result in cartilage necrosis of the tracheal wall. Erosion may also occur with a cuffless tube if the tip of the tube is lodged anteriorly, the innominate artery is high in the neck, or the tracheostomy is placed too low. This complication may be heralded by a &quot;sentinel&quot; bleed that may occur 3 days to 3 weeks before massive hemorrhage and should prompt an immediate fiberoptic tracheal examination. [ 26 ] If there is evidence of erosion or necrosis, the patient must be immediately evaluated in the operating room under general anesthesia, with the patient prepared for mediastinal exploration and thoracotomy. In instances of massive hemorrhage, direct digital pressure on the anterior wall of the stoma tract (posterior wall of the vessel) has been effective in controlling bleeding. Tracheal-innominate artery blowout carries a mortality rate of 85% to 90%. [ 7 ] [ 8 ] [ 37 ] Tracheoesophageal fistula is rare, with a reported incidence of 0.01% to 1%. [ 51 ] Tracheoesophageal fistula is thought to result from incidental damage to the posterior tracheal wall at the time of surgery or to be the product of two factors: an over inflated and improperly fitted cuffed tube, which places pressure on the posterior tracheal wall, together with an indwelling nasogastric tube in the esophagus. The diagnosis should be suspected clinically by coughing during eating, chronic cough on swallowing saliva, recurrent aspiration, and pneumonia. Barium swallow or methylene blue instilled into the esophagus and flexible fiberoptic evaluation may be diagnostic; however, generally a combination of these studies, with endoscopic evaluation, is often necessary. Once the diagnosis is confirmed, definitive surgical repair is undertaken. [ 22 ] [ 40 ] Tracheal stenosis and subglottic stenosis are complications predisposed by previous endotracheal tube intubation, high tracheostomy or cricothyroidotomy, and trauma to the airway. Patients at increased risk for tracheal stenosis include children and patients tracheotomized for closed head trauma. Meticulous surgical technique, aggressive treatment of postoperative infections, and the use of the high-volume, low-pressure cuffed tube help minimize the risk of tracheal stenosis. Tracheocutaneous fistula is a late complication, which is more common as the stomal tract is epithelialized with long-term cannulation. A persistent fistula causes continual tracheal secretions with skin irritation, disturbed phonation, and frequent infections. Infection and granulation tissue may play a role in persistent stomal fistulas. Persistent fistulas require excision of the fistula tract. Contraindications No absolute contraindications exist to open surgical tracheostomy . Bookmark URL: /das/book/view/59514421-2/1263/983.html/top History of difficult intubation Limited ability to extend the cervical spine Prothrombin time or partial thromboplastin time >1.5 times control Bleeding time >10 min Platelet count <40,000/mm 3 Positive end-expiratory pressure >15 cm H 2 O Short or obese neck Occluding thyroid mass or goiter over the tracheotomy site Active infection over the tracheotomy site Pulsating palpable blood vessel over the tracheotomy site Anatomic abnormality of the trachea Children younger than 12 years of age   About MD Consult  |  Contact Us  |  Terms and Conditions  |  Privacy Policy  |  Registered User Agreement                           www.mdconsult.com       Copyright © 2006 Elsevier Inc . All rights reserved.
    12. 12. TRACHEOSTOMY TUBE CARE <ul><li>Tracheostomy tube cuff pressures in a range of 20 to 25 mm Hg. </li></ul><ul><li>Overly low cuff pressures < 18 mm Hg, may cause the cuff to develop longitudinal folds, promote microaspiration of secretions collected above the cuff, and increase the risk for nosocomial pneumonia. </li></ul><ul><li>Excessively high cuff pressures above 25 to 35 mm Hg exceed capillary perfusion pressure and can result in compression of mucosal capillaries, which promotes mucosal ischemia and tracheal stenosis. </li></ul><ul><li>Cuff pressure should be measured with calibrated devices and recorded at least once every nursing shift and after every manipulation of the tracheostomy tube. </li></ul>
    13. 13. TRACHEOSTOMY TUBE CARE <ul><li>Chest Xray: </li></ul><ul><li>cuff has a width greater than the caliber of the trachea, which suggests the presence of a hyperinflated cuff and tracheal overdistention </li></ul>Heffner, Hess.Clinics in Chest Medicine 22 , 2001.
    14. 14. TRACHEOSTOMY TUBE CARE <ul><li>Humidification of the inspired gas is a standard of care for tracheostomized patients. </li></ul>Thermovent
    15. 15. •  Secretions in the trach •  Suspected aspiration of gastric or upper airway secretions •  Increase in peak airway pressures when on ventilator •  Increase in respirations or sustained cough or both •  Gradual or sudden decrease in ABG •  Sudden onset of respiratory distress when airway patency is questioned Indications For Suctioning
    16. 16. Tracheostomies should be suctioned whenever physical examination reveals the presence of secretions CLEARANCE OF SECRETIONS
    17. 17. SPEECH
    18. 18. SPEECH Tracheostomy Speaking Valve Passy-Muir A tracheostomy speaking valve is a one-way valve, allows air in, but not out forces air around the tracheostomy tube, through the vocal cords and out the mouth upon expiration, enabling the patient to vocalize
    19. 19. NUTRITION <ul><li>Tracheostomy tube prevents normal upward movement of the larynx during swallowing and hinders glottic closure. </li></ul><ul><li>Between 20% and 70% of patients with a chronic tracheostomy experience at least one episode of aspiration every 48 hours </li></ul><ul><li>Evaluation by speech therapist </li></ul><ul><li>Keep head elevated to 45° during periods of tube feeding </li></ul>Heffner, Hess.Clinics in Chest Medicine 22 , 2001.
    20. 20. WEANING FROM TRACHEOSTOMY <ul><li>Demonstrate stability for 24 to 48 hours after discontinuation of mechanical ventilation. </li></ul><ul><li>Tracheostomy stomas can narrow markedly or close within 48 to 72 hours after tube removal. </li></ul><ul><li>Deflating the tracheostomy cuff and capping the tube. </li></ul>
    21. 21. WEANING FROM TRACHEOTOMY <ul><li>The ability to breath and clear airway secretions around a small, capped tube signifies readiness for decannulation </li></ul><ul><li>Patients who fail breathing trials with capped tracheostomy tubes should be evaluated by flexible fiberoptic endoscopy for evidence of airway lesions and adequacy of airway function. </li></ul>
    22. 22. Complications of Tracheostomy <ul><li>Complications 5-40% </li></ul><ul><li>Mortality <2% </li></ul><ul><li>Complications are more frequent in emergency situations, severely ill patients and small children. </li></ul>
    23. 23. Complications of Tracheostomy <ul><ul><li>Stoma </li></ul></ul><ul><ul><ul><li>Stoma site infection </li></ul></ul></ul><ul><ul><ul><li>Stomal hemorrhage </li></ul></ul></ul><ul><ul><ul><li>Poor stoma healing after decannulation with scar, keloid, or tracheocutaneous fistula </li></ul></ul></ul>
    24. 24. Complications of Tracheostomy <ul><ul><li>Trachea </li></ul></ul><ul><ul><ul><li>Granuloma </li></ul></ul></ul><ul><ul><ul><li>Tracheoesophageal fistula </li></ul></ul></ul><ul><ul><ul><li>fewer than 1% of patients as a result of pressure necrosis of the tracheal and esophageal mucosa from the tube cuff </li></ul></ul></ul><ul><ul><ul><li>risks: high cuff pressures, presence of a nasogastric tube, excessive tube movement, and underlying diabetes mellitus </li></ul></ul></ul>
    25. 25. Complications of Tracheostomy <ul><ul><ul><li>Tracheoinnominate fistula: </li></ul></ul></ul><ul><ul><ul><li>0.4% with mortality rate of 85% to 90%. </li></ul></ul></ul><ul><ul><ul><li>Major airway hemorrhage may occur first within several days or as long as 7 months after performance of a tracheostomy. </li></ul></ul></ul><ul><ul><ul><li>Risk factors : excessive tube movement, low placement of the tracheostomy, sepsis, poor nutritional status, and corticosteroid therapy </li></ul></ul></ul><ul><ul><ul><li>Tracheal stenosis: </li></ul></ul></ul><ul><ul><ul><li>can develop from 1 to 6 months after decannulation </li></ul></ul></ul><ul><ul><ul><li>risk for tracheal stenosis ranges between 0% and 16% </li></ul></ul></ul><ul><ul><ul><li>Tracheomalacia </li></ul></ul></ul>
    26. 26. CONCLUSION <ul><li>The most common indications for tracheostomy is mechanical ventilation with prolonged tracheal intubation. </li></ul><ul><li>Tracheostomy: emergency and elective, improve quality of life. </li></ul><ul><li>Meticulous surgical technique. </li></ul><ul><li>Appropriate postoperative tracheostomy care to reduce complications. </li></ul>
    27. 28. Guidewire and catheter are advanced together into the trachea as far as the skin positioning marks on the guide catheter to the skin.[ Guidewire introduction, with removal of sheath PERCUTANEOUS DILATIONAL TRACHEOTOMY
    28. 29. 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
    29. 30. 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
    30. 31. PERCUTANEOUS DILATIONAL TRACHEOTOMY Cook Ciaglia percutaneous dilatational tracheostomy kit
    31. 36. TRACHEOSTOMY TUBE CARE <ul><li>Securing tracheostomy around patient’s neck. </li></ul><ul><li>Tube changes: </li></ul><ul><ul><li>Indications: soiled, cuff rupture. </li></ul></ul><ul><ul><li>Complications: insertion into a false passage bleeding, and patient discomfort. </li></ul></ul><ul><ul><li>Avoid within 1 st week. </li></ul></ul><ul><ul><li>First tube change by surgeon. </li></ul></ul><ul><ul><li>Difficult cases (obese, short and thick neck), be prepared for endotracheal intubation. </li></ul></ul>Use of this content is subject to the Terms and Conditions of the MD Consult web site. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed. , Copyright © 2005 Mosby, Inc. INDICATIONS FOR TRACHEOTOMY Current indications for tracheotomy are: prolonged intubation and mechanical ventilation, bypass of an upper airway obstruction, easier management of secretions, as an adjunct to chest or head and neck surgery in which ventilation problems or prolonged intubation are anticipated ( Table 106-2 ). The earliest indication for the procedure was upper airway obstruction resulting from trauma or infection. As late as the 1950s, the major indication for 2444 TABLE 106-2 -- RELATIVE CONTRAINDICATIONS TO PERFORM PERCUTANEOUS DILATIONAL TRACHEOTOMY tracheotomy was upper airway obstruction because of infectious disease including diphtheria, polio, Ludwig's angina, tetanus, and laryngotracheobronchitis. [ 29 ] [ 41 ] [ 49 ] Other causes of upper airway obstruction necessitating tracheotomy include obstruction due to neoplastic processes, or functional obstruction such as bilateral vocal cord paralysis or edema secondary to smoke inhalation or caustic agent ingestion. In such cases, patients are usually stabilized by tracheal intubation or with a cricothyrotomy and tracheotomy later. Although facial fractures in and of them selves are not an indication for tracheotomy, in cases of severe maxillo-facial trauma, tracheotomy is sometimes used to secure an airway where intubation would be difficult or damaging. Today, the most common indication for tracheotomy is prolonged tracheal intubation, usually with mechanical ventilation. A recent review of more than 1000 consecutive tracheotomies found that 76% were performed to facilitate mechanical ventilation. [ 21 ] Surgical Technique Tracheotomy is optimally performed under general anesthesia in the operating room. If necessary, the procedure may be performed under local anesthesia or in an intensive care setting. [ 29 ] In case a tracheotomy is being performed under local anesthesia, the surgeon and the anesthetist have to work in tandem to keep the patient maximally reassured. On most occasions the anesthetist may use minimal sedation to achieve patient comfort without compromising the ability to breathe spontaneously. Another critical precaution to keep in mind is to avoid the use of Bovie cautery. The surgical field may be getting the oxygenrich gas mixture from the nasal cannula or the ventilating mask. This simple precautionary measure will avert the risk of igniting fire in the surgical field. The basic technique consists of either a vertical incision from the cricoid cartilage, 1.5 inches inferiorly or a horizontal incision midway between the sternal notch and the cricoid cartilage ( Figure 106-1 ). The incision is carried down through the skin, subcutaneous tissue, and platysma to reveal the strap muscles. If the patient is obese and the adipose tissue obtrusive, a minimal cervical lipectomy may be performed. [ 23 ] At this level, the dissection should be in a vertical plane regardless of the skin incision chosen. The strap muscles are separated by a vertical incision through the bloodless midline raphe (linea Alba) and retracted from one another revealing the thyroid isthmus which typically lies over the third and fourth tracheal ring ( Figure 106-2 ). The isthmus may be dealt with in a number of ways. This decision is based on the position of the isthmus relative to the wound and the surgeon's personal preference. It may be superiorly retracted, transected, and suture-ligated ( Figure 106-3 ), transected slowly using a monopolar cautery (Bovie) [ 10 ] [ 28 ] ( Figure 106-4 ), or inferiorly retracted (least commonly used method). [ 28 ] The trachea is revealed and the third and fourth tracheal rings are identified using the cricoid as a landmark. As with the skin incision, there are equally reasonable choices for the entrance into the trachea. An inferiorly based trap door flap (Bjork flap) can be created using a Mayo scissor and sutured to the subcutaneous tissue using 3-0 chromic suture. Alternatively the anterior section of a single tracheal ring can be resected or a round or vertical oval window spanning two tracheal rings be excised [ 15 ] [ 29 ] [ 47 ] using a scalpel, curved Mayo scissor, or a tracheotomy punch ( Figure 106-5 and Figure 106-6 ). The endotracheal tube cuff is deflated and the tube slowly withdrawn by the anesthesiologist until the inferior tip of the tube is lined up with the superior border of the newly formed tracheal opening. A tracheotomy tube is then inserted through the tracheotomy into the airway and the patient is ventilated. Tracheotomy Complications The complications of tracheotomy may be categorized by the interval from the procedure to the onset of the complication and are thus divided into intraoperative, early, and late postoperative. It should be noted that there may be an overlap in the timeframe in which early, intermediate, and late complications present. It is important to note that specific patient populations, such as the pediatric, post head trauma, obese, burn patient, or seriously debilitated are more susceptible to complications related to tracheotomy. [ 20 ] 2445                                                       Figure 106-1 A, Surface anatomy of the neck with skin incision for the tracheotomy ( left ) and cricothyrotomy ( right ). B, A vertical skin incision is made between the cricoid and second tracheal ring as assessed by palpation through the skin. Tracheotomy holds a complication rate of between 5% to 40% depending on study design, patient follow-up, and the definition of the different complications. [ 46 ] In a recent study of 1130 surgical tracheotomies, the major complication rate for surgical tracheotomy was found to be as low as 4.3%, with a mortality rate of 0.7%. [ 20 ] Death from tracheotomy is caused most often by hemorrhage or tube displacement. It is important to note that the incidence of complications in emergency tracheotomy is 2 to 5 times that found in an elective procedure. The most common complication has classically been hemorrhage (3.7%), followed by tube obstruction (2.7%), and tube displacement (1.5%) The incidence 2446                                                     Figure 106-2 The strap muscles are separated through the bloodless midline raphe to reveal the underlying thyroid isthmus.                              Figure 106-3 The thyroid isthmus may be retracted or suture ligated. of pneumothorax, tracheal stenosis, and tracheoesophageal fistula is less than 1%. Immediate Complications Immediate complications of tracheotomy include those present during or at the termination of the operation. Although these complications are usually caused during surgery, they may appear hours or days after the tracheotomy is performed. Bleeding during the performance of a tracheotomy is most commonly the result of errors in surgical technique. Frequent sites of bleeding are the anterior jugular veins, the thyroid isthmus, and vascular variants such as the thyroid ima artery. [ 36 ] Other immediate complications include insertion of the tracheotomy tube into a false route, electrocautery-induced intraoperative fire, [ 1 ] and surgical injury to adjacent structures. Intermediate Complications Intermediate complications develop during the first hours to days after surgery. Again, hemorrhage may be a frequent postoperative complication of tracheotomy. 2447                                                         Figure 106-4 The thyroid isthmus may be safely transected slowly using a monopolar cautery (Bovie) when it obscures the proposed entrance site into the trachea.                              Figure 106-5 A horizontal incision can be made in the intracartilaginous space. Because many of these patients are hypotensive, bleeding does not occur until arterial blood pressure is restored or venous pressure is increased by coughing associated with canula placement. Minor oozing may be managed by light packing with oxidized cellulose, microfibrillar collagen, or tranexamic acid-soaked gauze packs. [ 27 ] Transient tracheitis and stomal cellulitis may occur, and all fresh tracheotomies should be attended to with strict local hygiene. Severe infection such as mediastinitis, clavicular osteomyelitis, and necrotizing fasciitis are rare, but have been reported after tracheostomy and must be treated aggressively. [ 48 ] Other known early postoperative complications include subcutaneous emphysema, pneumomediastinum,                              Figure 106-6 A tracheotomy punch is then used to make a circular window in the anterior wall of the trachea. and pneumothorax. All of these may result from excessive dissection of tissue planes at the time of tracheostomy , blockage of the cannula, or assisted ventilation with excessive pressure, causing dissection of air along the pretracheal fascia. The incidence of subcutaneous emphysema is 0% to 9% and the incidence of pneumothorax is 0% to 4% in adults. [ 43 ] Obstruction of the tracheotomy tube on the first few postoperative days is likely to result from blood clot, partial displacement, or tube impingement on the posterior tracheal wall. The incidence of tube obstruction is 2.5%. [ 43 ] Routine postoperative care including observation, humidification, and frequent gentle suctioning prevents tube obstruction. Dislodgment of the tracheotomy tube may be a fatal complication in the first few days after tracheotomy. Several factors that play a role in tube dislodgment are the length of the tube, thickness of the neck, site of tracheostomy , postoperative swelling, and method of securing the tube. As a general rule, the ties should be secured snugly, yet allow passage one finger between the ties and the neck to prevent neck constriction. We suture the flanges to the skin with monofilament suture in addition to the ties. In an emergent situation of accidental decannulation during the initial 48 hours after the tube placement, one failed attempt at replacement must be followed with orotracheal intubation. This often-neglected intervention can save many unnecessary mishaps. Late Complications A late complication such as delayed hemorrhage may be a result of traction on granulation tissue or from innominate artery erosion. Immediate investigation 2448 into the cause of bleeding is thus mandatory. Trachea-innominate fistula with massive hemorrhage occurs in 0.4% of tracheotomies. [ 14 ] Long-term tracheal intubation and ventilation with a cuffed tracheotomy tube may result in cartilage necrosis of the tracheal wall. Erosion may also occur with a cuffless tube if the tip of the tube is lodged anteriorly, the innominate artery is high in the neck, or the tracheostomy is placed too low. This complication may be heralded by a &quot;sentinel&quot; bleed that may occur 3 days to 3 weeks before massive hemorrhage and should prompt an immediate fiberoptic tracheal examination. [ 26 ] If there is evidence of erosion or necrosis, the patient must be immediately evaluated in the operating room under general anesthesia, with the patient prepared for mediastinal exploration and thoracotomy. In instances of massive hemorrhage, direct digital pressure on the anterior wall of the stoma tract (posterior wall of the vessel) has been effective in controlling bleeding. Tracheal-innominate artery blowout carries a mortality rate of 85% to 90%. [ 7 ] [ 8 ] [ 37 ] Tracheoesophageal fistula is rare, with a reported incidence of 0.01% to 1%. [ 51 ] Tracheoesophageal fistula is thought to result from incidental damage to the posterior tracheal wall at the time of surgery or to be the product of two factors: an over inflated and improperly fitted cuffed tube, which places pressure on the posterior tracheal wall, together with an indwelling nasogastric tube in the esophagus. The diagnosis should be suspected clinically by coughing during eating, chronic cough on swallowing saliva, recurrent aspiration, and pneumonia. Barium swallow or methylene blue instilled into the esophagus and flexible fiberoptic evaluation may be diagnostic; however, generally a combination of these studies, with endoscopic evaluation, is often necessary. Once the diagnosis is confirmed, definitive surgical repair is undertaken. [ 22 ] [ 40 ] Tracheal stenosis and subglottic stenosis are complications predisposed by previous endotracheal tube intubation, high tracheostomy or cricothyroidotomy, and trauma to the airway. Patients at increased risk for tracheal stenosis include children and patients tracheotomized for closed head trauma. Meticulous surgical technique, aggressive treatment of postoperative infections, and the use of the high-volume, low-pressure cuffed tube help minimize the risk of tracheal stenosis. Tracheocutaneous fistula is a late complication, which is more common as the stomal tract is epithelialized with long-term cannulation. A persistent fistula causes continual tracheal secretions with skin irritation, disturbed phonation, and frequent infections. Infection and granulation tissue may play a role in persistent stomal fistulas. Persistent fistulas require excision of the fistula tract. Contraindications No absolute contraindications exist to open surgical tracheostomy . Bookmark URL: /das/book/view/59514421-2/1263/983.html/top History of difficult intubation Limited ability to extend the cervical spine Prothrombin time or partial thromboplastin time >1.5 times control Bleeding time >10 min Platelet count <40,000/mm 3 Positive end-expiratory pressure >15 cm H 2 O Short or obese neck Occluding thyroid mass or goiter over the tracheotomy site Active infection over the tracheotomy site Pulsating palpable blood vessel over the tracheotomy site Anatomic abnormality of the trachea Children younger than 12 years of age   About MD Consult  |  Contact Us  |  Terms and Conditions  |  Privacy Policy  |  Registered User Agreement                           www.mdconsult.com       Copyright © 2006 Elsevier Inc . All rights reserved.
    32. 38. TRACHEOTOMY
    1. A particular slide catching your eye?

      Clipping is a handy way to collect important slides you want to go back to later.

    ×