2. Tracheostomy
A tracheotomy is a surgical opening in the trachea, while a tracheostomy is
the creation of a stoma at the skin surface which leads into the tracheal
lumen.
3.
4.
5.
6. Indications for tracheostomy
There are three main indications
1. Respiratory obstruction.
2. Retained secretions.
3. Respiratory insufficiency.
7. INDICATIONS FOR TRACHEOSTOMY
1. Respiratory obstruction
(a) Infections
(i) Acute laryngo-tracheo-bronchitis, acute epiglottitis, diphtheria
(ii) Ludwig’s angina, peritonsillar, retropharyngeal or parapharyngeal abscess, tongue
abscess
(b) Trauma
(i) External injury of larynx and trachea
(ii) Trauma due to endoscopies, especially in infants and children
(iii) Fractures of mandible or maxillofacial injuries
(c) Neoplasms
(d) Foreign body larynx
(e) Oedema larynx due to steam, irritant fumes or gases, allergy (angioneurotic or drug
sensitivity), radiation
8. (f) Bilateral abductor paralysis
(g) Congenital anomalies – Laryngeal web, cysts, tracheo-oesophageal fistula Bilateral choanal
atresia
2. Retained secretions
(a) Inability to cough
(i) Coma of any cause, e.g. head injuries, cerebrovascular accidents, narcotic overdose
(ii) Paralysis of respiratory muscles, e.g. spinal injuries, polio, Guillain–Barre syndrome,
myasthenia gravis
(iii) Spasm of respiratory muscles, tetanus, eclampsia, strychnine poisoning
(b) Painful cough
(c) Aspiration of pharyngeal secretions
10. Common indications of tracheostomy in infants and
children
Infants below 1 year
(mostly congenital lesions)
• Subglottic haemangioma
• Subglottic stenosis
• Laryngeal cyst
• Glottic web
• Bilateral vocal cord paralysis
Children
• Acute laryngo-tracheo-bronchitis
• Epiglottitis
• Diphtheria
• Laryngeal oedema (chemical/thermal injury)
• External laryngeal trauma
• Prolonged intubation
• Juvenile laryngeal papillomatosis
11. FUNCTIONS OF TRACHEOSTOMY
1. Alternative pathway for breathing.
2. Improves alveolar ventilation.
(a) Decreasing the dead space by 30–50% (normal dead space is 150 mL).
(b) Reducing the resistance to airflow.
3. Protects the airways ( cuffed tube )
(a) Pharyngeal secretions, as in case of bulbar paraly-sis or coma.
(b) Blood, as in haemorrhage from pharynx,larynx or maxillofacial injuries.
12. 4. Permits removal of tracheobronchial secretions.
When patient is unable to cough as in coma, head injuries, respiratory
paralysis; or when cough is painful, as in chest injuries or upper abdominal
operations,
5. Intermittent positive pressure respiration (IPPR).
If IPPR is required beyond 72 h, tracheostomy is superior to
intubation.
6. To administer anaesthesia.
In cases where endotracheal intubation is difficult or impossible as in
laryn- gopharyngeal growths or trismus.
13. Types of tracheostomy
• Emergency tracheostomy
• Elective or tranquil tracheostomy
• Permanent tracheostomy
• Percutaneous dilatational tracheostomy
• Mini tracheostomy (cricothyroidotomy)
18. Tracheostomy procedure
1. Written informed consent
2. Anaesthesia - GA/ LA
3. Position -supine, Neck EXTENSION, both shoulders of patient at same level
4. Skin incision
5. ALWAYS BE AT MIDLINE , DO NOT DEVIATE
37. Adults
Tracheostomy tube for adults is selected by the size (or number) of the tube.
Larger the size (number) greater is the inner diameter.
In adults, tubes of inner diameter varying between 6 and 9 or 10 mm are used.
Sometimes size of tube is expressed in French gauge (FG), which is 3.14 times
the outer diameter of the tube.
FG = outer diameter × π (π = 3.14 or approx 3)
For example, a tube of 36 FG will have an outer diameter of nearly 12.0 mm. Size
of Jackson’s or Negus tube is usu-ally indicated by FG
38. Types of tracheostomy tubes
- metal and plastic
- cuffed and Uncuffed
- Fenestrated and unfenestrated
- singke and double lumen
- Adjustable flange long tube - Extra length tracheostomy tubes are used when
pretracheal tissues are thick or swollen or to by-pass a growth or stenosis in
trachea. Flange in these cases is movable and fixed at a desired place
according to the thickness of tissues of the neck.
39. Classification of tubes according to the material they are made of.
A tracheostomy tube may be made of:
1. Silver - An alloy of silver, copper and phosphorus, e.g. Fuller, Negus or Jackson’s tube.
2. PVC (polyvinyl chloride). They are disposable, single use tubes and thermolabile, and thus
adjust to tracheal lumen.
3. Silicone. Bacteria and secretions do not adhere to the tube and there is minimum of crusting.
4. Siliconized PVC. It has the properties of both PVC and silicon, i.e. it is thermolabile and adjusts
to tracheal wall while silicon prevents crusting.
5. Silastic. It is soft and nonirritating, and minimizes crusting.
6. Armoured tubes. They are plastic tubes reinforced by a spiral or rings of stainless steel. They
are not easily kinked.
53. TITLE:
Use of Fenestrated Tracheostomy Tubes: A Comparative Study
AUTHORS/AFFILIATION:
Somu Lakshmanan,
Shiva Priya Jeyabalakrishnan ,
Prasanna K Saravanam
Department of Otorhinolaryngology, Sri Ramachandra Medical College and Research
Institute, Chennai, Tamil Nadu, India
Department of ENT, Head and Neck Surgery, Sri Ramachandra Medical College and
Research Institute, Chennai, Tamil Nadu, India
54. Was the purpose stated clearly?
Yes
Outline the purpose of the study.
To compare
- the types of fenestrated tubes in terms of granulation through fenestra, stomal
granulation, frequency of suctioning, and inner tube block.
- Type I is a fenestrated tube with multiple small fenestrae and type II is a
fenestrated tracheostomy tube with a single large fenestra
55.
56. How does the study apply to your research question/clinical practice
● Tracheostomy is one of the most commonly conducted procedures in critically
ill patients requiring long-term ventilator
● Studies have been conducted about the various complications and incidence
of granulation formation in fenestrated tracheostomy tubes.
● But there is no consensus in the literature describing the fenestra in
tracheostomy tubes (single or multiple fenestrae) and their comparison in
terms of granulation formation.
● The objective of this study is to compare the advantages and disadvantages
in terms of granulation adjacent to the fenestra, stomal granulation, frequency
of suctioning, and incidence of inner tube blocks in two types of fenestrated
tracheostomy tubes.
● Knowledge about various tracheostomy tubes gives us better outcome of
patient.
57. Was relevant background literature reviewed?
Yes
Describe the justification of the need for this study.
Knowledge of tracheostomy tubes, disadvantages and advantages of each
helps in choosing a better tube .
58. Background literature
1. Cox CE, Carson SS, Holmes GM, et al. Increase in tracheostomy for prolonged mechanical
ventilation in North Carolina, 1993- 2002
2. Yaremchuk K. Regular tracheostomy tube changes to prevent formation of granulation tissue.
Laryngoscope 2003;
3. Plummer AL, Gracey DR. Consensus conference on artificial airways in patients receiving
mechanical ventilation. Chest 1989
4. White AC, Kher S, O’Connor HH. Respiratory care. When to Change a Tracheostomy Tube 2010
5. Eisele RF. “Fenestrated tracheostomy tube. 1 Aug. 1989
6. Siddharth P, Mazzarella L. Granuloma associated with fenestrated tracheostomy tubes. Am J Surg
7. Bhatia G, Abraham V, Louis L. Tracheal granulation as a cause of unrecognized airway narrowing.
J Anaesthesiol, Clin Pharmacol 2012
8. Griggs A. Tracheostomy: suctioning and humidification. Emerg Nurse 1999
59. Describe the study design. Was the design appropriate for the study
question?
- Prospective, randomized controlled trial study
- Year - January 2015 and January 2016
- Published - 2021, International journal of head and neck surgery
- Consent taken
- Inclusion criteria - patients underwent surgical tracheostomy for prolonged
ventilation in tertiary care hospital between January 2015 and January 2016
- Exclusion criteria - Patients with indications other than prolonged ventilation
were excluded from the study.
60. Was the sample described in detail?
•Yes
•Sampling - size - A total of 87 patients were included in the study.
52 males
35 females
mean age of 46 years (ranging from 1 to 87 years).
•Prospective randomized controlled trial
•year 2021
•Type of approach chosen not according to patients choice
61. Intervention was described in detail?
•Yes
Description of the intervention.
•Prospective randomised controlled study
62. - A horizontal skin crease incision was applied 2 cm above the suprasternal
notch and dissection was done.
- The thyroid isthmus was retracted superiorly to reveal the second and third
tracheal rings and the tracheal incision was placed between these two rings.
- A double-lumen cuffed fenestrated (outer fenestrated tube with the non-
fenestrated inner cannula) tracheostomy tube was used during the
tracheostomy and secured with stay sutures and ties after confirming the
position of the tube.
- The stay sutures were removed on the 5th day and the skin sutures were
removed on the 7th day.
63. - On the 10th postoperative day, the tracheostomy tube was changed to either
type I (multiple small fenestrae in outer cannula) or type II (single large
fenestra) double-lumen tracheostomy tube.
- The patients were divided into two groups based on whether a type I (group I)
or type II (group II) tracheostomy tube was used.
- During every tube change, i.e., on the 10th day, 1 month, 3 months, and
before decannulation, a flexible laryngoscopy was done to assess the airway.
- The patency of the airway, the presence of stomal granulation, and the
presence of granulation adjacent to the fenestra were assessed. The above
parameters were documented and compared between the two groups.
64. Were the outcome measures reliable?
•Yes
Describe the outcomes and their reliability and applicability.
• Outcomes were documented which are reliable and can be used in clinical practice.
87 patients were subjected to a fiber-optic laryngoscopy at the time of tube change,
i.e., 10th day, 1 month, 3 months, and at the time of decannulation.
The parameters that were assessed include
65. 1. Presence of granulation through the fenestra or adjacent to the fenestra .
2. Presence of stomal granulation (peristomal/suprastomal/ infrastomal).
3. Frequency of daily suctioning.
4. Incidence of inner tube block .
66. There were a total of 40 patients in group I and 47 patients in group II.
67.
68.
69. End of 6 Months
At the end of 6 months, 38 patients in group I and 44 patients in group II were
decannulated.
Flexible laryngoscopy done at the time of decannulation showed granulation
through the fenestra in seven and two patients in groups I and II, respectively.
Evidence of stomal granulation was seen in three patients in group I and none of
the patients in group II.
The frequency of daily suctioning and incidence of inner tube block reduced
significantly in both groups.
70. Are the inclusions, Interventions and outcomes relevant/applicable to your
setting?
Yes it is applicable in our setting as we do tracheostomy frequently
71. What was the clinical importance of the results?
- 87 patients completed this study, 40 with type 1 and 47 with type 2.
72.
73. Conclusions were appropriate given study methods and results
• Yes
What did the study conclude? What are the implications of these results for
practice?
- Type II fenestrated tracheostomy tubes are more patient compliant.
- The incidence of inner tube block is comparatively less which makes it safe to
use and avoid life-threatening situations.
- Decannulation can be done earlier and without complications in patients with
type II tubes due to the less incidence of stomal granulation.
74. - Incidence of granulation through fenestra and bleeding during
tracheostomy tube change is less in patients with type II tubes.
- Thus, type II tube is safer to use and has minimal complications.
What were the main limitations or biases in the study?
● The study has its own limitation of having a small sample size.
● Further research and comparison of various parameters in larger randomized
controlled studies may provide clarity about the choice of tube and its
appropriate utility.
Do you agree with the author’s interpretations?
•Yes
75. Do you propose further studies on this topic? If so, why and how?
•Yes further studies are needed to compare different tubes and techniques of
tracheostomy to know better tubes and their outcomes with better techniques .
