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  • My mother underwent a tracheostomy but some thing is wrong and she is having difficulty in breadthing and ther is lot of cough coming in suction. resp rate is always above 35. can some one help.
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    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.


    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 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.
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  • defined as a trachea with excessive transverse narrowing and widened sagittal diameter of the intrathoracic portion of the trachea. This is very different from the C-shaped trachea seen in about 49% of normal adults

    1. 1. Moderator:- Dr.Vivek Student:Dr.Imran
    2. 2.  Contains glands, small arteries, nerves, lymph vessels and elastic fibers  Trachealis muscle overlies esophage al muscle and epithelium
    3. 3.  Average cross-sectional area of the male adult trachea is approximately 2.8 cm2 Transverse (lateral) diameter of 25 mm and sagittal (anteroposterior) diameter of 27 mm are the upper limits of normal (males)  The lower limit of normal for both transverse and sagittal diameters is about 13 mm in men and 10 mm in women
    4. 4. U-shaped trachea (27%) C-shaped trachea (49%)
    5. 5. A saber-sheath or scabbard trachea is. The saber sheath trachea has been described in up to 5 % of elderly men. Women - round configuration Men - sagittal widening and transverse narrowing.
    6. 6.  Tracheal Index (TI) defined as (transverse/saggital diameter)<0.6  12% of elderly men with COPD.
    7. 7. Normal shape A B Saber sheath Expansion during inhalation Circumferential collapse C D Dynamic collapse E F Crescent shape collapse
    8. 8. Tracheal Relationships Cervical Thoracic
    9. 9. Cervical Trachea Anterior Posterior Lateral Skin Sup. & Deep facia Esophagus 2 Lateral lobes of Thyroid Strap muscles Sternocleidomastoid Sternohyoid Sternothyroid Recurrnent Laryngeal Nerves Comman Carotid Artery Isthmus of Thyroid Prevertebral fascia Internal Jugalar VeinVagus Inferior Thyroid Vein Thyroidea Ima Artery<10% Omohyoid Pre-tracheal facia Plexus Thyroideus Impar External jugular vein
    10. 10. Thoracic Trachea Anterior Posterior Lateral Thymus Gland Esophagus Vagus Phrenic Nerves Left Branchiocephalic Vein Recurrnent Laryngeal Nerves Superior vena cava anterolaterally on right side Arch of Aorta Prevertebral fascia Lungs covered by Pleura The left common carotid and left subclavian arteries Thoracic Duct on left side Azygos vein on right side
    11. 11.   Esophagus lies Posterior Note Trachealis muscle
    12. 12.   Esophagus Recurrent Laryngeal Nerves 18
    13. 13. Cervical Tracheal RelationshipsAnterior Skin Superficial & Deep fascia. 2nd to the 4th rings are covered by the isthmus of the thyroid.
    14. 14.    Inferior Thyroid Veins Thyroidea Ima Artery>10% Pretrachal Fascia invests  Trachea  Thyroid Gland  Larynx
    15. 15.  Note:  Thyroidea Ima Vein  Plexus Thyroideus Impar
    16. 16.  2 Lateral LobesThyroid Gland
    17. 17.  Carotid Sheath and Contents  Common Carotid Artery  Internal Jugular Vein  Vagus Nerve Anterolateral View
    18. 18. Posterior View  Carotid Sheath and Contents  Internal Jugular Vein (Lateral)  Common Carotid Artery (Medial)  Vagus Nerve (Posterior)
    19. 19.  Thymus Gland (or Thymic Remnant in adults)
    20. 20.   Left Brachiocephalic Vein Aortic Arch
    21. 21.  Vagus Nerves  Phrenic Nerves  Lungs covered by Pleura
    22. 22. • General Sensation- Vagus & Recurrent Laryngeal Nerves  Autonomic Innervation  Sympathetic-Decreases Secretions(T1,T2)  Parasympathetic-Increases Secretions(Vagus)
    23. 23.  Inferior Thyroid Arteries- Cervical Portion  Bronchial Arteries- Thoracic Portion
    24. 24.  Venous plexuses situated around trachea and oesophagus ultimately drain into inferior thyroid venous plexus.  lymph nodes located around trachea, the brachio-cephalic and right common carotid arteries.
    25. 25. Indications & Complications of Tracheostomy
    26. 26. What is “Tracheostomy” The word “tracheostomy” is derived from the Latin “trachea” and “tomein” (to make an opening). Tracheostomy is an operative procedure that creates a surgical airway in the cervical trachea .
    27. 27. What is this & what are its indications ??? Answer at the end of presentation
    28. 28. 1932 to prevent pulmonary infection in neurologically impair patients secondary to infections (poliomyelitis). 1943 to remove bronchial secretions in cases of myasthenia gravis and tetanus. 1951 to reduce the volume of dead space, use in COPD and severe penumonia.
    29. 29. 1950 positive pressure through tracheostomy for patients with poliomyelitis. 1955 obstruction secondary to infection: diphteria, Ludwig’s angina. 1961 Obstructions secondary to tumour, infectious disease and trauma.
    30. 30. Tracheotomy Indications To bypass obstruction
    31. 31. Tracheotomy Indications Prolonged intubation - Need for prolonged respiratory support, such as in Bronchopulmonary Dysplasia - To reduce anatomic dead space and increase the chance for mechanical ventilation withdrawal - To improve the patient`s quality of life (easier toilet, ability to speak and eat, increase the mobility) - Neuromuscular diseases paralyzing or weakening chest muscles and diaphragm
    32. 32.  PROTECTION of AIRWAY  Neurological Diseases(Polyneuritis, GBS)  Coma (GCS<8, risk of aspiration)  Elective Tracheostomy as Adjunct to H&N surgeries  <14 days on ETT(relative)  >21 days on ETT
    33. 33. Tracheotomy Indications Miscellaneous -Congenital abnormalities. (Pierre Robin, Triecher Collins syndromes) - Obstructive Sleep Apnea Syndrome. - Aspirations related to muscle or sensory problems. -Prophylaxis (as preparation for extensive H&N procedures, before radiotherapy for H&N CA) -Cervical spinal cord injuries with respiratory muscles paralysis.
    34. 34.  No absolute contraindications exist to tracheostomy  RELATIVE  Laryngeal CA(strong)  it may lead to increased incidence of stomal recurrence(a diffuse infiltrate of neoplastic tissue at the junction of the amputated trachea and skin )
    35. 35.  Physical assessment also surgical and anesthesiological  CBC  PT, PTT, INR  Patient/apotropus confirmation
    36. 36. Types of Tracheostomy 1) Open procedure a) High tracheostomy (Cricothyroidectomy) b) Low tracheostomy 2) Percutaneous procedure
    37. 37. High tracheostomy (Cricothyroidectomy) Landmark Thyroid cartilage Cricothyroid membrane Crycoid cartilage
    38. 38. Emergency Cricothyrotomy Protocol Indications: A patient that requires intubation and Unable to intubate and Unable to adequately ventilate Conditions: Patient  40 kg and  12 years old Contraindications: Suspected fractured larynx Inability to localize the cricothyroid membrane
    39. 39. Techniques 1) Seldinger (Melker) Cricothyrotomy 2) Needle Cricothyrotomy
    40. 40. Low Tracheostomy Skin Prep with povidine iodine, chlorohexidine(savlon) Draping Good light source and suction machine ready and tested to be functional
    41. 41. Transverse Incision Incision 1 cm below the cricoid or halfway between the cricoid and the sternal notch. Incision length=6cm/ anterior border of SCM msc lateral
    42. 42. Blunt dissection of subcut tissue Transversely Retracted as shown
    43. 43. Strap msc is divided longitudinally at midline Thyroid ismuth is divided at midline by 2 haemostat and cut edge secured by 2/0 vicryl
    44. 44. Depending on the TT size abt 4cm longitudinal opening is made in trachea below 2nd ring
    45. 45. Tube is anchored
    46. 46. Percutaneous Dilational Tracheostomy Benefits include elimination of need for operating room use or anesthesia, and significant reduction in cost. Should be done in carefully selected patients Under fiber optic control To be ready to switch to open procedure
    47. 47. PERCUTANEOUS DILATIONAL TRACHEOTOMY Guidewire introduction, with removal of sheath Guidewire and catheter are advanced together into the trachea as far as the skin positioning marks on the guide catheter to the skin.[
    48. 48. Guidewire, guide catheter, and dilator unit are advanced together into the trachea to the skin positioning mark
    49. 49. 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
    50. 50. PCV check(pressure controlled ventilation) Repeat X-Ray soft tissue neck Strong Analgesia Antibiotics IV fluid until able to tolerate orally
    51. 51. Risk factors for complications Age: infants and adults over 75 Obesity Smoking Poor nutrition Recent illness, especially an upper-respiratory infection Alcoholism Chronic illness Diabetes
    52. 52.  Apnea due to loss of hypoxic respiratory drive. This is mainly important in the awake patient. Ventilatory support must be available  False root  Bleeding  Pneumothorax or pneumomediastinum
    53. 53. to the vocal cords (direct)  Injury to adjacent structures: recurrent  Damage laryngeal nerves, the great vessels, and the esophagus.  Post-obstructive  Hypotension  Arrhythmia pulmonary edema
    54. 54.        Early bleeding: This is usually the result of increased blood pressure as the patient emerges from anesthesia and begins to cough. Plugging with mucus Tracheitis Cellulitis Tube displacement Subcutaneous emphysema Atelectasis
    55. 55.         Bleeding - tracheoinnominate fistula Tracheo- and laryngomalacia Stenosis Tracheoesophageal fistula Tracheocutaneous fistula Granulation Scarring Failure to decannulate
    56. 56.  Tube changes:  Indications: soiled, cuff rupture.  Complications: insertion into a false passage bleeding, and patient discomfort.  Avoid within 1st week.  First tube change by surgeon.  Difficult cases (obese, short and thick neck), be prepared for endotracheal intubation.
    57. 57.  Tracheostomy tube cuff pressures ---20 to 25 mm Hg.  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.  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.  Cuff pressure should be measured with calibrated devices and recorded at least once every nursing shift and after every manipulation of the tracheostomy tube.
    58. 58.  Humidification of the inspired gas is a standard of care for tracheostomized patients. Thermovent
    59. 59. Indications For Suctioning • 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
    60. 60.  After the track is formed – 4-5 days after the operation.  Rate of exchange depends on clinical situation of the specific patient – type of discharge, type of tube, medical status, age..  Usually every 14 days.  Should be done by experienced staff.
    61. 61.   Cuffed and uncuffed Fenestrated and unfenestrated  Single and double lumen  Various diameters
    62. 62.   Uncuffed Cuffed To protect airway To allow ventilation
    63. 63.   Allow patient to ventilate past tube via upper airway Allow speech
    64. 64.   Double lumen allows easy cleaning Single lumen has a greater internal diameter
    65. 65. Other Types of Tubes Bivona Fome-Cuff Tracheaostomy Tube Montgomery T-Tube Single Cannular Shiley Pediatric TT
    66. 66. 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
    67. 67.  Tracheostomy tube prevents normal upward movement of the larynx during swallowing and hinders glottic closure.  Between 20% and 70% of patients with a chronic tracheostomy experience at least one episode of aspiration every 48 hours  Keep head elevated to 45° during periods of tube feeding
    68. 68.     Resolution of pathology that necessitated the tracheotomy (upper airway obstruction, pneumonia) Normal protective laryngeal mechanisms (no aspirations during normal swallowing, good coughing) No planed further interventions (radiotherapy, H&N operations) No mechanical ventilation
    69. 69. Answer Jackson’s tracheostomy Fuller’s tracheostomy tube