History of Tracheostomy Techniques Types Tubes of Trachesotomy Open Vs Percutaneous Dilatational Technique Early vs Late Trachestomy in ICU Setup Trachesotomy Care Suctioning Guidelines Techniques Humidification Woundcare

1. Clinical Meet 04/01/2018

2. Overview
• History
• Techniques Types Tubes of Trachesotomy
• Open Vs Percutaneous Dilatational Technique
• Early vs Late Trachestomy in ICU Setup
• Trachesotomy Care
– Suctioning Guidelines Techniques
– Humidification
– Woundcare

3. Tracheostomy is an operative
procedure that creates a
surgical airway in the cervical
trachea. 1,2
1 Mitchell RB, Hussey HM, Setzen G, Jacobs IN, Nussenbaum B, Dawson C, et al. Clinical consensus statement: tracheostomy
care. Otolaryngol Head Neck Surg. 2013 Jan. 148(1):6-20.
2 Young D, Harrison DA, Cuthbertson BH, Rowan K, TracMan Collaborators. Effect of early vs late tracheostomy placement on survival in
patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013 May 22. 309 (20):2121-9
“I cut trachea” (in greek) τραχειοστομία

5. •The tracheotomy is one of the oldest surgical procedures.
•Portrayed on Egyptian tablets dated back to 3600 BC.
•Asclepiades of Persia credited as the first person to perform a
tracheotomy in 100 BC.
•The first successful documented tracheotomy was performed
by Brasovala in the 15th century.

6. •First successful documented
tracheotomy was performed by
Antonio Musa Brasavola (1490-1554)
in the 15th century.
•An Italian Physician
•He published his account in 1546.
• Patient had suffered from a
laryngeal abscess
•Recovered from the procedure.

7. Guidi, Guido [Vidius] (1508-1569)
De anatome corporis humani libri VII.Venetiis, apud Juntas, 1611

8. The first five images depict the tracheotomy
procedure.
Between 1500 and 1833, there are reports of
only twenty-eight successful tracheotomies.
Armamentarium chirurgicum
bipartitum 1666

9. Introduced
Vertical Incison
& Specific Tracheostomy Tubes
HIERONYMUS FABRICIUS
(1537–1619 )
First paediatric
tracheostomy in 1620
NICHOLAS HABICOT
( 1550 – 1624 )

10. CHEVALIER JACKSON
( 1865 – 1958 )

11. Christmas in the
bronchoscopic clinic
ward.
Children with tracheostomies usually
lived in the hospital.
Photo from The Life of Chevalier
Jackson, An Autobiography
Copyright 1938 by MacMillan Company

12. ULYSSES S. GRANT
(1822 – 1885)
GEORGE WASHINGTON
( 1732 – 1799 )
Their lives could probably have been saved….

13. Various Antique Tracheostomy Tubes

15. ELECTIVE
TYPE of Trachesotomies

17. TYPE of Trachesotomies

18. TYPE of Trachesotomies

21. 1. Conventional Surgical Tracheostomy
2. Percutaneous Dilatational Tracheostomy

22. Ciaglia Blue Rhino kit containing needle, guide wire, and serial dilators
Percutaneous Dilational Tracheostomy-
Commercial Kits & Techniques

23. Ciaglia Blue Rhino kit technique

24. Griggs and Rapitrach systems

25. Griggs and Rapitrach Technique

26. The Percutwist system
Note the dilatation of the tract with a semi-sharp screw over a guide wire

29. •Inability to palpate thyroid and cricoid cartilages
•Thyromegaly or suprasternal mass
•Coagulation disorders
•Children
•Patients requiring a tracheostomy after leaving ICU
•Unavailability of flexible or rigid bronchoscope and/or
ultrasound
•Difficult airway
•Emergency procedures
Source: Percutaneous Dilational Tracheostomy Technique Thomas Deitmer, Johan Fagan.
The Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery by Johan Fagan (Licensed under a Creative
Commons Attribution - Non-Commercial 3.0 Unported License)
Percutaneous Dilatational Tracheostomy

31. Intensive Care Med (1991) 17:261-263
•A prospective non-randomised study
•The safety and utility of surgical and PCT techniques performed in ICU
•Standard indications for tracheostomy of prolonged mechanical ventilation (> 10 days)

32. •RCT of 30 PCT vs 30 Surgical Cases
•median time for insertion of the tracheostomy tube was 11.5 min (range 7–24 min) vs 15
min (range 5–47 min) (P<0.01).
•Minor bleeding was encountered in 6 cases in the PDT group as opposed to 24 cases in
the TR group (P<0.01),
•Major bleeding in none versus 2 cases, respectively.
Post-tracheostomy period,
•minor bleeding in 2 cases in the PDT vs 9 cases in the TR group (P<0.05), and major
bleeding was encountered in 1 case in each group.
•Minor infections were encountered in 3 cases in the PDT group as opposed to 11 cases in
the TR group (P<0.01). Major infection was encountered in none versus 8 cases,
respectively (P<0.01).

33. Prospective, randomized trial.
30 patients underwent PDT and 26 patients had ST. In one patient, PDT was converted to ST.
Mean time 11 mins (SD, 6; range, 2-40), vs 14 mins (SD, 6; range, 3-39).
In the PDT group, five patients had moderate bleeding during the procedure. In three
patients, the bleeding was resolved with compression; in one patient, it was resolved
with ligation of the vessel; and in one patient, it was resolved with electrocoagulation.
Bleeding did not cause any complications afterward.
In the PDT group, one patient had minimal oozing from the wound edge on the first
postoperative day and it was resolved spontaneously.

34. •368 abstracts, 15 prospective, randomized-controlled trials involving nearly 1,000 patients
•complications, case length, and cost-effectiveness.
•meta-analysis illustrates there is no clear difference but a trend toward fewer complications
in percutaneous techniques.
• Percutaneous tracheotomies are more cost-effective and provide greater feasibility in
terms of bedside capability and nonsurgical operation.

35. “Early vs Late Tracheostomy
in an ICU Care”

36. Method:
•A random-effects meta-analysis
•Combining data from three a priori-defined categories of timing of tracheotomy
(within 4 versus after 10 days, within 4 versus after 5 days, within 10 versus after
10 days)
•Estimate the weighted mean difference (WMD) or odds ratio (OR).
Results:
•142 studies 2689 patients included
•The tracheotomy rate was significantly higher with early than with late
tracheotomy
•Early tracheotomy was associated with
•more ventilator-free days
•a shorter ICU stay
•a shorter duration of sedation and reduced long-term mortality
than late tracheotomy

38. •106 patients over 4 years
•Early (< 3 weeks) vs Late
Results
•An early tracheostomy showed less complication vs late procedure.
•The length of stay in the ICU for patients who had an early tracheostomy was 26 days
while this period for patients who had late tracheostomy was 47 days.
•Mortality rate among patients who had early tracheostomy was 17.1% while for late
tracheostomy patients, it was 36.1%.

40. Latest Meta analysis in this topic published in Dec 19 2017
Aim: Evaluation of appropriate time of Tracheostomy in ICU Setting
Parameters: HAP, Mortality Length of Stay , Duration of Mech Vent.
English Articles: 1987- 2017; 692 articles; 2,22,501 patients
Results & Conclusion:
Significant Difference in favour of early tracheostomy (< 7 days) in adults and pediatric groups
In regards to
reduced duration of mechanical ventilation
less mortality rates
less number of ICU days stay
Regarding HAP
significant reduction by early tracheostomy in adult group
no significant difference in pediatric age group

41. Clinical Question
In mechanically ventilated adult patients with a high risk of prolonged ventilation, does
early tracheostomy compared with late tracheostomy reduce mortality at 30 days?
Design
Large, multi-centre, randomised, controlled trial
Pilot study and national survey to estimate baseline prevalence
70 adult, general Intensive Care Units across the UK
13 university associated
59 non-university associated
November 2004 to November 2008

42. Outcome
Primary outcome: all-cause mortality at 30-days was not statistically different between the
two groups
Early 30.8% vs late 31.5%
Secondary outcome:
There were no differences in survival at ICU discharge, hospital discharge, 1-year and
2-year follow-up
Duration of mechanical ventilation favoured early tracheostomy but this did not reach
statistical significance
Early 13.6 days vs late 15.2 days; reduction in mean duration 1.7 days; p=0.06
Median length of ICU stay were the same: early 13.0 days vs late 13.1 days
Only within the 30-day-surviving sub-group, there were statistically significantly fewer
days of sedation administration in the early group: early 5 days vs late 8 days
(p<0.001)

45. Consensus for timing of tracheostomy in critically ill patients has not yet been reached.

48. Frequency
Suction Catheter Size
Technique (Closed & Open)

49. 1. It is recommended that endotracheal suctioning should be performed only when
secretions are present, and not routinely;
2. It is suggested that pre-oxygenation be considered if the patient has a clinically
important reduction in oxygen saturation with suctioning;
3. Performing suctioning without disconnecting the patient from the ventilator is
suggested;
4. Use of shallow suction is suggested instead of deep suction, based on evidence
from infant and pediatric studies;
5. It is suggested that routine use of normal saline instillation prior to
endotracheal suction should not be performed;
AARC Clinical Practice Guidelines: Restrepo RD, Brown JM II, Hughes JM Endotracheal Suctioning of Mechanically Ventilated
Patients With Artificial Airways 2010 Respir Care 2010;55(6):758–764. © 2010 Daedalus Enterprises
American Association for Respiratory Care (AARC)
Guidelines- Recommendations

50. 5. The use of closed suction is suggested for adults with high FIO2, or PEEP, or at
risk for lung derecruitment, and for neonates;
6. Endotracheal suctioning without disconnection (closed system) is suggested in
neonates;
7. Avoidance of disconnection and use of lung recruitment maneuvers are
suggested if suctioning-induced lung derecruitment occurs in patients with
acute lung injury;
8. It is suggested that a suction catheter is used that occludes less than 50% the
lumen of the endotracheal tube in children and adults, and less than 70% in
infants;
9. It is suggested that the duration of the suctioning event be limited to less than
15 seconds
AARC Clinical Practice Guidelines: Restrepo RD, Brown JM II, Hughes JM Endotracheal Suctioning of Mechanically Ventilated
Patients With Artificial Airways 2010 Respir Care 2010;55(6):758–764. © 2010 Daedalus Enterprises
American Association for Respiratory Care (AARC)
Guidelines- Recommendations

59. Humidification is the key to prevent crusts blocking the tube

68. Tracheostomy Tube with Suction Port

69. Extra Long Adjustable Flange Tubes
PORTEX® Bivona® Adult TTS™ Adjustable Neck
Flange Hyperflex™ Tracheostomy Tubes

70. Extra Long Adjustable Flange Tubes

71. Double cuffed tubes use the alternation of the cuff inflation to allow pressure
relief on high risk tracheal mucosa,
e.g. tracheomalacia. E.g. Double cuff Portex.
Lanz™ system - This cuff system automatically controls and limits cuff pressure for
the entire duration of intubation. E.g. Tracheosoft Lanz™, Mallinckrodt.
Double cuffs

73. A= Stoma Pad
B C & D – Neck Straps

74. E: TTH Tracheostomy tube holder in
two parts.
F Tracheolife™ II HME with O2 and
suction port for spontaneously
breathing patients.
G Hygrolife™ II HME with CO2
sampling port for use with ventilated
patients.
H Swivel connector double swivel
connector with access for
bronchoscopy and tracheobronchial
suction, sterile

77. f/11 1/40 Sec ISO 125
Nikon D7000 200 mm
©Dr Mohonish N Chettri
25/12/2017