Tracheostomy complication decannulation

1. ...Tracheostomy
• 1. Complications
• 2. Post operative care
• 3. Pediatric tracheostomy
Roll. no. 11
Aditya Rana ( 2018 )
References- Scott- Browns,
PL Dhingra, BS Tuli , EEE
Ent

2. • 1. Immediate (at the time of operation):
(a) Haemorrhage - commonest fatal complication of
tracheostomy. Bleeding is due to damage to thyroid veins
or the thyroid isthmus. If there is significant bleeding at the
end of the procedure the wound should be explored and
any bleeding vessel ligated.
(b) Apnoea- this follows opening of trachea- prolonged
respiratory obstruction. This is due to sudden washing out
of CO2 which was act as a respiratory stimulus. Treatment
is carbogen 95% O2 + 5% CO2.
c) Air embolism- fortunately rare, if the large veins of the
neck are opened- air sucked into the veins- right atrium.
Complications

3. c) Aspiration of blood.
(d)Pneumothorax Due to injury to apical pleura.
(e)Injury to recurrent laryngeal nerves.
(f) Injury to oesophagus. This can occur with tip of knife while
incising the trachea- damage to the posterior wall of the
trachea and may result in tracheo-oesophageal fistula.

4. 2. Intermediate (during first few hours or
days):
•(a) Bleeding, reactionary or secondary.
•(b) Displacement of tube- the tube is adequately
secured at the time of procedure, by suturing the flanges of
the tube to the skin. If the tube is displaced and comes lie
in the pretracheal space. Dyspnoea slowly increases and
by the time the displacement is apparent the tube maybe
impossible to replace as the tracheotomy has virtually
closed.
•(c) Blocking of tube.

5. • (d) Subcutaneous emphysema - if the tracheostomy tube
or the trachea are obstructed and the skin incision has been
closed tightly, then air may be forced out into the soft tissues
of the neck during expiration resulting in subcutaneous
emphysema.
Surgical emphysema can track upto the lower
eyelids and down into the upper
chest. In severe cases the swelling
may cause displacement of the tube.
• e) Tracheitis and tracheobronchitis
with crusting in trachea.
• (f) Atelectasis and lung abscess.
• (g) Local wound infection and granulations.

6. 3. Late (with prolonged use of tube for weeks and months):
(a) Haemorrhage, due to erosion of major vessel.
(b) Laryngeal stenosis, due to perichondritis of cricoid
cartilage.
(c) Tracheal stenosis, due to tracheal ulceration and
infection.
(d) Tracheo-oesophageal fistula, due to prolonged use of
cuffed tube or erosion of trachea by the tip of tracheostomy
tube.
(e) Problems of decannulation. Seen commonly in infants
and children.
(f) Persistent tracheocutaneous fistula.
(g) Problems of tracheostomy scar. Keloid or unsightly
scar. Corrosion of tracheostomy tube and aspiration of its
fragments into the tracheobronchial tree.

7. Tracheostomy- Infants &
Children

8. 1. Great care and caution is required.
2. Trachea - soft and compressible - identification become
difficult- go deep and lateral to trachea injuring recurrent
laryngeal nerve even the carotid- so useful to have
bronchoscope and endotracheal tube - preferably done under
general anaesthesia.
3. During positioning - dont extend the neck too much-this
pulls structures from chest into the neck and injured the
pleura,innominate vessels and thymus.
4. Before incising trachea, silk sutures are placed in the
trachea, on either side of midline.
lumen is small- dont insert knife too deep- injure posterior
tracheal wall causing tracheo-oesophageal fistula.

9. 5. Trachea is simply incised, without excising a circular piece
of tracheal wall.
6. Selection of tube is important. It should be of proper
diameter, length and curvature.
Use soft silastic or portex tube. Metallic tubes cause more
trauma.
8. Take a postoperative X-ray of the neck and chest to
ascertain the position of the tracheostomy tube.

10. Post operative care
1. Constant supervision- bleeding, displacement or
blocking of the tube.
2. Suction- depending on the amount -every half an hour
or so; use sterile catheter with a Y- connector to break
suction force.
3. Preventing of crusting and tracheitis-
Proper humidification - humidifier, boiling kettle,
ultrasonic nebulizer.
If crusting occurs- few drops of normal or hypotonic
saline or ringer’s lactate- instilled in trachea - every 2-3
hrs - loosen crust. acetylcysteine solution - mucolytic.

11. 4. Care of tracheostomy tube - inner canula is removed
& cleaned - indicated for 1st 3 days.
Outer tube , unless blocked or displaced - should not be
removed for 3-4 days to allow a track to be formed when
tube placement will become easy. after 3-4 days outer
tube can be removed and cleaned everyday.
A cuffed tracheostomy tube is inserted initially so that
any bleeding does not get aspirated.The cuff is
deflated for few minutes every hour and is
permanently deflated after 12 hrs to prevent pressure
necrosis and stenosis.
The inserted cuffed portex tracheostomy tube is then
replaced with an uncuffed portex tube after 3 days.
Regular suctioning should be done for 5- 10 seconds after
every 1 - 2 hrs.

12. Thereafter this uncuffed tracheostomy
tube is changed every 2-3 days because it
tends to get obstructed from crusting.
If complete obstruction of the tube -
replaced with fresh one.
Tracheostomy tube can be washed
and reused.
Cleaning of the tube with saline and sodium bcarbonate is
done to frequently in a day as a measure to prevent crusting
and delaying obstruction.

13. Decannulation- The process whereby a tracheostomy tube
is removed once patient no longer needs it.
Decannulation should take place in an ordered sequence.
1. The tube should be blocked during the day and
unblocked at night for the first 24 hrs.
2. If the patient tolerates this then the tube can be
occluded for a full 24 hr period and if this is tolerated
then the tube can then be removed.
3. If patient cannot tolerate this occlusion , necessary
to downsize the tube to give more room around it.
4. Once the tube has been removed an airtight dressing
must be applied to occlude the stoma. The dressing should
be changed whenever an air leak appears to improve the
chance of full closure of the fistula.

14. Decannulating an infant or a young child-
1. Decannulate - operation theatre- trained nurse and an
anaesthetist.
2. Equipment for reintubation should be available
immediately - good headlight , laryngoscope, proper sized
endotracheal tube and a tracheostomy tray.
After decannulation - watch the child for several hours for
respiratory distress, tachycardia and colour oxymetry is
very useful to monitor oxygen saturation- may require blood
gas determinants.When attempt at decannulation are not
successful, look for the cause. It may be;
a) Persistence of the condition.
b) Obstructing granuloma around the stoma.
c) Tracheal edema or subglottic stenosis.
d) Incurving of tracheal wall at the sit of tracheostomy.
e) Tracheomalacia.
f) Psychological dependance on tracheostomy and
inability to tolerate the resistance of the upper airways.

15. Home Care- Patient Education
1.Stoma Care
2.Infection - personal hygiene
3.Inner tube not to be removed unless for cleansing
4.Inner tube to be atleast 3 times a day.
5.Nutrition
6.Communication- bell or a paper pad.
7.Avoid swimmimg
8.Avoid dust, sand ,smoke
9.Avoid wind and cold air
10.Avoid contact with person having contagious
illness.
11.Portable suction for travel.

17. Procedures for Immediate
Airway Management
1.Jaw thrust - lifting the jaw forward and extending neck
improves the airway by displacing the soft tissue. Neck
extension should be avoided in spinal injuries.
2. Oropharyngeal airway- displaces the tongue anteriorly
and relieves soft tissue obstruction- ventilation by face
mask- ambu bag used for inflation of air and oxygen.
3. Nasopharyngeal airway( trumpet )- inserted
transnasally into the posterior hypopharynx and relieves soft
tissue obstruction caused by tongue and hypopharynx,
better tolerated than oropharyngeal airway in awake patient.

18. 4. Laryngeal mask airway- device with a tube and a
triangular distal end which fits over the laryngeal inlet, oxygen
can be delivered directly into the trachea.
Alternative if standard mask ventilation is inadequate and
intubation unsuccessful.
5. Transtracheal jet ventilation - invasive procedure
6. Endotracheal intubation most rapid method . larynx is
visualised with a laryngoscope and endotracheal tube inserted.
Avoid hurried tracheostomy- in which complication rate is
higher. after intubation, an orderly tracheostomy can be
performed.
No anaesthesia required.

19. 7. Mini tracheostomy or Cricothyrotomy - procedure for
opening the airway through cricothyroid membrane.
Mini tracheostomy is an emergency procedure to buy
time to allow patient to be carried to operation theatre.
Commercial emergency kits are available.
As an elective procedure it has been done to clear the
bronchial secretions following thoracic surgery.
The procedure does not provide adequate ventilation.

20. THANK YOU

21. Q . No. 1 Complications of tracheostomy are all except-
Neet - pg
a) fracture cervical vertebra
b) pneumothorax
c) subcutaneous emphysema
d) apnoea
Q . no. 2 A 40 year old man who met with a motor vehicle
catastrophe came to the casuality with severe
maxillofacial trauma. His pulse rate was 120/ min , Bp was
100/70 , Spo2-80% with oxygen. What would be the
immediate management?
a) nasotracheal intubation
b) orotracheal intubation
c) intravenous fluid
d) tracheostomy