tracheostomy is important surgery in emergency and icu patient so this presentation is very good opportunity to gain informative ideas about this surgery

1. TracheostomyTracheostomy
DRDR
KHALID MOKBELKHALID MOKBEL
Prof. ORLProf. ORL
ConsultantConsultant
20122012

2. Tracheostomy ComplicationsTracheostomy Complications
1. Displaced Tube1. Displaced Tube
Can be fatalCan be fatal
 May be accidental or due to confused patientMay be accidental or due to confused patient
Call for helpCall for help
Insert an endotracheal tube into tracheal stomaInsert an endotracheal tube into tracheal stoma
Insert new tube over the endo tracheal tubeInsert new tube over the endo tracheal tube
The tube is stitched to the skin and also taped around the neckThe tube is stitched to the skin and also taped around the neck

3. Tracheostomy ComplicationsTracheostomy Complications
2. Tube blockage2. Tube blockage
Remove inner trach. tubeRemove inner trach. tube
tracheal suction by small diameter rubber cathetertracheal suction by small diameter rubber catheter
Instil 2 – 3mls sterile normal salineInstil 2 – 3mls sterile normal saline
Fibreoptic view may be helpfulFibreoptic view may be helpful
If the block is large, change tube in ORIf the block is large, change tube in OR

5. Tracheostomy ComplicationsTracheostomy Complications
3. Bleeding3. Bleeding
Likely to be small amount of oozing fromLikely to be small amount of oozing from
tracheostomy woundtracheostomy wound
Inflate cuff on tracheostomy tube toInflate cuff on tracheostomy tube to
protect airway until bleeding settledprotect airway until bleeding settled
If minor bleeding apply pressure orIf minor bleeding apply pressure or
adrenaline-soaked gauze packadrenaline-soaked gauze pack
Large bleed uncommon and usually inLarge bleed uncommon and usually in
emergency situationemergency situation

6. Tracheostomy ComplicationsTracheostomy Complications
4. Surgical emphysema4. Surgical emphysema
Usually due to too tight closure ofUsually due to too tight closure of
tracheostomy woundtracheostomy wound
May require removal of sutures to letMay require removal of sutures to let
trapped air escapetrapped air escape

7. Checking tube positionChecking tube position
Feel air flow from tube on your arm as patientFeel air flow from tube on your arm as patient
exhalesexhales
Observe patient’s breathing - noisy? difficult?Observe patient’s breathing - noisy? difficult?
use of accessory muscles?use of accessory muscles?
Observe patient’s colourObserve patient’s colour
If any doubt, fibreoptic scope can be passedIf any doubt, fibreoptic scope can be passed
down tube for direct vision of positiondown tube for direct vision of position
X-ray not generally helpfulX-ray not generally helpful

8. Changing the Tube 2Changing the Tube 2
Insert introducer into new tubeInsert introducer into new tube
Patient sits upright or lies supine with neckPatient sits upright or lies supine with neck
extendedextended
Observe track followed by old tube as it isObserve track followed by old tube as it is
removed and follow it when inserting newremoved and follow it when inserting new
tubetube
Fasten tapes with one finger between tapeFasten tapes with one finger between tape
and patient’s neckand patient’s neck
Check tube positionCheck tube position
Beware false track anterior to tracheaBeware false track anterior to trachea

9. Changing the Tube – railroadChanging the Tube – railroad
techniquetechnique
Cut both ends off largest possible suctionCut both ends off largest possible suction
cathetercatheter
Insert suction catheter down trache tubeInsert suction catheter down trache tube
(warn patient re coughing)(warn patient re coughing)
Remove tube over catheter, maintainingRemove tube over catheter, maintaining
catheter position in airwaycatheter position in airway
Insert new tube over catheterInsert new tube over catheter
Remove catheterRemove catheter
NB not possible if tube blocked – need toNB not possible if tube blocked – need to
use introduceruse introducer

10. Changing the Tube 1Changing the Tube 1
First change by ENT surgeon (unlessFirst change by ENT surgeon (unless
an emergency)an emergency)
Rarely difficultRarely difficult
““Railroad” technique recommended forRailroad” technique recommended for
first and difficult subsequent changesfirst and difficult subsequent changes

11. Tube trouble?Tube trouble?
Is patient’s breathing effortless?Is patient’s breathing effortless?
Is patient confused/aggressive?Is patient confused/aggressive?
Is patient able to speak without occludingIs patient able to speak without occluding
tube?tube?
Is breathing noisy?Is breathing noisy?
Wet - excess secretions?Wet - excess secretions?
Dry - crusted mucus?Dry - crusted mucus?
Can you pass a suction catheter past the endCan you pass a suction catheter past the end
of the tube (tube length approx 7 - 9cm)?of the tube (tube length approx 7 - 9cm)?

12. Suction techniqueSuction technique
Suction pressure (20kPa/150mmHg)Suction pressure (20kPa/150mmHg)
Suction OFF on entry, ON forSuction OFF on entry, ON for
withdrawal of catheterwithdrawal of catheter
Quickly – patient can’t breathe!Quickly – patient can’t breathe!
Circular motionCircular motion in tracheostomy tubein tracheostomy tube
onlyonly

16. Tracheostomy EquipmentTracheostomy Equipment
Humidified air/OHumidified air/O22 + elephant tubing,+ elephant tubing,
tracheostomy masktracheostomy mask
Spare tubesSpare tubes
1 same make and size as patient is wearing1 same make and size as patient is wearing
1 cuffed tube one size smaller1 cuffed tube one size smaller
Syringe to inflate cuffSyringe to inflate cuff
Tracheal dilatorsTracheal dilators
Lubricating gelLubricating gel
Stitch cutterStitch cutter

22. • EmergencyEmergency
TracheostomyTracheostomy
Within 2-4 mints with vertical incisionWithin 2-4 mints with vertical incision
• Cricothyrotomy/miniCricothyrotomy/mini
tracheostomytracheostomy
Transverse incision over theTransverse incision over the
cricothyroid membrane. Keep onlycricothyroid membrane. Keep only
for 3-5 daysfor 3-5 days

23. Elective TracheostomyElective Tracheostomy
AnaesthesiaAnaesthesia: G A: G A
Position:Position: Supine with sand bag underSupine with sand bag under
the shoulderthe shoulder
IncisionIncision:horizontal incision b/w cricoid:horizontal incision b/w cricoid
cartilage and suprasternal notch.cartilage and suprasternal notch.
Division /retractionDivision /retraction of thyroid isthmusof thyroid isthmus
Opening of TracheaOpening of Trachea and insertion ofand insertion of
tubetube

24. 4.4. Elective ProceduresElective Procedures
• For major head and neck
operations.

25. 3.3. Pulmonary ToiletPulmonary Toilet
• Those who cannot cough and
clear their chest.
• Prevent aspiration by low
pressure high volume cuff
tracheostomy tube.

26. 2.2. Pulmonary VentilationPulmonary Ventilation
• Tracheostomy should be
performed in a patient still
requiring ventilation through
an endotracheal tube for
more than a one week.

27. 1.1. Upper Airway ObstructionUpper Airway Obstruction
a. Trauma
b. Foreign body
c. Infections
d. Malignant lesions

29. IndicationsIndications
1.1. Upper Airway Obstruction.Upper Airway Obstruction.
2.2. Pulmonary Ventilation.Pulmonary Ventilation.
3. Pulmonary Toilet.3. Pulmonary Toilet.
4. Elective Procedure4. Elective Procedure

32. AnatomyAnatomy
• Trachea lies in midline of the neckTrachea lies in midline of the neck
extending from cricoid cartilageextending from cricoid cartilage
(C6) superiorly to the tracheal(C6) superiorly to the tracheal
bifurcation at the level of sternalbifurcation at the level of sternal
angle (T5).angle (T5).
• Comprises 16-20 C shapedComprises 16-20 C shaped
cartilage rings.cartilage rings.
• Length 10-12cm.Length 10-12cm.
• Diameter 15-20mm.Diameter 15-20mm.

33. TracheotomyTracheotomy
• operative procedure that createsoperative procedure that creates
an artificial opening in thean artificial opening in the
trachea.trachea.
TracheostomyTracheostomy
• ccreation of permanent or semireation of permanent or semi
permanent opening in trachea.permanent opening in trachea.

34. Pediatric TracheostomPediatric Tracheostom
Vertical incision in trachea b/w 2Vertical incision in trachea b/w 2ndnd
and 3and 3rdrd
ring.ring.
No excision of ant. Wall of tracheaNo excision of ant. Wall of trachea
Secure the tube with neck by two suturesSecure the tube with neck by two sutures

35. HOME CARE PLANHOME CARE PLAN
1.1. Education and training of theEducation and training of the
attendant.attendant.
2.2. Supply of dressing, suctionSupply of dressing, suction
catheters and suction machine.catheters and suction machine.
3.3. When to come to the hospital.When to come to the hospital.
4.4. Visit by community nurse.Visit by community nurse.

36. PROBLEMS DURINGPROBLEMS DURING
TRACHEOSTOMY CARETRACHEOSTOMY CARE
1.1. Dislocation of tracheostomy tube.Dislocation of tracheostomy tube.
2.2. Bleeding from stoma or duringBleeding from stoma or during
suction.suction.
3.3. Blockage of tracheostomy tube.Blockage of tracheostomy tube.
4.4. Aspiration and swallowing problems.Aspiration and swallowing problems.
5.5. Speaking problems.Speaking problems.

37. Chevalier Jackson (1865-1958)Chevalier Jackson (1865-1958)
1909 defined technique1909 defined technique
and factors leading toand factors leading to
complications ...complications ...
inadequate knowledge &inadequate knowledge &
skillsskills

38. Double lumen tubes 1880’sDouble lumen tubes 1880’s

39. Trocar and Cannula 1850’sTrocar and Cannula 1850’s

40. Golden oldies of trachy careGolden oldies of trachy care
1770 George Martine develops the inner1770 George Martine develops the inner
cannulacannula
1869 Trandelenburg first to describe the1869 Trandelenburg first to describe the
use of an inflatable cuff, fitted to a trachyuse of an inflatable cuff, fitted to a trachy
tubetube

41. CARE OF THE STOMA /CARE OF THE STOMA /
INFECTION CONTROLINFECTION CONTROL
THE STOMA HAS TO BETHE STOMA HAS TO BE
CARED FOR CAREFULLYCARED FOR CAREFULLY
IT NEEDS TO BE CLEANEDIT NEEDS TO BE CLEANED
AND INSPECTED 2-3AND INSPECTED 2-3
TIMES A DAYTIMES A DAY
IT SHOULD BE CLEANEDIT SHOULD BE CLEANED
USING ASEPTICUSING ASEPTIC
TECHNIQUE ANDTECHNIQUE AND
APPROPRIATEAPPROPRIATE
DRESSINGS APPLIED TODRESSINGS APPLIED TO
AID HEALINGAID HEALING
ONCE TUBE IS REMOVEDONCE TUBE IS REMOVED
THE STOMA WILL CLOSETHE STOMA WILL CLOSE
SPONTANEOUSLY OVER ASPONTANEOUSLY OVER A

42. PERI-OPERATIVEPERI-OPERATIVE
COMPLICATIONS OFCOMPLICATIONS OF
TRACHEOSTOMYTRACHEOSTOMY
HAEMORRHAGEHAEMORRHAGE
SURGICALSURGICAL
EMPHYSEMAEMPHYSEMA
PNEUMOTHORAXPNEUMOTHORAX
AIR EMBOLISMAIR EMBOLISM
CRICOIDCRICOID
CARTILAGECARTILAGE
DAMAGEDAMAGE
NERVE DAMAGENERVE DAMAGE

43. COMPONENTS OFCOMPONENTS OF
TRACHEOSTOMYTRACHEOSTOMY
SIZES RANGESIZES RANGE
FROM 2.5MM TOFROM 2.5MM TO
11 MM11 MM
CURVED TUBECURVED TUBE
INFLATABLEINFLATABLE
CUFFCUFF
FLANGES WITHFLANGES WITH
HOLESHOLES
TUBE BLADDERTUBE BLADDER

44. PERCUTANEOUS
TRACHEOSTOMY KIT

45. PERCUTANEOUS TRACHEOSTOMY
INSERTION KIT (RHINO)

46. ANATOMICAL POSITIONING OF
A TRACHEOSTOMY TUBE

47. TYPES OF TRACHEOSTOMYTYPES OF TRACHEOSTOMY
TUBETUBE
FenestratedFenestrated

48. TYPES OF TRACHEOSTOMYTYPES OF TRACHEOSTOMY
TUBETUBE
CuffedCuffed

49. TYPES OF TRACHEOSTOMYTYPES OF TRACHEOSTOMY
TUBETUBE
UncuffedUncuffed

50. TRACHEOSTOMY TUBESTRACHEOSTOMY TUBES
A tracheostomy tubeA tracheostomy tube
is:-is:-
– Inserted through theInserted through the
tracheostomy totracheostomy to
maintain a patentmaintain a patent
airwayairway
– Secured in place bySecured in place by
tapes tied around thetapes tied around the
neckneck

51. TracheostomyTracheostomy
ISIS
Creation of an opening in the anterior wallCreation of an opening in the anterior wall
of cervical trachea, and insertion ofof cervical trachea, and insertion of
tracheostomy tube, it may be permanenttracheostomy tube, it may be permanent
or temporaryor temporary

52. INDICATIONSINDICATIONS
Bypass : Upper Airway ObstructionBypass : Upper Airway Obstruction
SuctionSuction
VentilationVentilation
ProphylacticProphylactic
With LaryngectomyWith Laryngectomy

53. Upper Airway ObstructionUpper Airway Obstruction
SupralaryngealSupralaryngeal
LaryngealLaryngeal
SublaryngealSublaryngeal

54. Supra-laryngeal ObstructionSupra-laryngeal Obstruction
CongenitalCongenital
TraumaticTraumatic
InflammatoryInflammatory
NeoplasticNeoplastic
NeurogenicNeurogenic
AllergicAllergic

55. Supra-laryngeal obstructionSupra-laryngeal obstruction

59. Mechanism of InjuryMechanism of Injury
Blunt traumaBlunt trauma
– MVAMVA
– ClotheslineClothesline
– CrushingCrushing
– Strangulation injuriesStrangulation injuries
Penetrating traumaPenetrating trauma
– GSW- related to theGSW- related to the
type of weapontype of weapon
Directly penetration orDirectly penetration or
indirectly by the blastindirectly by the blast
effecteffect
– KnivesKnives
Cummings: laryngeal Injury. Otolaryngology: Head & Neck Surgery,Cummings: laryngeal Injury. Otolaryngology: Head & Neck Surgery,
4th ed4th ed.. Mosby, IncMosby, Inc,, 20052005

60. Laryngeal obstructionLaryngeal obstruction
CongenitalCongenital
TraumaticTraumatic
InflammatoryInflammatory
NeoplasticNeoplastic
AllergicAllergic
NeurogenicNeurogenic

61. LaryngealLaryngeal
CongenitalCongenital

62. 6262
Subglottic HemangiomaSubglottic Hemangioma

63. Subglottic StenosisSubglottic Stenosis

64. Subglottic stenosisSubglottic stenosis

65. LaryngomalaciaLaryngomalacia

67. Suction & VentilationSuction & Ventilation
ComaComa
Respiratory muscle paralysisRespiratory muscle paralysis
Respiratory ms myopathyRespiratory ms myopathy
Chest traumaChest trauma
Cardiothoracic SurgeryCardiothoracic Surgery
AspirationAspiration

68. ProphylacticProphylactic
Major surgery of head& neckMajor surgery of head& neck
 AngofibromaAngofibroma
 ParapharyngealParapharyngeal
 InfratemporalInfratemporal
 Partial laryngectomyPartial laryngectomy
 LaryngofissureLaryngofissure

69. Level of tracheostomyLevel of tracheostomy
Upper: above thyroid isthmusUpper: above thyroid isthmus
Mid : behind isthmusMid : behind isthmus
Lower: below isthmusLower: below isthmus

70. Types of trach. tubesTypes of trach. tubes

71. TechniquesTechniques
Surgical Open tracheostomySurgical Open tracheostomy
Percutaneous Dilation TracheostomyPercutaneous Dilation Tracheostomy

72. Surgical TracheostomySurgical Tracheostomy
AnaesthesiaAnaesthesia
Supine extended neckSupine extended neck
IncisionIncision
Dissection, ms splittingDissection, ms splitting
Incision of thyroid isthmusIncision of thyroid isthmus
Exposure of tracheal ringExposure of tracheal ring
Incision of tracheaIncision of trachea
Insertion of tracheostomy tube.Insertion of tracheostomy tube.

73. Types of TR incisionsTypes of TR incisions
TransverseTransverse
LongitudinalLongitudinal
CruciateCruciate
BjBjöörk flaprk flap
Circular excision of ringsCircular excision of rings

74. Important NoticesImportant Notices
Support the trachea during dissectionSupport the trachea during dissection
Pretracheal fasciaPretracheal fascia
Guide sutures into tracheal edgesGuide sutures into tracheal edges
Confirmation of OConfirmation of O²² saturation beforesaturation before
removal of endotracheal tube ***removal of endotracheal tube ***
Fixation by skin sutures & ties ***Fixation by skin sutures & ties ***

76. Percutaneous D TracheostomyPercutaneous D Tracheostomy
AnesthesiaAnesthesia
Anatomical landmarksAnatomical landmarks
Cannula & Needle insertionCannula & Needle insertion
Saline filled syringe test for bubblingSaline filled syringe test for bubbling
Guidwire insertion via the cannulaGuidwire insertion via the cannula
Initial dilatorInitial dilator
A guiding catheterA guiding catheter
CBR passing (main dilator)CBR passing (main dilator)
The T-tube with introducer is insertedThe T-tube with introducer is inserted

77. Advantages of PDTAdvantages of PDT
Rapid & easyRapid & easy
In ICU without transport to ORIn ICU without transport to OR
No need for OT requestNo need for OT request
Can be done at any timeCan be done at any time
Rapid healing of the stomaRapid healing of the stoma
Decreases ICU stayDecreases ICU stay

78. Disadvantages of PDTDisadvantages of PDT
Slightly Blind procedure, So bronchoscopySlightly Blind procedure, So bronchoscopy
is mandatoryis mandatory
Fracture of cricoid or tracheal ringsFracture of cricoid or tracheal rings
False passage in Paratracheal regionFalse passage in Paratracheal region
Blind injury of blood vesselsBlind injury of blood vessels
Any complications change it into STAny complications change it into ST

79. Advantages of STAdvantages of ST
Open procedureOpen procedure
Direct visualization of structuresDirect visualization of structures
Wide stoma creationWide stoma creation
No false passageNo false passage

80. Disadvantages of STDisadvantages of ST
More operation timeMore operation time
More manipulation of tissuesMore manipulation of tissues
Long woundLong wound
More infectionMore infection
OT request and scheduled listOT request and scheduled list
Disconnection and transport from ICUDisconnection and transport from ICU
More time for healing of stomaMore time for healing of stoma

81. Intraprocedural ComplicationsIntraprocedural Complications
BleedingBleeding
EmphysemaEmphysema
PneumothoraxPneumothorax
Injury of posterior wallInjury of posterior wall
Tracheo-esopheal fistulaTracheo-esopheal fistula
Injury of recurrent nInjury of recurrent n

82. Postprocdural ComplicationsPostprocdural Complications
ObstructionObstruction
BleedingBleeding
InfectionInfection
Tracheo-esophageal fistulaTracheo-esophageal fistula
Granulation tissue formationGranulation tissue formation
StenosisStenosis

83. PDT versus STPDT versus ST
PDT is the procedure of choice in ICUPDT is the procedure of choice in ICU
Bronchoscopic guidance is essentialBronchoscopic guidance is essential
Otolaryngologist must be requested inOtolaryngologist must be requested in
complications or difficultiescomplications or difficulties
ST is reserved for difficult PDTsST is reserved for difficult PDTs

84. Nursing CareNursing Care
 ObservationObservation
 SuctionSuction
 DressingDressing

85. ObservationObservation
BleedingBleeding
Respiration & O2 saturationRespiration & O2 saturation

86. SuctionSuction
 By small catheterBy small catheter
 IntermittentIntermittent
 Every ½ HEvery ½ H
 Saline instillationSaline instillation

87. Outer & Inner tubesOuter & Inner tubes
Outer T: is inside the patientOuter T: is inside the patient
is the main tubeis the main tube
never touchednever touched
Inner T: is inside the outer TInner T: is inside the outer T
it prevents crustation of OTit prevents crustation of OT
removed only for cleaningremoved only for cleaning
reinserted after cleaningreinserted after cleaning

88. DressingDressing
Bactegruth or sofratullBactegruth or sofratull
passed under the shoulder of outerpassed under the shoulder of outer
tube, never remove the tube for dressingtube, never remove the tube for dressing
 Never change the tie around the neckNever change the tie around the neck
 Except under doctorExcept under doctor‘‘ss observationobservation

89. Nurse ResponsibilitiesNurse Responsibilities
Observation for respirationObservation for respiration
Observation for bleedingObservation for bleeding
SuctionSuction
Cleaning of inner tubeCleaning of inner tube
Dressing by sofratulDressing by sofratul

90. Never for nurseNever for nurse
Never leave patient without suctionNever leave patient without suction
Never do suction by large catheterNever do suction by large catheter
Never remove the main tubeNever remove the main tube
Never change the tie around the neckNever change the tie around the neck