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Tracheostomy and its care by Dr.Ashwin menon

Slides regarding tracheostomy and care to be taken.

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Tracheostomy and its care by Dr.Ashwin menon

  2. 2. ANATOMY
  4. 4. JACKSON’S SAFETY TRIANGLE Triangular space in neck • Base: Lower end of thyroid cartilage • Apex: Suprasternal notch • Sides: Inner edges of sternocleidomastoid muscle So named as this marks the area through which safe dissection can be done for tracheostomy Also represents the area into which infiltration anesthesia is given during tracheostomy under local anesthesia
  5. 5. TRACHEA Depth from skin: 18 mm to 32 mm Length: 11 cm Levels: C6 to Upper border of T5 Rings: 16 to 20 2nd, 3rd, 4th rings are covered by thyroid isthmus Cartilaginous ring C-shaped i.e. incomplete posteriorly. The edges of the C are connected by trachealis muscle which helps in narrowing the tracheal lumen during coughing-Thus higher velocity of air is generated.
  6. 6. RELATIONS OF THE TRACHEA  Cervical part of trachea  Thoracic part of trachea
  7. 7.  CERVICAL PART OF THE TRACHEA  Anterior Relation:  The skin and the superf. & deep fascia.  Jugular arch & overlapped by the sternohyoid and sternothyroid muscles.  Tracheal cartilage 2-4 isthmus of the thyroid gland  Above which an anastomotic artery connect the b/l sup. Thyroid A  Below and in front are the pre tracheal fascia, inf. Thyroid V communicative band between Ant jugular V, thymic remnants & thyroidea ima A. In Children the brachio cephalic A crosses, obliquely in front of the trachea at or a little above the upper border of the manubrium; Left BCV also rise a little above this level
  8. 8.  Lateral Relation: • Paired lobes of the thyroid gland descending to the 5th or 6th tracheal cartilageas • The carotid sheath enclosing the common carotid A, IJV & vagus nerve. • The inferior thyroid A lies laterally.  Posterior Relation: • Oesophagus- running between the trachea & the vertebral column. • The recurrent laryngeal nerves ascend on either side.
  9. 9.  THORACIC PART OF TRACHEA  Anterior Relation:  Manubrium sterni  Origin of sternohyoid & sternothyroid Muscles  Thymic remnants.  Inferior Thyroid & Left brachiocephalic V  Aortic arch  Brachio cephalic A (R)  Left CCA  Deep cardiac plexus  Lymph nodes.
  10. 10.  Posterior Relation:  Oesophagus  Vertebral column  Thoracic duct (left & posterior to the oesophagus) Lateral Relation:  Right - Right lung upper lobe & pleura Right BCV, Sup. Venacava, Rt Vagus Nerve & Azygous V.  Left- Left CCA & Left subclavian A, Arch of Aorta, Left Vagus Nerve, Left recurrent laryngeal nerve
  11. 11.  BLOOD SUPPLY OF THE TRACHEA  Mainly by the Inferior Thyroid Artery  Thoracic end – Bronchial arteries which anastomose with the Inferior Thyroid A and also supply the Oesophagus  VEINS: to Inferior Thyroid venous plexus • LYMPHATICS: Pretracheal & (R & L) Paratracheal LN Inferior tracheobronchial ‘sub- carinal’nodes
  12. 12.  NERVE SUPPLY  Tracheal branches of the vagi.  Recurrent laryngeal nerves.  The sympathetic trunks. RLN – motor fibers to the muscles of the trachea an trachealis muscle, also carry sensory fibers from the mucous membrane. Sympathetic nerve fibers – derived mainly from middle cervical ganglion.
  13. 13. LAYERS OF DISSECTION Skin Adipose tissue Platysma (absent is midline) Two anterior jugular veins and anastomosing veins between them Deep fascia (investing layer) Strap muscles Thyroid Isthmus Trachea
  15. 15. Pre-Operative Check list  Indication  Clotting Profile of Patient  Screening  Good assistant  Correct size tube  Instruments This applies to Elective cases only
  16. 16. Position of Patient
  17. 17. Position (contd) The patient should be positioned on the operating table with the neck extended. This is accomplished by placing a shoulder pad under the patient’s shoulders. This results in extension of the neck and exposes more of the trachea as it is brought up out of the chest. The head should be supported in a head ring and the patient should be lying squarely on the table.
  18. 18. Marking the Incision The trachea and laryngeal cartilages should be palpated in order to establish where to make the incision. This should be a horizontal /vertical incision between the sternal notch and the cricoid cartilage, which can be felt just inferior to the cricothyroid ligament.
  19. 19. Infiltration
  20. 20. Infiltrate skin with 2% Xylocaine with 1:200,000 adrenaline either before scrubbing or after cleaning the surgical field with betadine or with an appropriate non- alcoholic, anti- septic, surgical skin preparation. A second tube should be available as well as a selection of smaller, and larger tubes in case a problem arises. A catheter mount is also needed to enable the anaesthetic tube to be attached to the tracheostomy tube. Other essential items include a cricoid hook, a tracheal dilator and sutures.
  21. 21. • The patient should be draped using three small and one large sticky drape. • A head drape should not be used, as it needs to be unwrapped in order to gain access to the ET tube and this cannot be done in a hurry, as it is cumbersome. • Place one small sticky drape on either side of the neck, up to the angle of the jaw making sure that the anaesthetic tube is not stuck to the drape. The third drape is applied horizontally just under the chin.
  22. 22. Incision The incision is made through the subcutaneous tissue and platysma, down to the deep cervical fascia. The anterior jugular veins will be encountered superficial to the deep cervical fascia on either side of the midline. Note that the trachea is deeper than one imagines.
  23. 23. DISSECTION A self-retaining retractor can now be inserted and the dissection continued until the strap muscles are encountered. These should be separated in the midline. The assistant can do this using a pair of Langenbeck retractors. The dissection is continued with blunt ended dissecting scissors. If one stays in the midline, it is a relatively bloodless field and one continues deeper until the thyroid isthmus is identified.
  24. 24. If the trachea is low in the neck and one is having difficulty accessing the upper trachea, then there are two strategies to bring the trachea further up into the neck. Firstly a Cricoid hook can be used. The hook is inserted into the trachea just under the cricoid cartilage and the trachea is gently pulled upwards into the incision. This usually works well. An alternative strategy is to insert a deep Travis retractor and place the upper arm against the lower edge of the thyroid cartilage and the lower, against the upper edge of the sternum. When the retractor is opened the trachea is drawn upwards by the pull on the more robust thyroid cartilage.
  25. 25. Thyroid Isthmus
  26. 26. Dealing with Thyroid Isthmus There are different opinions regarding this- 1. Dividing the Isthmus between two clamps and ligating it. 2. Pulling thyroid Isthmus up. 3. Pulling thyroid isthmus down.
  27. 27. Once the isthmus is divided or pulled up or down the trachea will be exposed and the rings should be counted. Meticulous haemostasis is essential at this stage as it is difficult to visualize the depths of the wound once the tube is in situ. The surgeon should therefore pay attention to any bleeding at this stage by judicious use of bipolar diathermy.
  28. 28. Tracheal Opening  The tracheostomy should be sited over the 2nd and 3rd or 3rd and 4th tracheal cartilages. It is always better to identify Cricoid cartilage by palpation and count the rings downwards.  The tracheostomy must not involve the first tracheal ring because of the high incidence of post-op, subglottic stenosis if it is divided.
  29. 29. • The trachea should be incised longitudinally in the midline through these cartilages or if the cartilages are heavily calcified, a window, big enough to take an appropriate sized tube, should be cut in the anterior aspect of the tracheal cartilages. • Care must be taken not to dissect laterally as the recurrent laryngeal nerves may be damaged. • A pair of heavy scissors may be necessary to cut through heavily calcified cartilages.
  30. 30.  When one is ready to make the incision in the trachea, the anaesthetist should be alerted so that he/she can be ready to withdraw the tube.  Check that all the equipment is available and working before making your incision. Make especially sure that the right size tube has been selected.
  31. 31.  If the trachea is relatively deep to the skin edge, an adjustable flange tube is recommended as there is less likelihood of the tube being displaced in the early post- operative period.
  32. 32.  Make every effort not to puncture the cuff of the tube. The easiest way to do this is to ask the anaesthetist to push the tube further down the trachea towards the carina before making the hole.  Once the trachea is incised the tube is withdrawn under direct vision until the tip is just above the incision.  It should not be removed as it can be rapidly advanced to secure the airway in the event of a problem.
  33. 33. Tracheostomy Tube Insertion  Tracheal dilators will be needed to enable the tube to be inserted into the tracheal lumen.  The assistant should now hold the tube in situ until it is secured. Use a flexible suction catheter down the tube to suction any blood or mucus out of the trachea and connect the catheter mount to the tracheostomy tube and the anaesthetic tubing.
  34. 34. Inflate the cuff of the tube with enough air to create a seal. The anaesthetist should confirm that there is good CO2 return and that the patient is oxygenating well and that the air-pressures are adequate. Check the cuff on the tracheostomy tube is staying inflated as it can be punctured by a sharp edge of calcified cartilage. If it has, then change the tube.
  35. 35. The tracheostomy wound should be closed with monofilament, interrupted sutures to the skin. This is a loose closure and no more than two or three sutures are needed on either side of the tube. Tight closure may result in surgical emphysema especially if positive pressure ventilation is used. The sutures can be removed after seven days.
  36. 36. Securing the Tube • The tube itself should be secured with both tracheostomy ties and sutures. • This will prevent the tube from falling out if someone is offended by blood on the ties and decides to change them in the immediate post- operative period! • The tube is sutured in place using a thick silk stitch. The stitch is placed through the loop provided for the ties and not through the plastic of the flange itself.
  37. 37.  The sutures are tied with just enough slack to allow the gauze soaked in betadine (or Lyofoam) dressing to be inserted between the skin and the tracheostomy tube  The tracheostomy tapes are tied around the neck only once the sand bag has been removed from behind the patient’s shoulders and the neck has been flexed.
  38. 38. The easiest way to securely fasten the tapes to the flange of the tube is to make a loop with a long and short limb and pass this loop through the flange and then pull the ends of the tape through the loop and pull them tight. This will lock the tape in place. Now pass the long ends of the tape under the patient’s neck and tie securely to the opposite short ends. The tapes should be tied in such a way that only the tip of one finger can be placed between them and the skin of the neck and they should be tied with proper knots and not bows!
  39. 39. Emergency Tracheostomy  Vertical Incision between Cricoid and Suprasternal notch.  Straight incision up to or including trachea in one incision.  Insert the tube as soon as possible  Once tube is in place and patient is ventilated, then hemostasis.
  40. 40. Indications 1. Upper Airway Obstruction. 2. Pulmonary Ventilation. 3. Pulmonary Toilet. 4. Elective Procedure.
  41. 41. 1. UPPER AIRWAY OBSTRUCTION a. Trauma b. Foreign body c. Infections d. Malignant lesions
  42. 42. 2. Pulmonary Ventilation • Tracheostomy should be performed in a patient still requiring ventilation through an endotracheal tube for more than a one week.
  43. 43. 3. Pulmonary Toilet • Those who cannot cough and clear their chest. • Prevent aspiration by low pressure high volume cuff tracheostomy tube.
  44. 44. 4. Elective Procedures • For major head and neck operations.
  45. 45. PEDIATRIC TRACHEOSTOMY Vertical incision in trachea b/w 2nd and 3rd ring. No excision of ant. Wall of trachea. Secure the tube with neck by two sutures.
  46. 46. INDICATIONS  In Infants: ◦ Subglottic haemangioma ◦ Subglottic stenosis ◦ Laryngeal cyst ◦ Glottic web ◦ B/L VC paralysis
  47. 47. INDICATIONS  In Children: ◦ Acute laryngotracheo bronchitis ◦ Epiglottitis ◦ Diphtheria ◦ Laryngeal oedema ◦ Ext. Laryngeal trauma ◦ Prolonged intubation ◦ Juvenile laryngeal papillomatosis
  48. 48. PERCUTANEUS DILATIONAL TRACHEOSTOMY  ICU Bed Side Tracheostomy  Use of guide wire and Dilators  Under the vision of Bronchoscope through endo tracheal tube  Less time.  Not suitable for thick neck and in emergency
  49. 49. COMPLICATIONS OF TRACHEOSTOMY  Intraoperative Complications.  Bleeding and injury to big vessels  Injury to tracheoesophageal wall  Pneumothorax  Early Complications  Bleeding  Tracheostomy tube obstruction  Tracheostomy tube displacement  Infection
  50. 50. COMPLICATIONS OF TRACHEOSTOMY  Late Complications  Tracheal Stenosis  Granulation tissue  Tracheocutaneus fistula  Tracheo - inominate fistula
  51. 51. PROBLEMS DURING TRACHEOSTOMY CARE Dislocation of tracheostomy tube. Bleeding from stoma or during suction. Blockage of tracheostomy tube. Aspiration and swallowing problems. Speaking problems.
  53. 53. AIMS  Prevent complications associated with tracheostomy.  Help in the full recovery of the patient.  Give the patients and attendants an understanding of the problem. Can be considered under two periods: 1)Care when the patient needs the tracheostomy. 2)Care when the patient needs to be weaned off the tracheostomy.
  54. 54. While doing tracheostomy care what to document in the file? Date and time: Size of the tube: Position and Patency: Condition of the tracheostomy wound: SaO2 with or without O2 supplementation: Chest : Secretions in suction: Condition of patient before care and after care: Signature and name:
  55. 55.  After doing a tracheostomy, you have put somebody into danger by preventing him from shouting for help if he needs any.  The best way to prevent this is by giving a hand bell to the patient which he can ring whenever he needs help.  However if the patient is on ventilator, we have electronic alarms-right.
  56. 56. Care when the patient needs the tracheostomy? 1) Care of the wound/stoma 2) Care of the tube 3) Care of the lungs and trachea First and foremost thing to do after a tracheostomy is done: Do a chest X ray. This helps in knowing the position of the tube, how far is it from the carina and if any problems have occurred during tracheostomy. Also the condition of the lung is documented.
  57. 57. Care of the wound/stoma  We have opened the skin into the lung by doing a tracheostomy.  Infection can enter from the surface into the lung or vice versa.  Also the incision site can get infected.  Hence a barrier is to be maintained between the lung and the skin.  Simple sterile dressing with an antibiotic soaked guaze is all that is needed.
  58. 58.  Take a simple 2 by 2 square gauze.  Clean the operative site with betadine.  Cut the gauze half in the midline.  Soak it with antibiotic solution or ointment.  Place the gauze in such a way that the cut part accomodates the tube and the remaining stays on the wound.  Inspect the wound daily for any granulations or infection.
  59. 59.  If there are granulations, antibiotic steroid is applied.  If there is infection, take a swab for c/s and treat accordingly.  Make sure the tube retainers are secure.  Change dressing once daily.  During the process of decannulation, just apply a tight bandage to the wound. It just heals without issues.
  60. 60. Care of the tube Change tube retainers if loose. Do not take any chance. Tube retainers should not be too tight or too loose. As a general rule, put two fingers beneath the knot while tying so as to get the adequate tension of the retainer. Tube to be changed every one week- asses the progress of the patient and change to suitable tube. If patient needs long term tracheostomy, better to change to a tube with least tissue reaction. Clean inner cannula regularly.
  61. 61. Check for the patency of the tube. When the tube is patent without any block, there is absolutely silent breathing. The air blast measured by keeping a cotton wool near the tracheostomy tube opening- there is very good movement of the wool. If there is noise, the the tube is partially blocked. If the patient is sweating, appearing tense and anxious, then the tube is near complete blocked. Do not depend on the SaO2 as it will not drop for a long time after the tube is blocked.
  62. 62.  Partial block can be cleared by suctioning.  Near complete block requires a tube change immediately, or else patient will land up in negative pressure pulmonary edema. What to do? Do not panic.  Deflate the cuff in case of cuffed tube.  Remove the inner cannula if it is there, there ends the matter.  Get a tube same size or smaller.  Change the tube. Law states that two medical personnel should be there while changing the tube.  If the tracheostomy is less than 48 hours old, have a tracheostomy set with you.  Alternatively use the rail road technique of changing the tube.
  63. 63. Changing the inner cannula
  64. 64. Railroading technique of changing tube Insert suction catheter and remove the tube, keep catheter in place without displacing Thread a new tube over the suction catheter and secure it in place,then remove the catheter.
  65. 65. Standard technique: give extension, remove the old tube, introduce the new tube as if introducing a suction catheter for suctioning. Do not force push the tube. It might form a false track.
  66. 66. Care of the lungs and trachea  Care of the cuff.  Suctioning.  Humidification and oxygenation.  Expulsion of secretions
  67. 67. Cuff pressure  Using a cuff pressure manometer, check the pressure of the tracheostomy cuff. Should be less than 25 cm of H2O. If more chances of tracheal injury. If more pressure is needed, then change the tube. As a simple rule, air in cc about half the size of tracheostomy tube is sufficient for adequate volume and pressure of the cuff.  Check if the cuff is functioning daily by pressing the pilot and waiting for it to slowing fill up.  Also patient will elicit a cough reflex when the pilot is pressed if cuff is intact.  Deflate cuff hourly for five minutes-not really needed if pressure and volume are correct.
  69. 69. SUCTIONING  Most of the problems related to tracheostomy happen due to the technique of wrong suctioning.  Vigorous suctioning can cause both barotrauma as well as physical trauma, leading to bleeding and lung collapse.  Unsterile technique can cause lung infection.  Timid technique can cause retention of secretions and tube block.  Suction sos if there is gurgling/rattling. No need for hourly suction.
  70. 70. Tips for suctioning:  Use a suction catheter whose size is less than or equal to half of the ID of the tracheostomy tube to be suctioned.  Set the suction pressure to 60-150 mm of Hg by adjusting the knob on the machine.  Do not introduce the suction catheter too much inside else it will injure the carina. See the chest x ray to find out how much away from the carina is the tube tip. Measure the length of the tube from the obturator. Mark on the suction catheter how much to introduce.  Alternatively use a flexible bronchoscope to measure the length.  Use sterile universal precautions.
  71. 71. Catheter sizes Colour of catheter Number in FG Size of catheter in mm Can be used with tracheostomy No. GREY 5 1.70 3.0, 3.5 LIGHT GREEN 6 2.00 4.0, 4.5, 5.0 BLUE 8 2.70 5.5, 6.0 BLACK 10 3.30 6.5,7.0,7.5 WHITE 12 4.00 8.0, 8.5, 9.0 DARK GREEN 14 4.70 9.0 ORANGE 16 5.30 WE DO NOT HAVE TRACHEOSTOMY TUBES FOR THIS ONES RED 18 6.00
  72. 72.  Instill few drops of saline into the tracheostomy opening. Followed by few drops of sodium bicarbonate solution. Helps in softening the secretions and easy expulsion.  Wait for cough reflex. Hold your breath. Introduce the suction catheter sterile in closed position and take it out slowly in revolving motion after opening the suction. Catheter should be out before you feel like re-breathing again. Can be repeated.  In case of ventilated patients, increase the PEEP, disconnect the tube, suction.
  73. 73. Closed suction system  Alternatively a novel method of suctioning called the closed suction system can be used wherein 1)there is no need to disconnect the patient from the ventilator while suctioning. 2)sterile technique 3)no need to change catheters 4)no need for sterile precautions 5)cost effective in the long run The set up is connected to the tracheostomy tube and kept. Suction can be done any time without disturbing the ventilation.
  75. 75. Care when the patient needs to be weaned off the tracheostomy 1)humidification, temperature regulation and oxygenation. 2)expulsions of secretions and swallowing 3)speech 4)home care 5)decannulation
  76. 76. Humidification, temperature regulation and oxygenation  Usually achieved while on oxygen because it is humidified. A HME(heat and moisture exchanger) is fixed to the circuit which does the job of conserving heat.  Oxygen can be given by mask or by T-piece recovery kit(if not on ventilator).  If patient not needing oxygen a Thermovent –T can be connected to the tracheostomy.  Alternatively , the stoma/tube can be kept covered with a wet gauze.
  77. 77. THERMOVENT -T
  78. 78. Expulsion of secretions  Physical therapy in the form of chest physiotherapy.  Pharmocological agents like terbutaline, bromhexine.  Swallowing therapy is started to help in handling the secretions and meet the nutritional needs.
  79. 79. Speech while on tracheostomy  If using an metal tube, patient can simply occlude the opening of the tube with thumb during expiration to phonate.  If using cuffed tubes, special tubes designed for the same to be used.  If using uncuffed portex or tracoe tubes, other than digital occlusion, specially designed speaking valves as attachments for the tubes are available.  Advantage being the hands are free, if needed, oxygen also can be delivered simultaneously which does not happen with digital occlusion.
  81. 81. CARE AT HOME  Patient and attendants are educated while in the hospital regarding self tracheostomy care.  Strictly no water sports.  Commercially available kits for dressing and tube cleaning can be purchased.  To buy a suction machine.  Tracheostomy shower cap to be used while taking a shower.  Always to carry a smaller size tube in case there is accidental decannulation.
  83. 83. DECANNULATION Tracheostomy is not needed if:  Indication for the procedure is tided over.  Patient is breathing without ventilator; maintaining saturation on room air.  Able to handle his secretions without aspiration .  Excellent cough reflex and healthy lung. Once a decision has been made that the patient does not need a tracheostomy any more, the procedure of decannulation is started.  IDL to look at condition of vocal cords.  X ray neck lateral view, to look at the airway above the tracheostomy.  Alternatively a flexible nasopharyngolaryngoscopy will evaluate everything.
  84. 84.  If the condition is feasible, first down size the tube to the smallest size through which only inspiration happens fully, but expiration happens through both glottis and the tube. Patient should be able to produce a faint voice without the tube being occluded, good voice with the tube occluded.  In adults about a size 6 Romson tube  Gradually block the tube for 48 hours and allow for normal activities.  If no distress, remove the tube and plaster it.  Observe for 24 hours and discharge.

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