General surgery ENT

1. Department of surgery, JNMC
Sawangi(M), Wardha

2. LERNING OBJCTIVES
 To know about surgical anatomy of trachea
 To know about various techniques of tracheostomy
 To know about various tubes used
 To know about things to look for during tracheostomy
 To know about complications occurring during the
procedure and their management

3. What is a Tracheostomy?
 A tracheostomy is a artificial (usually) surgically
created airway fashioned by making a hole in the
anterior wall of the trachea and the insertion of a
tracheostomy tube, which may or may not be
permanent

5. Why Perform a Tracheostomy 1
 Upper airway obstruction
 urgent (cricothyroidotomy)
 non-urgent (conventional tracheostomy)
 Facilitation of airway toilet
 Long term ventilation
 Difficulty in weaning the ventilator
 Decreases airway resistance (tube size)
 Paralysis of respiratory muscles (e.g. disease)
 Eliminates dead space

6. Why Perform a Tracheostomy 2
 Surgical reasons
 Including head and neck surgery
 Trauma
 Including burns

7. How To Create a Tracheostomy
 Cricothyroidotomy
 For Urgent Procedures
 Percutaneous Tracheostomy
 Can be done in the ICU at the bedside
 Surgical Tracheostomy
 Subthyroid incision to trachea between 2nd and 3rd
tracheal rings

8. When to Create a Tracheostomy
 Controversial
 ETT can be in situ for over 4 weeks in some studies!!!
 Generally, consider a tracheostomy if patient
intubated for 7 days with no foreseeable extubation in
the next few days

9. Procedure
 Skin
 Dissection
 Separate straps
 Divide thyroid isthmus
 Window in trachea
 Below 1st ring
 Stitch in place
Incision=ba
d
Hole=good

10. Landmarks
Thyroid cartilage
Cricothyroid
membrane
Crycoid cartilage

11. Types of Tracheostomy Tubes 1
 Cuffed, Uncuffed, Fenestrated, Unfenestrated
 Cuffed required for
 Aspiration risk
 PPV
 Fenestrated
 Facilitates weaning
 Allows vocalisation

12. Types of Tracheostomy Tubes 2
 “Button”
 A plug
 Useful when there is a possibility of requiring the
tracheostomy tube again
 Percutaneous Tracheostomy

14. Tracheostomy

15. cuffs
 To protect airway
 To allow ventilation
Uncuffed Cuffed

16. Single/Double lumen
 Double lumen allows
easy cleaning
 Single lumen has a
greater internal
diameter

18. Immediate Problems 1
 PTX (4%)
 Wound infection (reasonable common)
 Bleeding
 Usually only in coagulopathic patients
 Difficult insertion
 Accidental decannulation
 hypoxia and possible difficult re-insertion
 Occlusion due to secretions

19. Immediate Problems 2
 Air embolism
 Aspiration
 Surgical emphysema

20. Long Term Problems 1
 Subglottic stenosis
 Incidence decreased by low pressure cuffs
 Incidence increased by cricothyroidotomy over surgical
tracheostomy
 Tracheal stenosis
 Oesophago-tracheal fistula
 Increased bacterial colonisation of the airways

21. Long Term Problems 2
 Vocal cord dysfunction
 Chronic
 Recurrent laryngeal nerve injury
 Temporary
 Stomal granulations and scarring
 Non healing of wound
 Erosion into the innominate artery (<1%)
 Occurs in 1st and 2nd week
 Swallowing Problems

22. Benefits of a Tracheostomy
 More comfortable and more stable
 Tube size can be larger (less resistance)
 Allows tubes to be changed more easily
 Better quality suctioning
 Depending on indication for tube and the type of tube,
patients can eat and talk
 Can promote oral nutrition

23. Post-op care
 Nursing job with medical responsibility
 Regular gentle suctioning
 Meticulous wound and stoma care
 Primary goal is to keep tube in stoma
 Tube change after 5 days if required – earlier can be
risky
 ENT do not normally need to be involved in all
aspects of trache care!!

24. General Care of a Tracheostomy
 Sterile suctioning (as prone to infections)
 Gases given should be humidified
 Emergency equipment should be immediately present
(at bedside)

25. fenestrations
 Allow patient to
ventilate past tube via
upper airway
 Allow speech

26. Equipment of tube change
 Nurse or assistant
 Oxygen mask
 Tracheal dilators
 Suction
 New tube (tested)
 Good light source
 Bougie
 Intubation equipment available

27. Decannulation
 When ventilation or suctioning no longer needed, and
patient can control their own airway and not be at risk
for aspiration
 Can occur when patient has
 Good cough
 Good ABGs (relative, for the patient)
 Clear lungs
 No pathogens in sputum

28. Make sure…
 Ready to be decannulated
 No further need for tracheostomy
 Maintaining own airway
 Not aspirating

29. Steps to decannulation
1. Involve physio
2. Change to fenestrated uncuffed tube
3. Start capping off tracheostomy (NOT with a cuffed
unfenestrated tube!)
4. When 24 hrs of uninterrupted capping at normal
sats, decannulation is possible

30. Decannulation itself
1. Prepare equipment (Same as for tube change,
including fresh tube)
2. Take a deep breath
3. Remove tube and suction stoma
4. Close with steristrips and sleek
5. Daily dressing and steristrip change
6. Patient to cover wound when talking

31. • Always follow ABC
• A blocked tube is invariably the problem
• Remove tube if rapid suctioning fails or is
even slightly delayed
• Direct ventilation over stoma may be
effective
• An ET tube works well through a tracheal
stoma

36. In Summary
 Most traches are elective for a specific cause (or
perhaps multiple causes)
 Not free of complications which can be early
(immediate) or late
 Have many benefits over a conventional ETT
 May be permanent or temporary
 Cuffed or uncuffed, fenestrated or unfenestrated