Tracheostomy /certified fixed orthodontic courses by Indian dental academy

TRACHEOSTOMY
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Contents
•
•
•
•

History
Introduction
Cricothyrotomy
Tracheostomy
•
•
•
•
•
•
•

Indications
Armamentarium
Surgical anatomy
Procedure
Tracheostomy care & maintainance
Decannulation
Complications & their management .

• Percutaneous tracheostomy
• References

Introduction
• Trachea is a passage between the upper airways and lungs.
Any blockage or pathology above this level can impede air
entry. At these times making an opening in the trachea is a
safe technique in restoring air entry.


History
• 2000 BC :RigVeda
• 1000 BC : Ebers papyrus
• 400 BC: Hippocrates condemned tracheostomy, citing threat to carotid
arteries
• 1546 : first well-documented tracheostomy Antonius Musa Brasavola,
• 1921: Chevaliar Jackson – standardized the technique
- warned against high tracheostomy
• 1957: Shelden - Percutaneous tracheostomy


• 124 BC : Asclepiades – first tracheostomy
• 1620 : Nicholos Habicot – 4 successful tracheostmies
• 1718 :Lorenz Heister -tracheotomy, Negus –tracheostomy
• 1730 : George Martin – inner cannula
• 1833 : Trousseau – 200 cases of - diphtheria
• 1969:Toy and Weinstein - the guidewire approach PT.
• 1985 : Ciaglia et al – Percutaneous Dilatation
Tracheostomy.

CRICOTHYROTOMY
Synonyms
Tracheotomy , laryngotomy, high tracheostomy, low laryngotomy and coniotomy.


History
• Vicq d' Azyr - first description of
cricothyrotomy.
• 1921: Chevalier Jackson “ It should never be
taught ,even in life threatening situatins”
• 1976: Brantigan and Grow – 655
cricothyroidotomies - complication rate 6.1%

Types
• Surgical cricothyrotomy
• Needle cricothyrotomy with translaryngeal jet
ventilation
• Percutaneous cricothyrotomy

Indications
• Severe Maxillofacial trauma with upper airway obstruction.
• Oropharyngeal obstruction.
• Respiratory failure, sleep apnea syndrome
• Conditions in which tracheal intubation from above is either
contraindicated or unsuccessful.


Contraindications
• Children < 11 yrs.
• Elderly patients
• Crush injury to the larynx
• Preexisting laryngeal or tracheal pathology.
• Laryngeal inflammation
• After prolonged intubation

Surgical anatomy


Procedure


Cricothyrotomy vs tracheostomy
•

Faster, less than 2mins

•

Easier, with less instrumentation

•

Less dissection

•

Fewer surgical complications and less bleeding

•

Can be taught to those with little surgical training



Space narrow for tube



Perichondritis, laryngeal stenosis, voice changes

Complications
Acute complications
• Improper tube placement (emergency-36%, elective-1.3%)
• Hemorrhage & hematoma
• Posterior tracheal wall perforation
• Subcutaneous &/or mediastinal emphysema
• Thyroid perforation
Chronic complications
• Granulomas
• Perichondritis
• Subglottic stenosis (1.2% to 2.6%)
• Dysphonia(40%)

NEEDLE CRICOTHYROTOMY
• first described by Sanders in 1967
• Spoerel et al (1971) and
Klain&Smith(1977) defined the
indications and technique.
AdvCan be very quickly performed with
fewer complications.
DisadvCan provide oxygen for short period, not
a definitive airway.


Percutaneous Cricothyrotomy


Tracheostomy
• The surgical creation of an opening into the trachea to bypass
obstructions that are interfering with breathing,& insertion of a tube
into the opening to allow for normal breathing.


Indications
- Head and Neck Surgery- Otolaryngology: Byron J. Bailey
1.To bypass upper airway obstruction
2. To assist respiration over prolonged periods
3. To assist with clearance of lower respiratory secretions
4. To prevent aspiration of oral and gastric secretions


Rowe & Williams

Absolute indications for tracheostomy, for conditions other than impending
respiratory obstruction (IPPV):
•

When injuries are severe enough to cause hypercarbia and/or
hypoxaemia from the outset- flail chest, lung contusion or aspiration;
or developing later due to 'shock lung' (ARDS) or fat embolism.

•

Control of cerebral oedema (by controlling blood gases) in severe
head injuries


Indications for tracheostomy in
maxillofacial trauma
• When prolonged artificial ventilation is necessary esp severe
associated head and chest injuries
• To facilitate anaesthesia for surgical repair in major injuries
• To ensure a safe postoperative recovery after extensive reparative
surgery
• Following obstruction of the airway from laryngeal oedema or
occasional direct injury to the base of the tongue and oropharynx
• Serious haemorrhage into the airway particularly when a further
secondary haemorrhage is a possibility

- Synopsis of Otorhinolaryngology – Zakir Hussain

Timing of Tracheostomy
• The best time to do tracheostomy is the time when it is first felt
necessary, Tracheostomy has been recommended within 3 days of
intubation. (damage to the larynx & vocal cords is max b/w 3–7
days, if removed within this period, complete healing).
- RESPIRATORY CARE • APRIL 2005 VOL50 No 4 (483-487)

• The procedure is delayed long enough to allow extubation if
possible but is performed early enough to avoid complications of
long term intubation.
- Byron J. Bailey


Advantages
•

Decreases the amount of dead space by 70-100 ml

•

Reduces resistance to airflow and increases compliance

•

Provides Protection against aspiration.

•

Enables pt to swallow without reflex apnea.

•

Provides access to trachea for removing the secretions.

•

Delivery of medication & humidification to the
tracheobroncheal tree.


Adverse effects
•

Loss of heat & moisture exchange.

•

Desiccation of tracheal epithelium leading to loss or
metaplasia of ciliated cells

•

Increased mucus production

•

Increase in viscid mucin, formation of thick crusts,
blockage of the tube particularly in children.

Types of Tracheostomy.
• Elective
Emergency
• High Tracheostomy
Mid Tracheostomy
Low Tracheostomy
• Temporary
Permanent

Various techniques
•

Surgical/open method.

•

Percutaneous dilatation.


SURGICAL ANATOMY


Surgical
Anatomy


Tube selection
• Length
• Diameter
• Curvature
• Material
• Other features – cuff, fenestration, speaking
valve, tracheal button

Tubes available
• Metallic

– Fuller
– Jackson
– Alder hey

• Nonmetallic

– Portex – cuffed and noncuffed

• Others
–
–
–
–
–
–
–

Portex paediatric
Shiley paediatric
Rusch
Franklin
Edinburgh
Negus
Durhams lobster tail

- Parker
- Aberdeen
- Cole’s
- Patterson
- King college
- Holinger
- Salpekar


- KCH pattern
- Koenig’s
- Bivona foam
- Pit speaking
- Mc Ginnis
- Desaut
- Molyncke

STEPS
1.Airway control
2.Patient position
3. Anesthesia


Bjork flap


Tracheostomy: Pediatric
• Bronchoscope
• Vertical skin incision
• Retraction sutures
• Margins of tracheal
incision sutured to
skin

Tracheostomy care
Guidelines
• Bedside equipment.
• Care of the inner cannula,stoma site & ties.
• Suctioning of the tube.
• Humidification of inspired gases.
• Care for cuffed tube
• Decannulation: removal of tracheostomy tube.
• Dealing with emergencies.

Bedside equipment
• Spare tubes of Same / smaller size.

• Tracheal dilator.
• Suctioning equipment
-Ensure everyday equipment is assembled and working.
• Humidification unit
-Ensure everyday equipment is working properly.
• Container to hold speaking valve, occlusive cap/button or spare inner
cannula.

Care of the inner cannula, stoma
site & ties.
AIM:
1. To maintain a patent airway
2. To maintain skin integrity.
3. To prevent infection.
4. To prevent tube displacement


Suctioning


Humidification
Aims:
• To prevent drying of pulmonary secretions (tracheitis &
crust formation).
• To preserve muco-ciliary function.
Various methods of humidification
A) HEATED HUMIDIFIERS.
B) HEAT MOISTURE EXCHANGE FILTERS.
C) NEBULIZERS.

CARE OF CUFFED TRACHEOSTOMY
TUBE
• When to inflate the cuff
• Immediately post-operatively - to prevent aspiration
of blood or serous fluid from the wound
• To seal the trachea during mechanical ventilation
• To prevent aspiration of leakage from tracheooesophageal fistula
• To prevent aspiration due to laryngeal incompetence
•Deflate:
• first suction the oropharynx.
• Cuff should be deflated atleast 5mins every hr.

Tracheostomy decannulation
• Should be left in place no longer than necessary
• As soon as the patient's condition permits, reduced the size of tube to
avoid physiologic dependence on a large tube,
• Check for adequacy of the airway, ability to swallow and handle
secretions for 24 hrs and then plug the tube.
• Occlusion tolerated for 8-12 hrs, the tube is removed & the
tracheocutaneous fistula is taped shut.
• Bronchoscopy before decannulation in the pediatric patient,
• Immediately after decannulation, the patient must be closely observed,
and means for reestablishing the airway must be at hand.

Complications of Tracheostomy
• Immediate
–
–
–
–

Apnea
Bleeding
Pneumothorax
Damage to surrounding structures

–
–
–
–

Dislodgement
Blocked tube
Tracheitis
Subcutaneous emphysema

–
–
–
–
–
–

Tracheal stenosis
Tracheo-oesophageal fistula
Exuberant granulations
Scar
Tracheomalacia
Necrotising fascitis

• Intermediate

• Late


Immediate
1.Apnea- physiologic denervation of the peripheral chemoreceptors by the sudden
increase of p02; ventilatory assistance may be required.
2.Hemorrhage- raise in venous BP due to coughing associated with
insertion of the tube.
3.Pneumothorax
i. Respiratory obstruction - increased respiratory effort - air sucked
in mediastinum.
ii. secondary to laceration of the apex of pleural space (common in
children).
4.Injury of adjacent structures- dissection lateral & deep to the trachea.

Intermediate

1.Tracheitis and tracheobronchitis- severe in infants
-necrotizing tracheo-bronchitis is frequent.
-Humidification, nebulization & instillation of fluid/mucolytics.
2. Improper tube –
Too long -partial tracheal obstruction & possible rupture of the innominate artery.
- extend in one bronchus, atelectasis of the opp lung
Too short- displacement of the tube out of the trachea,

3.Obstruction of the tube- mucus plug/ blood clot due to lack of care.
- suction no relief in obstructive symptoms, change the tube

.
4.Subcutaneous emphysema- tight suturing or packing.
- Emphysema localized in the neck & upper chest but may
involve the whole body and progress to
pneumomediastinum and pneumothorax.
pneumothorax -chest drain with an underwater seal.
- Any constricting force around the tube b/w the skin& trachea
must be removed to prevent progression.


Late
1.Stenosis- injury and perichondritis of the cricoid cartilage.
- can occur at
-Cuff level
-Tracheostomy level
-Subglottic level


2.Exuberant granulations
-anterior tracheal wall result of delayed epithelialization in case of large
defects ,causing obstruction and bleeding.
3.Localized tracheomalacia- immediately superior& posteriorly to the healed opening.
-Use of large & sharply angled tube,
-avoided by using a more flexible tube of Teflon or Silastic.
4. Scar -vertical skin incision.
-longer duration of tracheostomy
-Vertical contracture,hypertrophic scar require a Z plasty.
5.Tracheocutaneous fistula-wound must be revised and closed with careful approximation of tissue
layers.

Tracheocutaneous
fistula


Tracheoesophageal
fistula


Percutaneous Tracheostomy
Shelden described a needle-guided trocar for access into the trachea.
Ciaglia et al described PDT based on the Seldinger technique, using
sequential dilators of increasing diameter.
INDICATIONS
Percutaneous tracheostomy has been proposed as an alternative to
open/surgical tech.


Extended Indications for Percutaneous
Tracheostomy
• patients with short, fat neck;
• inability to perform neck extension;
• enlarged isthmus of thyroid;
• previous tracheostomy; or
• coagulopathy and anti-coagulation therapy.


Complications of Percutaneous Tracheostomy
•

false passage of the tracheostomy tube,

•

pneumothorax,

•

delayed bleeding,

•

puncture of the posterior tracheal wall,

•

premature extubation during the procedure and loss of the
airway.


Comparison of safety and cost of percutaneous versus
surgical tracheostomy
- Bowen, Whitney et all
- Division of Surgical Oncology, University of Virginia Medical Center
- Am Surg. 2001 Jan;67(1):54-60. Links

Percutaneous

Surgical

Cases
Complication
rate

74
6.76%
(4.1%)

139
2.2%

Cost

$1750

%2600

- PDT costs less and requires less time but carries more risk of
complications. Careful patient selection and adequate experience will
reduce comlications

Endoscopic percutaneous dilatational tracheotomy: a
prospective evaluation of 500 consecutive cases
- Kost K.M.
-Department of Otolaryngology, McGill University, Canada
-Laryngoscope. 2005 Oct;115(10 Pt 2):1-30. Links

-Total complication rate was 9.2% (13.6% in the multiple dilator
group, and 6.5% in the single dilator group)
-

most common complications were oxygen desaturation (in 14 cases)
and bleeding (in 12 cases)

-

absence of serious complications such as pneumothorax and
pneumomediastinum were attributable to the use of bronchoscopy

-Endoscopic PDT is associated with a low complication rate and is at
least as safe as surgical www.indiandentalacademy.com
tracheotomy in the ICU setting

Percutaneous dilatational tracheostomy versus open
tracheostomy--a prospective, randomized, controlled
trial.
- Wu J.J., Huang et all
- Division of Trauma, Taipei Veterans General Hospital,
- J Chin Med Assoc. 2003 Aug;66(8):467-73
- 83 tracheostomies
- Procedure time was 22.0 +/- 12.1 minutes in PDT group, and
41.5 +/- 5.9 minutes in OT group,
- incidences of complications were not different between both
groups
- simple, safe and time-saving bedside procedure and can be
recommended when an elective tracheostomy is needed in a
critical patient.


Conclusion


References


Rowe &William’s Maxillofacial injuries 2nd edition-vol I



Oral & maxillofacial trauma :Fonseca-3rd edition-vol I



Bailey & love’s short practice of surgery 23rd edition.



Schwartz principles of surgery -8th edition .



Lange’s current diagnosis&treatment in otolaryngeology-head&neck
surgery.



Clinical &operative methods in ENT, head & neck surgery-A systemic
approach: Hazarica Nayak.



An atlas of head & neck surgery-Lore’ 3rd edition.



Operative otolaryngeo,head & neck surgery-Myers,vol I.

Thank


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