Download - Tracheostomy
Tracheostomy
TracheostomyDr. Roshana Mallawaarachchi03/07/20151BJA Education, June 2015
2History3One of the oldest surgical procedures.Antonio Musa Brasavola
Italian physician1st (well documented) successful tracheotomy, 1546
What is Tracheostomy?Tracheostomy
Creation of a stoma at the skin surface, which leads to the trachea.4Anatomy5
Anatomy6
Anatomy7
Anatomy8
IndicationsMaintain airwayUpper airway obstructionActual & potential obstructionFacilitate removal of bronchial secretionPoor cough effort with sputum retentionProtect the airway from aspirationNeuromuscular disorders, unconscious, head injuries, strokesMechanical ventilation Acute ICU, chronic hospital/communityFacilitate weaning from artificial ventilation 9Comparison - AdvantagesTracheostomyEndotracheal intubation Need for sedation
Easier & quicker to perform
Damage to glottis
Well tolerated for short periods
WOB
Patient comfortable
Weaning easier
10Comparison - DisdvantagesTracheostomyEndotracheal intubationInvasive procedureUnpleasant to tolerateBleeding & airway loss during procedureProlonged sedationStoma infection or breakdownDifficult to re-institute respiratory support without re-intubationScarring, tracheomalacia, stenosisWeaning more difficult after a long period of placementBlockage & displacementUpper airway traumaDamage to adjacent structuresDamage to vocal cordsSwallowing difficultiesBreaches larynx, risks aspirationSkilled procedureBlockage & displacement11Physiological effectsDead space, WOB Humidification, filtration lostMucus collection FB reaction local inflamationSpeech affectedSwallowing affectedAltered body image
12Features of TubesDiameter
Cuff
Inner tube
Features of TubesFenestration
Flexibility
Adjustable flange
Features of tubesSubglottic suctionSpeaking valve
16
Different airflow patterns
Types of tracheostomyTemporary or long term/permanent
Emergency or elective procedure
Method of insertion SurgicalPercutaneous
18Types of tracheostomyTemporaryAcute resp support, protection, Head Injury, neurological dis, maxillofacial/ENT procedures
Permanent/Long termChronic resp support, CA nasopharynx / larynx
19Emergency tracheostomyElective tracheostomy
Techniques for insertionOpen SurgicalOTENT/Trauma Sx
Percutaneous (PCT)ICUAnaesthetist/Intensivist
21
Different techniques
Horizontal slit - a horizontal or T-shaped opening
Window. Removal of small anterior portions - more permanent stoma window
Vertical slit - A U- or H-shaped opening, flaps tacked to skin edges with absorbable sutures (1wk) -semi-permanent stoma . Most modern adult surgical tracheostomies
Percutaneous Tracheostomy
Percutaneous TracheostomyICU - CA/intensivist (minimum 2 trained medical practitioners)Simple, quick, bedside - anaesthetic sedation +LAGuided by surface anatomyNeedle through the neck (fibroelastic tissue joining trach rings) into the trachea guide-wire through the needle. Higher approach/lower approachNeedle is removed dilate over the wire 2 techniques Ciaglia serial dilatational techniqueGriggs - Guidewire dilating forceps method (GWDF)
24Percutaneous TracheostomySecured by cloth ties, sutures or a holder. Less dissection, cutting than with a surgical techniqueLess tissue trauma and bleeding. (if bleeding sx trach diathermy/ligation)
To ensure correct needle placement - guided by fibreoptic endoscope
Immediate post op CXR, bleeding, sx emphysema, patency, pain relief
25Advantages of using fibereoptic endoscopeConfirmation - entry point - anterior trachea. B/w 11 and 1 oclock is ideal, although the closer to 12 oclock, the better
Confirms- entry site b/w 2nd & 3rd tracheal rings. tracheal ring fracture.
3.Avoid posterior tracheal wall damage & paratracheal or oesophageal insertion. 4.Ensure guidewire placement. 5.Successful placement in the lumen Allows aspiration of blood promptly from the airway
Correct placement of a needle and A puncture site that is guidewire within the trachea. lateral (towards 3 oclock)
Drawbacks in using a BronchoscopeNeed ETT atleast size 7mm ID Hypoventilation!Damaging endoscope with initial puncture into trachea.
Disadvantage of PCT
The tract take 7-10 days to mature but 2-4 days for a surgical tracheostomy.
If displaced early period, tissues spring back into their original places, but surgical tract usually sutured more likely to remain patent.
A tracheostomy tube should not be changed for 7-10 days.ContraindicationsCoagulopathyDifficult anatomyProximity to the site of recent trauma / SurgeryPotential for aggravated morbiditySevere gas exchange problemsAge < 12 (PCT)30Complications31
Care of the Tracheostomy Tubes32Essential equipment bedsideOperating suctionSuction CathetersGloves, eye protectionSpare Trach tube same sizeSmaller Trach dilatorsRebreathing bagCatheter mountTrach holders, dressing10ml syringeArtery forcepResus equip (ambu, ETT, laryngoscopes, drugs)
33HumidificationArtificial humidification - mandatory !
Inadequate humidification physiological changes - serious and potentially fatal, including: Retention of viscous, tenacious secretions Impaired mucociliary transport Inflammatory changes and necrosis of epithelium Destruction of cellular surface of airway causing inflammation, ulceration and bleeding Reduction in lung function (e.g. atelectasis/ pneumonia) Increased risk of bacterial infiltration.
34Methods of artificial humidification
Saline Nebulisation the viscosity of secretions - easier to remove by suction or cough.5 to 10mls 0.9% sterile saline - 2-4 hourly or as required.flow rate of 6-8 litres/minute - oxygen or air.
Heat Moisture Exchanger (HMEs) changed at least every 24 hours
Heated Humidification
Cold Humidification
Mucolytics Hypertonic saline or acetylcysteine (via nebuliser), carbocisteine (via mouth) or DNA-ases such as dornase alfa (used in conditions such as cyctic fibrosis)
Stoma filters or bibsContains a foam layer which absorbs moisture from pts expired gases. HydrationEnteral, intravenous or even subcutaneous.
Other methods of improving secretions Mobilizationwill help to improve the clearance of secretions
SuctioningIndicationsNoisy and or moist respirations Increased respiratory effort Prolonged expiratory breath sounds Restlessness Reduced oxygen saturation levels Increased or ineffective coughing Increased use of intercostal muscles Patient request More sinister signs of airway obstruction such as hypoxia and Cardiovascular changes
37The type of suctioning OpenClosed changed 72hrsSuck oral cavity aswell.
Preoxygenate prior to suctioning (esp O2 dependent)
Suction catheter selectiontoo large damage, occlude the tracheal tube hypoxia.diameter of the catheter should be not more than half the internal diameter of the tracheal tube. (Size of endotracheal or tracheostomy tube 2) x 2 = Correct French G
The frequency of suctioning Tracheal suction at least once per 8 hours. Failure to pass a suction catheter Red Flag - Blocked or Displaced prompt assessment by an appropriately trained individual .
The depth of suctioningShallow suctioning
Deepsuctioning Advancing the suction catheter through the tube until it reaches the carina (resistance) 10-15cm
Pressure : < 100-120 mmHg
The catheter should then be withdrawn slightly before suction is commenced (Guidelines 2013)
Duration: Max 10 sec
39Management of the inner cannulae Remove and inspectat least once per 8 hour shift if the patient shows any signs of respiratory distress.
For a patient undergoing mechanical ventilation, it may not be safe to repeatedly disconnect the ventilator circuit and change the inner tube routinely.
Cleaning or changing an inner tube should always represent the best balance of risks to the patient. Position neck extendedPreoxygenate, SuctionSterile techniqueRemove sterile NS or water - dry
40Cuff managementManagement of the distal cuff.
Tracheal capillary pressure 20-30mmHg Impairment of this blood flow - between 22-37mm Hg.Pressure should be kept between 15-25cmH2O (10-18mm Hg). Regular cuff pressure checks are carried out every 8 hour shift
41Stoma careInspect daily, clean dailyPus swab culture
42Oral carePreventing healthcare associated infections.
Dental plaque and the oropharynx can become colonized by bacteria and a biofilm can develop on the inside of airway devices.
Secretions can also pool in the subglottic region. Encourage self-care when possible
Patients teeth should be brushed with toothbrush and toothpaste at least twice a day.
Chlorhexidine mouth washing twice per day (not immediately after tooth brushing) 43Changing TubesIndications to change a tracheostomy tube - The tube in-situ: max. recommended duration: (ICS guidelines) Removable inner cannula - 30 days Single lumen tubes - 7-10 days - Facilitate weaning - inserting a smaller, un-cuffed or fenestrated tube - The patient needs ventilatory support or resuscitation and requires a change from an un-cuffed to a cuffed tube - To improve fit or comfort of tube - To replace a faulty tube - To resolve a misplaced or displaced tube
DONOT change within 72 hours, ideally not for 7 days
44Elective change of a tracheostomy tube
2 techniques:
A blind technique where the new tube is inserted directly into the old stoma A guided technique using a wire or bougie to remove the old tube over and to railroad the new tube over.
Pre-oxygenationPositioningSuck out secretions prior to cuff deflation.
Weaning & DecannulationMultidisciplinary assessment
Absolute requirements Patent upper airwaySpontaneous coughAbility to swallow secretions46Checklist before weaningIs the upper airway patent? (may require endoscopic assessment) Can the patient maintain and protect their airway spontaneously? Are they free from ventilatory support?Are they haemodynamically stable? Are they absent of fever or active infection? Is the patient consistently alert?Do they have a strong consistent cough (able to cough into mouth)? Do they have control of saliva + / - a competent swallow Are there any planned procedures requiring anaesthesia within next 7-10 days? Can we safely support the weaning process in the patients current clinical environment? 47Weaning1. Cuff deflation2. One-way valve to achieve 24 hr deflation3. Tolerate a Cap?4. Decannulation
48A patient with a tracheostomy suddenly desaturates!
How do you proceed?4950
51ReferencesTracheostomy management: Katharine Hunt, BJA Education, 15 (3): 149153 (2015)College of Anaesthesiology (Sri Lanka) Guidelines: Nov 2013 Ohs Intensive Care Manual 6th edition
52QuestionsAugust 2012 SAQ2. (a) What are the indications (25%) and contraindications (20%) of percutaneous tracheostomy (PCT)?
(b) List the potential complications of PCT. (55%)
53QuestionsFRCA May 1997(a) What are the indications for performing a tracheostomy?(b) List the complications of tracheostomy.
54QuestionsYou have been called urgently to attend a ventilated patient on the ICU who has become acutely agitated, hypertensive and profoundly hypoxic. A percutaneous tracheostomy was performed 18 hours ago and is being weaned from ventilatory support .
a) List possible causes for this patients acute hypoxia. (25%) b) What clinical features support an airway problem? (40%) c) How would you manage an airway problem in this patient? (35%) 55