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