Tracheostomy Tracheostomy and its careand its care

Included in my presentationIncluded in my presentation

• What is a stridor brief DDWhat is a stridor brief DD• tracheostomytracheostomy• HistoryHistory• Tracheostomy tubes and their insertion Tracheostomy tubes and their insertion • The operation The operation • Following surgery Following surgery • Equipment Required Equipment Required • Suctioning Suctioning • Precautions with a tracheostomy Precautions with a tracheostomy

StridorStridor• It is a audible sound produced as a result of turbulent airflowIt is a audible sound produced as a result of turbulent airflow

• obstruction to the passage of air in and out of the respiratory obstruction to the passage of air in and out of the respiratory tract results in stridor which is a cardinal sign of this tract results in stridor which is a cardinal sign of this obstructionobstruction

• Bernoulli,s PrincipleBernoulli,s Principle

• Stridor is usually high pitched and inspiratory but can be Stridor is usually high pitched and inspiratory but can be expiratory or biphasicexpiratory or biphasic

typestypes

Laryngeal supraglottic stridor is usually Laryngeal supraglottic stridor is usually inspiratoryinspiratory

Glottic stridor may be inspiratory or expiratoryGlottic stridor may be inspiratory or expiratory

Subglottic are always fixed and present with Subglottic are always fixed and present with biphasicbiphasic

bronchial stridor are expiratorybronchial stridor are expiratory

Causes Causes

• Nasopharyngeal Nasopharyngeal choanal choanal atresia,DNS,turbinateatresia,DNS,turbinate

• Facial skeletal abnormality Facial skeletal abnormality cleft cleft palatepalate

• Oropharyngeal Oropharyngeal tongue,tumorstongue,tumors

• Laryngeal Laryngeal supra,glottic,subsupra,glottic,sub

• Tracheal Tracheal stenosis,fistulastenosis,fistula

• Bronchial Bronchial LTB,FBLTB,FB

Congenital causesCongenital causes

• Web,Cysts Web,Cysts • Subglottic stenosisSubglottic stenosis• LaryngomalaciaLaryngomalacia• Vocal cord paralysisVocal cord paralysis• Cleft palateCleft palate• Vascular anamoliesVascular anamolies• Lymphangioma,haemangiomaLymphangioma,haemangioma

Acquired Apyrexial Acquired Apyrexial causescauses

foreign bodiesforeign bodies

traumatrauma

scaldsscalds

papillomaspapillomas

malignancy malignancy

Acquired Pyrexial causesAcquired Pyrexial causes

• acute epiglotitisacute epiglotitis• acute laryngitisacute laryngitis• acute laryngo tracheo acute laryngo tracheo

bronchitis LTBbronchitis LTB• diphtheriadiphtheria

Stertor Stertor

• Limited or complete cessation of Limited or complete cessation of airflow but is reversibleairflow but is reversible

• Is produced because of problems Is produced because of problems above the level of larynxabove the level of larynx

• Low pitched sound with snoringLow pitched sound with snoring• Indicate a pharyngeal or Indicate a pharyngeal or

nasopharyngeal obstructionnasopharyngeal obstruction

What Is A Tracheostomy ?What Is A Tracheostomy ?

• A surgical A surgical opening into the opening into the trachea below trachea below the larynx the larynx providing an providing an alternative alternative airway, airway, bypassing the bypassing the upper passagesupper passages

HistoryHistory• 3600 BC A tracheotomy was found pictured on 3600 BC A tracheotomy was found pictured on

egyptian tablet egyptian tablet• 100 BC Asclepiades of Greece first surgeon100 BC Asclepiades of Greece first surgeon• 16th century Antonius Musa saved a patient 16th century Antonius Musa saved a patient • 1718 Lorenz Heister coined the term 1718 Lorenz Heister coined the term

tracheotomytracheotomy• 1855-1936 indicated in polio epidemic1855-1936 indicated in polio epidemic• 1940 Diphtheria the most important 1940 Diphtheria the most important

indicationindication

• Chevalier Jackson refined operative technique to Chevalier Jackson refined operative technique to an art and standardized it by reducing the an art and standardized it by reducing the operative mortality rate from 25% to 2%operative mortality rate from 25% to 2%

•

History History contcont

Indications Indications

1. Upper Airway obstruction1. Upper Airway obstruction Congenital,traumatic,infective,paralytic,neoplasticCongenital,traumatic,infective,paralytic,neoplastic

2. Respiratory insufficiency2. Respiratory insufficiency Respiratory failure,emphysema,head Respiratory failure,emphysema,head

injuries,drugs,cppvinjuries,drugs,cppv

3. Tracheobronchial protection3. Tracheobronchial protection Retained secretion,inability to Retained secretion,inability to

cough,coma,trauma,ccf,pul.oedemacough,coma,trauma,ccf,pul.oedema

4. Elective to other procedures4. Elective to other procedures Any major surgery on mouth ,pharynx or larynxAny major surgery on mouth ,pharynx or larynx

procedureprocedure

• The Operation takes about thirty minutes The Operation takes about thirty minutes

• Procedure involvesProcedure involves

– horizontal incision made into the skin horizontal incision made into the skin

– vertical incision made through the rings of trachael vertical incision made through the rings of trachael cartilage cartilage

– layers of skin and muscle are sutured to provide a layers of skin and muscle are sutured to provide a path for the trache tube to follow path for the trache tube to follow

Tracheostomy TubesTracheostomy Tubes

– inserted through inserted through the the tracheostomy to tracheostomy to maintain a maintain a patent airway patent airway

– secured in place secured in place by tapes tied by tapes tied around the neckaround the neck

Types of trache tubesTypes of trache tubes

• Metal tubes outer and innerMetal tubes outer and inner inner tubes little longerinner tubes little longer easy cleaningeasy cleaning cant produce airtight sealcant produce airtight seal• Non metal made of silastic Non metal made of silastic cuffed or noncuffedcuffed or noncuffed can be connected to can be connected to

anaesthesiaanaesthesia less traumaticless traumatic

Cleaning Reusable Inner Cleaning Reusable Inner CannulaCannula

• The inner cannula is one of the most The inner cannula is one of the most important parts of the tracheostomy important parts of the tracheostomy tube. Its presence in the outer tube tube. Its presence in the outer tube ensures that the tube is kept clear of ensures that the tube is kept clear of secretion buildup, since it can be secretion buildup, since it can be removed and cleaned. removed and cleaned.

• Generally, it should be removed and Generally, it should be removed and cleaned every two to three hours for the cleaned every two to three hours for the first two daysfirst two days

• Inner cannula care always requires strict Inner cannula care always requires strict aseptic technique.aseptic technique.

Cuffed Tracheostomy Cuffed Tracheostomy TubeTube

• designed to provide minimal trauma to thedesigned to provide minimal trauma to the

mucosa and trachea.mucosa and trachea.• Cuff inflation is necessary to provide a Cuff inflation is necessary to provide a

seal for mechanical ventilation of your seal for mechanical ventilation of your patient. patient.

• It is also indicated to protect the lower It is also indicated to protect the lower airway from the aspiration of gastric airway from the aspiration of gastric contents. contents.

ComplicationsComplications

• ImmediateImmediate

• IntermediateIntermediate

• DelayedDelayed

complicationscomplications

• The incidence of operative and early The incidence of operative and early hemorrhage is reported to be hemorrhage is reported to be approximately 5%. Major approximately 5%. Major hemorrhage during the procedure is hemorrhage during the procedure is rare but even minor bleeding can be rare but even minor bleeding can be life-threatening if it interferes with life-threatening if it interferes with the identification of the trachea or the identification of the trachea or gaining access to the airway. gaining access to the airway.

Tracheostomy Tracheostomy ComplicationsComplications

• children with tracheostomies are children with tracheostomies are more prone to respiratory more prone to respiratory infections infections – tracheostomy tube bypases bodies tracheostomy tube bypases bodies

defence mechanisms defence mechanisms

• some signs of infection: some signs of infection: – febrile febrile – inflammed stoma site inflammed stoma site – foul odour emitted from tracheostomyfoul odour emitted from tracheostomy

complicationscomplications

• Pneumothorax and Pneumothorax and pneumomediastinum pneumomediastinum are well-recognized are well-recognized complications complications following following tracheotomy. The tracheotomy. The incidence in adults incidence in adults has been reported at has been reported at 2 to 5%. In children, 2 to 5%. In children, the incidence may be the incidence may be as high as 17% and is as high as 17% and is the single most fatal the single most fatal complication complication

complicationscomplications

• Obstruction of the tracheotomy tube is Obstruction of the tracheotomy tube is common. Obstruction in the first 24 hours common. Obstruction in the first 24 hours is because of tube impingement on the is because of tube impingement on the posterior tracheal wall, a blood clot, or posterior tracheal wall, a blood clot, or mucous plug. Obstruction and mucous plug. Obstruction and decannulation are the most common decannulation are the most common serious early complication in children. The serious early complication in children. The gravity of decannulation in the first 24 gravity of decannulation in the first 24 hours is emphasized in the fact that this hours is emphasized in the fact that this event is associated with a 25% mortality event is associated with a 25% mortality

complicationscomplications

• the rate of stomal infection has been the rate of stomal infection has been reported to be as high as 36%.reported to be as high as 36%.

the incidence of cellulitis and the incidence of cellulitis and purulence has generally been purulence has generally been reported at 3 to 8%. reported at 3 to 8%.

• the mortality rate has remained less the mortality rate has remained less than 5% with a total complication than 5% with a total complication rate of 14% to as high as 66%rate of 14% to as high as 66%

complicationscomplications

• Most dramatic and fatal complication of Most dramatic and fatal complication of tracheotomy is massive hemorrhage and tracheotomy is massive hemorrhage and is usually related to erosion of the is usually related to erosion of the innominate arteryinnominate artery

• The incidence of tracheoinnominate The incidence of tracheoinnominate artery fistula has been reported to be artery fistula has been reported to be 0.4 to 4.5%. Innominate artery rupture 0.4 to 4.5%. Innominate artery rupture has been associated with tracheal has been associated with tracheal necrosis secondary to infection and necrosis secondary to infection and from erosion from the tracheotomy from erosion from the tracheotomy tube. tube.

complicationscomplications

• Tracheoesophageal fistula complicating Tracheoesophageal fistula complicating tracheotomy occurs with an incidence tracheotomy occurs with an incidence of 0.01%. of 0.01%.

• while the complications of tracheotomy while the complications of tracheotomy may be severe, with proper precautions may be severe, with proper precautions and prompt management, the mortality and prompt management, the mortality and morbidity of this procedure may be and morbidity of this procedure may be minimizedminimized

Normally nasal breathingNormally nasal breathing

– humidifies humidifies – filters and filters and – warms air before it enters our lungs warms air before it enters our lungs

• the tracheostomy bypasses these the tracheostomy bypasses these mechanisms so that the air is cooler, mechanisms so that the air is cooler, dryer and not as clean. In response to dryer and not as clean. In response to these changes the body produces more these changes the body produces more mucous, which may require mucous, which may require humidification to aid expulsionhumidification to aid expulsion

Suctioning procedure.Suctioning procedure.

• 1. A tracheostomy is an open surgical 1. A tracheostomy is an open surgical wound and strict asepsis and wound and strict asepsis and universal precautions should be universal precautions should be observed.observed.

• 2. A clear explanation of the 2. A clear explanation of the procedure with reassurance will help procedure with reassurance will help to decrease the patient’s anxiety and to decrease the patient’s anxiety and fears.fears.

Promoting comfortPromoting comfort

• Give analgesics for pain. Remember Give analgesics for pain. Remember that an incision created the that an incision created the tracheostomy.tracheostomy.

• Be calm and reassuring. Patients Be calm and reassuring. Patients with a tracheostomy report with a tracheostomy report sensations of chokingsensations of choking

Tracheostomy Tube Tracheostomy Tube ChangesChanges

• tracheostomy tubes are routinely tracheostomy tubes are routinely changed weekly or any time a changed weekly or any time a blockage is suspected blockage is suspected

• tubes are changed to prevent tubes are changed to prevent build up of secretions on the wall build up of secretions on the wall of the tube of the tube

• the change in the child occurs the change in the child occurs before feed to minimise the risk of before feed to minimise the risk of aspiration aspiration

• to be demonstrated in videoto be demonstrated in video

Eating With A Eating With A TracheostomyTracheostomy

• a tracheostomy will not usually a tracheostomy will not usually affect the ability to swallow affect the ability to swallow

• encouraging fluids helps to thin encouraging fluids helps to thin secretions secretions

Following SurgeryFollowing Surgery

• patient requires vigilant patient requires vigilant observation until the first tube observation until the first tube change has been performed change has been performed

• A doctor performs the first tube A doctor performs the first tube change to prevent false tracts change to prevent false tracts from developing, due to incorrect from developing, due to incorrect insertion procedure, as the insertion procedure, as the opening into the airway or stoma opening into the airway or stoma is not well formed at this stageis not well formed at this stage

Psychological CarePsychological Care

• Many tracheostomy patients are totally Many tracheostomy patients are totally dependent upon thedependent upon the

caregivers and can do little for themselves.caregivers and can do little for themselves.

Since the patient, especially with an inflated Since the patient, especially with an inflated cuffed tube, will be unable to speak, every word cuffed tube, will be unable to speak, every word and action of the staff is carefully observed. and action of the staff is carefully observed.

• It is imperative that an atmosphere of calmness It is imperative that an atmosphere of calmness and confidence be created for the patient since and confidence be created for the patient since emotional status will influence breathing pattern emotional status will influence breathing pattern and acceptanceand acceptance

Skin CareSkin Care

• The care of the skin around the The care of the skin around the stoma site should be considered one stoma site should be considered one of the more important procedures in of the more important procedures in the care of the tracheostomythe care of the tracheostomy

• The new surgical site needs to be The new surgical site needs to be cleaned and dressed frequently as it cleaned and dressed frequently as it heals. heals.

Decannulation ProcedureDecannulation Procedure

• When the patient is being weaned When the patient is being weaned from mechanical ventilation or from from mechanical ventilation or from the tracheostomy tube itself, the use the tracheostomy tube itself, the use of a fenestrated tracheostomy tube of a fenestrated tracheostomy tube may facilitate the decannulation may facilitate the decannulation procedure procedure

In SummaryIn Summary

• tracheostomies are often created to tracheostomies are often created to bypass upper airway obstructions bypass upper airway obstructions

• the patient must have in their the patient must have in their vicinity at all times, one tube the vicinity at all times, one tube the same size and one a size smaller in same size and one a size smaller in case of blockage case of blockage

• children with tracheostomies must children with tracheostomies must be supervised around water be supervised around water

• children with tracheostomies are children with tracheostomies are more prone to respiratory infectionsmore prone to respiratory infections

ReferencesReferences

• internet: internet: – www.tracheostomy.com www.tracheostomy.com – http://wellness.ucdavis.edu/child http://wellness.ucdavis.edu/child – www.rch.unimelb.edu.au/intranet/handbook/www.rch.unimelb.edu.au/intranet/handbook/

trach.htm trach.htm – texts: texts: – Myer.C, Cotton.R, Shott.S,1995 The Pediatric Myer.C, Cotton.R, Shott.S,1995 The Pediatric

Airway, J.B Lippincott company PennyslvanniaAirway, J.B Lippincott company Pennyslvannia