2. The following are emergency airways
except
A. Cricothyroidotomy
B. Tracheostomy
C. Oropharyngeal airway
D. Nasopharyngeal airway
E. AMBU bag
3. Complications of Tracheostomy
A. Tracheal Stenosis
B. Swallowing difficulty
C. Permanent voice change
D. Breathing difficulty
E. Hemorrhage
4. Concerning post op care
A. always have a spare tube by the bedside
B. Its important to carry patients & caregivers along
C. Ability to cough determines time to decannulate
D. No need to suction patient
E. Tracheostomy Tract is formed in 7days
5. Concerning Tracheostomy
A. Tracheostomy tube is usually changed monthly
B. Patient with tracheostomy tube cannot speak
C. Tracheostomy can be permanent or temporary
D. It can be used to relieve upper airway obstruction
6. Outline
Definition
Historical background
Indication
Anatomy of the trachea
Alternatives to tracheostomy
Types of Tracheostomy
Procedure
Part & types of tracheostomy tube
Post op care
Complication
summary
7. Definition
An operative procedure that
creates a surgical airway in the
cervical trachea
A Surgical fistula created between
the anterior wall of the trachea
and the skin outside, which can be
maintained with or without a tube.
8. History
The first known depiction of tracheostomy is from 3600 BC, on Egyptian
tablets
The first scientific reliable description of successful tracheostomy by the
surgeon who performed it was by Antonio Musa Brasavola in 1546, for
relief of airway obstruction from enlarged tonsils.
In the early 20th century, tracheostomy was made much safer, technical
aspects of the procedure were refined and described in detail by the
famous surgeon Chevalier Jackson.
9. Major indications
Upper airway obstruction
Tracheobronchial toileting
Adjunct to head and neck surgery( to allow for easy
manipulation & patient turning
Respiratory Insufficiency
11. Benefits of tracheostomy
Improved oral hygiene for the intubated patient
Decreased requirement for sedation in the intubated patient
Oral movement for communication, nutrition and hydration (with
manipulation)
Reduction in damage to the larynx, mouth or nose from prolonged
endotracheal intubation
Vocalisation (with manipulation)
Improved patient comfort
12. Tracheal anatomy
It is D-shaped, with incomplete
cartilaginous rings anteriorly and laterally,
and a straight membranous wall
posteriorly
starts from the inferior part of the larynx
(cricoid cartilage) in the neck, opposite
the 6th cervical vertebra, to the
intervertebral disc between T4-5
vertebrae in the thorax
The thyroid isthmus is located between
second and third tracheal rings,
13. the innominate artery most often crosses the
anterior trachea in an oblique fashion distal or
inferior to the third tracheal ring
the aortic arch crosses above the carina.
The coronal and sagittal tracheal dimensions vary in
males and females.
The upper limits of the coronal and sagittal
diameters in men are 25 and 27 mm, respectively.
In women, they are 21 and 23 mm, respectively.
14. Innervation And Blood Supply
The recurrent laryngeal nerves lie in close
proximity to the trachea within the
tracheoesophageal groove.
The blood supply to the cervical trachea
enters posteriolaterally from the inferior
thyroid artery
ultrasound probe in the intended area of
dissection to confirm the absence of any
significant vasculature
15. Alternatives to Tracheosotomy
Endoluminal Intubation
Emergent cricothyrotomy
should be considered only when the patient is in a very difficult life threatening
situation and thus the need to use extreme measures
No conscientious physician should perform any procedure known (even
colloquially) as a slash
Percutaneous transtracheal jet ventilation (PTJV)
16. Emergent cricothyrotomy
Advantage:
cricothyroid membrane is superficial and readily accessible, with
minimal dissection required.
Disadvantage:
cricothyroid membrane is small and adjacent structures (eg,
conus elasticus, cricothyroid muscles, central cricothyroid
arteries) are jeopardized;
the cannula may not fit.
Damage to the cricoid cartilage from the scalpel or pressure
necrosis leads to perichondritis and possibly stenosis
overall complication rate:
32%, which is 5 times that of tracheostomy under controlled
circumstances
17. Urgent tracheostomy
Patients in acute respiratory distress may need acute surgical intervention
Urgent tracheostomy can be performed in a controlled environment (eg,
operating room) with the patient under local anaesthesia.
18. Indications for Urgent Tracheostomy
Congenital anomaly (eg, laryngeal hypoplasia, vascular web)
Upper airway foreign body that cannot be dislodged with Heimlich and basic
cardiac life support manoeuvres
Supraglottic or glottic pathologic condition (eg, infection, neoplasm,
bilateral vocal cord paralysis)
Neck trauma that results in severe injury to the thyroid or cricoid cartilages,
hyoid bone, or great vessels
Subcutaneous emphysema
19. Facial fractures that may lead to upper airway
obstruction (e.g, comminuted fractures of the mid
face and mandible)
Upper airway edema from trauma, burns, infection,
or anaphylaxis
Prophylaxis (as in preparation for extensive head
and neck procedures and the convalescent period)
Severe sleep apnea not amendable to continuous
positive airway pressure devices or other less
invasive surgery
20. Elective tracheostomy
Most are performed in patients who are already intubated and who are
undergoing a tracheostomy for prolonged intubation
patients undergoing extensive head and neck procedures may receive a
tracheostomy during the operative procedure to facilitate airway control
during convalescence
A smaller population of patients with chronic pulmonary problems (eg,
sleep apnea) elects to undergo tracheostomy
21. Best practice protocol
Initial decision for tracheostomy by attending physician
Attending physician to discuss procedure with patient and/or family
Informed consent by Surgeon (risks, benefits, and alternatives)
Pre op: CBC, Coagulation profile, Group and screen
NPO after midnight
23. Open tracheostomy: Patient positioning
• Best performed in an operating room with adequate
equipment and assistance
• Position the unconscious or anesthetized patient
supine with the neck extended and the shoulders
elevated on a small roll.
• can also be done at the bedside in the intensive care
unit
• Overextension of the neck should be avoided
because it further narrows the airway
• overextension can lead to placement of the
tracheostomy too low (toward the carina) and too
close to the innominate artery (especially in the very
mobile paediatric trachea).
24. Open tracheostomy: Skin Incision
Palpate the landmarks (eg, thyroid notch, sternal
notch, cricoid cartilage) and mark them with a pen
Apply anaesthesia
3-cm vertical skin incision initiated below the inferior
cricoid cartilage.
Many advocate the horizontal skin incision, which is
made along relaxed skin tension lines and gives better
cosmesis but a horizontal incision may trap more
secretions.
Subcutaneous fat may be removed with
electrocautery to aid in exposure and to prevent later
fat necrosis
Meticulous hemostasis throughout the procedure
25. Open tracheostomy: Dissection
Dissection proceeds through the platysma until the
midline raphe between the strap muscles is identified
Palpate the inferior limit of the field to assess the
proximity of the innominate artery
Cauterize or ligate aberrant anterior jugular veins
and smaller vessels.
Midline dissection is essential for hemostasis and
avoidance of paratracheal structures
The strap muscles are separated and retracted
laterally, exposing the pretracheal fascia and the
thyroid isthmus.
26. The lateral retraction also serves to stabilize the trachea in the midline
the thyroid isthmus, typically lies anteriorly over the first 2-3 tracheal
rings
A retracted isthmus may be irritated if it rubs against the tracheostomy
tube in the postoperative period, causing bleeding
Thus although it may be retracted out of the field, it must often be divided
in some cases.
Elevate the isthmus off the trachea with a hemostat and divide it
Division is performed sharply or with electrocautery and suture ligature
Dry the field
27. Open tracheostomy: trachea incision
Clean the remaining fascia off of the anterior
face of the trachea
warn the anaesthesiologist of impending
airway entry
Complete preparations for Deflate
endotracheal tube balloon
Injection of topical anaesthesia can stem the
cough reflex of an awake patient
Make tracheal opening
Simple horizontal (bedside)
T-Shape
U-shape
H-shape
28. silk stay suture can be placed through the tracheal wall
on each side and taped to the neck skin on either side.
Marking the tape that holds these sutures to the skin
with "Do not change or remove" is prudent
These sutures are removed after the first tracheostomy
tube change 5-7 days postoperatively
29. Open tracheostomy: Trachea entry
Suction secretions and blood
Slowly withdraw endotracheal tube
Secure the cricoid with a hook and elevate it
superiorly to facilitate control of the tracheal
entry
Replace lateral retractors into trachea
Enter trachea
airway is confirmed intact based on carbon
dioxide return and bilateral breath sounds
secure the tracheostomy tube to the skin with
4-0 permanent sutures.
30. Attach a tracheostomy collar with the head flexed to avoid
unnecessary slack in the collar
To avoid the risk of subcutaneous emphysema and subsequent
pneumomediastinum, the skin is not closed
Place a sponge soaked with iodine or petrolatum gauze between
the skin and the flange for 24 hours to deflect infection and
anxiety about minor oozing of the skin edge.
https://img.medscape.com/pi/meds/ckb/68/27068.mp4
32. Tracheostomy Tube size
Ideal tube size
maximizes the functional internal diameter
while limiting the outer diameter to
approximately three quarters of the internal
diameter of the trachea
reduces airway resistance and the work of
breathing while facilitating airflow around the
tube
Most women no. 6 Shiley cuffed tracheostomy
tube
Most men no. 8 Shiley cuffed tracheostomy
33. Ideally, the end of the tracheostomy tube should be 2-3 cm from
the carina to avoid the potential for the tube to enter the
mainstem bronchus with neck flexion
A tube that is too short abuts the posterior tracheal wall, causing
obstruction and ulceration.
A tube that is too long curves forward and erodes the anterior
tracheal wall, which can be perilously close to the innominate
artery.
34. Tracheostomy Tube types
1. single-cannula tubes:
a. Uncuffed (A)
b. cuffed (B):
2. Double-cannula
• Removable inner tubes
• fenestrated and non
fenestrated inner cannulae
• Obturator for insertion
35.
36. Cuffed Tracheostomy tubes
Allow positive pressure ventilation and prevent aspiration
Indications :
Risk of aspiration
Newly formed stoma in adult
Positive-pressure ventilation
Bleeding (eg, in a multiple-trauma patient)
Unstable condition
37. Contraindications :
Child younger than 12 years
Significant risk of tracheal tissue damage from cuff
irritates the trachea and provokes and trap secretions,
even when deflated
Use only when necessary
Even modern low-pressure cuffs should be deflated
regularly (four times a day) to prevent pressure necrosis
cuff pressures should be checked regularly in patients on
mechanical ventilation
38. Uncuffed tracheostomy tubes
Indications :
Stable stoma
Paediatric and neonatal patients
Upper-airway obstruction due to tumours or
neuromuscular disorders causing vocal cord palsy
Contraindications:
Dependent on positive-pressure ventilation
Significant risk of aspiration
Newly formed tracheostomy
39. Fenestrated Tracheosotomy tubes
permit airflow, which, in addition to air leaking
around the tube, allows the patient to phonate and
cough more effectively
single or multiple fenestrations on the superior
curvature of the shaft
Both Outer and /or inner
Cuffed fenestrated tubes are particularly used in
patients who are being weaned off their
tracheostomy when a period of cuff inflation and
deflation is required
Fenestrated cuffed and
uncuffed tubes.
40. Uncuffed fenestrated tubes are used in patients who no
longer depend on a cuffed tube.
contraindicated in patients who require positive-
pressure ventilation, as some of the air will leak out of
the fenestrations.
Standard fenestrations are rarely in the right place; if flush
with the tracheal wall, they instead cause irritation and
granulation and should not be used.
41. Flange or neck plate
attached to the proximal end of the tube prevents
the tube from descending into the trachea
allows for securing the tube with tapes, ties, or
sutures
tube size and type is often imprinted on the neck
plate for easy identification
Certain tubes have a swivel neck plate that rotates
on two planes and facilitates dressing and wound
care
These also allow distal tracheal obstructions to be
bypassed through a conventional tracheostomy
Adult swivel, neonatal, and
pediatric neck flanges.
42. Adjustable-neck-flange
tubes
Certain tubes have an adjustable flange that
allows variable tube length and may be
useful in patients with larger necks.
These also allow distal tracheal obstructions
to be bypassed through a conventional
tracheostomy
Bivona and Portex adjustable-
neck-flange tubes.
43. Post Op care
Manage in intensive care for first 24 hours
Keep spare tube by patients bedside, preferably have a
tracheostomy tray
Surgical review POD1 + follow up instructions
First trach change + suture removal POD7
Observe in hospital for stoma maturity then discharge
44. If the patient is stable for 24 - 48 hours with the
trach cuff deflated or with a cuffless tube in
place, the patient may be discharged at the
attending physicians discretion.
For awake patients who are tolerating a cuffless
trach or a deflated trach cuff, a Passey-Muir
(speaking) valve may be ordered by the
attending physician or pulmonologist
45. A qualified respiratory therapist can apply the
speaking valve and instruct the patient in it's use.
When necessary, speech therapy should be consulted
to help the patient phonate correctly with the speaking
valve
46.
47.
48.
49. Follow up
Tracheostomy risks include blocking of the tube by debris, and dislocation of
the tracheostomy cannula
use of a multidisciplinary team and a tracheostomy-care protocol can improve
outcomes
Role of ICU nurses, ENT surgeons and intensivist
Dependent on available technology, teaching activities, and personnel involved
in the decision to remove the tracheostomy
Cleaning the inner cannula might prevent infection, and although the inner
cannula increases the imposed work of breathing, it helps keep a clear artificial
airway.
An important part of follow-up is the decision on when to decannulate
50. Long-Term Tracheostomy Care
Patient and caregiver education/ training
basic airway anatomy
medical justification for the tracheostomy,
tube description and operation,
Appropriate tube selection
signs and symptoms of respiratory and upper-airway distress,
Airway management/ventilation
signs and symptoms of aspiration,
suctioning technique,
tracheostomy tube-cleaning and maintenance,
51. stoma-site assessment and cleaning,
cardiopulmonary resuscitation,
emergency decannulation and reinsertion procedures,
tube-change procedure,
Equipment supply, use and ordering procedures,
Humidification needs
Speech
financial issues.
scheduled follow-up plan with the attending physician
52. Decannulation
Removal of tracheostomy cannula
most important criteria regarding the decision to decannulate are
ability to cough, frequency of airway suctioning, and the patient’s
condition
If it is felt that trach is no longer needed and will not be needed in
the foreseeable future, a trial of breathing with the trach cuff
deflated will be undertaken.
If this is tolerated, the current trach tube may remain in place with
the cuff deflated, or change the trach to a cuffless smaller tube
(#6 Shiley).
53. The trach tube may then be plugged with the plug (with
a red button) provided with the trach tube.
If the patient is stable for 24 - 48 h with the trach
plugged, remove the trach, and the stoma will be
allowed to close.
If upper airway pathology such as tracheal stenosis is
suspected, the pulmonologist will perform a flexible
bronchoscopy prior to decannulation.
Once the tube has been removed, occlude stoma with a
tight dressing
Change dressing when airleak becomes apparent to
prevent tracheocutaneous fistula
54.
55.
56.
57.
58. Late complications
Tracheal Stenosis
Swallowing difficulty
Permanent voice change
Tracheocutaneous fistula
Scarring of the neck
Decannulation problem
Disfiguring Scar
59. Summary
Tracheostomy is an operative procedure that creates a surgical
airway in the cervical trachea.
It is a viable alternative to prolonged endotracheal intubation,
any patient requiring intubation for >5-7days should be on
tracheostomy
It has several benefits to the patient, physician and caregiver
It could be emergent or elective
It could be done through a percutaneous or open approach
Post operative and long term care are important, so patient
and care giver should be adequately educated and carried
along
60. Refrences
Cheung, Nora H, and Lena M Napolitano. "Tracheostomy: Epidemiology, Indications, Timing,
Technique, and Outcomes." Respiratory Care 59.6 (2014): 895-919.Web. 18 June. 2018.
Freeman BD, Isabella K, Lin N, Buchman TG. A meta-analysis of prospective trials comparing
percutaneous and surgical tracheostomy in critically ill patients. Chest. 2000 Nov. 118(5):1412-8.
Higgins KM, Punthakee X. Meta-analysis comparison of open versus percutaneous
tracheostomy. Laryngoscope. 2007 Mar. 117(3):447-54.
Lewarski JS. Long-term care of the patient with a tracheostomy. Respiratory care. 2005 Apr
1;50(4):534-7.
MacIntyre NR, Cook DJ, Ely EW Jr, et al. Evidence-based guidelines for weaning and
discontinuing ventilatory support: a collective task force facilitated by the American College of
Chest Physicians; the American Association for Respiratory Care; and the American College of
Critical Care Medicine. Chest. 2001 Dec. 120(6 Suppl):375S-95S.
61. Mitchell RB, Hussey HM, Setzen G, Jacobs IN, Nussenbaum B,
Dawson C, et al. Clinical consensus statement: tracheostomy
care. Otolaryngol Head Neck Surg. 2013 Jan. 148(1):6-20. [
Tobin AE. Tracheostomy teams - filling a void. Crit Care Resusc. 2009
Mar. 11(1):3-4.
Young PJ, Pakeerathan S, Blunt MC, Subramanya S. A low-volume,
low-pressure tracheal tube cuff reduces pulmonary aspiration. Crit
Care Med. 2006 Mar. 34(3):632-9.
Joshua Tackie Ofoli. Tracheostomy, indications, procedure and care
ppt at 2018 national update
