Download - TRACHEOSTOMY BY DR JUVERIA MAJEED MS ENT
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DR JUVERIA MAJEEDMS ENT,
Govt.ENT Hospital/Osmania Medical College
TRACHEOSTOMY
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A Tracheostomy is an artificially( usually) surgically created airway fashioned by making a hole in the anterior wall of trachea and the insertion of a tracheostomy tube, which may or may not be permanent.
Tracheotomy is the opening into trachea where as tracheostomy is converting the opening into stoma onto the skin surface.
What is a tracheostomy?
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Tracheostomy is one of the oldest surgical procedure.
A tracheotomy was portrayed by the Egyptians and Indians in the early years.
Extensive history of tracheostomy can be best divided into five periods:
1. The period of Legend (3100BC to AD 1546)- The first elective tracheotomy by Asclepiadus of
Bithynia in AD100. This operation ws described by Claudius Galen,
renowned physician in AD 131 References were made to tracheotomy, but was
considered both useless and dangerous due to high risk of wound infection
Hippocrates condemned tracheostomy
History
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2. The period of Fear(AD 1546-1833) in the history of tracheostomy:
During this era, this procedure ws considered as irresponsible and barbaric.
By early 1600s, it started getting acceptable for few conditions like FBs etc.
Bcoz of fear and mistrust abt procedure, it prevented therapatic use of it, for eg. In 1799,dec4th,first US president died of acute(within 36 hours) upper airway obstruction sec. to peritonsillar abscess
3.The period of Dramatisation(AD 1833-1932):
It was considered as operation of life or death.
The operative technique of tracheostomy was studied, refined and defined by Chevalier Jackson in 1909.
He also designed the metallic double lumen tube
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4. The period of Enthusiasm(AD 1932- 1965) Wherein saying “if u think tracheostomy……do it” became
popular. Indications for tr. Were actively sought for and both
surgical and medical world became strong advocates for it 5.The period of Rationalisation(AD 1965 to present): In 1965, it became apparent tht oral or nasal intubation
was quicker and safer than tr. So began this period wherein tr. Vs intubation ws debated.
Seldinger introduced PCT in 1953 PCT using guidewire introduced by Ciaglia et al. In 1990 Griggs et al developed another guidewire dilating
forceps for PCT
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Surgical anatomy of trachea The trachea begins at the
lower border of cricoid cartilage(C6) superiorly to the tracheal bifurcation at the level of sternal angle(T5).
Made up of 16 to 22 C-shaped cartilage anteriorly joined by annular ligaments and posteriorly by trachealis muscle.
Located in midline position,but can be deviated to right as in advanced age or severe COPD.
The average distance from cricoid to carina is approx 12-16 cm long,2.3 cm wide.
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Anterior to the trachea in the neck is the isthmus of the thyroid gland at about the level of 2nd to 4th tracheal cartilages.
Below this is the inferior thyroid veins, lymph nodes, and sometimes a thyroid ima artery.
Anterior to all of these are the strap muscles. Lateral to trachea in the neck are the lobes of
thyroid gland, great vessels and recurrent laryngeal vessels.
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The innominate artery crosses the trachea either behind the sternum or in the lower portion of neck.
During tracheostomy the careful surgeon will palpate this region to assess the presenceof high riding innominate artery.
The jugular venous arch connecting two anterior jugular veins lies superficial to the strap muscles just above the suprasternal notch.
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The basic anatomical relationships need to be kept in mind in performing a tracheostomy.
High tracheostomies (above 2nd tracheal cartilage) are generally associated with a higher rate of tracheal stenosis and perichondritis of cricoid cartilage.
Low tracheostomy (below 4th tracheal cartilages) will encounter more vascular structures such as thyroid veins, ant. Jugular arch, or a high innominate artery.
Neck anatomy and its relevance to tracheostomy
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Horizontal skin incisions tend to be more cosmetic, although the ext. jugular veins and lateral anatomic structures must be considered during dissection.
Vertical skin incisions tend to be avascular. Paediatric larynx and tracheal anatomy
varies from adult and has a great clinical signiicance.
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Paediatric vs Adult airway
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Arteries of central neck: Common carotid A. Carotid bifurcation Internal carotid A Ext. carotid A. and br. Superficial veins of central neck: Ext. Jugular vein and ant jugular vein Deep veins of central neck: Internal jugular vein
Important structures to be careful while performing tracheostomy
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Nerves of central neck: Cutaneous innervation Tenth nerve and its br. Twelfth nerve and ansa cervicalis
Visceral structures of neck Thyroid gland Larynx Trachea and esophagus
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Indications for TracheostomyProlonged intubation
Facilitation of ventilation support
Inability of patient to manage secretions
Upper airway obstruction
Inability to intubate
Adjunct to major head and neck surgery
Adjunct to management of major head and neck trauma
Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.2005.
Goldenberg D, et al Tracheotomy: changing indications and a review of 1,130 cases, J Otolaryngol 31:211–215, 2002
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Indications: Mechanical Obstruction
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Tracheostomy in a number of medical and surgical conditions e.g.:-
Trauma to the chest. C.C.F. & pulmonary edema. C.O.P.D Head injury. Coma. Strychnine poisoning. Tetanus, Rabies, Poliomyelitis. Neurological conditions.
Before doing major head and neck surgery tracheostomy is done to prevent post operative complications.
Indications
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Emergency tracheostomy
Elective – therapeutic or prophylactic
Permanent
Types of Tracheostomy
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Emergency: when airway is complete or almost completely obstructing as in FBs or acute infections.
Elective: planned unhurried procedure.Often temporary and closed when indication is over.
Therapeutic: to relieve respiratory obstruction,remove tracheobronchial secretions or gv assisted ventilation.
Prophylactic: in extensive surgeries of tongue, floor of mouth, mandibular resection or laryngofissure.
Permanent tracheostomy: In b/l abd. paralysis, laryngectomy, laryngopharyngectomy.
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high
Above the level of thyroid isthmus
-Violates 1st tracheal ring -Ca larynx
Types of tracheostomy
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Position: supine with a pillow under the trachea. This brings trachea forward.
Anesthesia: mostly done under local with 2% lignocaine with epinephrine. Sometimes GA is used.
Incision:Vertical- midline of neck, from cricoid above to sternal notch.
Most favoured incision. Can be used in both elective and emergency. Rapid access with minimum bleeding and tissue dissection.
Horizontal -2 fingers breadth above the sternal notch. Used in elective procedure only. Cosmetically better scar.
Technique & Steps of operation
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Strap muscles separated in midline and retracted laterally.
Thyroid isthmus is displaced upwards or divided-ligated.
Identification of tracheal rings by colour and palpation
confirmation- 4% lignocaine loaded syringe introduced, withdrawn to see for air bubbles, also to suppress cough.
Vertical incision given in trachea from below upwards in 3 or 4th tracheal rings
Tube of appropriate size used. Tied to neck with reaf knot.
Skin sutures not required.
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Incision 1 cm below the cricoid or halfway between the cricoid and the sternal notch.
Retractors are placed, the skin is retracted, and the strap muscles are visualized in the midline. The muscles are divided along the raphe, then retracted laterally
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Inserting a Tracheostomy Tube:
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Baby with One Fingertip
Securing the Tracheostomy Tube
D
One Fingertip Fits Under the Adult Ties
BLS
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ANATOMICAL POSITIONING OF A TRACHEOSTOMY TUBE
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INFANTS
•Sub glottic haemangioma
•Sub glottic stenosis
•Laryngeal cyst
•Glottic web
•Bilateral vocal cord paralysis
CHILDREN
•Acute laryngotracheal bronchitis
•Epiglottitis
•Diphtheria
•External laryngeal trauma
•Prolonged intubation
•Juvenile laryngeal papillomatosis
•Bilateral abductor paralysis
Paediatric tracheostomy indications
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GA Trachea –soft and compressible Too much of extension- Pleural injury,
innominate , thymus injury Silk sutures on either side of trachea to
secure it in midline Not to incise deeply as it can cause
posterior tracheal wall injury. Not to excise ant. Wall of trachea- only
incision is given Avoid infolding of ant tracheal wall Proper selection of T tube
Paediatric Tracheostomy
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Nursing: constant supervision of pt after tracheostomy for bleeding, displacement or blocking of tube and removal of secretions.
Removal of secretions: Suction Prevention of crusting and tracheitis:
Humidification, use of normal or hypotonic saline or RL. If tenacious secretions, use of N-acetylcysteine to loosen crusts
Care of T.tube: Inner tube cleaning Care of inflatable cuff Dressing: to avoid maceration of skin from
secretions Breathing exercises: recommeded to ventilate
the lungs fully and prevent pulmonary infections
A calling bell, slate and a pencil for communication
Post operative care
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ICU Bed SideTracheostomy Minimally invasive alternative to open
tracheostomy Use of guide wire and Dilators Under the vision of Bronchoscope through
endotracheal tube Less time ,Less Expensive Not suitable for thick neck and in
emergency
Percutaneus Dilational Tracheostomy
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Percutaneous tracheostomy
INTRODUCTION OF TRACHEAL NEEDLE
Placement of guide wireINSERTION OF GUIDING CATHETER
SERIAL DILATIONPlacement of tracheostomy tube
Percutaneous tracheostomy
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Intraoperative Complications.
Anaesthesia complications
Bleeding and injury to big vessels
Apnoea- due to sudden washout of co2
Injury to recurrent laryngeal nerve
Injury to tracheoesophageal wall
Pneumothorax- injury to apical pleura
Complications of Tracheostomy
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Bleeding, reactionary or secondary Tracheostomy tube obstruction Tracheostomy tube displacement Subcutanoues empysema Tracheitis and tracheobronchitis with
crusting in trachea Atelectasis and lung abcess Local wound infection and
granulations
Early Complications
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• Hemorrhage, due to erosion of major vessels• Laryngeal stenosis, due to perichondritis of
cricoid cartilage• Tracheal stenosis, due to tracheal ulceration and
infection• Tracheo –oesophageal fistula• Problems of decannulation• Persistant tracheocutaneous fistula• Problems of T.scar- keloid formation• Corrosion of tracheostomy tube and aspiration of
its fragments into tracheo bronchial tree
Late complications
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04/15/2023 37
TRACHEAL STENOSIS & TRACHEO-INNOMINATE ARTERY FISTULA
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T. tube should not kept longer than necessary
To decannulate, it shud be plugged or corked and the pt shud be able to sleep overnight with the tube closed before decannulation
After tube removal , pt is closely monitored for resp.distress and tachycardia
Decannulation
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It may be: Persistance of the condition for which
tracheostomy was done. Obstructing granulations: around stoma or
at tip of tube Tracheal oedema or subglottic stenoses Incurving of tracheal wall at the site of
tracheostome Tracheomalacia Psychological depandance
Difficult Decannulation
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1. Increased patient mobility2. More secure airway3. Increased comfort4. Improved airway suctioning5. Early transfer of ventilator-dependent
patients from the intensive care unit (ICU)
6. Less direct endolaryngeal injury7. Enhanced oral nutrition8. Enhanced phonation and communication9. Decreased airway resistance for
promoting weaning from mechanical ventilation
10.Decreased risk for nosocomial pneumonia in patient subgroups
Tracheostomy vs Intubation
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TRACHEOSTOMY TUBES A tracheostomy tube
is:-◦ Inserted through the
tracheostomy to maintain a patent airway
◦ Secured in place by tapes tied around the neck
◦ Ideal T.tube: ◦ Rigid enough to maintain
the airway.◦ Yet flexible enough to
limit tissue damage◦ Comfortable to the pt.
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Parts of tracheostomy tubes
Parts Description Outer cannula 1. Main body of the tube which passes
into trachea2. Diameter – inner dia of this outer
cannula
Inner cannula 1. Removable tube –passes into outer tube
2. A bit longer 3. Can be locked
Cuff 1. Balloon at the distal end2. Protection
Pilot balloon 1. Ext balloon connected by a inflation line to cuff
Flange – neck plate
1. Supports the tube2. Straight strip- adults3. Angulated- pediatric4. Adjustable flanges- bulky neck
Introducer/ obturator
1. Beveled tip shaft2. Smooth round dilating tip 3. Reduces trauma – insertion
Fenestrations 1. Single/ multiple2. Speaking 3. Coughing
Adaptor 1. Ventilatory equipment
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Passy Muir valve Speaking valves are
one way valves that allow inhalation through the tracheostomy tube but block exhalation through the cannula forcing exhaled gas through vocal cords allowing phonation
Accessories- speaking valve
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TYPES OF TRACHEOSTOMY TUBE
Cuffed- when inflated, this tube seals the airway and prevents the aspiration of oral or gastric secretions.
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Maintains airway once aspiration risk has passed.
Increases airflow to the larynx.
Required in Long term T. pts Pts who do not
require a seal Paediatrics
Uncuffed Tube
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TYPES OF TRACHEOSTOMY TUBE
Fenestrated
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JACKSON’S TRACHEOSTOMY TUBE-
Metallic tracheostomy tubes
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JACKSON’S TRACHEOSTOMY TUBE-
Metallic tracheostomy tubes
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Metallic tracheostomy tubes
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HOLLINGER’S TRACHEOSTOMY TUBE-
Metallic tracheostomy tubes
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TUCKERS’ TRACHEOSTOMY TUBE-
Metallic tracheostomy tubes
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MARTIN’S TRACHEOSTOMY TUBE-
Metallic tracheostomy tubes
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PVC- Most cost effective, for short term use , More prone to infections.
Silicone –soft material, unique characteristic of reducing adherence of secretions and bacteria
Siliconised PVC- sufficient rigidity, Thermosensitive, More pt. comfortable. Eg Portex ultra
Silver- 92.8% silver, Cu and P with silver lining, For prolonged use. Eg Negus and Chavelier Jackson
Sialistic –silicon rubber, less rigid. Eg. Moore
What are tubes made of
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Complications of tube
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