Tracheostomy….
Indications & care
What is“Tracheotomy”
• The word “tracheotomy” is derived
from the Latin “trachea” and
“tomein” (to make an opening).
• Tracheostomy is an operative
procedure that creates a surgical
airway in the cervical trachea .
Tracheostomy History.
• Ttracheotomy is one of the oldest surgical procedures. it was
even pictured on Egyptian tablets in 3600 BC !
• 2000 BC: The Rgveda described a healed tracheostomy
incision.
• 100 BC: Asclepiades described a tracheostomy incision for
improving the airway.
• Ca 400 BC: Hippocrates condemned tracheostomy, citing
threat to carotid arteries.
•
• Ca 50 AD: Aretaeus of Cappadocia warned against
performing tracheostomy because of the risk of secondary
wound infections.
Tracheostomy History
• 1805: Viq d'Azur described cricothyrotomy.
• 1833: Trousseau reported 200 cases of diphtheria
treated with tracheotomy.
• 1909: Chevalier Jackson codified
indications and techniques for modern
tracheotomy and warned of complications
of high tracheotomy (cricothyrotomy).
• 1932: Wilson advocated prophylactic tracheotomy in
cases of poliomyelitis.
Relative anatomy
• Major blood vessels (carotids,
innominate a., jugular veins)
• Thyroid gland
• Esophagus
• Larynx
• Nerves (Rec.Laryngeal)
• Cervical spine
Tracheostomy Indications
To bypass obstruction
- Tumors (of oropharynx, larynx, upper trachea)
- Infections (epiglottitis,severetracheobronchitis)
- Bilateral Vocal Cord Paralysis
- Trauma (laryngeal, maxillofacial fractures)
- Edema (tongue, laryngopharynx)
- Intubation failure
- Foreign body obstruction
- Subglottic or tracheal stenosis
Tracheostomy Indications
Prolonged intubation
• Need for prolonged respiratory support, such
as in Bronchopulmonary Dysplasia
• To reduce anatomic dead space and increase
the chance for mechanical ventilation
withdrawl
• To prevent decubitus and secondary infections
in oropharynx (and trachea and tracheal
perforations ?!)
• To improve the patient`s quality of life (easier
toilet, ability to speak and eat (not in
comatose patient), increase the mobility)
• Neuromuscular diseases paralyzing or
weakening chest muscles and diaphragm
Tracheotomy Indications
Miscellaneous
• Congenital abnormalities (tracheomalatia, subglottic or glottic
stenosis, craniofacial abnormalities (Pierre Robin, Triecher
Collins syndromes)
• Obstructive Sleep Apnea Syndrome
• Aspirations related to muscle or sensory problems
• Prophylaxis (as preparation for extensive H&N procedures,
before radiotherapy for H&N CA)
• Cervical spinal cord injuries with respiratory muscles paralysis
Tracheotomy advantages
• Less irritation of nose, mouth and throat
mucous membranes
• A nasal tube carries a higher risk of incurring
sinusitis
• Cleansing the mouth is much easier to perform
thus preventing oral cavity infections
• The patient is more able to cough up mucus as
the airway distance is shorter
• Ability to speak
• When awake and if the patient can swallow and
his condition allows it, he may eat and drink
Tracheostomy disadvantages
• Some irritation or pain in the neck region in the
first days after placing the canula.
• A scar will remain visible on the neck (after
removal of the tranchea canula).
• Possible complications.
Preoperative workup
• Physical assessment also surgical
and anesthesiological
• CBC
• PT, PTT, INR
• Patient/apotropus confirmation
Surgical techniques
• Open procedure
• Percutaneous
procedure
Surgical techniques
open procedure
Surgical techniques
open procedure
Surgical techniques
open procedure
Surgical techniques
open procedure
Complications - general
• Rate in children • Rate in adults –
- up to 70% up to 66%
• Tracheotomy
related death -
2-3%(overall)
Complications
immediate
• Apnea due to loss of hypoxic respiratory drive. This is
mainly important in the awake patient. Ventilatory support must
be available.
• False root
• Bleeding
• Pneumothorax or pneumomediastinum
Complications
Immediate
• Damage to the vocal cords (direct)
• Injury to adjacent structures: recurrent
laryngeal nerves, the great vessels, and the esophagus.
• Post-obstructive pulmonary edema
• Hypotension
• Arrhythmia
Complications
Early
• Early bleeding: This is usually the result of increased
blood pressure as the patient emerges from
anesthesia and begins to cough.
• Plugging with mucus
• Tracheitis
• Cellulitis
• Tube displacement
• Subcutaneous emphysema
• Atelectasis
Complications
Late
• Bleeding - tracheoinnominate fistula
• Tracheo- and laryngomalatia
• Stenosis
• Tracheoesophageal fistula
• Tracheocutaneous fistula
• Granulation
• Scarring
• Failure to decannulate
Complications
Late
Tracheotomy care
• Suctioning• Not aggressive and not too
much deep
• Skin care • To prevent irritation and
secondary inflammation due
to discharge
• Inner tube
• Once or more daily remove
care
and clean. Attention on crusts
Tracheotomy care
•
Tracheotomy care
• Humidification • “Artificial nose”
• Tube position • To prevent decubitus of
trachea
• Tube position • Not to cover with
blanket!
• Pay attention on
patient’s beard and chin
position!
Tube change
• After the tract is mature – 4-5 days
after the operation
• Rate of change depends on clinical
situation of the specific patient – type
of discharge, type of tube, medical
status, age..
• Should be done by experienced staff
TYPES OF TRACHEOSTOMY
TUBES
• CUFLESS TUBES
• CUFFED TUBES
Speech with tracheotomy
• It`s possible to speak
with tracheotomy, also
for mechanically
ventilated patients
and for spontaneous
breathers.
Speech with tracheotomy
• Spontaneous
breathers
• Tolerate cuffless
mech. ventilation
• Conscious patient
Speech with tracheotomy
(Passy-Muir valves)
• For
mechanically
dependent
patients that
may tolerate cuff
deflation
• For unable to
close the tube
outlet with finger
(quadriplegia)
Eating with tracheotomy
