Upper airway obstruction, intubation 3eeeeeeererrer4and tracheostomy final.pptx

Categorical

1. Upper airway obstruction, intubation and tracheostomy Simon Peter Namingira / Sangadi Gilbert. Tutor; Dr. Kabagenyi Fiona- Pediatric Otolaryngologist

2. AIRWAY DYNAMICS Poiseuille’s law may be applied to the airway and dictates that the airway resistance is inversely proportional to the fourth power of its radius; a 50% reduction in the radius of the airway therefore results in a 16-fold increase in resistance to airflow.

3. Airway dynamics 1mm of narrowing in a 4mm diameter infantile airway thus results in a 75% change in airflow As cross-sectional area decreases, airflow velocity increases. The smaller the airway, the greater the impact of airway oedema and the more grave the concern.

4. Airway dynamics The Bernoulli principle is also of fundamental importance in relation to the paediatric airway. Increased airflow velocity results in negative pressure on the walls of the airway leading to inward collapse. Previously smooth or ‘laminar’ airflow then becomes more turbulent

5. Introduction The causes of upper airway obstruction are varied with some being immediately apparent whereas others are subtle.

6. Aetiologies of rapidly progressive airway obstruction include; penetrating or blunt trauma to the head and neck region, infections or oedema of the upper airway, vocal cord paralysis foreign body inhalation.

7. Examples of laryngeal causes of UAO obstruction in children Congenital Acquired in neonates Acquired in children Laryngomalacia Vocal cord palsy Laryngeal stenosis Laryngeal cysts Webs Laryngeal atresia Vallecular cyst Arytenoid fixation Posterior laryngeal cleft Intubation trauma Surgical trauma (e.g. laser) Laryngeal stenosis Arytenoid fixation Reflux laryngitis Intubation trauma Croup Recurrent respiratory papillomatosis Hereditary angioedema Epidermolysis bullosa Foreign body Dislocated arytenoid Epiglottitis Trauma – fracture Caustic and thermal burns Haemangioma Lymphovascular malformation

8. Examples of naso - and oropharyngeal causes of upper airway obstruction congenital Acquired neonate Acquired – children Choanal atresia Choanal stenosis Mid-nasal stenosis Piriform aperture stenosis Glioma Encephalocoele Meningocoele Dermoid / teratoma Craniofacial abnormalities Micrognathia – glossoptosis Lingual thyroid Lymphovascular malformation Neonatal rhinitis Allergic rhinitis Adenoiditis Adenotonsillar hypertrophy Foreign body Non-allergic rhinitis Retropharyngeal abscess Infectious mononucleosis Ludwig’s angina Thermal and caustic burns

9. Examples of tracheal causes of upper airway obstruction Congenital Acquired neonate Acquired children Tracheal stenosis Tracheal atresia Trapped first tracheal ring Complete rings Micro (stovepipe) trachea Haemangioma Primary tracheomalacia Secondary tracheomalacia – vascular compression Post- intubation/ instrumentation/ tracheal stenosis Reflux tracheitis Croup Bacterial tracheitis Foreign body Localized malacia secondary to a tracheostomy or TOF repair Thyroid masses Lymphovascular malformation Mediastinal tumours

10. Aetiologies Primary malignancy of the head and neck may also present with acute airway obstruction

11. .

12. Symptoms and Signs In the absence of acute trauma to the upper airway, presenting symptoms include; Stridor and stertor dyspnoea , cough, voice change, dysphagia, pain on swallowing referred otalgia Drooling Bleeding Fractures and subcutaneous emphysema

13. Clinical presentation

14. Stridor and stertor Stridor is a high-pitched noise that can be mistaken for wheeze Stridor denotes turbulent airflow and heralds complete airway obstruction. Inspiratory stridor is usually from obstruction at and above the glottic larynx, whereas expiratory stridor is from the intrathoracic airway and biphasic from the subglottis and trachea

15. Stridor and stertor Stertor is defined as a heavy snoring sound that is lowpitched and indicates obstruction or collapse in the pharyngeal airway

16. Voice change Changes in the vocal quality arise from impaired vocal fold vibration or altered vocal cord movement. Hoarseness results from many types of injuries and may signal oedema , mucosal disruption, cartilaginous injury and impaired vocal cord movement. the greater the degree of hoarseness, the greater the severity of laryngeal injury.

17. Voice change Aphonia is often associated with severe injury.

18. On examination there may be increased work of breathing and accessory muscles of respiration use. Drooling implies either pharyngeal or oesophageal obstruction or the avoidance of swallowing due to pain. bleeding denotes mucosal trauma or exposure of a vascular structure by an invasive lesion. Significant pharyngeal trauma and fractures of the laryngeal skeleton or trachea may give rise to surgical emphysema

19. MANAGEMENT Assessment Initial assessment and immediate mgt of the pt with UAO is very important. Follow ABCDE approach. The airway (with appropriate consideration of the cervical spine in trauma) is always the 1 st step in pt mgt , followed by consideration of breathing and circulation. This leads on to a neurological assessment and then a general evaluation. The general evaluation includes a determination of the extent and severity of the neck/chest injury

20. Assessment

21. Treatment ‘the time to do a tracheostomy is when you first think of it’,

22. Medical Interventions Administer high-flow oxygen via a face mask with a reservoir bag and use of humidification if practically possible. Heliox (80% helium:20% oxygen) results in less turbulent flow and allows the patient to experience reduced resistance during breathing. Steroids reduce mucosal oedema . Broad-spectrum antibiotics should be given in any case where acute infection is suspected. Adrenaline nebulisers also can help to reduce airway oedema

23. Airway Interventions Simple airway adjuncts such as an oral Guedel airway or nasopharyngeal airway may assist with situations of supraglottic airway compromise.

24. ORAL AIRWAY bypasses obstruction in the oral cavity and nose. It can be used to assist ventilatory resuscitation with a facemask and ambubag . facilitates suctioning of the airway. Used in pts with lOC or obstruction due to nasal injury Pitfalls not be tolerated if the gag reflex is present. Easily displaced

25. NASOPHARYNGEAL AIRWAY An NPA is a soft silicone plastic tube bypasses obstruction at the level of the oropharynx, e.g. in Ludwig’s angina or angioedema and in cases of trauma with facial fractures. NPA also facilitates suction. Use is contraindicated in pts with severe head or facial injuries with suspected skull base fractures

26. Airway Interventions ETT is the intervention of choice where there has been a loss of respiratory drive necessitating assisted ventilation, or in cases of progressive UAO. The usual route of intubation is via the mouth. An alternative route is transnasal intubation using endoscopic guidance

27. Airway intervention relative contraindications include; cervical spine fractures, severe facial trauma and laryngeal trauma.

28. Cricothyroidotomy In the emergency setting of ‘can’t intubate, can’t oxygenate’ (CICO), a surgical cricothyroidotomy using the ‘scalpel– bougie ’ technique Steps Extend the patient’s neck, palpate the cricothyroid membrane in the midline incise the skin vertically and the underlying membrane horizontally using a size 10 scalpel. Insert an airway bougie and railroad a size 6 ETT over the bougie into the airway.

29. Imaging

30. Imaging

31. Imaging

32. Imaging

33. Imaging

34. Imaging

35. Imaging

36. Imaging

37. Imaging

38. Imaging

39. Imaging

40. Imaging

41. Imaging

42. Definitions A tracheotomy is the creation of a hole into the trachea. A tracheostomy is the fashioning of a permanent opening or stoma between the trachea and the skin

43. Operative techniques Open tracheostomy Percutaneous tracheostomy Debulking tracheostomy

44. Introduction Classification Emergency Vs Elective An emergency tracheostomy is a rare procedure, perhaps only indicated in cases of severe trauma or very late presentation Elective temporary tracheostomy is for prolonged ventilatory support in a ventilated patient. A temporary vs Permanent Temporary tracheostomy may also be planned as part of a major surgical procedure in which there are anticipated concerns about post-operative swelling or bleeding, which may precipitate upper airway obstruction. A permanent or ‘end’ tracheostomy is an elective procedure carried out as part of a surgical procedure involving the removal of the larynx, such as a laryngectomy or pharyngo-laryngectomy.

45. Paediatric vs adult airway Smaller airway in the paediatric patient: the average diameter of the sub glottis in a fully term baby is 3.5mm, an adolescent is 7mm an adult 10-14mm Larger head and prominent occiput in paediatric patient Larger tongue The infant hyoid and larynx are situated higher than in an adult Short concave vocal cords in paediatric population, compared to horizontal in adults Omega shaped, shorted epiglottis in an infant Cartilage is soft and less prominent in an infant Lower airways are less developed in an infant

46. Pediatric Vs adult airway

47. Paediatric vs adult tracheostomy Smaller tubes tubes (neonatal and paediatric sizes) No inner cannula in paediatric /neonatal tubes No fenestrated tubes in paediatric /neonatal tubes Most paediatric tubes are cuffless (although cuffed tubes are used when required for ventilation) Paediatric cuffed tubes do not prevent aspiration of secretions The size of the tube will increase as the child grows!

48. Indications of tracheostomy Upper airway obstruction Prolonged ventilation Removal of secretions to reduce anatomical dead space Part of another procedure ( e.g laryngectomy / pharyngolaryngectomy )

49. Contraindications There are no absolute contraindications to tracheostomy. However, in patients with a terminal prognosis, very careful consideration must be given to the psychological effect on the patient and the quality-of-life aspects. There is no right or wrong answer and each patient must be approached on an individual basis

50. Upper airway obstruction Epiglottitis/ supraglottitis Craniofacial abnormalities Tumor Bilateral vocal cord paralysis Angioedema Foreign body Blunt/penetrating neck trauma

51. UAO Life-threatening No other means of relieving the obstruction (e.g. nasopharyngeal airway or prong) is appropriate, then a tracheostomy must be considered.

52. .

53. Prolonged intubation The long-term complications of prolonged endotracheal intubation are well recognized: ulceration at the level of the glottis and, particularly in children, the subglottis , Can lead to cicatrization stenosis of the airway. Being softer and more flexible than the adult and with correct selection of tube size and appropriate intensive care, the neonatal larynx is able to tolerate prolonged intubation for relatively longer than the adult. Premature babies may now be intubated for several weeks before permanent damage becomes a risk. Although practice varies in different units, tracheostomy should normally be considered in older children after 2–3 weeks of endotracheal intubation. A number of studies recommend a tracheostomy within 7 days for both adults and pediatrics Kassi et al:2018 JPIC – prolonged long term ETT intubation AND role of tracheostomy: Patient and provide factors. There was no significant difference in out comes of prolonged intubation vs tracheostomy . Physician expertise is key in determining need although 50% of patients we were recommended

54. Long-term and home ventilation Indications for long-term ventilation include: congenital central hypoventilation syndrome spinal injury congenital myopathy airway malacia chronic lung disease.

55. Effects of tracheostomy Laryngeal bypass – loss of cough and phonation Reduction in respiratory dead space Loss of nasal mucosa filtration and humidification Increased risk of infection Tube acts as foreign body leading to local inflammation

56. Preparation Surgical Instruments Tracheal Dilator:  Specifically designed to hold the tracheal opening. ( Laborde and Trouseau ) Scalpels and blade : Used for making incisions in the skin and surrounding tissues.  Forceps:  Various types of forceps are used to grasp and manipulate tissue.  Scissors : Specialized, curved scissors are used for cutting tissues and sutures.  Needle & Syringe : for local anesthesia and for the initial needle-based entry into the trachea.  Light Source Fiberoptic Bronchoscope : To visualize the airway and ensure proper placement of the tube.  Pediatric considerations: Appropriate sizes of instruments

57. Preparation Supplies Tracheostomy Tube : The correct type and size of tracheostomy tube for the patient.  Tracheostomy Tube Ties/Velcro Straps : To secure the tube in place.  Suction Supplies: Including a suction catheter, tubing, and a suction source to clear secretions.  Dressing Supplies : Gauze and sterile dressings to cover the stoma site.  Suture Cutter : For removing sutures after the procedure.  Lubricant:  A water-soluble lubricant to facilitate tube insertion.  Manometer:  For checking the pressure of the tracheostomy tube cuff .  Prediction of tracheostomy tube size for paediatric long-term ventilation: an audit of children with spinal cord injury Behl, S. et al. British Journal of Anaesthesia, Volume 94, Issue 1, 88 – 91 Linear correlation from 2 to 14 years

58. Types of tracheostomy tubes Adjustable Flange Tracheostomy Tubes Tubes with sub-glottic suction Fenestrated tubes

59. Preparation Emergency & Support Equipment Personal Protective Equipment (PPE): Including gloves, masks, and eye protection for the surgical team.  Manual Resuscitator (Bag-Valve-Mask): To provide manual ventilation if needed.  Emergency Airway Equipment: Such as a spare tracheostomy tube of the correct size

60. Surgical steps - position Positioning: Supine variations sitting Stabilized neck Adult With the patient’s neck in the natural or neutral position or slightly flexed, mark a horizontal line at the level of the cricoid cartilage about 2 to 3 cm in length The tracheostomy is created below the 1st tracheal ring to avoid subglottic stenosis as a result of scarring Pead: Theoretically, increases the risk of injury to the great vessels in the root of the anterior neck; In practice, with careful dissection and identification of structures this is rarely a clinical problem. Overextension: risk exposing a significant part of the intrathoracic trachea and can lead to an incision in the low tracheostomies

61. Skin preparation Skin preparation Asepsis must be observed and skin prepared with iodine or alcohol. Draping with sterile line

62. Local anesthesia STEP 3. Infiltrate the skin and subcutaneous tissues with lidocaine (Xylocaine)/epinephrine solution diluted to 1: 100,000

63. Skin Incision and dissection Adult: Horizontal incision Incise through the skin and subcutaneous tissues down to the level of the sternohyoid muscles, Retracting the overlying soft tissues superiorly and inferiorly with sharp hooks and dissecting them off the strap muscles to expose the median raphe over a 2- to 3-cm distance Pead: Vertical incision (midline dissection, easier placement of maturation sutures Minimize blood loss through diathermy Stay in midline Regularly palpate the trachea to avoid straying and ensuring that it is not carotid.

64. Dissection Elevation of strap muscles: Use a curved clamp to undermine the strap muscles sufficiently on either side of the midline so as to allow the insertion of army navy retractors for lateral retraction to expose the thyroid isthmus.

65. Dissection fat pad Expose the pre-tracheal fat pad immediately below the isthmus where the investing middle layer of the deep cervical fascia is thinnest. Dissect through this fat pad vertically in the midline so as to expose the anterior face of the trachea

66. Tracheal infiltration If the patient is under local anesthesia, then at this point with the anterior face of the trachea exposed, infiltrate the tracheal lumen with lidocaine (Xylocaine).

67. Tracheal incision Types Vertical incision Tracheal flaps (inferior or superior) Cruciate Location Between 2 tracheal rings (3rd and 4 th ) over the anterior 90 to 120 degrees of its face .

68. Insertion of TT Dilate the incision Spread the incision in a vertical direction using a clamp or tracheal dilator to create sufficient room for tracheotomy tube insertion. With the trachea open, pull back or have the anesthesiologist pull back the endotracheal tube so the tip is just above the tracheal opening and insert the tracheotomy tube.

69. Secure the TT Inflate the cuff Secure the tracheotomy faceplate with ties tightened with the patient’s neck flexed so as to allow only two fingers within the loop Measure the cuff pressure ensuring that is less 15-25 mmHg or 20-30 cm of water

70. Low tracheostomy A tracheotomy should not be placed below the 4th tracheal ring as: The distance btn the skin and the trachea increases inferiorly, which makes tracheal intubation more difficult A low tracheostomy may compress and erode the innominate artery which passes between the manubrium sterni and the trachea. Causing innominate artery erosion and fatal haemorrhage . Might be preceded by a so-called “sentinel bleed”

71. High tracheostomy It is important not to place the tracheotomy above the 2nd tracheal ring, as inflammation may cause subglottic oedema , chondritis of the cricoid cartilage, and subglottic stenosis.

72. Special Considerations for the Obese Patient Obstructive airway pathology is commonly comorbid with obesity and can complicate both the initial procedure and decannulation plans Patients and family should be counseled accordingly. Removal of excessive subcutaneous tissue is advisable Maturation of the stoma with half-mattress sutures btn skin and trachea Extended-length tracheostomy tubes (e.g., Shiley XLT) are available to better match the patient’s anatomy

73. Special Considerations for Pediatric Tracheostomy Airway misadventures are potentially catastrophic consequences in children. Pediatric tracheostomy tubes ( Shiley #3 or smaller) do not have inner cannulas. Naso - and orogastric tubes are removed prior to tracheostomy A vertical skin incision may be preferred Repeated palpation to ensure midline dissection is paramount

74. Special Considerations for Pediatric Tracheostomy The thyroid isthmus is always divided so it does not obstruct the tract in case of accidental decannulation . Non-dissolvable monofilament traction sutures are placed lateral to the proposed tracheal incision to facilitate exposure; they are labeled LEFT and RIGHT, taped securely to the chest, and removed following successful 1 st tube change. Maturation of the stoma with half-mattress sutures btn skin and trachea using dissolvable suture. Flanges are securely tied around the neck using shoestring-style ties. the flange is not sutured to the skin,

75. Post operative care Maintain a multidisciplinary team that is ready to act / respond including emergency contact lines. Educate and communicate effectively to patients and care givers on; the indication, course, expected changes such as changes loss of voice reassure throughout as and when these changes occur educate the patient and caregivers to recognize and appropriately report any danger signs bleeding, excessive pain, swelling and noisy labored breathing.

76. Post operative care Monitor Airway, Breathing and Circulation by Monitor: Indications that the patient may have obstruction Noisy 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 Moniot for hypoxia and cardiovascular changes.  routine physical measurements such as Respiratory rate, Oxygen saturation every 30 minutes and the first 6 hours and one hourly after in next 48 hours.

77. Post operative care Maintain key equipment checklist on the patient bed side that should be reviewed every 12 hours to ensure that the following equipment is readily available, functional and team has the knowledge to use it; Suction equipment KY jelly Suction catheter Two back up TT (same size and one size smaller) Obturator (specifically used for initial tracheostomy placement present and readily available).  Normal saline and a non-distractable syringe for instilling saline or a proper humidification equipment is available and functioning correctly. Basic (Face masks, airway adjuncts, supraglottic airway devices) and advanced equipment (laryngoscopes and endotracheal tubes) should be readily available.

78. Tube and skin care: Ensure the TT is secured properly and in the correct position secured by straps and ties.  Keep the flange, tracheostomy dressing, ties, or straps clean and dry.  Change the dressing daily or as when it becomes wet or soiled with secretions  Check for any signs of skin breakdown or infection around the stoma.  Cuff Management: Monitor cuff pressure every 8 hours by palpating the cuff balloon or maintaining it within 20-25mmHg. Deflate the cuff as soon as possible when he patient no longer requires but no longer 48 hours Change the TT from cuffed to uncuffed when patient has adequate respiratory effort after de-cuffing.

79. Tracheostomy change Change is generally 7 POD.

80. Suction and Humidification Explain to the patient and consider analgesia Switch on the suction, select appropriate pressure. Determine the appropriate size of suction catheter: (Size of endotracheal or tracheostomy tube – 2) x 2 = Correct French gauge Wash hands and wear appropriate equipment, Consider preoxygenation, Prepare the device and emergency kit, do not suction for longer 10 seconds. Use sterile suction catheters and routinely replace them every 24 hours or at any time if contaminated or blocked by secretions Use appropriate pressures from as little as -80 mmHg to -300mmHg not greater than -150 mmHg (-20kPa). Do not suction deep; suction within the lumen of the tube and for not longer than 10 seconds.

81. Suction and Humidification Humidification: Ensure adequate humidification of inspired air to prevent airway drying and the formation of thick, difficult-to-clear secretions by; HME (heat moisture exchanger) monitor patency every 24 hrs Instill 2 to 4 drops (less than 2 ml) of sterile normal saline to the stoma before suction Encouraging the patient to drink, if the patient is able to drink; If UNABLE to drink independently, monitor hydration status and correct appropriately to help thin secretions.  Mobilize where need engage physiotherapist to minimise displacement Encourage the patient ambulate to enhance clearance Use of mucolytics (nebulized NS) Use fiber filters or bibs

82. Post-operative care Stoma Care: Clean the stoma and surrounding skin gently with a damp washcloth or cotton swab and sterile water and keep the stoma and surrounding skin are thoroughly dried after cleaning.  Check for any signs of skin breakdown or infection around the stoma.  Apply a dry dressing to the stoma if needed, especially if there is skin irritation or excessive secretions.  Regularly assess the stoma for signs of infection, such as redness, swelling, or drainage.  Apply skin barrier film if required and allow to dry. 

83. Post operative care Vocalization, communication and oral intake: Collaborate with the speech and language therapy (SLT) team to To assess communication and swallowing needs of the patients Train the patients and care givers to communicate using verbal and non-verbal communication methods such as providing a writing pad or agreed sign language Orient bedside staff should be familiar with tools and their use.

84. Postoperative care Chest X-ray Exclude pneumothorax Exclude surgical emphysema Check tube length and confirm tip position relative to carina Antibiotics may be required for a week postoperatively Communicate and educate Nursing staff should be informed how to use the stay sutures Nursing staff are informed about the correct length and size of the suction tube to avoid distal tracheal trauma and granulations distal to the tip of the tracheostomy tube Documentation

85. Discharge Educate the at least 2 responsible adult care givers : tube changing, the recognition and initial treatment of complications and basic life-support training. Try to link to support homes/ health care facilities for support Appropriate documentation

86. Discharge with patient in situ Issue a tracheostomy passport / discharge note that details about a patient’s tracheostomy and its history to other healthcare providers highlighting The reason for insertion Type and size of tracheostomy tube Any problems with the native upper airway The schedule for tube changing, including who will do this Plans for future reviews of the tracheostomy (when, who) Criteria for re-assessment for tube removal

87. Follow up- Safety Initiatives An emergency minimum set of equipment should accompany a tracheostomy patient at all times, including spare tubes, suction catheters and dressings Bedhead documentation should be displayed at all times providing immediately visible information including tube size and length, and existing upper airway abnormalities Emergency treatment algorithms should be provided for attending resuscitation teams

88. Complications Complication rates vary widely in the literature, ranging from 10% to 90%. Most of these events are minor and easily treatable, but catastrophic events do occur. In a survey of otolaryngologists, 55% of respondents reported experiencing at least a single catastrophic event during their careers. Although 15% of children with tracheotomies may die while still cannulated , tracheotomy-specific mortality is relatively rare, ranging from 0.5% to 3.6%

89. Complications Early account for 15%

90. Complications of Tracheostomy General Tube obstruction Accidental decannulation General complications of surgery and anaesthesia Death

91. COMPLICATIONS Early (Up to 1 week) Account for 15% Hemorrhage Wound infection Pneumothorax Tube obstruction False passage Apnoea Jugular vein occlusion Subcutaneous Emphysema infection General Tube obstruction Accidental decannulation General complications of surgery and anaesthesia Death

92. Early complications- Subcutaneous emphysema Air may be forced into the subcutaneous tissues during or shortly after tracheostomy. Factors predisposing to this complication include the following: Excessive coughing Use of an uncuffed tracheostomy tube Tight suturing of the wound around the tracheostomy tube Packing of the wound If the subcutaneous emphysema is severe, the wound should be opened and any packing removed.

93. Early complications- Accidental decannulation Patient factors that may predispose to displacement of the tube include the following: Obesity Excessive coughing Agitation Physical factors include the following: Incorrect tube selection (usually too short) Incorrect location of the opening into the trachea (usually too low) Creation of a false passage Loosened or inadequately tied tracheostomy tapes Use of bulky dressings under the neck flange

94. LATE COMPLICATIONS (63%) Bleeding Granulation Trachea-cutaneous fistula (allow 6–12 months before closure Tracheal, laryngeal, or subglottic stenosis Failure to decannulate Skin: Dermatitis and ulceration Mucous plugging Tracheitis Aspiration Psychological factors Social effects Aphonia and or speech delay Suprastomal collapse

95. Late complications- Granulation tissue Considered to be a late complication or sequela of tracheostomy, variably reported as occurring in 3-80% of cases May lead to bleeding, difficult tube changes, delayed decannulation , and even completely obstruct the tracheostomy tube Factors believed to favor formation of granulation tissue include the following: Bacterial infection, Gastroesophageal reflux, Suture material, Powder from surgical gloves Treatment Topical treatments such as steroid creams, antibiotic ointments, and silver nitrate may be beneficial. Larger amounts of granulation tissue, particularly when obstructive, may require surgical excision, with or without the use of the laser.

96. Late complications- Tracheoinnominate fistula Rare, Usually occurs within the first 3 wks after tracheostomy May occur in patients of any age Predisposing factors include the following: Placing the tracheostomy low in the neck Aberrant course of the innominate artery such that it crosses the trachea at an abnormally high level Selection of an excessively long or curved tube, the tip of which may erode the trachea and the vessel wall deep to it Overextending the neck during the tracheostomy procedure Prolonged excessive pressure on the tracheal wall by an inflated cuff Tracheal infection

97. . Rupture of the innominate artery is usually heralded by a “sentinel bleed,” which may stop and be followed a few days later by a catastrophic hemorrhage. The patient coughs up bright red blood from the tracheostomy tube. If recognized, the cuff of the tracheostomy tube should immediately be overinflated suprasternal pressure applied in an attempt to control the hemorrhage emergency thoracotomy

98. Late complications- Tracheal Stenosis and Tracheomalacia Late complications due to over-inflation of the tracheostomy tube cuff with resultant necrosis of mucosal and ultimately the underlying cartilage rings Prevention requires careful monitoring of tracheostomy cuff pressures by nursing staff

99. Complications

100. Decision to Decannulate Removal of a tracheostomy leads to a significant change in the physiology of the upper airway. The dead space is doubled and airway resistance is trebled. With a longstanding tracheostomy, the child may have no memory of mouth and nose breathing and the new sensation may be distressing (‘ decannulation panic’).

101. Decannulation Decannulation may be considered when the original condition requiring tracheostomy has improved, Steps: Endoscopic assessment of the airway prior to definitive decannulation. Vocal cord mobility and Airway patency (stoma collapse, stenosis, granualation Exclude comorbidity and the need for further surgery. Pulmonary disease Cardiac disease Neurological disease

102. Great Ormond Street Protocol for Ward Decannulation Day Procedure 1 Admission, downsize to 3.0 tube 2 Block for 12 hr from 8 a.m. If successful, continue overnight for a further 12 hr 3 Decannulate , occlude stoma with adhesive tape and dressing. Observe on the ward 4 Observe off the ward 5 Discharge

103. Cincinnati Criteria for Decannulation Patient tolerates tracheotomy tube downsizing. Patient is able to use a tracheotomy cap for all waking hours. Patient successfully completes a 48-hour capping period while admitted to the hospital for observation. Direct laryngoscopy and bronchoscopy rules out any anomaly in the patient that would preclude decannulation . Patient completes a capped tracheotomy sleep study with favorable results (apnea hypopnea index <10, obstructive index <5, end tidal CO2 >50 mm Hg for less than 25% of sleep time)

104. References Scott-Brown’s Essential Otorhinolaryngology Head & Neck Surgery , 1 st edition Cummings Otolaryngology–Head and Neck surgery, 7 th edition. Scott-Brown’s Otorhinolaryngology Head and Neck Surgery, 8 th edition Operative Otolaryngology Head and Neck Surgery 3 rd edition , Eugene N. Myers, Carl H. Snyderman Atlas of HEAD & NECK SURGERY (2011), James I. Cohen, Gary L. Clayman https://tracheostomy.org.uk/healthcare-staff/basic-care/understanding-range-of-tubes Open access atlas of otolaryngology, head & neck operative surgery