Percutaneous tracheostomy

1. Dr Nor Hidayah Zainool Abidin Supervisor: Dr Noryani Percutaneous Tracheostomy 11/3/2015 prepared by Anor Hidayah

2. OUTLINES History of Tracheostomy Definitions Indications Complications Tracheostomy Tubes & Components procedure Inner Cannula & Stoma Site Care Flange and Stay Suture Care Suctioning Cuffed Tracheostomy Care Changing a Tracheostomy Tube Tracheostomy weaning and removal 11/3/2015 prepared by Anor Hidayah

3. History of tracheostomy Tracheotomy was first depicted on  Egyptian   artifacts in 3600 BC It was described in the  Rigveda , a  Sanskrit  text, circa 2000 BC 11/3/2015 prepared by Anor Hidayah

4. Ibnu Sina  (980-1037) D escribed tracheal intubation in  The Canon of Medicine  in order to facilitate breathing . Ibn Zuhr  (1091–1161) in the 12th century The first correct description of the tracheotomy operation for treatment of asphyxiation 11/3/2015 prepared by Anor Hidayah

5. Tracheotomies were used in the early 1800's for airway inflammation in children due to Diphtheria. The first documented successful tracheotomy performed on a child was reported in 1808. 11/3/2015 prepared by Anor Hidayah

6. In 1965, McDonald and Stocks describe the use of intubation and respiratory support in neonate. Many more children surviving with tracheostomies due to subglottic stenosis 11/3/2015 prepared by Anor Hidayah

7. The percutaneous dilatational tracheostomy (PDT) introduced by Ciaglia   et al . in 1985, which involves progressive dilatation with blunt-tipped dilators, is the most frequently used and evaluated in the literature. In 1989, Schachner   et al . introduced a rapid PT technique, Rapitrac , which did not get considerable acceptance because of complications associated with, and reservations towards, the sharp edges of the dilating forceps. 11/3/2015 prepared by Anor Hidayah

8. Basic tracheal anatomy Trachea lies midline of the neck Extending from cricoid cartilage (C6) superiorly To the tracheal bifurcation (level of sternal angle T5) Comprises of 16 – 20 C shaped cartilage ring Length about 10 - 12cm 11/3/2015 prepared by Anor Hidayah

9. Definitions W ord tracheostomy is derived from two words meaning “I cut trachea” in Greek 11/3/2015 prepared by Anor Hidayah

10. Tracheostomy Tube Components 11/3/2015 prepared by Anor Hidayah

11. Indications of Tracheostomy Acute upper airway obstruction Chronic upper airway obstruction Injury or post head and neck surgery  To obtain and maintain a patent airway when compromised To facilitate weaning from mechanical ventilation To prevent and /or treat retained tracheobronchial secretions To reduce the risk of pulmonary aspiration 11/3/2015 prepared by Anor Hidayah

12. Timing of Tracheostomy Early tracheostomy was associated : Similar survival at one month Improve short term clinical outcome early tracheostomy did not change any outcomes at one year 11/3/2015 prepared by Anor Hidayah

13. Multicenter trial (419 patients) that randomly early (mean 7 days) VS late tracheostomy (mean 14 days) 11/3/2015 prepared by Anor Hidayah

14. The timing of tracheostomy did not appear to impact 30 day or 2 year mortality or ICU length of stay Does not appear to impact the rate of nosocomial pneumonia following tracheostomy 11/3/2015 prepared by Anor Hidayah

15. Decision for tracheostomy Mechanical ventilation anticipated to last between 10 and 21 days After an initial period of stabilization on the ventilator (generally, within 3–7 days) Daily assessment for ventilatory weaning need for continued intubation readiness to wean When apparent that the patient will require prolonged ventilator assistance Individualized according to the clinical circumstances and the patient's preference The decision left to the attending Specialist/ Intensivist 11/3/2015 prepared by Anor Hidayah

16. ● Factors that increase the likelihood poor prehospitalization functional status poor nutritional status poor pulmonary function advanced age nosocomial pneumonia administration of aerosol treatments a witnessed aspiration event reintubation 11/3/2015 prepared by Anor Hidayah

17. Advantages of tracheostomy Reduced laryngeal damage Reduced laryngeal stenosis Less voice damage Better secretion removal with suctioning Lower incidence of tube obstruction Less oral injury (tongue, teeth, palate) Improved patient comfort Less sedation/analgesia required Better oral hygiene Enhance nursing care 11/3/2015 prepared by Anor Hidayah

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19. Improved ability to communicate  lip reading Preservation of glottic competence Less aspiration risk Better preserved swallowing,  earlier oral feeding Lower resistance to gas flow Less tube dead space  better weaning from mechanical ventilation Ease of reinsertion if displaced Allows less skilled care Advantages of tracheostomy 11/3/2015 prepared by Anor Hidayah

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21. Disadvantages of Tracheostomy Tracheal complications Aggressive procedure Risk of stomal infection Esthetic sequelae Bleeding Psychological trauma Organizational difficulties Increased risk in ward 11/3/2015 prepared by Anor Hidayah

22. Nosocomial pneumonia A retrospective study of 137 patients who underwent tracheostomy significant bacterial colonization (>100,000  cfu /mL) fever on the day of tracheostomy the need for sedation beyond 24 hours after tracheostomy There was a 26% incidence of pneumonia in the study population, occurring at a mean of 9 days after the tracheostomy. Nosocomial pneumonia 11/3/2015 prepared by Anor Hidayah

23. Study reports – Nosocomial infectio n Prospective cohort study of over 800 mechanically ventilated Case-control study of 354 patients who were mechanically ventilated for more than seven days The timing of tracheostomy (early versus late) does not appear to impact the rate of nosocomial pneumonia following tracheostomy 11/3/2015 prepared by Anor Hidayah

24. Associated Clinical Complications 11/3/2015 prepared by Anor Hidayah

25. Advantages of Percutaneous Dilatation Technique Simple technique C an be done at the bedside in ICU Reduces the risks associated with the possible need to transfer a critically ill patient out of the ICU D oes not require operating theatre  less expensive in terms of human and material resources Possibly less waiting time for patient Early tracheostomy Associated with less peristomal bleeding 11/3/2015 prepared by Anor Hidayah

26. Contraindications Age < 15 yrs Gross distortion of the neck due to haematoma, tumor , thyromegaly or scarring from previous neck surgery Un-correctable bleeding diathesis Obese , short or bull neck that obscures the anatomical landmarks in the neck Inability to extend the neck because of cervical fusion, rheumatoid arthritis, or other cervical spine instability 11/3/2015 prepared by Anor Hidayah

27. Percutaneous Insertion Procedure to be done in ICU 11/3/2015 prepared by Anor Hidayah

28. P atient preparation Take GSH, Latest FBC, BUSE and Coagulation profile Withhold anticoagulants Draw bedside curtains The procedure is explained in full to the patient and/or significant others. Consent obtained. Record in the medical notes. Fast patient for 6 hours Discontinue deeding 6 hours prior to the procedure A spirate the nasogastric tube again immediately prior to the procedure. Prepare all required equipment Proper position the patient supine Ensure the head of the bed area is free from obstruction 11/3/2015 prepared by Anor Hidayah

29. Patient preparation To facilitate the procedure the patient is administered a combination of Propofol and +/- an opioid via an IV infusion . Full monitoring is instituted, and ventilatory parameters altered Fio2 increased to 100 % Tidal volume increased to compensate for airleak around deflated ETT cuff A djust peak airway pressure alarm to allow for the raised pressures during ETT manipulation. The patient’s eyes are taped closed 11/3/2015 prepared by Anor Hidayah

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33. Inner Cannula & Stoma Site Care 11/3/2015 prepared by Anor Hidayah

34. Securing Tracheostomy Ties Velcro Ties Bring longer piece ( B) around neck and underneath section ( A) Leave 1 finger space between ties and patients neck. 11/3/2015 prepared by Anor Hidayah

35. Securing Tracheostomy Ties Cotton Ties Bring one long end around the neck and tie to short end in single knot. Repeat on the other side ensuring that 1 finger space is remaining between the ties and the patient’s neck Tracheostomy ties  changed when wet or soiled and routinely at least once a week . 2 person involve 11/3/2015 prepared by Anor Hidayah

36. Flange and Stay Suture Care Most surgically inserted tracheostomy tubes and occasionally percutaneous tubes are secured in position with silk sutures Removal time: at the time of the first tube change i.e . approximately 5 - 7 days post insertion Observe suture sites for signs of infection and treat accordingly 11/3/2015 prepared by Anor Hidayah

37. Suctioning to remove endotracheal secretions  maintain patent airway as needed  pulmonary secretions Selecting appropriate catheter size. ensure the suction catheter is < /= 1/2 the internal diameter of tracheostomy tube . (Tube size x 3) / 2 8 x 3 /2 = 12 11/3/2015 prepared by Anor Hidayah

38. Suctioning Procedure vacuum pressure is > 20Kpa’s / 100- 150mmHg Ventilated patient  hyper-oxygenated ( i.e. increase FiO2 to 100%) for > 30 seconds prior to suctioning, to minimise hypoxia during and after the suctioning event. Maintaining sterility Insert the suction catheter to approximately 15cm without applying suctioning Smoothly withdraw catheter from the airway applying continuous suction. = / < 15secs . 3 times per-session. The Nurse must undertake the following: Explain the procedure to the patient Perform hand hygiene and apply sterile gloves Apply apron and fluid shield mask 11/3/2015 prepared by Anor Hidayah

39. Cuffed Tracheostomy Care Indications for Cuffed Tube Use: The patient required mechanically ventilation Less than 24/48hours post insertion. high risk aspiration from gastric or oral secretions Unstable condition Stabilises the tracheostomy tube in the trachea . Indications for cuff re-inflation: Desaturation (must check inner cannula first) Respiratory or cardiovascular distress Constant oral drooling No swallows observed 11/3/2015 prepared by Anor Hidayah

40. Cuff Pressure Measurement An underinflated cuff i.e. pressure too low, can lead to inadequate seal around the cuff increasing risk of aspiration causing loss of positive pressure where the patient is ventilated The recommended cuff pressure  25cmH2O Cuff pressures should not exceed 32cmH20. If leak present  increase tube size Palpation of the external balloon is not an adequate method of pressure estimation 11/3/2015 prepared by Anor Hidayah

41. C uff deflation procedure: Explain procedure to the patients. Suction oropharynx to remove any secretions With the assistance of a 2nd nurse , suction via tracheostomy tube while the second nurse slowly aspirates air from air inlet port. Once deflated, expiratory noises may be heard as air passes up around the tracheostomy tube  reassure the patient that this is normal and will settle   11/3/2015 prepared by Anor Hidayah

42. Stoma Care At least once a day or more frequently  reduce the risk of skin irritation and peri-stomal infection . Stoma Cleaning Procedure Remove and dispose of any soiled dressings Using aseptic technique, clean the stoma site using gauze and normal saline apply a skin barrier cream on patient’s skin is excoriated  i.e . soft paraffin 11/3/2015 prepared by Anor Hidayah

43. Changing a Tracheostomy Tube The recommended minimum time before the first tube change or decannulation is 5-7days following surgical tracheostomy 7- 10days following percutaneous tracheostomy. Rationale: To enable the tract to become established and minimise risk of occlusion . 11/3/2015 prepared by Anor Hidayah

44. Document the type of tube, size , the date it was performed and last changed Ventilated patient  fast patient for 4 hours before tube changed. Emergency equipment 11/3/2015 prepared by Anor Hidayah

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50. Tracheostomy weaning and removal M edically stable The primary indication for tracheostomy has been resolved. Spontaneously breathing off the ventilator for 24-48 hours . E ffective cough reflex Free from serious bronchopulmonary infection Minimal pulmonary secretions (suctioning < 4-6 hourly) O2 Therapy is less that 40% (FiO2 < .4) Successfully tolerating cuff deflation. A dequate nutritional intake 11/3/2015 prepared by Anor Hidayah

51. Weaning Procedure 11/3/2015 prepared by Anor Hidayah

52. Stage 1- Cuff Deflation This is usually carried out 24 – 48 hrs after tube insertion Why? To assess if patient can manage their own airway and manage their own oral secretions despite alteration in tracheal airflow . 11/3/2015 prepared by Anor Hidayah

53. Stage 2- Downsizing Usually undertaken 5-7 days after the original tube insertion Rationale : Airflow is increased either around or through the tracheostomy tube and this reduces the work of breathing for the patient . 11/3/2015 prepared by Anor Hidayah

54. Stage 3- Speaking valve at least 48-72 hours post tracheostomy, prior to the initial placement allowing air in through the valve on inspiration, but closing on expiration Where speaking valve is tolerated the patient and valve: Ensure Cuff is deflated prior to applying / using the speaking valve Do Not Leave the Speaking Valve on overnight unless specifically ordered 11/3/2015 prepared by Anor Hidayah

55. Stage 4 - Decannulation Decannulation Cap  blocks the tracheostomy tube  patient breathe through nose and mouth Rationale The use of a decannulation cap increases patient confidence and gradually increases respiratory muscle strength and avoids over exertion. Capping is tolerated for at least 24 consecutive hours 11/3/2015 prepared by Anor Hidayah

56. Stage 5 Decannulation ( Removal of the Tracheostomy Tube ) INDICATION The decision to decannulation / remove tube is based on the ability of the patient to maintain their own airway without the tracheostomy tube insitu . 11/3/2015 prepared by Anor Hidayah

57. Stage 5 Decannulation Predictors Patient has successfully completed the latter 4 stages of weaning. ( not all patients will go through each stage of the process ) Patient is able to expectorate pulmonary secretions effectively Patient is not myopathic 11/3/2015 prepared by Anor Hidayah