PERCUTANEOUS TRACHEOSTOMY- -NOV[1].pptx

Various information related to procedure of traceostomy

1. Tracheostomy –state of the art Dr. Rajesh Chawla MD, FCCM,FCCP,EDIC,EDARM Senior Consultant Respiratory and Critical Care Medicine , Indraprastha Apollo Hospitals, New Delhi Past President, National College of Chest Physicians Past Chancellor, Indian College of Critical Care Medicine Past President, Indian Society of Critical Care Medicine

2. Word tracheostomy is derived from two words meaning “I cut trachea” in Greek prepared by Anor Hidayah Tracheotomy Incision made below the cricoid cartilage through the 2nd – 4th tracheal ring Tracheostomy The opening or stoma made by this incision. Tracheostomy Tube Artificial airway inserted into the trachea during tracheotomy.

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

4. 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

5. Indications of Emergency Tracheostomy Patients with acute upper airway obstruction who failed intubation with an endotracheal tube or in whom an endotracheal tube cannot be placed Patients with select fractures of the oropharynx, face, and neck Patients with penetrating laryngeal trauma.

6. Indications of Tracheostomy Patients who have undergone, or are anticipated to require, prolonged mechanical ventilation and have difficulty weaning off the ventilator Patients with poor airway protection who need ventilation and/or secretion control ( eg , neuromuscular disorders associated with bulbar weakness or recurrent aspiration).  To prevent and /or treat retained tracheobronchial secretions Patients with severe subglottic stenosis unresponsive to conventional therapies. Patients with severe vocal cord paralysis who are refractory to other therapies. Post Surgical Tracheostomy

7. Contraindications C ellulitis of the anterior neck, absence of a cervical trachea ( eg , due to prior resection) Unstable patient Uncorrectable bleeding diathesis Gross distortion of the neck due to haematoma , tumor, thyromegaly or scarring from previous neck surgery A high-riding innominate or thyroid internal mammary artery

8. Contraindications High vent support Fio2 more than o.6 and PEEP above 12 High vasopressor support Obese, short or bull neck that obscures the anatomic landmarks in the neck Inability to extend the neck - cervical fusion, rheumatoid arthritis, or other cervical spine instability

9. Advantages of Tracheostomy Reduced work of breathing Improved comfort and reduced need for sedation Faciltation of weaning Better secretion removal with suctioning Lower incidence of tube obstruction Less oral injury (tongue, teeth, palate) Reduced laryngeal damage Reduced laryngeal stenosis Less voice damag Improved patient comfort Less sedation/analgesia required Better oral hygiene Enhance nursing care

10. Disadvantages of Tracheostomy Tracheal complications Aggressive procedure Risk of stomal infection Bleeding Psychological trauma Organizational difficulties Increased risk in ward

11. Decide Timing The decision about tracheostomy requires anticipation of the duration of expected mechanical ventilation and the expected benefits and risks of the procedure. Time of PCT could be 7–14 days of intubation or less than 7 days for anticipated prolonged ventilation

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 < 2 weeks Early > 2 weeks Late

13. O observational series R andomized trials M eta- analyses terms of mortality M echanical ventilation days length of stay 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 Crit Care Med. 2023;51(2):310. Epub 2022 Dec 7. 

14. Tracheostomy is considered to be an aerosol-generating procedure. T he later timing of tracheostomy may be a justifiable consideration in this population, The risk of infectious transmission is less of a concern later in the course 14 TO 21 DAYS Covid 19

15. Types of Tracheostomy Surgical Percutaneous Tracheostomy

16. PCT vs ST A meta-analysis of 22 studies comparing PT and ST No significant differences in mortality and intraoperative or post-operative bleeding risk. There was a significantly lower rate of infection (pooled odds ratio 0.20 P≤0.0001) with PCT Shorter procedure time (pooled OR −1.7 to 0.7, P≤0.001) with PT compared to ST (66).

17. Surgical Tracheostomy A 2–3 cm long incision is made in the anterior neck midway between the cricoid cartilage and the sternal notch The skin and platysma are dissected Strap muscles are then retracted laterally to expose the thyroid isthmus After adequate hemostasis is achieved, a cricoid hook or lateral stay sutures are used as needed to expose the trachea

18. Surgical Tracheostomy A small opening is made on the trachea. Often a bjork flap is created, where part of a tracheal cartilage is incised, folded and sutured to maintain patency of the stoma. The tracheostomy tube is then inserted through this stoma

19. Techniques AGriggs forceps to dilate the stoma over a guidewire and then extended to dilate the stoma. Fantoni et al., where after introduction of a guidewire in the anterior tracheal wall, the dilator and the tracheostomy tube are pulled through the larynx in a retrograde fashion Ciaglia Blue Rhino Portex Ultraperc Single Stage Dilator Technique

20. Percutaneous Dilational Tracheostomy - Techniques The serial dilator technique was introduced where sequentially larger dilators were used to create a stoma.

21. Advantages of Percutaneous single stage Dilatation Technique Simple technique Can 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 Does not require operating theatre less expensive in terms of human and material resources Possibly less waiting time for patient Associated with less peristomal bleeding

22. Percutaneous Tracheostomy Prepare For The Procedure A PCT set as per the type decided by the physician A bronchoscope and its attachments/Ultrasound machine Continuous monitoring of ECG, blood pressure, and oximetry Functioning intravenous access A sterile setup with enough sterile linen and instruments

23. Prepare For The Procedure A crash cart with a laryngoscope and endotracheal tubes and emergency drugs Suction equipment Medications 1% Xylocaine with epinephrine Sedating and paralyzing agents

24. Form Your Team The operating physician. One physician -managing the upper airway and bronchoscope, manipulates the tube to allow PCT. The paramedical staff/technician who assists with the bronchoscope and handling of the endotracheal tube. Another paramedical/medical staff monitoring the vitals and administering medication.

25. Types of tubes Cuffed or Uncuffed tube Fenestrated tube or nonfenestrated tube With or without inner cannula With subglottic aspiration

26. Patient Preparation Withhold anticoagulants- when 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 Aspirate the nasogastric tube again immediately prior to the procedure. Prepare all required equipment

27. Preparation- check the equipment Check the tube after inflation of ballon Check the dilator Check the introducer and tracheostomy

28. Patient Preparation –sedation and paralysis To facilitate the procedure the patient is administered a combination of Propofol and +/- an opioid and neuromuscular agent via an IV infusion. Full monitoring is instituted

29. Patient Preparation - Vent Settings Fio2 increased to 100% Tidal volume increased to compensate for airleak around deflated ETT cuff Adjust peak airway pressure alarm to allow for the raised pressures during ETT manipulation. The patient’s eyes are taped closed

30. Positioning Patient should be supine Put a towel below the shoulder and extend the neck Mark the landmark points

31. PCT - Procedure This enhances the distance between the sternal notch and the cricoid cartilage allowing easier access to trachea. The tracheal rings are palpated to identify the sternal notch and the cricoid cartilage.

32. PCT - Procedure Once the landmarks ( sternal notch, tracheal rings and cricoid cartilage) are identified The anterior neck area is cleaned and the surface is covered with sterile drape. If the cricoid cartilage or tracheal rings cannot be palpated, we prefer to avoid the percutaneous technique.

33. Role of Ultrasound In PT PT can be advantageous especially in select patient groups, such as those who are morbidly obese or have difficult neck anatomy Easy identification of pretracheal vascular structures that might pose a hemorrhage risk during PT It can also provide an estimate of skin to trachea distance, especially in obese population Portable ultrasound before PT to identify the tracheal rings, thyroid isthmus, neighboring blood vessels may help provide a safe location for needle insertion

34. Role of Bronchoscopy Procedure duration was shorter when bronchoscopy is used (16 vs. 45 mins, Safe tracheostomy tube placement was possible in the absence of bronchoscopic guidance by ensuring free mobility of the guide wire at each step.

35. Ultrasound Guided PDT Compared To Bronchoscopy No significant difference in complication rate No significant difference procedural duration

36. Procedure Identify the 1st , 2nd tracheal rings and the cricoid cartilage are with indentation from outside and by visualization through the bronchoscope.

37. Preparation A 1.5- 2cm incision is made in midline. With help of curved Kelly forceps and blunt dissection the trachea is slowly approached.

38. Preparation Introduce needle with canula with tip directing Caudally bettter under FOB guidence .

39. Procedure A guidewire is inserted through the needle and the needle is removed.

40. A pre dilator is then inserted over the guidewire Followed by a curved, tapering dilator is inserted to dilate the stoma.

41. Once the stoma is adequately dilated, tracheostomy tube is loaded onto a introducer is inserted over the guidewire into the trachea

42. Bronchoscope is then removed from the ETT Inserted through the tracheostomy tube to confirm placement by visualizing the trachea or the carina. The distal end of the tracheostomy tube should be at least 1 inch or more proximal to the main carina.

43. Confirmation Chest auscultation Capnography Fiberbronchoscopy Tidal volume return on ventilator graphics

44. Percutaneous Insertion Procedure to be done in ICU Landmark Needle i nject i on Guidewire insertion I ntroduc e r Dilatation Trachy tube insertion

45. Surgicel Absorbable hemostat Oxidized regenerated cellulose To control small bleeding

46. Securing Tracheostomy Ties Velcro Ties Bring longer piece (B) around neck and underneath section (A) Leave 1 finger space between ties and patients neck. Prepared by Anor Hidayah

47. 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

48. Suture or No Suture In One Large Series Of 1,175 Tracheotomies, Accidental Decannulation Was Not Found To Be Associated With Suture Placement Use Of Outer Flange Security Sutures To Anchor The Tracheostomy Tube Was Associated With Lower Incidence Of Postoperative Bleeding

49. Associated Clinical Complications Immediate : Haemorrhage Loss of airway Pneumothorax Pneumomediastinum Accidental displacement of the tube Cardiac or resiratory decompensation In t erme d iate: Tube occlusion by secretions and/or blood Infection Cuff over/under inflation Late: Tracheal ulceration Tracheo-cutaneous fistula Granulation tissue (skin/tracheal) Tracheal stenosis Scar formation

50. Postoperative Care of The Tracheostomy Tube Wound and dressing care Daily examination of the stoma is needed to identify infections or excoriations of the skin. Keep the wound clean and free of blood and secretions, especially in the immediate posttracheostomy period.

51. Postoperative Care of The Tracheostomy Tube Dressing changes should be performed at least twice a day and when the dressings are soiled. When changing dressings and tapes, special care is needed to avoid accidental dislodgement of the tracheostomy tube. The inner cannula if used is changed daily or more frequently if necessary

52. Humidification Humidification of inspired gases prevents obstruction of the tube by inspissated secretions and maintains mucociliary clearance and cough reflex. Heat and moisture exchangers are preferred over heated humidifiers.

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

54. 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

55. To help maintain a patent airway To prevent infection To maintain skin integrity To help prevent tube displacement O b jective Inner cannula must be checked at least every 4hrs Stoma site must be checked at least daily or when attending cannula. Site must be kept clean and dry Ties: ensure they are clean and dry Frequency Inner Cannula & Stoma Site Care

56. 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 → 20 to 30cmH2O Cuff pressures should not exceed 32cmH20. If leak present → increase tube size Prepared by Anor Hidayah Palpation of the external balloon is not an adequate method of pressure estimation

57. 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. Changed every 28-30 days For weaning purposes i.e. downsizing, change to cuff less or fenestrated. Elective In d ications Tube dislodgement or accidental removal Tube obstruction (decreased risk when using double lumen tubes). Emerg e ncy Elective

58. 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 1st Tube change Must always be carried out by a doctor The track from the skin to the trachea may not be well formed Subsequent tube changes Registered competent nurse

59. Nutrition The patient must be consistently alert and able to follow complex commands. Adequate cough and swallowing reflexes. Adequate oral motor strength. A significant respiratory reserve. Assess swallowing function. Oral feeding is done under supervision of a caregiver and carefully assessed for aspiration or regurgitation.

60. Tracheostomy Weaning And Removal Medically stable The primary indication for tracheostomy has been resolved. Spontaneously breathing off the ventilator for 24-48 hours. Effective 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. Adequate nutritional intake

61. Training And Competency Perioperative and late complication rates were significantly reduced after the first 20 patients. Practice on mannequins or animal model during initial training can improve the skills and minimize complications

62. Conclusions 2 methods of Tracheostomy – surgical open Tracheostomy and percutaneous tracheostomy Percutaneous tracheostomy offer many benefits and a good alternative Timing of tracheostomy does not have clear association with better outcome but its clearly have many benefit in term of patient comfort and nursing care

63. Conclusions Percutaneous tracheostomy does not have clear association with nosocomial pneumonia Tracheostomy care knowledge and skills is important for both doctors and nurses

64. Thank you for your kind attention