Presentation (3) shshaiehdhdhxhshshsh.pptx

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1. BY DR. BANSARI AKBARI ENT RESIDENT

2. Tracheostomy is making an opening in the anterior wall of trachea and converting it into a stoma on the skin surface which leads into the tracheal lumen.

3. Functions of tracheostomy :- 1. Alternative pathway for breathing. 2. Improves alveolar ventilation. 3. Protects the airways. By using cuffed tube, tracheobronchial tree is protected against aspiration of: (a) Pharyngeal secretions.(b) B lood . 4. Permits removal of tracheobronchial secretions. 5. Intermittent positive pressure respiration (IPPR). If IPPR is required beyond 72 h, tracheostomy is superior to intubation. 6. To administer anaesthesia. In cases where endotra cheal intubation is difficult or impossible as in laryngopharyngeal growths or tris mus .

4. Indications ofTracheostomy •There are three main indications • A. Respiratory obstruction. • B. Retained secretions. • C. Respiratory insufficiency

5. A) Respiratory obstruction- 1.  Infections Acute  laryngo t racheobronchitis,acute   epiglottitis , diphtheria Ludwig’s  angina,p eritonsillar , r etropharyngeal  or  parapharyngeal  abscess, tongue abscess •2. Trauma : External injury of larynx and trachea ,Trauma due to  endoscopie especially infants and children,Fractures of mandible or maxillofacial injuries •3. Neoplasms - Benign and malignant neoplasms of larynx, pharynx, upper trachea, tongue and thyroid •4. Foreign body larynx •5. Oedema larynx •6. Bilateral abductor paralysis •7. Congenital anomalies - Laryngeal web, cysts,  tracheo e s ophageal  fistula ,  Bilateral  choanal  atresia

6. B.  Retained secreations - •1. Inability to cough •Coma of any cause, e.g. head injuries, cerebrovascular accidents, narcotic overdose •Paralysis of respiratory muscles, e.g. spinal injuries, polio, Guillain-Barre syndrome, myasthenia  gravis •Spasm of respiratory muscles, tetanus, eclampsia, strychnine poisoning •2. Painful cough •3. Aspiration of pharyngeal  secreations .

7. C.  Respiratory insufficiency- •Chronic lung conditions,  like emphysema,  chronicbronchitis , bronchiectasis, atelectasis

8. Types of tracheostomy :- Emergency tracheostomy Elective or tranquil tracheostomy Permanent tracheostomy Percutaneous dilatational tracheostomy Mini tracheostomy ( cricothyroidotomy )

9. 1) EMERGENCY TRACHEOSTOM Y. It is employed when airway obstruction is complete or almost complete and there is an urgent need to establish the airway. 2) ELECTIVE TRACHEOSTOMY - This is a planned, unhur rie d procedure. It is of two types:(a) Therapeutic - to relieve respiratory obstruction, remove tracheobronchial secretions or give assisted ventila tion . ( b) Prophylactic, to guard against anticipated respiratory obstruction or aspiration of blood or pharyngeal se creations such as in extensive surgery of tongue, floor of mouth, mandibular resection . Elective tracheostomy is often temporary and is closed when indication is over .

10. 3. PERMANENT TRACHEOSTOMY. –is an elective procedure carried out as part of surgical procedure involving removal of larynx ,such as laryngectomy or pharyngolaryngectomy . It is also created in laryngeal diversion procedures used to prevent aspiration . In laryngectomy or laryngopharyngectomy , lower tra cheal stump is brought to surface and stitched to the skin.

11. Based on level of trachea - High tracheostomy- A bove  the level of thyroid isthmus (done at level of 1 st tracheal ring) It can cause perichondritis  of the cricoid cartilage and  subglottic stenosis and is always avoided. Only indication : carcinoma of larynx  because in such cases, total larynx anyway would  ultimately  be removed and a fresh tracheostome  made in a clean area lower down . Mid tracheostomy - preferred one Done through  II or III rings and would entail division of the thyroid isthmus or its retraction upwards or downwards  toexpose  this part of trachea Low tracheostomy- below the level of isthmus. Trachea is deep at this level and close to several large vessels; also there are difficulties with Tra cheostomy  tube which impinges on  suprasternal  notch.

12. Technique- Whenever possible, endotracheal intubation should be done before tracheostomy. This is specially important in infants and children  • Position supine with a pillow under the shoulders so that neck is extended. • Anaesthesia •No anaesthesia  in unconscious patients/ emergency procedure. • In conscious patients, 1-2% lignocaine with epinephrine is infiltrated in line of incision and area of dissection . •GA with intubation+/-

13. Steps of procedure - 1) A vertical  incisio n in the midline of neck, extending from cricoid  Cartilage to just above the sternal notch. This is the most favoured  incision and can be  used in emergency and  elective procedures . It gives rapid access with minimum of bleeding and tissue dissection . A transverse incision, 5 cm long, made two fingers' breadth above the sternal notch can be used in elective procedures. It has the advantage of a cosmeti cally better scar .

14. 2. After incision, tissues are dissected in the midline. Dilated veins are either displaced or ligated . 3. Strap muscles are separated in the midline and retract- ed laterally. 4. Thyroid isthmus is displaced upwards or divided be-tween the clamps, and suture ligated. 5. A few drops of 4% lignocaine are injected into the tra chea to suppress cough when trachea is incised. 6. Trachea is fixed with a hook and opened with a vertical incision in the region of third and fourth or third and second rings. This is then converted into a circular opening. The first tracheal ring is never divided as peri chondritis of cricoid cartilage with stenosis can result. Tracheostomy tube of appropriate size is inserted and secured by tape s.

15. Complications - A . Immediate ( at the time of operation): • 1. Haemorrhage. • 2. Apnoea. This follows opening of trachea in  patient who had  prolonged respiratory   obstruction.  This is due to sudden washing out of CO2 whic h was  acting as a respiratory stimulus.  • 3. Pneumothorax due to injury to apical pleura. • 4. Injury to recurrent laryngeal nerves. • 5. Aspiration of blood. • 6. Injury to oesophagus - This can occur with tip of knife while incising the  trachea and  may result in  tracheoesophageal  fistula.

16. B. Intermediate -( during first few hours or days): • 1. Bleeding, reactionary or secondary. • 2. Displacement of tube. • 3. Blocking of tube. • 4. Subcutaneous emphysema. • 5.  Tracheitis  and  tracheobronchitis  with crusting  intrachea . • 6. Atelectasis and lung abscess. • 7. Local wound infection and granulations.

17. • C. Late ( with prolonged use of tube for weeks and months): • 1. Haemorrhage, due to erosion of major vessel. • 2. Laryngeal stenosis, due to  perichondritis  of cricoid cartilage. • 3. Tracheal stenosis, due to tracheal ulceration and infection. • 4  Tracheoesophageal  fistula, due to prolonged use of cuffed tube or  erosio n of trachea by the tip of tracheostomy tube. • 5. Problems of  decannulation . Seen commonly in infants and children. • 6. Persistent  tracheocutaneous  fistula. • 7. Problems of tracheostomy scar. Keloid or unsightly scar. • 8. Corrosion of tracheostomy tube and aspiration of its fragments into the  tracheobronchial  tree.

18. POSTOPERATIVE CARE 1) Constant supervision. After tracheostomy, constant supervision of the patient for bleeding, displacement or blocking of tube and removal of secretions is essential. 2 ) Suction - Depending on the amount of secretion, suc tion may be required every 2hourly or so. 3 ) Prevention of crusting and tracheitis . This is achieved by(a) Proper humidification, by use of humidifier . b) If crusting occurs, a few drops of normal or hypo tonic saline or RL instilled into trachea to loosen crusts . 4) Care of tracheostomy tube. Inner cannula should beremoved and cleaned as and when indicated for the first 3 days. Outer tube, unless blocked or displaced, should not be removed for 3-4 days to allow a track to be formed when tube placement will become easy. After 3-4 days, outer tube can be removed and cleaned every day. If cuffed tube is used, it should be periodically deflated to prevent pressure necrosis or dilatation of trachea . Decannulation . Tracheostomy tube should not be kept longer than necessary. Prolonged use of tube leads to tracheobronchial infections, tracheal ulceration, granula tions , stenosis and unsightly scars . To decannulate a patient, tracheostomy tube is plugged and the patient closely observed. If the patient can tolerate it for 24 h, tube can be safely removed.

19. CRICOTHYROTOMY OR LARYNGOTOMY OR MINI TRACHEOSTOMY. In this emergent procedure ,opening is made through cricothyroid membrane . Patient's head and neck is extended, lower border of thyroid cartilage and cricoid ring are identified. Skin in this area is incised vertically and then cricothyroid membrane cut with transverse incision. This space can be kept open with small tracheostomy tube or by inserting any hollow tube to maintain airway . It is followed by tracheostomy which is done at the earliest to complications such as perichondritis , subglottic edema and laryngeal stenosis .

20. Different types of tubes -