Tracheostomy

A Tracheostomy is a medical procedure either temporary or permanent that involves creating an opening in the neck in order to place a tube into a person's windpipe.

1. TRACHEOSTOMY Dr.HIMANSHU SONI Fellow in Head and Neck Oncology - FHNO Fellow in Craniomaxillofacial Trauma – AOMSI Oral and Maxillofacial Surgeon

2. Contents Introduction History Indications & contraindications for Tracheostomy Armamentarium & Surgical anatomy Surgical/open tracheostomy Tracheostomy care & maintenance Complications Percutaneous tracheostomy References

3. Introduction Trachea is a conduit b/w the upper airway and the lungs, It delivers moist warm air, expels CO2 & secretions from the R S. Blockage at any point along this conduit can be fatal, surgical creation of an opening into the trachea is the principle way of securing the airway .

4. TRACHEOTOMY Surgical procedure in which an opening is made in the anterior wall of the trachea to establish an airway. Often temporary and reversible. Hiester 1718 TRACHEOSTOMY( tomos = cut , stoma=mouth) Surgical creation of an opening into the trachea through the neck with the trachea being brought into continuity with the skin. Most often, not always permanent. - Negus 1938

5. History 2000 BC :Rig Veda 400 BC: Hippocrates condemned tracheostomy, citing threat to carotid arteries. Hierronymus , Fabricus and Habicot provided the first technical descriptions of surgical procedure. 1546 : first successful tracheostomy Antonius Mvsa Brasavola ,

6. 1921: Jackson defined and refined surgical airway management technique 1955: Percutaneous tracheostomy was described by Shelden, 1969: Toy and Weinstein described a PT using the guide wire approach of Seldinger. 1985 Ciaglia et al described PDT.

7. Functions of tracheostomy Alternative pathway for breathing : circumvents obstruction in upper airway Improves alveolar ventilation :↓ ses dead space & resistance to airflow Protects airway : against aspiration Permits removal of tracheobronchial secreations Intermittent positive pressure respiration : if >72hrs better than intubation

8. Indications 1.Acute upper airway obstruction 2. Potential upper airway obstruction 3. Protection of the lower airway 4. Patients requiring artificial respiration . Bailey &Love’s short practice of surgery

9. Absolute indications for Tracheostomy, for conditions other than impending respiratory obstruction, include (IPPV): When injuries are severe enough to cause hypercarbia and/or hypoxemia from the outset- flail chest, lung contusion or aspiration. Control of cerebral oedema (by controlling blood gases) in severe head injuries Rowe & Williams Indications

10. Indications Major laryngeal trauma Inability to intubate or perform needle cricothyrotomy in pediatric pt Facilitation of management of cervical spine injury or oncologic ressection of head & neck. Laryngeal foreign body or pathology (e.g., tumor) prohibiting cricothyrotomy Prolonged ventillation Fonseca trauma

11. TYPE of T r acheso t omies

12. Evolution in indications tracheostomy in children Acute epiglottitis and laryngotracheobronchitis no longer represent an indication for tracheostomy . Acc to retrospective study conducted by Froelich et al in 46 children undergoing tracheostomy b/w 1996-2001, there was decrease in frequency of tracheostomy due to upper airway obstructions & An increasing indications were noted for chronic disorders requiring prolonged ventilator dependence. Int J of Pediatric Otorhinolaryngo (2006) 70, 115—119

13. CONTRAINDICATIONS Emergency tracheostomy is contraindicated if the patient’s airway can be secured by other means (needle/open cricothyrotomy) In an expanding hematoma.

14. SURGICAL ANATOMY

15. JAC K SO N ’S SAFETY TRIANGLE T riangular space i n neck Bas e : Lo w e r en d o f thyroi d ca r tilage Ap e x : Sup r a ste r n a l notch Sides : Inn e r ed g e s o f ste r nocleid omastoid muscle So na m e d a s th i s m ar k s the ar ea th rou g h whic h sa f e dissec t io n can b e don e fo r t rache o stom y Also repre s en t s the ar ea int o whic h infil t ra t ion anes t hesi a i s give n du r in g t rache o stom y un d e r local anesthesia

16. ‘ Tracheal-tug’ The intimate relationship between the arch of the aorta and the trachea and left bronchus is responsible for the physical sign known as ‘tracheal-tug’, characteristic of aneurysms of the aortic arch.

17. Types of tracheostomy Emergency Elective / tranquil Therapeutic : to relieve respiratory obstruction Prophylactic : to guard against anticipated respiratory obstruction or aspiration Permanent Percutaneous dialational Mini tracheostomy ( Cricothyrotomy )

18. The golden rule of tracheostomy —based entirely on anatomical considerations is ‘stick exactly to the midline’. If this is not done, major vessels are in jeopardy and it is possible, although the student may not credit it, to miss the trachea entirely.

19. Armamentarium

20. Various type of the tubes Silver/Metal tubes - outdated. E.g. Alder-Hey and Sheffield. Plastic tubes -most commonly used. flexible, comfortable & less traumatic. Silicon tubes- E.g.- Romsons tubes, Portex tubes, Shiley tubes. Polyvinylchloride (PVC) tubes Silastic tubes

21. Tube selection The length - The standard tube lengths are 60–90 mm (adult), 39–45 mm (pediatric) and 30–36 mm (neo-natal). The diameter - largest tube that fits comfortably should be used. (this is approx 3/4th diameter of the trachea.) woman- No.6 or No.7 man- No.7 or No.8. Cuff tube- necessary when aspiration is a problem or when a positive pressure ventilation is required. Cuff should be deflated at regular intervals atleast 5mins/hr.

22. TRACHEOSTOMY SURGICAL STEPS

23. STEPS 1.Airway control endotracheal intubation/ventilation and oxygenation by means of a bag and mask. If the airway is under control, a more orderly & less traumatic tracheostomy can be performed. 2.Patient position-supine position, place shoulder pad & head ring for to allow maximum extension of neck.

24. The incision is made through the Subcutaneous tissue and platysma , down to the deep cervical fascia. The anterior jugular veins will be Encountered superficial to the deep cervical fascia on either side of the midline. Note that the trachea is deeper than one imagines.

25. A self-retaining retractor can now be inserted and the dissection continued until the strap muscles are encountered. These should be separated in the midline. The assistant can do this using a pair of Langenbeck retractors. The dissection is continued with blunt ended dissecting scissors. If one stays in the midline, it is a relatively bloodless field and one continues deeper until the thyroid isthmus is identified.

26. 2 PRINCIPLES OF ENTERING TRACHEA Cricoid cartilage or 1 st tracheal ring must not be cut or injured Incision in trachea must not extend below 4 th tracheal ring Tracheostomy hook between 1 st & 2 nd tracheal ring, superior traction to elevate trachea Various entrance incisions like U, INVERTED U, T AND CRUCIFORM, or a window may be created.

27. A traction suture with 2-0 silk from tip of flap to inferior margin of skin Trousseau dialator or kelly hemostat inserted and spread vertically Tracheal lumen should be visualised an inferiorlv hinged tracheal flap Bjork’s flap is made which is sutured to the skin.

28. If the trachea is low in the neck and one is having difficulty accessing the upper trachea, then there are two strategies to bring the trachea further up into the neck. Firstly a Cricoid hook can be used. The hook is inserted into the trachea just under the cricoid cartilage and the trachea is gently pulled upwards into the incision. This usually works well. An alternative strategy is to insert a deep Travis retractor and place the upper arm against the lower edge of the thyroid cartilage and the lower, against the upper edge of the sternum. When the retractor is opened the trachea is drawn upwards by the pull on the more robust thyroid cartilage.

29. DEALING WITH THYROID ISTHMUS There are different opinions regarding this 1. Dividing the Isthmus between two clamps and ligating it. 2. Pulling thyroid Isthmus up. 3. Pulling thyroid isthmus down. Once the isthmus is divided or pulled up or down the trachea will be exposed and the rings should be counted.

30. T RACH E OS T OMY T U B E INS ERTI O N T ra c heal d i lators will be n e eded to enable the tu b e to be inser t ed in to th e tracheal lu m en. The assis t ant sh o uld n o w hold the tu b e in s i tu u ntil it is secured. Use a flex i b l e s u ction c a th eter d o wn th e tu be to sucti o n any blo od or m ucus o ut of the trachea a nd c o n nect th e c a th eter m o u nt to the trach e os t o m y tu b e and the ana e sth etic tu b in g

31. TYPES OF TRACHEOSTOMY TUBES CUFLESS TUBES CUFFED TUBES

32. Types of Tracheostomy Tubes Parts of a Tracheostomy Tube Tube with inner Cannula

33. Metal tube with inner cannula and obturator   Single Cannular Shiley Pediatric Tracheostomy Tube Obturator at Right

34. Skin closure incision should not be sutured or dressed tightly. (subcutaneous emphysema, pneumomediastinum & pneumothorax.) A small gauze pad may be placed b/w the flange of the tube and the skin

35. Tracheostomy : Pediatric Anatomical consideraions Do me of pleura extends in to neck and is this vulnerable to injury The hyoid bone, thyroid cartilage and the cricoid cartilage lie higher in the neck. Trachea is pliable and difficult to palpate Recurrent laryngeal nerve Neck is short so less working space Cricoid can be injured

36. VARIATION In children short neck: left brachiocephalic vein may come up above the suprasternal notch so that dissection is rather more difficult and dangerous. Also, child’s trachea is softer and more mobile than the adult’s and therefore not so readily identified and isolated. Its softness means that care must be taken, in incising the child’s trachea, not to let the scalpel plunge through and damage the underlying oesophagus. In contrast, the trachea may be ossified in the elderly and small bone shears required to open into it.

37. Tr acheostomy: Pediatric 1.Bronchoscope/ETT inserted to provide, an airway and rigidity to the trachea. 2. Do not to insert the knife too deeply 3. A vertical skin incision is used. Before the anterior tracheal wall is incised, silk retraction sutures are placed in either side of the midline. 4. Tape the silk retraction sutures to the chest wall 5. Silastic tubes are preferable Routine Post-op R/G of the neck and chest.

38. Tracheostomy care Fixation of tube Positioning Suctioning Humidification Changing of tube Care of inflatable cuff Dressing Decannulation Breathing exercises and nutrition

39. Bedside equipment • Spare tubes of Same / smaller size. • Tracheal dilator. • Suctioning equipment -Ensure everyday equipment is assembled and working. • Humidification unit -Ensure everyday equipment is working properly. • Container to hold speaking valve, occlusive cap/button or spare inner cannula .

40. Fixation of tube

41. Positioning

42. Suctioning

43. Humidification Aims: To prevent drying of pulmonary secretions ( tracheitis & crust formation). To preserve muco-ciliary function. Various methods of humidification A) HEATED HUMIDIFIERS. B) HEAT MOISTURE EXCHANGE FILTERS. C) NEBULIZERS. -In addition to atmospheric humidification, -Instill 3 -4 drops of hypotonic saline/ sodium bicarbonate 1-2ml/h -Thick, copious secretions use mucolytic agents .

44. Dressing

45. Care of the tube Fresh tracheostomy should be left in place for 3 - 5 days for the permanent tract to form. loss of the tracheal opening into the neck wound, disastrous consequences. A tube in an infant should not be changed for the first time without a bronchoscope on hand.

46. CARE OF CUFFED TRACHEOSTOMY TUBE Inflate: • Immediately post-op • during mechanical ventilation Deflate: • Cuff should be deflated atleast 5mins every hr. • First suction the oropharynx .

47. SPIROMETER Recommended cuff pressure is <25cm Using a cu f f p r essu r e m ano m et e r , check the pressu r e of the t r acheo s to m y cu f f. Shou l d be l e ss t h an 25 cm of H2O. If m ore chances of tracheal inju r y . If m ore pressure is needed, then change the tube. As a si m ple r ule, air in cc about half the size of t r acheo s to m y tube is su f ficient for adequa t e volu m e and pressu r e of t he cu f f. .

48. Breathing exercises and nutrition

49. It is r e c om m ended th a t en d ot r ac h eal suct i on i n g shoul d b e p er f or m ed only when sec r e tions a r e p r ese n t, and n o t r o u ti ne ly; It is su g g e s t ed th a t p r e- o x y g en a tion b e c ons i de r ed if the p a ti e n t ha s a c l i n i c al l y i m por t a n t r edu c ti o n in o x y g en s a tu r a ti o n w i th suct i on i n g ; P er f or m i n g s u c ti on i n g withou t di s c on n ectin g the p a ti e n t f r o m the v e n ti l at o r is su g g e s t ed; U s e o f s h a l low s u ctio n is su g g e s t ed i n s t ead o f dee p s u c ti on , base d o n e v i den c e f r o m in f a n t a n d ped i a tr i c s tudi es; It is su g g e s t ed th a t r outine u s e of normal saline in s till a ti o n pr i o r t o endo t r ac h eal suct i o n s ho u ld not be per f ormed ; A m e ri c an A s so ci atio n fo r R e spirator y C a r e ( A A RC) G u i d eli n es - R e com m endati o ns AA R C Cl i ni c al P r ac t ice Guide l in e s: Res trepo RD, B ro w n JM I I , Hug hes JM E ndo t racheal Suct i on i n g o f Mec ha n i c a lly V e n til a t ed P at ie n ts W ith Arti f ici a l Ai r ways 2 10 R e s p ir Car e 2 1 ; 5 5( 6 ) : 7 5 8 – 764. © 2 10 Daeda l u s Ent erpr ises

50. Th e u s e of close d s u ctio n is su g g e s t ed f o r adults w i th h igh FI O 2, o r PEE P , o r a t r i s k f o r l un g de r ecru i t m e n t, and f o r neon a t es; E n d ot r ac h eal suct i on i n g withou t di s c on n ectio n ( c l o s ed s y s t e m ) is su g g e s t ed in neon a t es; 7. A v oidance of di s c on n ectio n and us e o f l un g r ecru i t m e n t maneu v e r s a r e su g g e s t ed if suct i on i n g - i n d uced l u n g de r ecru i t m e n t oc c u r s in p a ti e n ts w i th ac u t e l un g i nju r y; It is su g g e s t ed th a t a suct i o n c a th e t er is u se d th a t o c cl u d es less than 5 % the l u m en o f the endo t r ac h eal tube in c h i l d r en and adult s , and less than 7 % in i n f a n ts; It is su g g e s t ed th a t t h e d u r a ti o n o f the suct i on i n g e v e n t b e l i m i t ed t o less than 15 seconds A m e ri c an A s so ci atio n fo r R e spirator y C a r e ( A A RC) G u i d eli n es - R e com m endati o ns AA R C Cl i ni c al P r ac t ice Guide l in e s: Res trepo RD, B ro w n JM I I , Hug hes JM E ndo t racheal Suct i on i n g o f Mec ha n i c a lly V e n til a t ed P at ie n ts W ith Arti f ici a l Ai r ways 2 10 R e s p ir Car e 2 1 ; 5 5( 6 ) : 7 5 8 – 764. © 2 10 Daeda l u s Ent erpr ises

51. Complications of tracheostomy Immediate Intermediate Late

52. Immediate Hemorrhage Air embolism Apnoea Cardiac arrest Local damage

53. Hemorrhage Anterior jugular veins Inferior thyroid veins Thyroid gland

54. Air embolism Inadvertent opening of large neck veins Air sucked in and passing rapidly into right atrium Tamponade and death

55. Apnoea Sudden discharge of carbon dioxide Allow the patient to breath a mixture of 95% oxygen and 5% carbon dioxide during the procedure

56. Cardiac arrest Exessive adrenaline production Rapid rise of ph Hyperkalemia

57. Local damage

58. Intermediate Dislodgement Surgical emphysema Pneumothorax / pneumomediastinum Scabs and crusts Infection Tracheal necrosis Tracheoarterial fistula Tracheo-oesophageal fistula Dysphagia

59. Dislodgement Post operative oedema , hematoma and emhysema Prevention: Suturing flanges in early period and tapes in later period

60. Surgical emphysema Subcutaneous emphysema is alarming but it is not fatal Too large incision Tube partially obstructed/diverts air into soft tissues Too tight closure of subcutaneous tissues Excessive coughing

61. Pnuemothorax / pneumomedistinum Direct puncturing of pleura Tube is inserted between the anterior wall of trachea and soft tissues of anterior mediastinum

62. Scabs and cysts Tracheostomy alters the basic physiology

63. Infection Pseudomonas, stahphylococcus , hemolytic streptococci and candida

64. Tracheal necrosis Over sized tracheostomy tubes, Improper curve of the tube, Impingement of tip of the tube Pressure of cuff

65. Tracheoarterial fistula Occurs in 0.1-1% Mortality 80-90% Hemmorrhage occurring 3days to 6wks after tracheostomy should be thought of as a result of TIF Low tracheal incision Improper position of tube against the vessel Improper curve or length of tube Secondary to pressure

66. Traheo-oesophagial fistula Over inflated or improperly fitting cuffed tube Positive pressure ventilation

67. Dysphagia Managed by feeding through ryles tube

68. Late Stenosis Difficulty with decannulation Tracheo cutaneous fistula

69. Stenosis 3 distinct levels 1)stoma 2)cuff site 3) tip of tube Caused by Inflatable cuff Scar contracture

70. Difficulty in decannulation In long standing cases Granulations Fibrous masses Tracheal strictures

71. Tracheocutaneous fistula and scars Due to migration of squamous epithelium from skin into trachea

72. Patients with respiratory failure who cannot be weaned within 7-10 days Most severely injured trauma patients who require air way support more than 5 days

73. Percutaneous tracheotomy (history) 1955, Shelden et al - first attempt with cutting trocar into the trachea. 1985, Ciaglia et al - percutaneous dilational tracheostomy (PDT) 1989, Schachner et al - Rapitrach 1990, Griggs et al - the guidewire dilating forceps (GWDF)

74. Surgical techniques Percutaneous procedure Introduction of tracheal needle Placement of guide wire

75. Surgical techniques Percutaneous procedure Insertion of guiding catheter Serial dilation

76. Placement of tracheostomy tube

77. Ciagli a Blue R hi n o kit con t ai nin g n ee d le, gui de wi r e , and s e ria l dil at o r s P e r cu t an e ous Dil a ti o nal T r acheo s t o m y - Com me r cia l Ki ts & T echniques

78. Tracheal lumen entered below 2 nd ring with introducer needle

79. Griggs guidewire dilating forceps (GWDF) technique 2002 Percu Twist technique

80. Gri g g s and Ra p it r ach s y st ems

81. Gr i g gs a n d R a pi t r a c h T echn i que

82. Th e P e r cutwi s t s y s t em No t e the d il a t a t i o n o f the t r act w i th a s em i - s harp sc r e w o v er a gu i d e w i r e

83. Complications of Percutaneous Tracheostomy Complications of Percutaneous technique are not common false passage of the tracheostomy tube, pneumothorax, delayed bleeding, puncture of the posterior tracheal wall, premature extubation during the procedure and loss of the airway .

84. I n t e n s i v e Ca r e Med (1991) 17 : 26 1 - 263 • A p r ospe ctiv e no n - r and o m ised s tu d y • Th e s a f ety and utility of s u r gi cal and P C T t e c h n i q u es p e r f ormed in ICU • S t an d a r d in d i c a ti on s f or t r ach e o s t o m y of p r ol o n g ed m e c h an i cal v e n t i l a ti o n (> 10 d a y s)

85. • R C T o f 30 P C T v s 30 Su r gi c al Ca s es • me di an t i me f o r in s ert i o n o f the t r acheo s t o m y tube w as 11.5 min ( r ange 7– 24 mi n ) v s 15 m i n ( r an g e 5 –47 m i n ) ( P <0.01 ) . • M i no r b l eed in g w as en c ou n t e r ed i n 6 c as es i n the P D T g r ou p as op p os e d t o 24 c as es i n the T R g r ou p ( P <0. 01 ) , • Major bl e ed i n g i n non e v e r s us 2 c as e s, r e s p e c t i v el y . P o s t -t r ache o s t o m y p e rio d, • mi no r b l eed in g i n 2 c as es i n the P D T v s 9 c as es in the T R g r ou p ( P <0. 05 ) , and maj or b l eed in g w as en c ou n t e r ed i n 1 c as e in e ach g r oup. • M i no r i n f ect i on s w e r e en c ou n t e r ed i n 3 c as es in the P D T g r ou p as oppo s ed t o 11 c as es i n the T R g r ou p ( P <0. 01 ) . Major in f ect i o n w as en c ou n t e r ed i n non e v e r s us 8 c as e s, r e s p e c t i v el y ( P <0. 01 ) .

86. P r osp e cti v e , r an d omi z ed trial. 30 p a t ie n ts u n d e r w e n t P D T and 26 p a t ie n ts had S T . I n o n e p a t ie n t, P D T w as c o n v er t ed t o S T . Mean time 1 1 m i n s ( S D , 6; r an g e, 2-40 ) , v s 1 4 m i n s ( S D , 6; r an g e, 3-39 ) . In the P D T g r o u p, fi v e p a tie n ts h ad m o d e r a t e b l eed in g d ur i n g the p r o ced u r e. In th r ee p a t ie n ts, t h e b l eed in g w as r e so l v ed w i th c omp r e ss i on ; i n on e p a t ie n t, i t w as r e so l v ed w i th li g a t i o n o f the v e s s el; and in on e p a t ie n t, i t w as r e so l v ed w i th el ec t r o c oa g u l a t i o n . Bl ee d i n g d id no t c au s e a n y c omp l i c a t i on s a f t e r w a r d. In the P D T g r oup , on e p a t ie n t ha d mi ni mal o o z i n g f r o m the w oun d ed g e o n the f i r s t po s t op e r a t i v e d a y and i t w as r e so l v ed s po n t an eou s l y .

87. • 368 a b s t r acts, 15 p r os p e ct i v e , r an d o m i z e d- co n t r o l l e d tri a ls i n v o l vi n g n e a r ly 1,000 p a tie n ts • c omp l i c a t i on s , c as e l en g th, and c o s t - e f f ect iv ene ss. • m e t a-ana l y s is illu s t r a t es the r e i s n o c l ear d i f f e r en c e b u t a t r en d t o w a r d f e w er c om p li c a t i ons i n p e r c u t an eou s t echn iqu e s. P e r c u t an eou s t r acheo t om i es a r e m o r e c o s t - e f f ect iv e a n d p r o vi d e g r e a t er f ea sib i l i ty i n t erms o f b ed s i d e c apa b i l i ty and no n s u r gi c al op e r a t i on.

88. References Rowe &William’s Maxillofacial injuries 2nd edition- vol I Oral & maxillofacial trauma : Fonseca- 3rd edition- vol I Bailey & love’s short practice of surgery 23rd edition. Scott and Brown’s Otolaryngology 6 th edition vol I , vol II Operative otolaryngology Head and Neck – Eugene N Myers vol I Diseaes of Nose ,Throat , Ear – Logen Turner Text book of Otolaryngology and head and neck surgery - Byron &Bailey Clinically oriented Anatomy -5 th edition – Keith L Moore An atlas of head & neck surgery- Lore’ 3 rd edition Internet sources

89. ??????????? HORIZONTAL VS VERTICAL INCISION KNIFE VS CAUTERY NO. OF SUTUIRES TYPE OF FLAP