Tracheostomy

full and complete outline of tracheostomy with procedure.

1. TRACHEOSTOMY C.ABRAHAM BENSON RAJ

2. ANATOMY OF TRACHEA Trachea or wind pipe is a cartilaginous tube that connects the pharynx and larynx to the lungs, allowing the passage of air. Trachea extends from larynx (at the level of C6) and branches into two primary bronchi (at the level of T4-T5). It is located anterior to the esophagus.

3. STRUCTURE Trachea contains rings of hyaline cartilage which are C shaped, connected to each other by the smooth trachealis muscle. C shaped design of the trachea helps to ensure that the trachea will not collapse. And the rings are joined vertically by a band of fibrous connective tissue – The annular ligament of trachea. At the top of trachea the cricoid cartilage attaches it to the larynx – the only complete ring.

4. The crico tracheal ligament connects the cricoid cartilage with the 1 st ring of trachea . Trachealis muscle overlies esophageal muscle and forms the posterior wall of trachea . Trachea – length - 11 cm. Inner diameter – 1.5 to 2 cms. Outer diameter – 2.1 to 2.7 cms. Number of cartilages – 16 to 20.

5. WALL OF TRACHEA The layers of tracheal wall, from deep to superficial are Mucosa Sub mucosa Hyaline cartilage Adventitia

6. Mucosa Consists of pseudo-stratified ciliated columnar epithelium with goblet cells that produce mucus. It warms and removes foreign particles from the air as it flows through the trachea. Submucosa Consists of areolar connective tissue that contains seromucous glands and their ducts. The glands secretes a combination of water and mucus to that secreted by the goblet cells. Hyaline cartilage A cartilaginous layer containing C-shaped cartilage rings. Adventitia Band of loose connective tissue that loosely bind the trachea to the esophagus and other nearly organs.

7. TRACHEA - RELATIONS CERVICAL TRACHEAL POSTERIOR Esophagus, Trachealis muscle ANTERIOR 2 nd and 4 th rings are covered by the isthmus of thyroid. LATERAL 2 lateral lobes (thyroid gland) Posterior

8. Anterior and lateral

9. THORACIC TRACHEAL ANTERIOR Thymus gland Left brachio cephalic vein, A ortic arch LATERAL Vagus nerve

10. Thoracic tracheal relations

11. TRACHEA NERVE SUPPLY Vagus and recurrent laryngeal nerves BLOOD SUPPLY Cervical portion – Inferior Thyroid Artery Thoracic portion – Bronchial arteries VENOUS DRAINAGE Inferior Thyroid venous plexus

12. TRACHEOSTOMY – DEFINITION Operative procedure that creates a surgical airway in the cervical trachea. Surgical procedure to bypass the airway in the patient with upper airway obstruction, to make tracheobronchial toilet easier in the patient with decreased consciousness or for the need of mechanical ventilation.

13. Used in 2 types of conditions Acute setting – usually in emergency to obtain an airway and in ventilated patients who are having difficulty in weaning. Chronic setting – usually when the patient is to be ventilated for the longer term.

14. INDICATIONS GENERAL To bypass an obstructed upper airway. To clean and remove secretions from airway. To more easily and usually more safely, deliver oxygen to the lungs. AIRWAY BYPASS Severe inflammation of face, neck and larynx. Tracheal injury Upper airway tumour Neck radiotherapy Facial trauma – multiple fractures Severe head and neck operating procedures

15. 2. BRONCHIAL TOILET Head trauma with consciousness disturbances and ineffective cough Tracheobronchitis with an edema and lot of secretions Thoracic trauma with ineffective cough Post surgical procedure with inadequate cough 3. EASIER VENTILATION Prolonged ventilation after intubation >7days. To reduce anatomic dead space and increases the chance for mechanical ventilation withdrawal Neuro muscular diseases (GBS,MG,etc) paralyzing or weakening chest muscles and diaphragm COMA (GCS <8, risk of aspiration)

16. PRE OPERATIVE INFORMED CONSENT – EXPLAIN ABOUT Operating procedure Loss of voice when tracheostomy tube is still in trachea Complication of procedure Do blood tests and check levels of CBC, PT, PTT, INR.

17. TYPES OF TRACHEOSTOMY OPEN PROCEDURE High tracheostomy (cricothyroidectomy) Low tracheostomy 2. PERCUTANEOUS PROCEDURE

18. PROCEDURE – SURGICAL TRACHEOSTOMY POSITIONING Supine with neck extended over a shoulder roll. Head is placed over a head ring. ANAESTHETIC PREPARATION Local anaesthetic with 1% lidocaine with 1:100,000 adrenaline solution.

19. TRACH TRAY INSTRUMENTS Retractor Artery forceps Dilator Scalpel knife- handle for surgical blade Dressing forceps Scissors Needle holder Blunt hook retractor

20. PARTS OF A TRACHEOSTOMY TUBE

21. PROCEDURE Before tracheostomy put patient on 100% FiO 2 and continuously monitor the patient. Follow strict aseptic process. Skin preparation with povidine iodine, chlorohexidine. Sterile drapping. Good light source and suction apparatus ready and tested to be functional. Ambu bag, facemask and bains circuit – standby. Appropriate sized tracheostomy tubes must be available. If the patient is obese and has a short, thick neck, a longer tracheostomy tube should be used.

22. TRANSVERSE INCISION Incision 1 cm below the cricoid or over the 2 nd tracheal ring. Incision length – 2 to 3 cm.

23. Blunt dissection of subcutaneous tissue. Transversely retracted until the thyroid isthmus is identified.

24. If the gland lies superior to the 3 rd tracheal ring, it can be bluntly undermined and retracted to gain access to the trachea. If isthmus overlies the 2 nd and 3 rd tracheal ring, it must be either mobilised or a small incision is made to clear a space for tracheostomy.

25. A window of tracheal tissue is removed. This window is approximately the size of desired tracheostomy tube. The ETT should be withdrawn till it is just visible above the proximal end of stoma, and leave ETT in place. The ETT should not be completely removed from the airway until the correct placement of tracheostomy tube is confirmed and secured Trachea is maintained open with blunt hooks on the right and left, clean existing secretions by using suction catheter. While inserting the tracheostomy tube, position the axis perpendicular to the TT, after entering turn the direction parallel to the axis of trachea, proceed according to the curve of the TT into the lumen of trachea.

26. Check TT into the lumen of trachea, the whole latch is released, assistant hold the TT, then it is fixed with sutures at the right and left flanges of TT to the skin of the neck and installing a ribbon strap around the neck. If the incision is too wide, skin is sutured loosely. Between TT flange and skin, put a sterile gauze cushion. Then TT is connected to the ventilator and ETT is pulled out.

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29. PROCEDURE – PERCUTANEOUS DILATATIONAL TRACHEOSTOMY Positioning, anaesthetic preparation and sterile drapping must be followed as in open tracheostomy. For percutaneous Tracheostomy, do laryngoscopy and withdraw ETT till the cuff is just visible below the vocal cords. Assist withdrawal and refix ETT temporarily.

30. PDT SET - CONTENTS 14 G cannula Guide wire set with introducer Initial dilator Stiffener Single stage dilator (rhino) Trach tube Syringe for balloon inflation

31. A 1.5cm vertical incision is made at midline space below cricoid cartilage. A minimal dissection is performed onto the pretracheal tissues in order to push the thyroid isthmus downward. A 14 gauge introducer needle is then inserted into the trachea with constant aspiration on the syringe between 1 st and 2 nd or 2 nd and 3 rd tracheal rings. The successful introduction of the needle into the trachea confirmed by air bubbles into the saline filled syringe during aspiration.

32. Once the introducer needle is in correct position, a guide wire is then inserted into the tracheal lumen .

33. The introducer needle is withdrawn, leaving the guide wire in place.

34. A well lubricated dilation is performed by the dilator (rhino).

35. The TT mounted on the dilator is then threaded over it and introduced into the tracheal lumen. The guide wire and dilator are removed. The tracheostomy tube flanges are then secured with suture and ties around the neck.

36. POST – OP MANAGEMENT Chest X-Ray Strong analgesia Antibiotics Tracheostomy tube care Constant supervision for any bleeding or block Suctioning Proper humidification by use of HME or nebulisations.

37. COMPLICATIONS INTRA OP Bleeding Pneumothorax Cricoid cartilage injury Esophageal perforation Tracheoesophageal fistula Vocal cord injury

38. POST OP EARLY Infection at operating site Subcutaneous emphysema Impaired swallowing function because of cuff LATE Granuloma Laryngotracheal stenosis Scarring Failure to decannulate

39. CONTRAINDICATIONS No absolute contraindications Relative Child <12 years PEEP >15cm H 2 O Abnormal anatomy Occluding thyroid mass

40. TRACH TUBE CARE Inner cannula should be removed and cleaned every 6 hrs. TUBE CHANGE INDICATION – soiled, cuff rupture, blocked COMPLICATION – Insertion into a false passage AVOID TUBE CHANGE WITHIN 1 WEEK. CUFF PRESSURE SHOULD BE MAINTAINED WITHIN 20-25mmHg.

41. TYPES OF TRACH TUBES Cuffed and uncuffed Fenestrated and unfenestrated Metal tracheostomy tube

42. CUFFED AND UNCUFFED TUBES CUFFED To protect airway To allow ventilation UNCUFFED Used for patients with tracheal problems

43. FENESTRATED AND UNFENESTRATED Allow patient to ventilate past tube via upper airway Allow speech

44. METAL TRACHEOSTOMY TUBE

45. DECANNULATION The process by which a tracheostomy tube is removed when the patient no longer needs it.

46. Resolution of pathology that necessitated the tracheostomy (upper airway obstruction, pneumonia, etc.) Normal protective laryngeal mechanisms (no aspirations during normal swallowing, good cough) No planned further interventions (radiotherapy, head and neck operations) No mechanical ventilation. INDICATIONS

47. METHODS OF DECANNULATION One step method Sequential downsizing : This is a staged procedure when the tracheostomy is performed for upper airway obstruction. Every 3 to 4 days, a smaller size tracheostomy tube is inserted and the patient is assessed for discomfort. If the patient is able to tolerate the smallest tube, the tube is then capped overnight, the patient is decannulated the next morning.

48. Decannulation equipments O 2 Mask and suction with equipments Tracheostomy tubes (one same size and one size smaller) Sterile gauze or dressing Intubation tray in case of emergency Scissors

49. PROCEDURE Procedure should only be performed between 8am and 4pm during working hours when more help is available. Monitor the patient continuously P osition: pillow under the shoulder with head tilt and chin lift. Explain the procedure to the patient. Suction tracheostomy and clean stoma. Undo ties and remove tracheostomy tube.

50. Observe for any respiratory distress Tachypnea Stridor Chest retraction Tachycardia Restlessness Apply occlusive dressing to the stoma site Reassess patient for signs of respiratory distress Sit patient up and encourage coughing.

51. FOLLOWING DECANNULATION Monitor respiratory rate, heart rate, oxygen saturation and work of breathing Observe for respiratory obstruction during sleep Encourage coughing to clear secretions Avoid suctioning the stoma unless otherwise indicated in an emergency situation as this may cause trauma. DECANNULATION FAILURE – CAUSES Blockage of stomal site with mucous plug because of inadequate cough. Tracheobronchomalacia

52. STOMA SITE CARE DRESSING The stoma site is covered with a small square gauze and then by an occlusive dressing. Stoma site to be assessed daily and cleaned .