TRACHEOSTOMY BY DR JUVERIA MAJEED MS ENT

Oldest surgical procedure- Tracheostomy!! Know about it...

1. DR JUVERIA MAJEED MS ENT, Govt.ENT Hospital/ Osmania Medical College TRACHEOSTOMY

2. A Tracheostomy is an artificially( usually) surgically created airway fashioned by making a hole in the anterior wall of trachea and the insertion of a tracheostomy tube, which may or may not be permanent. Tracheotomy is the opening into trachea where as tracheostomy is converting the opening into stoma onto the skin surface. What is a tracheostomy?

3. Tracheostomy is one of the oldest surgical procedure. A tracheotomy was portrayed by the Egyptians and Indians in the early years. Extensive history of tracheostomy can be best divided into five periods: 1. The period of Legend (3100BC to AD 1546)- The first elective tracheotomy by Asclepiadus of Bithynia in AD100. This operation ws described by Claudius Galen, renowned physician in AD 131 References were made to tracheotomy, but was considered both useless and dangerous due to high risk of wound infection Hippocrates condemned tracheostomy History

4. 2. The period of Fear(AD 1546-1833) in the history of tracheostomy: During this era, this procedure ws considered as irresponsible and barbaric. By early 1600s, it started getting acceptable for few conditions like FBs etc. Bcoz of fear and mistrust abt procedure, it prevented therapatic use of it, for eg . In 1799,dec4th,first US president died of acute(within 36 hours) upper airway obstruction sec. to peritonsillar abscess 3.The period of Dramatisation (AD 1833-1932): It was considered as operation of life or death. The operative technique of tracheostomy was studied, refined and defined by Chevalier Jackson in 1909. He also designed the metallic double lumen tube

5. 4. The period of Enthusiasm(AD 1932- 1965) Wherein saying “ if u think tracheostomy……do it ” became popular. Indications for tr. Were actively sought for and both surgical and medical world became strong advocates for it 5.The period of Rationalisation (AD 1965 to present): In 1965, it became apparent tht oral or nasal intubation was quicker and safer than tr. So began this period wherein tr. Vs intubation ws debated. Seldinger introduced PCT in 1953 PCT using guidewire introduced by Ciaglia et al. In 1990 Griggs et al developed another guidewire dilating forceps for PCT

6. Surgical anatomy of trachea The trachea begins at the lower border of cricoid cartilage(C6) superiorly to the tracheal bifurcation at the level of sternal angle(T5). Made up of 16 to 22 C-shaped cartilage anteriorly joined by annular ligaments and posteriorly by trachealis muscle. Located in midline position,but can be deviated to right as in advanced age or severe COPD. The average distance from cricoid to carina is approx 12-16 cm long,2.3 cm wide.

7. Anterior to the trachea in the neck is the isthmus of the thyroid gland at about the level of 2 nd to 4 th tracheal cartilages. Below this is the inferior thyroid veins, lymph nodes, and sometimes a thyroid ima artery. Anterior to all of these are the strap muscles. Lateral to trachea in the neck are the lobes of thyroid gland, great vessels and recurrent laryngeal vessels.

8. The innominate artery crosses the trachea either behind the sternum or in the lower portion of neck. During tracheostomy the careful surgeon will palpate this region to assess the presenceof high riding innominate artery. The jugular venous arch connecting two anterior jugular veins lies superficial to the strap muscles just above the suprasternal notch.

9. The basic anatomical relationships need to be kept in mind in performing a tracheostomy. High tracheostomies (above 2 nd tracheal cartilage) are generally associated with a higher rate of tracheal stenosis and perichondritis of cricoid cartilage. Low tracheostomy (below 4 th tracheal cartilages) will encounter more vascular structures such as thyroid veins, ant. Jugular arch, or a high innominate artery. Neck anatomy and its relevance to tracheostomy

10. Horizontal skin incisions tend to be more cosmetic, although the ext. jugular veins and lateral anatomic structures must be considered during dissection. Vertical skin incisions tend to be avascular . Paediatric larynx and tracheal anatomy varies from adult and has a great clinical signiicance .

11. Paediatric vs Adult airway

12. Arteries of central neck: Common carotid A. Carotid bifurcation Internal carotid A Ext. carotid A. and br . Superficial veins of central neck: Ext. Jugular vein and ant jugular vein Deep veins of central neck: Internal jugular vein Important structures to be careful while performing tracheostomy

13. Nerves of central neck : Cutaneous innervation Tenth nerve and its br. Twelfth nerve and ansa cervicalis Visceral structures of neck Thyroid gland Larynx Trachea and esophagus

14. Indications for Tracheostomy Prolonged intubation Facilitation of ventilation support Inability of patient to manage secretions Upper airway obstruction Inability to intubate Adjunct to major head and neck surgery Adjunct to management of major head and neck trauma Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.2005. Goldenberg D, et al Tracheotomy: changing indications and a review of 1,130 cases, J Otolaryngol 31:211–215, 2002

15. Indications: Mechanical Obstruction

16. Tracheostomy in a number of medical and surgical conditions e.g.:- Trauma to the chest. C.C.F. & pulmonary edema. C.O.P.D Head injury. Coma. Strychnine poisoning. Tetanus, Rabies, Poliomyelitis. Neurological conditions . Before doing major head and neck surgery tracheostomy is done to prevent post operative complications. Indications

17. Types of Tracheostomy

18. Emergency: when airway is complete or almost completely obstructing as in FBs or acute infections. Elective: planned unhurried procedure.Often temporary and closed when indication is over. Therapeutic: to relieve respiratory obstruction,remove tracheobronchial secretions or gv assisted ventilation. Prophylactic: in extensive surgeries of tongue, floor of mouth, mandibular resection or laryngofissure . Permanent tracheostomy: In b/l abd . paralysis, laryngectomy , laryngopharyngectomy .

19. Types of tracheostomy

20. Position: supine with a pillow under the trachea. This brings trachea forward. Anesthesia: mostly done under local with 2% lignocaine with epinephrine. Sometimes GA is used. Incision:Vertical - midline of neck, from cricoid above to sternal notch. Most favoured incision. Can be used in both elective and emergency. Rapid access with minimum bleeding and tissue dissection. Horizontal -2 fingers breadth above the sternal notch. Used in elective procedure only. Cosmetically better scar. Technique & Steps of operation

21. Strap muscles separated in midline and retracted laterally. Thyroid isthmus is displaced upwards or divided- ligated . Identification of tracheal rings by colour and palpation confirmation- 4% lignocaine loaded syringe introduced, withdrawn to see for air bubbles, also to suppress cough. Vertical incision given in trachea from below upwards in 3 or 4 th tracheal rings Tube of appropriate size used. Tied to neck with reaf knot. Skin sutures not required.

22. Incision 1 cm below the cricoid or halfway between the cricoid and the sternal notch. Retractors are placed, the skin is retracted, and the strap muscles are visualized in the midline. The muscles are divided along the raphe , then retracted laterally

23. Inserting a Tracheostomy Tube:

24. Baby with One Fingertip Securing the Tracheostomy Tube D One Fingertip Fits Under the Adult Ties BLS

25. ANATOMICAL POSITIONING OF A TRACHEOSTOMY TUBE

26. INFANTS Sub glottic haemangioma Sub glottic stenosis Laryngeal cyst Glottic web Bilateral vocal cord paralysis CHILDREN Acute laryngotracheal bronchitis Epiglottitis Diphtheria External laryngeal trauma Prolonged intubation Juvenile laryngeal papillomatosis Bilateral abductor paralysis Paediatric tracheostomy indications

27. GA Trachea –soft and compressible Too much of extension- Pleural injury, innominate , thymus injury Silk sutures on either side of trachea to secure it in midline Not to incise deeply as it can cause posterior tracheal wall injury. Not to excise ant. Wall of trachea- only incision is given Avoid infolding of ant tracheal wall Proper selection of T tube Paediatric Tracheostomy

28. Nursing : constant supervision of pt after tracheostomy for bleeding, displacement or blocking of tube and removal of secretions. Removal of secretions : Suction Prevention of crusting and tracheitis : Humidification, use of normal or hypotonic saline or RL. If tenacious secretions, use of N- acetylcysteine to loosen crusts Care of T.tube : Inner tube cleaning Care of inflatable cuff Dressing : to avoid maceration of skin from secretions Breathing exercises : recommeded to ventilate the lungs fully and prevent pulmonary infections A calling bell, slate and a pencil for communication Post operative care

29. ICU Bed SideTracheostomy Minimally invasive alternative to open tracheostomy Use of guide wire and Dilators Under the vision of Bronchoscope through endotracheal tube Less time ,Less Expensive Not suitable for thick neck and in emergency Percutaneus Dilational Tracheostomy

30. Percutaneous tracheostomy Introduction of tracheal needle Placement of guide wire Insertion of guiding catheter Serial dilation Placement of tracheostomy tube Percutaneous tracheostomy

31. Intraoperative Complications . Anaesthesia complications Bleeding and injury to big vessels Apnoea - due to sudden washout of co2 Injury to recurrent laryngeal nerve Injury to tracheoesophageal wall Pneumothorax - injury to apical pleura Complications of Tracheostomy

32. Bleeding, reactionary or secondary Tracheostomy tube obstruction Tracheostomy tube displacement Subcutanoues empysema Tracheitis and tracheobronchitis with crusting in trachea Atelectasis and lung abcess Local wound infection and granulations Early Complications

33. Hemorrhage, due to erosion of major vessels Laryngeal stenosis , due to perichondritis of cricoid cartilage Tracheal stenosis , due to tracheal ulceration and infection Tracheo – oesophageal fistula Problems of decannulation Persistant tracheocutaneous fistula Problems of T.scar - keloid formation Corrosion of tracheostomy tube and aspiration of its fragments into tracheo bronchial tree Late complications

34. TRACHEAL STENOSIS & TRACHEO-INNOMINATE ARTERY FISTULA 5/24/2015 37

35. T. tube should not kept longer than necessary To decannulate , it shud be plugged or corked and the pt shud be able to sleep overnight with the tube closed before decannulation After tube removal , pt is closely monitored for resp.distress and tachycardia Decannulation

36. It may be: Persistance of the condition for which tracheostomy was done. Obstructing granulations: around stoma or at tip of tube Tracheal oedema or subglottic stenoses Incurving of tracheal wall at the site of tracheostome Tracheomalacia Psychological depandance Difficult Decannulation

37. Increased patient mobility More secure airway Increased comfort Improved airway suctioning Early transfer of ventilator-dependent patients from the intensive care unit (ICU) Less direct endolaryngeal injury Enhanced oral nutrition Enhanced phonation and communication Decreased airway resistance for promoting weaning from mechanical ventilation Decreased risk for nosocomial pneumonia in patient subgroups Tracheostomy vs Intubation

38. TRACHEOSTOMY TUBES A tracheostomy tube is:- Inserted through the tracheostomy to maintain a patent airway Secured in place by tapes tied around the neck Ideal T.tube : Rigid enough to maintain the airway. Yet flexible enough to limit tissue damage Comfortable to the pt.

39. Parts of tracheostomy tubes Parts Description Outer cannula Main body of the tube which passes into trachea Diameter – inner dia of this outer cannula Inner cannula Removable tube –passes into outer tube A bit longer Can be locked Cuff Balloon at the distal end Protection Pilot balloon Ext balloon connected by a inflation line to cuff Flange – neck plate Supports the tube Straight strip- adults Angulated- pediatric Adjustable flanges- bulky neck Introducer/ obturator Beveled tip shaft Smooth round dilating tip Reduces trauma – insertion Fenestrations Single/ multiple Speaking Coughing Adaptor Ventilatory equipment

40. Passy Muir valve Speaking valves are one way valves that allow inhalation through the tracheostomy tube but block exhalation through the cannula forcing exhaled gas through vocal cords allowing phonation Accessories- speaking valve

41. TYPES OF TRACHEOSTOMY TUBE Cuffed - when inflated, this tube seals the airway and prevents the aspiration of oral or gastric secretions.

42. Maintains airway once aspiration risk has passed. Increases airflow to the larynx. Required in Long term T. pts Pts who do not require a seal Paediatrics Uncuffed Tube

43. TYPES OF TRACHEOSTOMY TUBE Fenestrated

44. Jackson’s tracheostomy tube- Metallic tracheostomy tubes

45. Jackson’s tracheostomy tube- Metallic tracheostomy tubes

46. Metallic tracheostomy tubes

47. Hollinger’s tracheostomy tube- Metallic tracheostomy tubes

48. Tuckers’ tracheostomy tube- Metallic tracheostomy tubes

49. martin’s tracheostomy tube- Metallic tracheostomy tubes

50. PVC- Most cost effective, for short term use , More prone to infections. Silicone –soft material, unique characteristic of reducing adherence of secretions and bacteria Siliconised PVC- sufficient rigidity, Thermosensitive , More pt. comfortable. Eg Portex ultra Silver- 92.8% silver, Cu and P with silver lining, For prolonged use. Eg Negus and Chavelier Jackson Sialistic –silicon rubber, less rigid. Eg . Moore What are tubes made of

51. Complications of tube