tracheostomy .pptx

Tracheostomy procedure, types

1. T racheostomy

2. A natomy The trachea is a tube 10–11 cm long, formed of cartilage and fibromuscular membrane. Level C6 to T5 (ends by dividing into left and right bronchi)

3. Relations of cervical trachea Anteriorly; the cervical part of the trachea is crossed by skin and by the superficial and deep fasciae. It is also crossed by the jugular arch and overlapped by sternohyoid and sternothyroid. The second to fourth tracheal cartilages are crossed by the isthmus of the thyroid gland

4. Laterally: The paired lobes of the thyroid gland, which descend to the fifth or sixth tracheal cartilage, and the common carotid and inferior thyroid arteries are lateral relations. The recurrent laryngeal nerves ascend on each side, in the trachea- esophagal groove

5. Posteriorly Esophagus

6. Relations of thoracic trachea Anterior relations: manubrium sterni , the origins of sternohyoid and sternothyroid, the thymic remnants and the inferior thyroid veins. The brachiocephalic and left common carotid arteries come to lie on the right and left of the trachea, respectively, as they diverge upwards into the neck. At a lower level, the aortic arch, brachiocephalic trunk, left common carotid artery, left brachiocephalic vein, deep cardiac plexus and lymph nodes are all anterior to the trachea.

7. Posterior relations: Esophagus Vertebral column Lateral relations: Laterally and on the right are the right lung and pleura, right vagus nerve, right brachiocephalic vein, superior vena cava and azygos vein.

8. On the left are the arch of the aorta, left common carotid and subclavian arteries. The left recurrent laryngeal nerve is at first situated between the trachea and aortic arch, and then lies within or just anterior to the tracheo-oesophageal groove

9. Trachea The trachea is supplied mainly by branches of the inferior thyroid arteries, which anastomose with ascending branches of the bronchial arteries. Veins draining the trachea end in the inferior thyroid venous plexus. The lymph vessels pass to the pretracheal and paratracheal lymph nodes. The trachea is innervated by branches from the vagi , recurrent laryngeal nerves and sympathetic trunks.

10. H istory Alexander the Great in the fourth century bc.1,2. The first successful tracheostomy was attributed to Antonio Musa Brasavola , who recorded saving the life of a patient close to death from an “abscess of the windpipe” in 1546. In 1620, Nicholas Habicot of Paris published a 108-page book on tracheostomy, the first work devoted solely to this operation. Despite these success stories, tracheostomy remained a marginal procedure viewed with suspicion and fear for several centuries because of very high morbidity and mortality rates. In 1799, when Dr. Elisha Dick recommended tracheostomy for a patient in airway distress, two colleagues vocally opposed him, and on December14, 1799, George Washington died of acute upper airway obstruction.

11. Prevailing attitudes toward tracheostomy changed dramatically in the 19th century - brettonneau Many of the patients who underwent tracheostomy suffered from diphtheria and unfortunately died of the toxic effect of the disease, even though the airway obstruction had been relieved by the procedure. Chevalier Jackson -1909 Jackson’s teachings were in large part responsible for reducing the mortality of tracheostomy to less than 2% and reducing the incidence of laryngeal stenosis, particularly in children

12. Definition Surgically created airway by making a hole in the anterior wall of trachea and placing a tube

13. Types Temporary (elective or emergency) or permanent High /mid/ low

14. I ndications Upper airway obstruction Removal of secretions Prolonged ventilation Part of another procedure

15. Upper airway obstruction Trauma Foreign body Corrosives and burns Infections Malignant lesions

16. Removal of secretions To provide access for adequate pulmonary toilet The accumulation of secretions in the lower respiratory tract is responsible for a reduction in gas diffusion within the alveoli. This results in respiratory failure. A tracheostomy reduces the dead space, so reducing the work of breathing and also makes it easier to aspirate secretions with less upset to the patient.

17. Prolonged ventilation A tracheostomy should be performed in a patient still requiring ventilation through an endotracheal tube extending beyond 7 days Tracheostomy is the safest means of assisting ventilation where prolonged positive pressure is needed. It is easier to secure a tracheostomy tube than either an orotracheal or nasotracheal tube and the reduced dead space assists weaning of respiratory support.

18. Part of another procedure A temporary tracheostomy should be regarded as mandatory for all major resections involving the oral cavity or pharynx. In these cases, the tracheostomy allows protection of the lower airway from aspiration of blood, in the event of a hemorrhage, as well as guarding against upper airway obstruction from postoperative swelling

19. PREOPERATIVE CONSIDERATIONS Requires informed consent Coagulopathies should be corrected to an International Normalized Ratio (INR) of less than 1.5, with more than 50,000 functioning platelets. Cessation of aspirin or other nonsteroidal anti-inflammatory medications for 10 days preoperatively is ideal but not absolutely necessary. Cessation of anti-coagulants prior is necessary A cross-match should be obtained if the hemoglobin is less than 10 g.

20. Instruments

21. Position The patient is placed on the operating table with a rolled towel or sheet under the shoulders to extend the neck unless the patient has documented or suspected cervical spine injuries

22. An esthesia Local anesthesia: Lidocaine (Xylocaine) 1% with 1:100,000 epinephrine is injected into the skin and subcutaneous tissue where the incision will be placed Can be done under general anesthesia

23. Base: lower end of thyroid cartilage Apex: suprasternal notch Sides: medial border of sternocleidomastoid

24. Incision A transverse incision is made in the skin approximately 1 cm above the suprasternal notch 5 cm in length, 2 cm below lower border of cricoid cartilage (or half way between cricoid cartilage anf sternal notch

25. Once the skin has been incised, dissection continues through the subcutaneous tissues to the strap muscles, which are retracted laterally, following blunt dissection in the midline to separate them. Ligation of anterior jugular vein

26. Following this manoeuvre , the thyroid isthmus should be visible. The isthmus should be clamped, divided and transfixed.

27. Incision in trachea made at the level of second and third tracheal rings

28. Types of tracheostomy Upper: at the level of the first and second tracheal rings Middle: 2 nd and 3 rd tracheal rings Lower: 5 th and 6 th tracheal rings

29. In infants and children, a vertical incision is made between third and the fourth tracheal rings without removing any cartilage. In most older patients, the tracheal ring is calcified, and heavy scissors must be used to excise a small portion of the tracheal ring after transverse incisions have been made in the area just above and below the tracheal ring. This maneuver effectively leaves a rectangular window in the trachea.

30. The tracheal lumen is exposed. The endotracheal tube is withdrawn proximally to a point just above the incision in the trachea, but is not yet removed.

31. The tracheostomy tube, with its previously tested cuff deflated, is slipped into the trachea using a small amount of water-soluble lubricant. With the tube in place, the cuff is inflated just enough to provide a seal and the volume noted.

32. Position to be confirmed from capnograph

33. Only when the tracheostomy tube is functioning satisfactorily the endotracheal tube removed.

34. When in position the tube is retained by tapes passed around the neck and secured. Only one fingertip should be admitted between the tape and the patient’s neck, and the tapes should be tied over the skin Patient’s head to be well flexed when the ties are being knotted, so that it doesn’t become slack

35. The skin is closed loosely with 3-0 nylon monofilament vertical mattress sutures. (To prevent subcutaneous emphysema, the incision should not be sutured or packed)

36. Post- operative care Frequent suctioning of tracheal secretions through inner cannula Frequent cleaning of inner cannula along with removal of inner cannula Cuff to be deflated frequently Betadine gauze dressing over the stoma Crusting may occur in trachea so adequate humidification required.

37. Complications- intra-op Hemorrhage; injury to thyroid veins and thyroid isthmus Air embolism Intra- operative trachea- esophagal fistula Pneumothorax Recurrent laryngeal nerve injury Injury to cricoid cartilage

38. Immediate Hemorrhage Infection Tube obstruction Surgical emphysema Tracheal ulceration Displaced tracheostomy tube

39. Late Granulation tissue Tracheo - esophagal fistula Tracheal stenosis Rupture of innominate artery

40. Indications for decannulation Normal protective laryngeal mechanism (no aspirations) No further plan for mechanical ventilation

41. D ecannulation The tube should be blocked during the day and unblocked at night for the first 24 hours. If the patient tolerates this, then the tube can be occluded for a full 24-hour period and if this is tolerated then the tube can then be removed. If the patient is unable to tolerate this occlusion of the tube, then it may be necessary to downsize the tube to give more room around the tube.

42. fenestration

43. Following decannulation: To note for respiratory distress

44. percutaneous tracheostomy ICU bed procedure

45. Pre-operative technique Contraindications to PDT include the inability to palpate the cricoid cartilage above the sternal notch, the presence of a midline neck mass, a high innominate artery, or large thyroid gland. Ideally, platelets should be 50,000 or greater and the INR corrected to less than or equal to 1.5. Cross-matching is not necessary even in the presence of low hemoglobin levels.

46. Local anesthesia, consisting of 1% or 2% lidocaine with 1:100,000 epinephrine is used for generous infiltration of the incision site and pretracheal soft tissue. Frequently used medications include propofol, administered as a continuous infusion or in boluses, midazolam, and fentanyl ( Sublimaze ).

47. Technique The patient is positioned as for conventional tracheostomy with the neck extended as long as there is no contraindication A 1.5- to 2-cm. skin incision, is made at the level of the second and third tracheal rings This corresponds to approximately one fingerbreadth above the sternal notch or two fingerbreadths below the cricoid

48. An appropriately sized flexible bronchoscope with a suction port is inserted through an adapter into the ET tube and advanced until the tip of the bronchoscope lies flush with the ET tube. The tracheal rings are palpated and a no. 14 or no. 16 Teflon catheter introducer needle is inserted between the first and second or second and third tracheal rings

49. The needle is removed, and a J-tipped guidewire is threaded through the remaining catheter into the trachea

50. This catheter sheath is removed and replaced by a 14F introducer dilator

51. This single dilator is introduced over the guidewire/guiding catheter unit in an arc conforming to the tract undergoing dilatation. Some collapse of the anterior tracheal wall may occur during dilatation Slight overdilatation facilitates placement of the tracheostomy tube. The tracheostomy tube, prefitted with the appropriately sized loading dilator, is threaded over the guidewire/guiding catheter unit into the trachea

52. At this point, the dilator, guiding catheter, and J-wire are removed (Fig. 68-18) and replaced with the inner cannula. The cuff is inflated and ventilation is continued through the tracheostomy tube.

53. Complications Desaturation Bleeding Infection Accidental Extubation Posterior Wall Injury Technical Misadventures False Passage, Pneumothorax, and Pneumomediastinum Accidental Decannulation

54. Emergency tracheostomy Position similar to that of elective tracheostomy A long midline incision- split through skin and sc tissue Next incision to be on the trachea Insertion of tracheostomy tube after adequate dilatation

55. Pediatric tracheostomy Incision: vertical, between the 2 nd and third ring Indication: Epiglottitis, croup, diptheria , laryngeal trauma, juvenile laryngeo papilloma

56. References Greys anatomy Stell and maran head and neck oncology Rob and smith operative procedures Complications in head and neck surgery Ent head and neck procedures operative guide Surgery of trachea and bronchi Operative otorhinolaryngology ( by nigel bleach) Operative otorhinolaryngology (by eugene ) Master techniques in otorhinolaryngology

57. Thank you