1. Components of a standard tracheostomy tube

2. Protocol Criteria for Tracheostomy Decannulation Attempt
Following Successful Liberation From Prolonged Mechanical Ventilation
Absence of distress and stable arterial blood gases on prolonged mechanical ventilation for 5 days
Stable clinical condition indicated by factors such as:
Hemodynamic stability
Absence of fever, sepsis, or active infection
PaCO2 60 mm Hg
Normal endoscopic examination or revealing stenotic lesions
occupying 30% of the airway
Absence of delirium or psychiatric disorders
Adequate swallowing evaluated by gag reflex, blue dye, and video fluoroscopy
Patient able to expectorate on request
Maximum expiratory pressure 40 cm H2O

3. ComplicationsNo. ofcasesPercent ofTotal Outcome
Complications of Tracheotomy in a Series of 1,130 Patients: Goldenberg D, Ari EG, Golz A, Danino J, Netzer A, Joachims HZ. Tracheotomy complications: a retrospective study of 1130 cases. Otolaryngol Head Neck Surg 2000;123(4):495–500.
ComplicationsNo. ofcasesPercent ofTotal Outcome
Tracheal stenosis
Hemorrhage
Tracheocutaneous fistula
Infection
Pneumothorax
Tube decannulation/obstruction
Subcutaneous emphysema
Tracheoesophageal fistula

4. Anterior oblique view of larynx and trachea
Anterior oblique view of larynx and trachea. The preferred anatomic locations for placing standard tracheostomy, percutaneous tracheostomy, and cricothyroidotomy are indicated

5. directly proportional to length
The resistance to flow of gas through a tube, represented by the Poiseuille equation
directly proportional to length
inversely proportional to the radius of the tube
raised to the 4th power (when flow is laminar)
When flow becomes turbulent, airways resistance becomes inversely proportional to the radius of the tube raised to the 5th power.
small reductions in tube radius result in large increases in resistance.
Turbulent flow occurs when flow rates are high, when secretions adhere to the inside of the tube and because of tube curvature.

6. 1. Frost EA. Tracing the tracheostomy
1. Frost EA. Tracing the tracheostomy. Ann Otol Rhinol Laryngol 1976; 85(5 Pt 1):618–624
The word tracheostomy is derived from 2 Greek words meaning “I cut the trachea.”

7. Raw and Vd (deadspace vol)
endotracheal
trach
Size ID length Vd
mm cm ml
Size ID length Vd
mm cm ml

8. Diagrams of the dead-space volume of the upper airway (A), a tracheostomy tube (B), and an oral endotracheal tube (C).

9. Trach vs ett effect on WOB
Tracheostomy tubes have an important effect on respiratory
physiology. The most recent and methodological
robust studies indicate that these tubes reduce resistive and
elastic WOB when compared to ETTs. This is a result of
tracheostomy tubes lessening inspiratory and expiratory
airways resistance and intrinsic PEEP.

10. Before tracheostomy Vt ml 329 Ve l/m 9.2 F b/m 28 PEEPi cm/h20 2.9
Respiratory variables before and after tracheostomy in 20 Surgical Intensive Care paients. Davis K Jr, Campbell RS, Johannigman JA, Valente JF, Branson RD. Changes in respiratory mechanics after tracheostomy. Arch Surg 1999;134(1):59–62.
Before tracheostomy
Vt ml
Ve l/m
F b/m
PEEPi cm/h
PTP cm/h20xs/min 236
WOB J/L
WOB J/min
Exp RAW
After tracheostomy p

11. Davis et al study 20 surgical patients 14 men Mean age 58
Acute lung injury
Ventilate mean 16 days
Met extubation criteria
Failed extubation twice before trach decision
80% had #8 ETT
20% #7 ETT
Measurements: 6-8 hours before and 12 hours after surgical trach.

12. Techniques of Performing an Open or Surgical Tracheostomy
the 2nd tracheal ring is divided
laterally and the anterior portion removed
Instead of resecting and removing
the tracheal ring, it can be used to create a flap, which can
be attached to the skin. This method, described by Bjork.,

13. TECHNIQUE FOR PERFORMING Percutaneous TRACHEOSTOMY
Fiberopic bronchoscopy is used to help place the guide
wire correctly for PDT. Here the wire is seen in the anterior part or
the trachea, passing between the 2nd and 3rd tracheal rings.
Here is the bronchoscopic view of the tip of a dilator entering
the trachea over the guide wire during placement of a percutaneous
dilational tracheostomy.

14. TECHNIQUES FOR PERFORMING Percutaneous TRACHEOSTOMY
a series of tapered dilators are
sequentially inserted over the guide wire to create the stoma for
placement of the tracheotomy tube.
The Blue Rhino is a single dilator that can be used instead of the sequential dilators of the Ciaglia method

15. sacred book of Hindu medicine, written between 2000 and 1000 BC.
It is referred to in 2 of the 3 oldest known medical works, both mention cutting into the neck to access the windpipe.
The Rig Veda,
sacred book of Hindu medicine, written between 2000 and 1000 BC.
The Ebers Papyrus, dating from about 1550
BC. The Ebers Papyrus is written in hieratic Egyptian writing and preserves for us the most voluminous record of ancient Egyptian medicine known.
The ancient Chinese text Huang Ti Nei Ching Su Wen contains no reference to any surgical procedure.

16. Gordon BL. The romance of medicine: the story of the evolution of medicine from occult practices and primitive times. Philadelphia: FA Davis; 1947:461. Greek history
In the 8th century BC, Homer is said to have described the relief of choking persons on cutting into the trachea.
Hippocrates (4th century BC) may have referred to tracheal cannulation as a treatment for quinsy (peritonsillar abscess).
Alexander the Great, in
the 4th century BC, “punctured the trachea of a soldier with the point of his sword when he saw the man choking from a bone lodged in his throat.”

17. McClelland RM. Tracheostomy: its management and alternatives
McClelland RM. Tracheostomy: its management and alternatives. Proc R Soc Med 1972;65(4):401– Frost EA.. Tracing the tracheostomy. Ann Otol Rhinol Laryngol 1976;85(5 Pt 1):618–624
Both Aretaeus and Galen, in the 2nd Century AD, wrote that Asclepiades of Bithynia performed elective tracheostomy in around 100 BC. McClelland RM
Galen, the most eminent Greek physician after Hippocrates.
Antyllus of Rome told in AD 340 of making a transverse incision between the 3rd and 4th tracheal rings, drawing the cartilages apart with hooks, and subsequently sewing the edges of the wound together once the patient could breathe more freely. Frost EA
Antyllus', a 4th century Roman physician.

18. Only in the 16th century did reference to the performance of tracheostomy reappear (an entire millenium referenceless).
The first account of the procedure to be written by the surgeon who performed it
was by Brasavola in 1546, who used it to relieve airway obstruction from enlarged tonsils. McClelland RM
Antonio Musa Brassavola (variously spelled Brasavoli, Brasavola, or Brasavoli, born January 16, 1500 in Ferrara) was an Italian physician and one of the most famous of his time.
At about the same time , Fabricius ab Aquadependente is said to have performed a tracheostomy on a patient with a foreign body in the larynx , as well as on several other occasions. Frost EA
The first step towards percutaneous tracheotomy was made by the famous Italian anatomist and surgeon Fabricius of Aquapendente ( ).
Sanatorius , in 1590, first used a trocar for tracheostomy, and reported leaving a cannula in place for 3 days. Frost EA
The Italian surgeon Sanctorio Sanctorius ( ) was probably the first surgeon to describe
percutaneous tracheotomy (Sanctorius, 1626).

19. Frost EA. Tracing the tracheostomy
Frost EA. Tracing the tracheostomy. Ann Otol Rhinol Laryngol 1976; 85(5 Pt 1):618–624.
The word tracheostomy was first used by Heister in 1739 (German surgeon Laurentius Heister( ).

20. Trach bed 1 George Washington?
George Washington, who died in 1799, developed progressive upper-airway obstruction, the cause of which is thought most likely to have been acute epiglottitis. Scheidemandel HH. Did George Washington die of quinsy? Arch Otolaryngol 1976;102(9):519–521.5.
Witt CB Jr. The health and controversial death of George Washington. Ear Nose Throat J 2001;80(2):102–105.
The prominent physician Elisha C Dick, who examined the former president, recommended tracheostomy, but was overruled by the other physicians in attendance. Frost EA. Tracing the tracheostomy . Ann OtolRhinol Laryngol 1976;85(5 Pt 1):618–624.
Witt CB Jr. The health and controversial death of George Washington Ear Nose Throat J 2001;80(2):102–105.

21. indications and techniques of tracheostomy.
Frost EA. Tracing the tracheostomy. Ann Otol Rhinol Laryngol 1976; 85(5 Pt 1):618–624.
In the early 19th century, performance of the procedure became more widespread and there were multiple reports in the medical literature. Trousseau reported in 1869 on 215 patients in whom tracheostomy was performed in the treatment of diphtheria (with 47 survivors), his series having begun during the 1830s.
The 1860 yearbook of the New Sydenham Society contained some 38 papers devoted to
indications and techniques of tracheostomy.

22. Jackson C. Tracheotomy. Laryngoscope 1909;19:285–290.
In this country,the famous surgeon Chevalier Jackson refined the technical aspects of the procedure and described them in detail in 1909.
Chevalier Jackson standardized the indications for tracheostomy, the technique itself, and the instruments used, around the turn of the 20th century. He developed anatomically correct tracheostomy tubes, recommended a“high” tracheostomy location (ring 2 or 3).

23. 1. Merriam-Webster Online Dictionary:
Is It Tracheostomy or Tracheotomy—or Both? Reference to “definitive” sources does not help. For example, 3 authoritative dictionaries define the 2 terms as follows:
Merriam-Webster Online Dictionary:
• Tracheostomy: the surgical formation of an opening into
the trachea through the neck especially to allow the passage
of air
• Tracheotomy: the surgical operation of cutting into the
trachea especially through the skin
Stedman’s Medical Dictionary:
• Tracheostomy: An operation to make an opening into
the trachea.
• Tracheotomy: The operation of incising the trachea, usually
intended to be temporary
3. Oxford English Dictionary:• Tracheostomy: The operation of making an opening in
the trachea near its upper end, so that the patient can
breathe through it; also, the opening so made
• Tracheotomy: = tracheostomy

24. Tracheostomy tubes are used to:
administer positive-pressure ventilation
provide a patent airway
provide protection from aspiration
Airway protection in head injured or comatose patient
and in postoperative neurosurgical patients
provide access to the lower respiratory tract for airway clearance

25. Tracheostomy tube selectionID OD
Curve
Angled
Curved
Length
Xl proximal
Xl distal
normal
Cuffed
Low pressure
Fenestrated
Non-fenestrated
Tight to shaft
Foam
Uncuffed

26. Cuff deflated: Airway resistance
Chest 1996;110: Hussy, Bishop. Conclusion: The effort required to move gas across the native upper airway in the absence of a fenestration may be substantial. If a patient is to breathe through the native airway, a fenestrated tube should be used unless the tracheostomy tube is a #4.

27. Size differences Portex vs Shiley
Shiley uses the Jackson scale most of the time (xl and SCT uses ISO)
w/IC #4 = ID= 5.0, #6= ID 6.4, #8= ID 7.6 , #10= ID 8.9mm.
Portex uses the International Standards Organization (ISO) scale. Median –measure at shaft.
The functional internal diameter size. Subtract 1mm for inner cannula.
w/o IC #6= ID 6mm, #7 =ID 7mm, #8= ID 8mm

28. anatomy
the rigid cricoid cartilage encases a 1.5–2.0-cm region known as the subglottic space.
Inferior to cricoid is the trachea, a cylindrical tube that extends inferiorly and slightly posteriorly.
The trachea is made up of 18–22 C-shaped rings consisting of rigid cartilage anteriorly and laterally, and a membranous posterior portion.
In the average adult, the distance from cricoid to carina is approximately 11 cm in length, with a range of 10–13 cm.

29. resistance through Shiley tracheostomy tubes
# cm H2O/L/s
# “
# “ #
Mullins JB, Templer JW, Kong J, Davis WE, Hinson J. Airway
resistance and work of breathing in tracheostomy tubes. Laryngoscope 1993;103(12):1367–1372

30. Tracheal shapes 100 males and 100 females Annals of the Royal College of Surgeons of England (1984) vol. 66, C=C, U=U, D=D, E=elliptical, T=triangular, O= circular mean age 68 (32-90), mean height 164.5cm, 195 Anglo- Saxon and 5 Asian.
shape #Male
#Female
C 14
U 33
D 16
E 21
T 16
O 0 38 10 6 45 1
The tone of the trachealis muscle that bridges the gaps posteriorly between rings is responsible for the shape differences.

31. Possible Reasons Why Tracheostomy Might Facilitate Weaning
1.Reduced dead space
2.Less airway resistance
3.Decreased work of breathing
4.Better secretion removal with suctioning
5.Less likelihood of tube obstruction
6.Improved patient comfort
7.Less need for sedation
8.Better glottic function, with less risk of aspiration
9.Ability to move patient out of the intensive care unit
10.Changes in clinician behavior

32. Dimensions (mm) of Portex Blue Line Ultra Suctionaide Tracheostomy Tube Designed for Subglottic Suction
Inner Diameter Outer Diameter Length

33. Portex cuffed trach

34. Uncuffed and cuffed trach tubes

35. Blue Line® Extra Horizontal Length AdjustableNeck Flange Cuffed Tracheostomy Tubes
Portex

36. Tracheostomy tube with inner cannula and obturator

37. Angled versus curved tracheostomy tubes
Angled versus curved tracheostomy tubes. Note that the angled tube has a straight portion and a curved portion, whereas the curved tube has a uniform angle of curvature.

38. Low-profile tracheostomy tube. Smiths Medical, Keene, New Hampshire.

39. Extra-length tracheostomy tubes

40. Blue Line® Extra Vertical Length Tracheostomy Tubes with Double Cuff
Portex

41. UniPerc™ Extra Length Adjustable Flange Tracheostomy Tubes.
Can be used with Perc kit. Markings line up.
Portex

42. Flexible tracheostomy tubes with adjustable flange. Hv high-volume
Flexible tracheostomy tubes with adjustable flange. Hv high-volume. LP low-pressure.

43. Examples of low-pressure, tight-to-shaft, and foam-filled tracheostomy tube cuffs.

44. Foam cuff design

45. Fenestrated tracheostomy tubes. Note the 3 styles of fenestration.
Shiley on left and Portex on right. Portex uncuffed fenestrated at bottom.

46. Examples of decannulation caps (below) and associated inner cannulae

47. An example of an inner cannula in which the 15-mm ventilator attachment is connected to the inner cannula. If the inner cannula is removed, it is not possible to attach the ventilator.

48. Portex and Shiley percutaneous tracheostomy tubes.
The Perc trach has a tapered tip and the  cuff is bonded down .

49. Subglottic suction tubes
Subglottic suction tubes. Portex Blue Line Ultra Suctionaid tracheostomy tube. The arrow indicates the position of the suction port above the cuff. (Courtesy of Smiths Medical, Keene, New Hampshire.) Dimensions of Portex Blue Line Ultra Suctionaide Tracheostomy Tube Designed for Subglottic Suction

50. Olympic tracheostomy button (Olympic Medical, Seattle, Washington) positioned against the anterior tracheal wall. The tube is occluded with a solid plug (A) and fitted exactly to length with spacing washers (B). On the right is shown the distal flower-petal flanges (C) that expand to fit the tube into the trachea without sutures or ties. A positive-pressure adapter (D) can be attached to allow assisted ventilation.

51. Montgomery T-tube (stent) (left) and Montgomery silicone tracheal cannula (right). Purpose: Prevent stomal closure and allow access to trachea for suctioning. Emergency ventilation: Stopper in place and Mask bag.

52. Oxygen therapy Pathologic correlates for hypoxemia
Low inspired O2: high altitude, smoke inhalation.
Alveolar hypoventilation: COPD acute exacerbation, Acute asthma exacerbation, neuromuscular weakness.
Ventilation-perfusion mismatch: COPD exacerbation, asthma exacerbation, mild CHF, mild pna, mild atelectasis.
Shunt, right to left: severe exacerbation COPD/asthma, severe CHF/pneumonia/atelectasis, ARDS.
Diffusion defect: acts a a V/Q mismatch.

53. Calculated shunt table
Work this table back and forth to determine FIO2 change and device change.

54. Oxygen devices
Low flow vs high flow; aka variable O2 devices vs fixed O2 devices.

55. Clinical Guidelines for Selections of Oxygen Devices
A)The amount of oxygen (FiO2) desired (*This is the fundamental consideration.)
B) The degree of FiO2 precision required.
(*The Venturi mask is the mask of choice for “CO2 retainers”.)
C)Patient comfort and compliance.
D)The need for aerosol mist.

56. Low Flow device Nasal Cannula – 24-40%
1) Most commonly used device because of excellent patient tolerance.
2) The delivered oxygen at any flow setting depends primarily on the patient’s ventilatory pattern.
3) Can deliver from 24 – 40% oxygen and is ordered at flows of ¼ to 6 liters per minute.
4) Humidification should be used for flows greater than 4L/minute.
(*Exceptions: Humidification for flow rates <4L/min may be considered if the patient requests it, if the patient experiences epistaxis, or if the patient complains of a dry nose, dry secretions, and/or a sore throat.)

57. Low Flow device Partial Rebreather Mask – 60-80%
1) A reservoir bag is added to the simple mask design to deliver over 60% oxygen (from 60-80% oxygen).
2) A Non-Rebreather Mask is used and the 2 flaps are removed to create a Partial Non-Rebreather Mask.
3) The system allows the first part of the patient’s exhalation to enter the bag (anatomic dead space gas).
4) The reservoir bag should NOT deflate completely on inspiration. If this occurs, the patient may rebreathe his or her own CO2.
5) Partial rebreathers should always run at about 10 liter/minute to prevent total collapse.

58. Low flow: partial rebreathing mask 60-80% O2 (no valves)

59. Low Flow device Non-Rebreather Mask – 80-100%
1) The use of valves in the non-rebreather mask allows for one way flow of 100% oxygen into the reservoir bag and then out to the patient with no rebreathing of expired gas.
2) This delivery system is used when one needs to deliver a high percentage of oxygen quickly.
3) Flow rates of 10 – 15 liters per minute theoretically provide the patient’s entire inspired volume.
4) Increased respiratory drive along with improper seal of the mask may all for room air to be inspired.
6) The non rebreather mask contains 2 valves. Check labeling to be sure valves are latex free.

60. Low flow device: non-rebreathing mask 80-100% O2

61. Low Flow device 40-60% O2 High Flow Nasal Cannula 8-15 l/m

62. High flow device Vapotherm 8-40 l/m any FIO2

63. High flow Venti mask

64. Large volume nebulizer (left) Humidifier (right)

65. High flow Aerosol mask 21-100% O2

66. High flow trach collar 21-100% O2