2Protocol Criteria for Tracheostomy Decannulation Attempt Following Successful Liberation From Prolonged Mechanical VentilationAbsence of distress and stable arterial blood gases on prolonged mechanical ventilation for 5 daysStable clinical condition indicated by factors such as:Hemodynamic stabilityAbsence of fever, sepsis, or active infectionPaCO2 60 mm HgNormal endoscopic examination or revealing stenotic lesionsoccupying 30% of the airwayAbsence of delirium or psychiatric disordersAdequate swallowing evaluated by gag reflex, blue dye, and video fluoroscopyPatient able to expectorate on requestMaximum expiratory pressure 40 cm H2O
3ComplicationsNo. 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 OutcomeTracheal stenosisHemorrhageTracheocutaneous fistulaInfectionPneumothoraxTube decannulation/obstructionSubcutaneous emphysemaTracheoesophageal fistula
4Anterior 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
5directly proportional to length The resistance to flow of gas through a tube, represented by the Poiseuille equationdirectly proportional to lengthinversely proportional to the radius of the tuberaised 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.
61. Frost EA. Tracing the tracheostomy 1. Frost EA. Tracing the tracheostomy. Ann Otol Rhinol Laryngol 1976; 85(5 Pt 1):618–624The word tracheostomy is derived from 2 Greek words meaning “I cut the trachea.”
7Raw and Vd (deadspace vol) endotrachealtrachSize ID length Vdmm cm mlSize ID length Vdmm cm ml
8Diagrams of the dead-space volume of the upper airway (A), a tracheostomy tube (B), and an oral endotracheal tube (C).
9Trach vs ett effect on WOB Tracheostomy tubes have an important effect on respiratoryphysiology. The most recent and methodologicalrobust studies indicate that these tubes reduce resistive andelastic WOB when compared to ETTs. This is a result oftracheostomy tubes lessening inspiratory and expiratoryairways resistance and intrinsic PEEP.
10Before 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 tracheostomyVt mlVe l/mF b/mPEEPi cm/hPTP cm/h20xs/min 236WOB J/LWOB J/minExp RAWAfter tracheostomy p
11Davis et al study 20 surgical patients 14 men Mean age 58 Acute lung injuryVentilate mean 16 daysMet extubation criteriaFailed extubation twice before trach decision80% had #8 ETT20% #7 ETTMeasurements: 6-8 hours before and 12 hours after surgical trach.
12Techniques of Performing an Open or Surgical Tracheostomy the 2nd tracheal ring is dividedlaterally and the anterior portion removedInstead of resecting and removingthe tracheal ring, it can be used to create a flap, which canbe attached to the skin. This method, described by Bjork.,
13TECHNIQUE FOR PERFORMING Percutaneous TRACHEOSTOMY Fiberopic bronchoscopy is used to help place the guidewire correctly for PDT. Here the wire is seen in the anterior part orthe trachea, passing between the 2nd and 3rd tracheal rings.Here is the bronchoscopic view of the tip of a dilator enteringthe trachea over the guide wire during placement of a percutaneousdilational tracheostomy.
14TECHNIQUES FOR PERFORMING Percutaneous TRACHEOSTOMY a series of tapered dilators aresequentially inserted over the guide wire to create the stoma forplacement of the tracheotomy tube.The Blue Rhino is a single dilator that can be used instead of the sequential dilators of the Ciaglia method
15sacred 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 1550BC. 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.
16Gordon BL. The romance of medicine: the story of the evolution of medicine from occult practices and primitive times. Philadelphia: FA Davis; 1947:461. Greek historyIn 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, inthe 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.”
17McClelland 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):618–624Both Aretaeus and Galen, in the 2nd Century AD, wrote that Asclepiades of Bithynia performed elective tracheostomy in around 100 BC. McClelland RMGalen, 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 EAAntyllus', a 4th century Roman physician.
18Only 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 itwas by Brasavola in 1546, who used it to relieve airway obstruction from enlarged tonsils. McClelland RMAntonio 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 EAThe 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 EAThe Italian surgeon Sanctorio Sanctorius ( ) was probably the first surgeon to describepercutaneous tracheotomy (Sanctorius, 1626).
19Frost 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( ).
20Trach 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.
21indications 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 toindications and techniques of tracheostomy.
22Jackson 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).
231. 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 intothe trachea through the neck especially to allow the passageof air• Tracheotomy: the surgical operation of cutting into thetrachea especially through the skinStedman’s Medical Dictionary:• Tracheostomy: An operation to make an opening intothe trachea.• Tracheotomy: The operation of incising the trachea, usuallyintended to be temporary3. Oxford English Dictionary:• Tracheostomy: The operation of making an opening inthe trachea near its upper end, so that the patient canbreathe through it; also, the opening so made• Tracheotomy: = tracheostomy
24Tracheostomy tubes are used to: administer positive-pressure ventilationprovide a patent airwayprovide protection from aspirationAirway protection in head injured or comatose patientand in postoperative neurosurgical patientsprovide access to the lower respiratory tract for airway clearance
25Tracheostomy tube selection IDODCurveAngledCurvedLengthXl proximalXl distalnormalCuffedLow pressureFenestratedNon-fenestratedTight to shaftFoamUncuffed
26Cuff 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.
27Size 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
28anatomythe 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.
29resistance through Shiley tracheostomy tubes # cm H2O/L/s# “# “#Mullins JB, Templer JW, Kong J, Davis WE, Hinson J. Airwayresistance and work of breathing in tracheostomy tubes. Laryngoscope 1993;103(12):1367–1372
30Tracheal 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#FemaleC 14U 33D 16E 21T 16O 038106451The tone of the trachealis muscle that bridges the gaps posteriorly between rings is responsible for the shape differences.
31Possible Reasons Why Tracheostomy Might Facilitate Weaning 1.Reduced dead space2.Less airway resistance3.Decreased work of breathing4.Better secretion removal with suctioning5.Less likelihood of tube obstruction6.Improved patient comfort7.Less need for sedation8.Better glottic function, with less risk of aspiration9.Ability to move patient out of the intensive care unit10.Changes in clinician behavior
32Dimensions (mm) of Portex Blue Line Ultra Suctionaide Tracheostomy Tube Designed for Subglottic SuctionInner Diameter Outer Diameter Length
36Tracheostomy tube with inner cannula and obturator
37Angled 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.
38Low-profile tracheostomy tube. Smiths Medical, Keene, New Hampshire.
45Fenestrated tracheostomy tubes. Note the 3 styles of fenestration. Shiley on left and Portex on right. Portex uncuffed fenestrated at bottom.
46Examples of decannulation caps (below) and associated inner cannulae
47An 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.
48Portex and Shiley percutaneous tracheostomy tubes. The Perc trach has a tapered tip and the cuff is bonded down .
49Subglottic 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
50Olympic 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.
51Montgomery 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.
52Oxygen 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.
53Calculated shunt table Work this table back and forth to determine FIO2 change and device change.
54Oxygen devicesLow flow vs high flow; aka variable O2 devices vs fixed O2 devices.
55Clinical 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.
56Low 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.)
57Low 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.
58Low flow: partial rebreathing mask 60-80% O2 (no valves)
59Low 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.