Presentation on theme: "Tracheotomy Dr J A Anderson MD MSc. FRCS(C)"— Presentation transcript:
1Tracheotomy Dr J A Anderson MD MSc. FRCS(C) Chief Department of Otolaryngology HNSSt Michael’s HospitalUniversity of TorontoPOS November 201215/04/2017
2Tracheotomy Indications Technique Complications Open and percutaneousComplicationsPhysiology of a tracheotomyTroubleshootingDecannulationThe outline for the talkPercutaneous may be new to some and a short video is available time permitting.The altered respiratory physiology is an important topic and it is the basis of a lot of the required tracheotomy care to prevent obstruction and other complications
3TracheotomyCreation of communication between the trachea and the cervical skin with insertion of a tube
4Indications Airway obstruction Pulmonary Secretions Ventilation Prolonged mechanical ventilationMay assist in weaning from mechanical ventilationPrevention of glottic stenosis/complication of prolonged ettWhy the pt was trached in the first place is crucial if you are called to manage a complication or make a decision regarding care of a trach tube pt.
5Fixed Airway Obstruction Tumours of upper aero digestive tractChronic airway obstruction up to 80% lumenExternal compression by tumourAnaplastic thyroid, massive lymphadenopathyForeign BodyGlottic Stenosis/tracheal stenosisTrauma upper airway
6Non-Fixed Airway Obstruction TraumaExpanding neck hematomaMaxillofacial traumaLaryngeal fractureInflammatoryInhalation injuryAnaphylaxisEpiglottitisLudwig’s Angina/Deep Neck space infectionBilateral vocal cord paralysisFiberoptic Intubation can be successfulSome of these may be managed with a flexible endoscopic intubation and then a trach may be performed ie Ludwigs angina, maxillofacial trauma (need ett out of the way, expect arch bars)
7Pulmonary Secretion Clearance Aspiration / dysphagiaCOPDBronchiectesisStasis of secretionsPoor coughPoor respiratory reserveMain goal is to prevent pneumonia/sepsis with better secretion clearance with suctioning/cough via trach.The medical conditions that predispose to the indication overlap considerably. For example, neurologic deficits are a common reason for significant aspiration, poor cough and inability to swallow.Recovery from a significant head injury or stroke may take months and trach care is an important issue for this patient population.
8Ventilation Neuromuscular disorder affecting respiratory muscles Reduced respiratory effortLimited pulmonary reserveCOPD, Scoliosis, bronchiectesisCentral respiratory depressionReduced LOCSevere obstructive sleep apneaCor pulmonale, failure CPAPThe second historical indication for tracheotomy was for polio in Up until then, the only indication was for acute upper airways obstruction with a very high mortality rate.Neuro indications could be bilateral paralysis of diaphragm to brainstem stroke or post head injury.A common indication particularly the chronic care and rehabilitation facilities. However, at times patient require reassessment as to whether or not their original indication still necessitates a tracheotomy for their care and in most cases this is straight forward following the decannulation protocol but in others, a more formal evaluation is needed.Patients often are send to SMH from outside institutions for this assessment regarding tracheotomy.
9Prolonged Intubation 7-10 days ett Risk Factors for Glottic Stenosis DiabetesFemaleSize ETT and # ettHemodynamic instabilityIncidence glottic stenosis: 5% over 10 days (Whited 1984)The video clip shows a man about 4 months post bypass who was ett for 21 days and never trached. He has significant stridor and no abduction of his cords at all. In fact, it nicely shows that as he inhales, his vocal get slightly pulled together (due to Bernoulli effect, negative pressure against the glottis as airflow if drawn in). As he exhales, his cords are alightly more open but his airway is about 3 mm wide at most.I just show the clip long enough to demonstrate this and then move on to next slide.This is a frequent reason that a patient fails decannulation. Surgical procedures can address the problem in some individuals but not all. Can be a cause of permanent tracheostomy.ie endoscopic laser arytenoidectomy or external laryngotracheoplastyLower video shows another patient who underwent open laryngoplasty with a stent in for four weeks and then was decannulated. St the start of the video, his wife say Wow Bob because she and the pt have been following his glottic stenosis prob lem with the video monitor during each examination and they both became quite good at understanding the findings on endoscopy. He has an open posterior glottic and some mobility of his folds but still not normal.
12Prolonged Intubation Weaning from ventilator Relative indication for tracheotomyModest gains in respiratory function after tracheotomy may be enough to increase chance of successful weaning from ventilatorTrend of patients ventilator requirements5 day reversibility of common ICU admitting diagnosesThis is an relative indication for tracheotomy. Many patients in the ICU have a tracheotomy performed because the ICU team feels that with just these modest changes, it may tip the balance in favour of the patient weaning from the ventilator. There is no exact protocol for this but a combination of factors including current ventilator settings (ie how much O2 , Peep) neurological status, other comorbidities like CAD, renal failure and how reversible their current acute condition are all factors taken into account. Often, the staff just ‘know’ if they trach a patient, they will likely wean.
13Tracheotomy Decision made patient requires tracheotomy Open or percutaneous technique75% of tracheotomies done at SMH are done percutaneously in ICU at bedsideVariations of open tracheotomy techniqueGeneral principles are the sameExternal approach through neck soft tissueCreation of opening in tracheaPlacement of tube to maintain airwayCuffed tube placed during GA usually changed to a non cuffed fenestrated for voicing and /or planning for decannulationBasically, all patients are considered by the ENT service as a potential percutaneous tracheotomy. If they do meet the indications for a perc, the patient has an open trach in the OR.
14Technique Diagrams from Lore, Surgical Atlas 1988 Brief outline of procedure, standard approach, pt ett, under ga, next extended, between 2-3 ring etc.Diagrams from Lore, Surgical Atlas 1988
15Equipment Tracheotomy set Tracheotomy tube Right angles, cricoid hook, trach spreaderTracheotomy tubeShiley most commonSelect size (6, 8 most common)Cuffed non-fenestrated for most ICU patientsFenestrated if voicing expected (use non-fen inner cannula during procedure)
16Open TracheotomyTransverse incision half way between cricoid and sternal notchRetractionDivide strap muscles in midlinePosition the patientNeck extendedRoll under shouldersArms tuckedOn OR bedPalpate landmarks
17TechniqueDiagrams from Lore, Surgical Atlas 1988
18Technique cont’d Thyroid isthmus Divide or retract Identify cricoid and upper tracheal rings using blunt dissectionBlunt cricoid hook helpfulRetract cricoid in superior directionTracheotomy tube cuff checked and obturator inDeflate cuff of endotracheal tubeHorizontal incision between tracheal rings (below the second ring)Suction lumen if necessarySpread rings apart with spreader or scissors
19Technique 2 DO NOT use cautery on the trachea FIRE! This is when it is tempting to use cautery on the trachea. There is a risk of tracheal fire if you use electrocautery on the trachea when opening the rings. The ignitor is the cautery, the accelerant is the oxygen and the ett tube burns.DO NOT use cautery on the tracheaFIRE!
21TechniqueEndotracheal tube withdrawn until just above the open tracheal siteTracheotomy tube with obturator, pushed into mid lumen of trachea, then directed inferiorlyObturator withdrawn and inner cannula placedAnaesthetic connector tubing passed over and connectedCuff inflatedDO NOT LET GO OF THE TUBE
22Final Anaesthesia: Check CO2, good breath sounds Sew in the trach tube shield to skinLoosely approximate incisionTrach ties
23Contraindications Medically well enough for GA PEEP < 20 mm Hg Uncontrolled coagulopathyAirway pathology below tracheotomy site
24Percutaneous Tracheotomy Bedside tracheotomy in ICU patientsAn alternative not replacement for open trachGeneral anaesthesia and paralysis for procedureFiberoptic broncoscopic guidanceCiaglia ‘Blue Rhino” by Cooke $200Bronchoscopic guidanceExperienced personnelAnaesthesiaRespiratory therapistSurgeon
25Selection of Patients Must be able to palpate landmarks adequately Cricoid above sternal notchLow larynx/cricoidHigh innominate artery problematicPEEP > 20 contraindicationAdvantagesSmaller wound, less dissectionICU settingSet uptime 20 minutesProcedures time less than 10 minutesAnatomy is main limiting factor once pt is medically well enough to consider a tracheotomy.OR costs at least 1000 an hour/ Trach tube cost is the same for either, Shiley etcGetting access to do a trach in the OR can be difficult since they are elective procedures and can delay timing of tracheotomy which may mean the pt stay in the ICu longer
26Percutaneous Tracheotomy DisadvantagesNot for everyoneMust ventilate with ETT in high positionMaybe an air leak during procedureMust use Shiley tubeExperienced personnelContraindications same as open andAnatomic limitationsNot for everyone means the patient, the setting and the surgeon. The necessary ICU setting, appropriate staff for anaesthesia, bronchoscopic guidance and surgical experience important to successfully performing this procedure with very low complication rate (<1%).
27Technique Identify landmarks Local anaesthetic Small incision midline ETT moved superiorly until cuff at cordsBronchoscope with connector in ETTNeedle in midline into tracheaGuide wire passed inferiorlySmall calibre dilatorWire sheath and ‘blue rhino’ dilator pushed along wire into tracheaTrach tube with fitted introducer passed over wire into tracheaMay delete slide and just talk over video.
28Video Percutaneous Tracheotomy Video is 2 minutes of perc procedure and I orient the audience to the anatomy, indicate that the bronchoscopic view can be on a video monitor so everyone involved can visualize the procedure. Anaesthesia runs the bronch and d\anaethesia and paralysis.The technique itself takes less than ten minutes but the ICU takes 20 minutes for set up. Patient position, drugs, find all personnel required etc.The blue rhino dilator is the large curved blue dilator and it is a single dilator kit. SHiley tubes 4 6 or 8 can be used.
29Tracheotomy Tubes Portex and Shiley common brands of trach tubes. SMH uses exclusively shiley tubes in part for surgeon preference and in part to conform to a consistent protocol for nursing and respiratory care.We had problems when different tubes and inner cannulas were either not available or did not fit and made a decision to conform to one type of trach tube . Occasionally a special needs of a patient might require an alternate tube.The essential material is polyvinyl chloride or PVC with an outer cannula and in most types, also an inner cannula. Inner cannulas are designed to increase safety by allowing the inner cannula to be moved is obstructed with secretions or blood.The Fenesra is the hole in the back of the trach to faciliate airflow through the tube and not just around the tube if the patient is voicing or planning decannulation. The initial tube placed is also a cuffed one since the patient is under a GA.The sizes between these two main types is not the same. Shiley uses the diameter of the inner cannula as the size ie 6mm or 8mm. Portex uses an alternate system. Portex tubes have closer to a 90degree curvature in the tube and Shiley is less acutely angled. This may make one or the other more comfortable depending on their neck shape and thickness of soft tissue between the neck and the trachea in a patient with longterm or permanent tracheotomyA size 6 and 8 are the most common tube sizes used.Portex and Shiley common brands of trach tubes.Shiley used as standard tube at St Michael’s Hospital.
30Tracheotomy TubesJackson or Stainless steel: flatter shield, different material sometimes better tolerated by one patients’ tissues than anotherI will often try a metal or other material tube when granulation tissue is problematic but the metal tube is obviously more rigid and less conforming to the airway.Moore tubes are silicone and quite soft and flexible. They come in normal and extra long length and also conform to patient stome/trachea.Neither are fenestrated.
31Tracheotomy Tubes Bivona or foam cuff Tracoe Cuffless Speaking valve Two other tubes used in a different patient populations.Bivona is a foam cuff and inflates with a larger surface contact area on the tracheal mucosa. They also come in an extra long tube that can be extra long coming out of the neck or extra long at the tip of the tube for difficult to fit patients.These are for ventilator dependent patients and these do not have an inner cannula due to the silicone material- secretions are not supposed to adhere).Patients who tend to tend to have an airleak with the standard tube and low pressure, high volume air filled cuff (like Shiley) may do better with Bivona foame cuff. The fome cuff is supposed to be less traumatic for tracheal mucosa with low pressure and larger surface area contact.The trach tube on the right is a Tracoe which is a cuffless thermo adaptive tube that does conform to the patients stoma/tracheal shape over time. I have many patients who use this tube who are ambulatory and they find it more comfortable with less granulation tissue formation. It is flatter and fits under a shirt better but the speaking valve which is integrated with the inner cannula, does make a small click as it closes. Downside is that the tube breaks easier, cracks more readily and they cost a lot. Shiley cost 85$ cdn and a tracoe is $400 at least. They last about 6 months on average.Paper by Jarrett et al 2002 on Biofilms on Tracheostomy tubesCompared PVC, silicone, stainless steel and sterling silver.A biofilm is an organized matrix of bacterial colonies. Most comon pathogens are pseudomonas and staph epidermidis which form polysaccharide matrices. Pseudomonas in particular likes to form a sessile colonies of bacteria that attaches to surfaces.They cultured the tube surfaces with the two pathogens and noted no difference on biofilm formation .Bivona or foam cuffTracoe CufflessSpeaking valve
32Complications: Intraoperative Bleeding 2.8%*Recurrent laryngeal nerve injuryTracheoesophageal fistulaPneumothorax: rareFalse passageAnterior dissection most commonIncidence <1%*Kost et al 1994Intraop complications are uncommon and we also have a similar experience of around a 1% complication rate.
33Odd Things That Can Happen Trach tube place upside downNo CO2 tracing despite surgeon positive tube is in the airwayCut the pilot tube of the cuff while cutting the suturesTrach tube coughed across table after correct placementDifficulty with air leakCuff leak/tube too short or not large enough /position tubeBlocked tube secondary to secretions/blood
34Tracheotomy: Early Complications BleedingMinor commonMajor tracheoinnominate fistula (<0.2%)*Obstruction of tube (2.5%)*Dislodgement (1.4%)*Pneumothorax ( %)*Wound InfectionLocal care, antibiotics (staph/pseudomonas)Tube obstruction with secretions or blood is the most common problem.Next most common is a wound infection, often staph or pseudmonas and treated with local wound care and antibiotics, usually resolves.More rare is a true chondritis due to a pseudomonas infection of the tracheal cartilage. This can be a serious problem in a diabetic with loss of tracheal rings and difficulties used the stoma with poor fit and airleak. If this is extensive, the trach tube has to be removed after the pt intubated and the wound is packed with wet to dry packing until it closes.
35Late Complications Tracheal stenosis Tracheal chondritis Subglottis stenosis- high tracheotomyTracheomalaciaTracheoesophageal fistulaFailure of stoma closure when decannulatedOverall complication rate 15-30% in ICU patientslargely minor with no long term morbidity
36Tracheoinnominate Fistula More than 10 days post tracheotomy (as early as 5 days)Sentinel bleedAngiogram/CTA for diagnosisSurgical explorationInterventional radiology-stentAssociated with low tracheotomy placement, wound infection or aberrant artery
37Late Complications/Stoma The risk of a massive bleed from a tracheo innominate fistula is very rare. In fifteen years at SMH there have been 2 known death associated with this complication. Both complicated with wound infection in severely ill patients. At least two weeks post op. This is usually during their inpatient stay in an acute care setting.Longterm complications from tracheotomy are usually local issues like granulation tissue, bleeding and infections. patients tend to develop granulation tissue at their stoma site in response to the presence of foreign material. This can cause localized infection, minor bleeding and at time obstruct the fenestra of their tube with the pedunculated tissue.Video clip shows a view of a stoma with trach removed using a flexible nasendosope. At site, there is moderate granulation tissue inside the stoma and the tracheal wall is moderately dry with some mild crusting and flecks of blood. The patient coughs and clears mildly sticky secretions.Humidification must be provided since the usual method of nasal humidification and heating of air is bypassed with a tracheotomy. This is beneficial to the mucosa but the skin around the stoma does not tolerate being constantly wet. I often recommend that patients use saline drops placed into the trach tube several times a day to add extra mucosal humidification (assuming the patient has a decent cough) .Minor amount of bleeding common due to granulation tissue /dry mucosa
38Stoma and Inferior View Vocal Folds Video shows much cleaner stoma, healthy mucosa and minimal granulation tissue. Inferior view of vocal folds is not done on every patient but we do examine the airway with a flexible endosocpe prior to decannulation if there has been any difficulties with decannulation protocol or if there has been an airway obstruction.
39Physiology of Tracheotomy Neck breathingBypass upper airway and nasal functionLoss of humidification/heat airflowDryness, thick secretionsVoicing possible with speaking valveLoss of smell /reduced tasteLoss glottic closure function for coughCough function Normally glottic closure permits a blast of increased intrathorcic pressure to bolster cough and assist in secretion clearance.Hassle factor: pts and caregivers would all prefer not to look after a trach. High on the inconvenient level and requires training and a certain comfort level with cleaning and cannula care. Nonetheless, tracheotomy is often a necessary part of complex patient.
40Physiology of Tracheotomy Respiration AdvantagesLower work of breathing (30%) c/w normal airwayFacilitates secretion clearanceAspiration or thick secretionsLess dead space (100 mL)Reduced airway resistanceAssists in patient independence from mechanical ventilationPatient comfort (better than ett)Epstein 2005 Respiratory CareChadda et al Measured WOB on 10 pts while trached, then after decannulation and WOB increased by up to 30% when trach removedObvious access for secretion clearance particularly important in patients who have florid aspiration and or significant pulmonary secretions with a reduced cough.Often a multifactorial problems with respiratory function ie brainstem stroke with reduced respiratory and/or laryngeal function on a neuromuscular level with aspiration causing recurrent pneumonia and thick secretions.Lowered airway resistant has not been proven to be significant at times due to; 1) tube lumen smaller than normal glottic aperture and 2) turbulent airflow due to increased flow rate and shape of the tubeMany patients who fail extubation are successfully weaned once tracheotomy is performed. Literature is mixed but support appears to support tracheotomy in ett patients who have been difficult to wean that there is reduced work of breathing (elastic and resistive)Patient comfort should not be underestimated when compared with endotracheal intubation. However, many patients not on mech ventilation would be more comfortable without a tracheotomy tube.
41Physiology of Tracheotomy Respiration DisadvantagesTube diameter and shapeincreases turbulent airflow, secretions adhere inside tubeLoss of humidification/heat function of upper airwayCiliary function affectedBiofilm colonizationDiminish cough/loss glottic closureReduce laryngeal elevation during swallowPatient comfort (better no tube at all)Lowered airway resistant has not been proven to be significant at times due t 1) tube lumen smaller than normal glottic aperture and 2) turbulent airflow due to increased flow rate and shape of the tubeHowever, many patients not on mech ventilation would be more comfortable without a tracheotomy tube.Physiology of tracheotomy and its effects are contradictory. On one hand, a trach facilitates pulmonary secretion clearance and at the same time, the loss of humidification/heat transfer by bypassing upper airway thickens secretions and can cause mucosa dessication. The resulting loss of ciliary function and thickened secretions can predispose to mucous stasis subsequent respiratory infections.
42Dysphagia Common issue in neurological impaired pt Tube required for secretion management particularly in patient with florid aspirateTube presence associated with limitation of the cephalad excursion of larynx during swallow and can contribute to dysphagia/aspirationEndoscopic / fluoroscopic assessmentThis problem comes up in the head injury and neurologically affected population quite often. On one hand, the trach is indicated to deal with aspiration and on the other hand, it contributes to it.Wide variation in patient swallowing function and neurological status.Floridly aspirating patient are staying trached to clear secretion and helpfully prevent pneumonia.Microaspiratoin patients with minimal aspiration on deglutition study with good cough and clearance of the aspirate and no other indication ,I would try decannulating.In the middle, I often want information from the nursing unit where the patient has been about the quantity and thickness of secretions. If suction is rare, pt able to clear secretion well through tube, swallowing their saliva, will trial corking / decannulation. Worse come to worse, trach has to get put back in.Upper airway examination for vocal fold function, clearing secretions and an assessment by speech language pathology is indicated.A bedside swallow assessment can be very helpful and a formal deglutition study if possible.I frequently assess patient because the SLP involved needs more information about laryngeal function either regarding airway, voice or swallowing.Speech Therapy assessment!
43Postoperative Tracheotomy Care Humidification via trach mask/Instill salineClear secretions, prevent crustInner cannula cleaning tid at leastIf non-ventilated, change cuffed tube to non-cuffed at 5-7 daysTies changed 2 people if possibleMost hospital have nursing/RT protocolTeach everyone trach care including patient, familyThe altered physiology is reflected in the required tracheotomy care. Combination of nursing and respiratory care. Many patients/family members can be taught some portions or all of trach care. This increases comfort level and safety. In my opinion, the more individuals who are able to change and clean an inner cannula around a trach dependent patient, the better.
44Inner Cannula Care Frequently done tid or more Saline and hydrogen peroxide (1:1) and trach brushRinse with sterile water/saline and reinsertSpare inner cannula and store in clean covered containerTies should be one finger tight and square knotAmbulatory and independent living trach patients end up always doing their own trach care or with family member to help. The nursing guidance and home care at the beginning is crucial but their knowledge base increases quickly and they do not need nursing care long term.Keep the ties snug around the neck. A trach tube that can wiggle too much ends up causing more discomfort, coughing and granulation tissue.Respiratory Therapy Protocol SMH
45Troubleshooting Dislodgement CausesTies too looseCoughcuff deflatedtube too short/wrong size for patientClinical signsDifficulty in ventilating patientIncreased airway pressureSuction catheter obstructedNon Ventilated PatientPoor coughSudden voice changeStridor, SOBSuction catheter blockedCausestrach ties too looseCoughing tube outCuff deflatedtube too short for that patient’s anatomy
46What to do: Dislodgement Extend neckRemove inner cannulaUse obturator to redirect tracheotomy tube into lumenIf patient in distress and does not have fixed obstruction above, pull out trach tubeVentilate with mask/intubateUse flex bronchoscope or replace/ORExtending the neck to to place tube is important since this is the position that it was put in and it makes the easiest alignment to replace tube.Try to remove inner cannula is pt in distress since secretions are the most common cause of obstruction and replacing the inner cannula is often effective.The obturator is used to replace the outer cannula if it is dislodged.Important to know why the patient is trached. If there is no airway obstruction, the track is blocked and none of the above has worked, rempoving the trach may be the best way to temporarily relieve the obstruction. Most patients who are not ventilated with a trach can be intubated if needed or breath with an oxygen mask or oral airway in place.
47Troubleshooting Tube Obstructed Mucous plug or blood clot most likelyGranulation tissue, particularly fenestrated tubesRemove inner cannula, suction, instill salineBronchoscopyIf no other recourse, pull out trach tube and if necessary, replace new tube with obturatorIntubate/ventilate from above
48Troubleshooting: Bleeding Bleeding around trach stomaMinor bleeding immediately post-opModerate bleeding/venous oozing often related to thyroidExamine woundPack, surgicel, if not controlled, take back to ORBleeding from within lumenOften related to suctioningBroncoscopy examDry mucosaGranulation tissueCoagulopathyRare innominate fistulaAround stoma bleeding can also be from granulation tissue which can be excised and cauterized usually at bedside.or in clinic setting. Post op minor stoma bleeding often treated with local packing and silver nitrate or surgicel packing.Increase saline instillation /humidification to reduce mucosal bleeding.
49DecannulationGoal is to ensure patient can tolerate increased airway resistance/work of breathing and secretion clearance30% increase WOB transition from trach breathing to upper airway breathingWhen to take a trach tube out. Pt must be able to tolerate increased work of breathing to remove trach, and cope with their secretions,Micro aspiration can at times be tolerated if the patient has a sensate trachea and can clear the secretion well. This is an area where sometimes a trial of decannulation may be the only way to ‘test’ if the patient can cope with minor aspiration without pneumonia developing.
50Decannulation Indication for tracheotomy has resolved/improved Patient able to cope with secretionsUpper airway patent - examined if necessaryAppropriate vocal cord functionGood respiratory reserve/overall respiratory statusGag reflex present (5-10% no gag)Micro aspiration can at times be tolerated if the patient has a sensate trachea and can clear the secretion well. This is an area where sometimes a trial of decannulation may be the only way to ‘test’ if the patient can cope with minor aspiration without pneumonia developing.No gag present in 5-10% of normals.
51Decannulation Stable clinical condition Adequate swallowing Hemodynamic stabilityAbsence of fever, sepsis infectionAdequate swallowingGag reflex, bedside swallowing assessment, video fluoscopyMaximum expiratory pressure > 40 cm H2OMicro aspiration can at times be tolerated if the patient has a sensate trachea and can clear well. This is an area where sometimes a trial of decannulation may be the only way to ‘test’ if the patient can cppe with minor aspiration without pneumonia developing.Max expiratory pressure RT can measure.Ceriana et al 2003
52Decannulation Protocol Downsize tube to either 4 or 6 ShileyCuffless fenestrated tubeGradually increase corking/cap of trachCorked hours before decannulationRemove tracheostomy tubeOcclusive dressing for stomaPersistent patent stomaOccasionally requires local flap to closeOutpatient procedure under local, infection commonCan decannulate with downsizing but easier to breath around tube is fenestra is not ideally positioned within trachea and stoma does close around smaller tube.Usually a 6 Shiley in most patient, occasioally a 4 in a smaller woman.I will wait 2 – 3 months before closing with a flap.Almost always they get infected and I want the stoma as small as possible.
53Difficult to Decannulate Granulation tissueFenestra obstructedTracheal mucosal edema/supraglottic edemaNG, aspirationLaryngeal pathologyGlottic stenosis, cord paralysisPulmonary secretionsIncrease airway resistance not toleratedPresence of NG can increase supraglottic edema, reflux, stasis of secretion in hypopharynx. If likely to have prolonged inability to swallow and pt may be able to be decannulated with a good cough and secretion clearance, suggest g-tube placement.
54Tracheotomy: Summary Safe method of airway management Open versus percutaneous technique availableComplications largely minorMortality rare from procedure directly0.3%* in last 30 years (grouped data)Mortality rate for this procedure was close to 100%in the late 1800s and 40% in 1930s.
55SummaryAdvantages/risks of a tracheotomy for that individual patient must outweigh the disadvantages/risks without one.Indication for TracheotomyMedical comorbiditiesRespiratory /deglutition functionAbility to cope with secretionsTrial of corking/decannulation
56Cricothyroidotomy Open versus percutaneous technique Prep and position as for trachIdentify landmarksLocal anaestheticIncision over cricothyroid membranePlacement of small tracheotomy tube, ETT or large bore needle with attachment for ventilation
57Cricothyroidotomy Advantages Quick c/w open trach No laryngeal injury Failure of intubation attempts in emergency situationDisadvantagesCan cause laryngeal injuryMust be sure of landmarksSmall tube required