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12/05/2015 1 Tracheotomy Dr J A Anderson MD MSc. FRCS(C) Chief Department of Otolaryngology HNS St Michael’s Hospital University of Toronto POS November.

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Presentation on theme: "12/05/2015 1 Tracheotomy Dr J A Anderson MD MSc. FRCS(C) Chief Department of Otolaryngology HNS St Michael’s Hospital University of Toronto POS November."— Presentation transcript:

1 12/05/2015 1 Tracheotomy Dr J A Anderson MD MSc. FRCS(C) Chief Department of Otolaryngology HNS St Michael’s Hospital University of Toronto POS November 2012

2 Tracheotomy Indications Technique Open and percutaneous Complications Physiology of a tracheotomy Troubleshooting Decannulation

3 Tracheotomy Creation of communication between the trachea and the cervical skin with insertion of a tube

4 Indications Airway obstruction Pulmonary Secretions Ventilation Prolonged mechanical ventilation May assist in weaning from mechanical ventilation Prevention of glottic stenosis/complication of prolonged ett

5 Fixed Airway Obstruction Tumours of upper aero digestive tract Chronic airway obstruction up to 80% lumen External compression by tumour Anaplastic thyroid, massive lymphadenopathy Foreign Body Glottic Stenosis/tracheal stenosis Trauma upper airway

6 Non-Fixed Airway Obstruction Trauma Expanding neck hematoma Maxillofacial trauma Laryngeal fracture Inflammatory Inhalation injury Anaphylaxis Epiglottitis Ludwig’s Angina/Deep Neck space infection Bilateral vocal cord paralysis Fiberoptic Intubation can be successful

7 Pulmonary Secretion Clearance Aspiration / dysphagia COPD Bronchiectesis Stasis of secretions Poor cough Poor respiratory reserve

8 Ventilation Neuromuscular disorder affecting respiratory muscles Reduced respiratory effort Limited pulmonary reserve COPD, Scoliosis, bronchiectesis Central respiratory depression Reduced LOC Severe obstructive sleep apnea Cor pulmonale, failure CPAP

9 Prolonged Intubation 7-10 days ett Risk Factors for Glottic Stenosis Diabetes Female Size ETT and # ett Hemodynamic instability Incidence glottic stenosis: 5% over 10 days (Whited 1984)

10 Example 1 Subglottic Stenosis

11 Example 3 Combined Glottic/Tracheal Stenosis

12 Prolonged Intubation Weaning from ventilator Relative indication for tracheotomy Modest gains in respiratory function after tracheotomy may be enough to increase chance of successful weaning from ventilator Trend of patients ventilator requirements 5 day reversibility of common ICU admitting diagnoses

13 Tracheotomy Decision made patient requires tracheotomy Open or percutaneous technique 75% of tracheotomies done at SMH are done percutaneously in ICU at bedside Variations of open tracheotomy technique General principles are the same External approach through neck soft tissue Creation of opening in trachea Placement of tube to maintain airway

14 Technique Diagrams from Lore, Surgical Atlas 1988

15 Equipment Tracheotomy set Right angles, cricoid hook, trach spreader Tracheotomy tube Shiley most common Select size (6, 8 most common) Cuffed non-fenestrated for most ICU patients Fenestrated if voicing expected (use non-fen inner cannula during procedure)

16 Open Tracheotomy 1. Position the patient Neck extended Roll under shoulders Arms tucked On OR bed 2. Palpate landmarks 3. Transverse incision half way between cricoid and sternal notch 4. Retraction 5. Divide strap muscles in midline

17 Technique Diagrams from Lore, Surgical Atlas 1988

18 Technique cont’d 6. Thyroid isthmus 7. Divide or retract 8. Identify cricoid and upper tracheal rings using blunt dissection 9. Blunt cricoid hook helpful 10. Retract cricoid in superior direction 10. Tracheotomy tube cuff checked and obturator in 11. Deflate cuff of endotracheal tube 12. Horizontal incision between tracheal rings (below the second ring) 13. Suction lumen if necessary 14. Spread rings apart with spreader or scissors

19 Technique 2 DO NOT use cautery on the trachea FIRE!

20 Technique 3

21 Technique 15. Endotracheal tube withdrawn until just above the open tracheal site 16. Tracheotomy tube with obturator, pushed into mid lumen of trachea, then directed inferiorly 17. Obturator withdrawn and inner cannula placed 18. Anaesthetic connector tubing passed over and connected 19. Cuff inflated 20. DO NOT LET GO OF THE TUBE

22 Final 21. Anaesthesia: Check CO 2, good breath sounds 22. Sew in the trach tube shield to skin 23. Loosely approximate incision 24. Trach ties

23 Contraindications Medically well enough for GA PEEP < 20 mm Hg Uncontrolled coagulopathy Airway pathology below tracheotomy site

24 Percutaneous Tracheotomy Bedside tracheotomy in ICU patients An alternative not replacement for open trach General anaesthesia and paralysis for procedure Fiberoptic broncoscopic guidance Ciaglia ‘Blue Rhino” by Cooke $200 Bronchoscopic guidance Experienced personnel Anaesthesia Respiratory therapist Surgeon

25 Selection of Patients Must be able to palpate landmarks adequately Cricoid above sternal notch Low larynx/cricoid High innominate artery problematic PEEP > 20 contraindication Advantages Smaller wound, less dissection ICU setting Set uptime 20 minutes Procedures time less than 10 minutes

26 Percutaneous Tracheotomy Disadvantages Not for everyone Must ventilate with ETT in high position Maybe an air leak during procedure Must use Shiley tube Experienced personnel Contraindications same as open and Anatomic limitations

27 Technique 1. Identify landmarks 2. Local anaesthetic 3. Small incision midline 4. ETT moved superiorly until cuff at cords 5. Bronchoscope with connector in ETT 6. Needle in midline into trachea 8. Guide wire passed inferiorly 9. Small calibre dilator 10. Wire sheath and ‘blue rhino’ dilator pushed along wire into trachea 11. Trach tube with fitted introducer passed over wire into trachea

28 Video Percutaneous Tracheotomy

29 Tracheotomy Tubes Portex and Shiley common brands of trach tubes. Shiley used as standard tube at St Michael’s Hospital.

30 Tracheotomy Tubes

31 Bivona or foam cuffTracoe Cuffless Speaking valve

32 Complications: Intraoperative Bleeding 2.8%* Recurrent laryngeal nerve injury Tracheoesophageal fistula Pneumothorax: rare False passage Anterior dissection most common Incidence <1% *Kost et al 1994

33 Odd Things That Can Happen Trach tube place upside down No CO 2 tracing despite surgeon positive tube is in the airway Cut the pilot tube of the cuff while cutting the sutures Trach tube coughed across table after correct placement Difficulty with air leak Cuff leak/tube too short or not large enough /position tube Blocked tube secondary to secretions/blood

34 Tracheotomy: Early Complications Bleeding Minor common Major tracheoinnominate fistula (<0.2%)* Obstruction of tube (2.5%)* Dislodgement (1.4%)* Pneumothorax (1 - 2.5%)* Wound Infection Local care, antibiotics (staph/pseudomonas)

35 Late Complications Tracheal stenosis Tracheal chondritis Subglottis stenosis- high tracheotomy Tracheomalacia Tracheoesophageal fistula Failure of stoma closure when decannulated Overall complication rate 15-30% in ICU patients largely minor with no long term morbidity

36 Tracheoinnominate Fistula More than 10 days post tracheotomy (as early as 5 days) Sentinel bleed Angiogram/CTA for diagnosis Surgical exploration Interventional radiology-stent Associated with low tracheotomy placement, wound infection or aberrant artery

37 Late Complications/Stoma Minor amount of bleeding common due to granulation tissue /dry mucosa

38 Stoma and Inferior View Vocal Folds

39 Physiology of Tracheotomy Neck breathing Bypass upper airway and nasal function Loss of humidification/heat airflow Dryness, thick secretions Voicing possible with speaking valve Loss of smell /reduced taste Loss glottic closure function for cough

40 Physiology of Tracheotomy Respiration Advantages Lower work of breathing (30%) c/w normal airway Facilitates secretion clearance Aspiration or thick secretions Less dead space (100 mL) Reduced airway resistance Assists in patient independence from mechanical ventilation Patient comfort (better than ett)  Epstein 2005 Respiratory Care

41 Physiology of Tracheotomy Respiration Disadvantages Tube diameter and shape increases turbulent airflow, secretions adhere inside tube Loss of humidification/heat function of upper airway Ciliary function affected Biofilm colonization Diminish cough/loss glottic closure Reduce laryngeal elevation during swallow Patient comfort (better no tube at all)

42 Dysphagia Common issue in neurological impaired pt Tube required for secretion management particularly in patient with florid aspirate Tube presence associated with limitation of the cephalad excursion of larynx during swallow and can contribute to dysphagia/aspiration Endoscopic / fluoroscopic assessment Speech Therapy assessment!

43 Postoperative Tracheotomy Care Humidification via trach mask/Instill saline Clear secretions, prevent crust Inner cannula cleaning tid at least If non-ventilated, change cuffed tube to non- cuffed at 5-7 days Ties changed 2 people if possible Most hospital have nursing/RT protocol Teach everyone trach care including patient, family

44 Inner Cannula Care Frequently done tid or more Saline and hydrogen peroxide (1:1) and trach brush Rinse with sterile water/saline and reinsert Spare inner cannula and store in clean covered container Ties should be one finger tight and square knot Respiratory Therapy Protocol SMH

45 Troubleshooting Dislodgement Causes Ties too loose Cough cuff deflated tube too short/wrong size for patient Clinical signs Difficulty in ventilating patient Increased airway pressure Suction catheter obstructed Non Ventilated Patient Poor cough Sudden voice change Stridor, SOB Suction catheter blocked

46 What to do: Dislodgement Extend neck Remove inner cannula Use obturator to redirect tracheotomy tube into lumen If patient in distress and does not have fixed obstruction above, pull out trach tube If patient in distress and does not have fixed obstruction above, pull out trach tube Ventilate with mask/intubate Use flex bronchoscope or replace/OR

47 Troubleshooting Tube Obstructed Mucous plug or blood clot most likely Granulation tissue, particularly fenestrated tubes Remove inner cannula, suction, instill saline Bronchoscopy If no other recourse, pull out trach tube and if necessary, replace new tube with obturator Intubate/ventilate from above

48 Troubleshooting: Bleeding around Bleeding around trach stoma Minor bleeding immediately post-op Moderate bleeding/venous oozing often related to thyroid Examine wound Pack, surgicel, if not controlled, take back to OR within Bleeding from within lumen Often related to suctioning Broncoscopy exam Dry mucosa Granulation tissue Coagulopathy Rare innominate fistula

49 Decannulation increased Goal is to ensure patient can tolerate increased airway resistance/work of breathing and secretion clearance 30% increase WOB transition from trach breathing to upper airway breathing

50 Decannulation Indication for tracheotomy has resolved/improved Patient able to cope with secretions Upper airway patent - examined if necessary Appropriate vocal cord function Good respiratory reserve/overall respiratory status Gag reflex present (5-10% no gag)

51 Decannulation Stable clinical condition Hemodynamic stability Absence of fever, sepsis infection Adequate swallowing Gag reflex, bedside swallowing assessment, video fluoscopy Maximum expiratory pressure > 40 cm H 2 O Ceriana et al 2003

52 Decannulation Protocol Downsize tube to either 4 or 6 Shiley Cuffless fenestrated tube Gradually increase corking/cap of trach Corked 24-48 hours before decannulation Remove tracheostomy tube Occlusive dressing for stoma Persistent patent stoma Occasionally requires local flap to close Outpatient procedure under local, infection common

53 Difficult to Decannulate Granulation tissue Fenestra obstructed Tracheal mucosal edema/supraglottic edema NG, aspiration Laryngeal pathology Glottic stenosis, cord paralysis Pulmonary secretions Increase airway resistance not tolerated

54 Tracheotomy: Summary Safe method of airway management Open versus percutaneous technique available Complications largely minor Mortality rare from procedure directly 0.3%* in last 30 years (grouped data)

55 Summary Advantages/risks of a tracheotomy for that individual patient must outweigh the disadvantages/risks without one. Indication for Tracheotomy Medical comorbidities Respiratory /deglutition function Ability to cope with secretions Trial of corking/decannulation

56 Cricothyroidotomy Open versus percutaneous technique Prep and position as for trach Identify landmarks Local anaesthetic Incision over cricothyroid membrane Placement of small tracheotomy tube, ETT or large bore needle with attachment for ventilation

57 Cricothyroidotomy Advantages Quick c/w open trach No laryngeal injury Failure of intubation attempts in emergency situation Disadvantages Can cause laryngeal injury Must be sure of landmarks Small tube required

58 Cricothyroidotomy

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