TRACHEOSTOMY

TRACHEOSTOMY

History

Tracheostomy is one of the oldest surgical procedures.

A tracheotomy was portrayed on Egyptian tablets dated back to 3600 BC.

Asclepiades of Persia is credited as the first person to perform a tracheotomy in 100 BC.

The first successful tracheostomy was performed by Brasovala in the 15th century. 

Tracheostomy
 History and indications

1932 prevent pulmonary infection in neurologically impair patients secondary to infections (poliomyelitis).

1943 remove bronchial secretions in cases of myasthenia gravis and tetanus.

1951 reduce the volume of dead space, use in COPD and severe penumonia.

1950 positive pressure through tracheostomy for patients with poliomyelitis.

1955 obstruction secondary to infection: diphteria, Ludwig’s angina.

1961 Obstructions secondary to tumour, infectious disease and trauma.

INDICATIONS FOR TRACHEOSTOMY

INDICATIONS FOR TRACHEOSTOMY

TRACHEOSTOMY VS TRANSLARYNGEAL INTUBATION

Increased patient mobility

More secure airway

Increased comfort

Improved airway suctioning

Early transfer of ventilator-dependent patients from the intensive care unit (ICU)

Less direct endolaryngeal injury

Enhanced oral nutrition

Enhanced phonation and communication

Decreased airway resistance for promoting weaning from mechanical ventilation

Decreased risk for nosocomial pneumonia in patient subgroups

Shiley tracheostomy tube: #6

Shiley tracheostomy tube: #8  for bronchoscopy.

TRACHEOSTOMY TUBE CARE

Securing tracheostomy around patient’s neck.

TRACHEOSTOMY TUBE CARE

Tube changes:

Indications: soiled, cuff rupture.

Complications: insertion into a false passage bleeding, and patient discomfort.

Avoid within 1^st week.

First tube change by surgeon.

Difficult cases (obese, short and thick neck), be prepared for endotracheal intubation.

TRACHEOSTOMY TUBE CARE

Tracheostomy tube cuff pressures in a range of 20 to 25 mm Hg.

Overly low cuff pressures < 18 mm Hg, may cause the cuff to develop longitudinal folds, promote microaspiration of secretions collected above the cuff, and increase the risk for nosocomial pneumonia.

Excessively high cuff pressures above 25 to 35 mm Hg exceed capillary perfusion pressure and can result in compression of mucosal capillaries, which promotes mucosal ischemia and tracheal stenosis.

Cuff pressure should be measured with calibrated devices and recorded at least once every nursing shift and after every manipulation of the tracheostomy tube.

TRACHEOSTOMY TUBE CARE

Chest Xray:

                        cuff has a width greater than the caliber of the trachea, which suggests the presence of a hyperinflated cuff and tracheal overdistention

TRACHEOSTOMY TUBE CARE

Humidification of the inspired gas is a standard of care for tracheostomized patients.

SPEECH

SPEECH

NUTRITION

Tracheostomy tube prevents normal upward movement of the larynx during swallowing and hinders glottic closure.

Between 20% and 70% of patients with a chronic tracheostomy experience at least one episode of aspiration every 48 hours

Evaluation by speech therapist

Keep head elevated to 45° during periods of tube feeding

WEANING FROM TRACHEOSTOMY

Demonstrate stability for 24 to 48 hours after discontinuation of mechanical ventilation.

Tracheostomy stomas can narrow markedly or close within 48 to 72 hours after tube removal.

Deflating the tracheostomy cuff and capping the tube.

WEANING FROM TRACHEOTOMY

The ability to breath and clear airway secretions around a small, capped tube signifies readiness for decannulation

Patients who fail breathing trials with capped tracheostomy tubes should be evaluated by flexible fiberoptic endoscopy for evidence of airway lesions and adequacy of airway function.

Complications of Tracheostomy

Complications 5-40%

Mortality <2%

Complications are more frequent in emergency situations, severely ill patients and small children.

Complications of Tracheostomy

Stoma

Stoma site infection

Stomal hemorrhage

Poor stoma healing after decannulation with scar, keloid, or tracheocutaneous fistula

Complications of Tracheostomy

Trachea

Granuloma

Tracheoesophageal fistula

                        fewer than 1% of patients as a result of pressure necrosis of the tracheal and esophageal mucosa from the tube cuff

                        risks: high cuff pressures, presence of a nasogastric tube, excessive tube movement, and underlying diabetes mellitus

Complications of Tracheostomy

Tracheoinnominate fistula:

                        0.4% with mortality rate of 85% to 90%.

                        Major airway hemorrhage may occur first within several days or as long as 7 months after performance of a tracheostomy.  

                        Risk factors : excessive tube movement, low placement of the tracheostomy, sepsis, poor nutritional status, and corticosteroid therapy

Tracheal stenosis:

                        can develop from 1 to 6 months after decannulation

                        risk for tracheal stenosis ranges between 0% and 16%

Tracheomalacia

CONCLUSION

The most common indications for tracheostomy is mechanical ventilation with prolonged tracheal intubation.

Tracheostomy: emergency and elective, improve quality of life.

Meticulous surgical technique.

Appropriate postoperative tracheostomy care to reduce complications.

PERCUTANEOUS DILATIONAL TRACHEOTOMY

PERCUTANEOUS DILATIONAL TRACHEOTOMY

PERCUTANEOUS DILATIONAL TRACHEOTOMY

TRACHEOSTOMY TUBE CARE

Securing tracheostomy around patient’s neck.

Tube changes:

Indications: soiled, cuff rupture.

Complications: insertion into a false passage bleeding, and patient discomfort.

Avoid within 1^st week.

First tube change by surgeon.

Difficult cases (obese, short and thick neck), be prepared for endotracheal intubation.

TRACHEOTOMY