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Tracheotomy

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Title: Tracheotomy


1
Tracheotomy
2
What isTracheotomy
  • The word tracheotomy is derived from the Latin
    trachea and tomein (to make an opening).
  • Tracheostomy is an operative procedure that
    creates a surgical airway in the cervical trachea
    .

3
Tracheotomy. History.
  • Ttracheotomy is one of the oldest surgical
    procedures. it was even pictured on Egyptian
    tablets in 3600 BC !
  • 2000 BC The Rgveda described a healed
    tracheostomy incision.
  • 100 BC Asclepiades described a tracheostomy
    incision for improving the airway.
  • Ca 400 BC Hippocrates condemned tracheostomy,
    citing threat to carotid arteries.
  • Ca 50 AD Aretaeus of Cappadocia warned against
    performing tracheostomy because of the risk of
    secondary wound infections.

4
Tracheotomy. History.
  • Ca 100 AD Antyllus described the first familiar
    tracheotomy a horizontal incision between 2
    tracheal rings to bypass upper airway
    obstruction. He also pointed out that tracheotomy
    would not ameliorate distal airway disease (eg,
    bronchitis).
  • 131 AD Galen elucidated laryngeal and tracheal
    anatomy. He was the first to localize voice
    production to the larynx and to define laryngeal
    innervation. Additionally, he described the
    supralaryngeal contribution to respiration (eg,
    warming, humidifying, filtering).
  • 400 AD The Talmud advocated longitudinal
    incision

5
Tracheotomy. History.
  • Ca 400 AD Caelius Aurelianus derided
    tracheostomy as a "senseless, frivolous, and even
    criminal invention of Asclepiades."
  • 600 AD The Susruta Samhita contained routine
    acknowledgment of tracheotomy as accepted therapy
    in India.
  • Ca 600 AD Dante pronounced it "a suitable
    punishment for a sinner in the depths of the
    Inferno."

6
Tracheotomy. History.
  • 1546 Brasavola published account of tracheotomy
    for tonsillar obstruction. He was the first
    person known to have actually performed the
    successful operation.
  • 1561-1636 Sanctorius was the first to use a
    trocar and cannula. He left the cannula in place
    for 3 days.
  • 1550-1624 Habicot performed a series of 4
    tracheotomies for obstructing foreign bodies.
  • 1702-1743 George Martine developed inner
    cannula.
  • 1718 Lorenz Heister coined the term
    "tracheotomy," which was previously known as
    "laryngotomy" or "bronchotomy

7
Tracheotomy. History
  • 1805 Viq d'Azur described cricothyrotomy.
  • 1833 Trousseau reported 200 cases of diphtheria
    treated with tracheotomy.
  • 1909 Chevalier Jackson codified indications and
    techniques for modern tracheotomy and warned of
    complications of high tracheotomy
    (cricothyrotomy).
  • 1932 Wilson advocated prophylactic tracheotomy
    in cases of poliomyelitis.

8
TracheotomyRelative anatomy
  • Major blood vessels (carotis, innominate a.,
    jugular veins)
  • Thyroid gland
  • Esophagus
  • Larynx
  • Nerves (Rec.Laryngeal)
  • Cervical spine

9
TracheotomyRelative anatomy
10
Tracheotomy Indications To bypass obstruction
  • - Tumors (of oropharynx, larynx, upper trachea)
  • Infections (epiglottitis, severe
  • tracheobronchitis)
  • - Bilateral Vocal Cord Paralysis
  • Trauma (laryngeal, maxillofacial fractures)
  • Edema (tongue, laryngopharynx)
  • Intubation failure
  • Foreign body obstruction
  • Subglottic or tracheal stenosis

11
Tracheotomy IndicationsProlonged intubation
  • Need for prolonged respiratory support, such as
    in Bronchopulmonary Dysplasia
  • To reduce anatomic dead space and increase the
    chance for mechanical ventilation withdrawal
  • To prevent decubitus and secondary infections in
    oropharynx (and trachea and tracheal perforations
    ?!)
  • To improve the patients quality of life (easier
    toilet, ability to speak and eat (not in comatose
    patient), increase the mobility)
  • Neuromuscular diseases paralyzing or weakening
    chest muscles and diaphragm

12
Tracheotomy Indicationsmiscellaneous
  • Congenital abnormalities (tracheomalatia,
    subglottic or glottic stenosis, craniofacial
    abnormalities (Pierre Robin, Triecher Collins
    syndromes)
  • Obstructive Sleep Apnea Syndrome
  • Aspirations related to muscle or sensory problems
  • Prophylaxis (as preparation for extensive HN
    procedures, before radiotherapy for HN CA)
  • Cervical spinal cord injuries with respiratory
    muscles paralysis

13
Tracheotomy advantages
  • Less irritation of nose, mouth and throat mucous
    membranes
  • A nasal tube carries a higher risk of incurring
    sinusitis
  • Cleansing the mouth is much easier to perform
    thus preventing oral cavity infections
  • The patient is more able to cough up mucus as the
    airway distance is shorter
  • Ability to speak
  • When awake and if the patient can swallow and his
    condition allows it, he may eat and drink

14
Tracheotomy disadvantages
  • Some irritation or pain in the neck region in the
    first days after placing the canula.
  • A scar will remain visible on the neck (after
    removal of the tranchea canula).
  • Possible complications.

15
Preoperative workup
  • Physical assessment also surgical and
    anesthesiological
  • CBC
  • PT, PTT, INR
  • Patient/apotropus confirmation

16
Surgical techniques
  • Open procedure
  • Percutaneous procedure

17
Surgical techniquesopen procedure
18
Surgical techniquesopen procedure
19
Surgical techniquesopen procedure
20
Surgical techniquesopen procedure
21
Percutaneous tracheotomy(history)
  • 1955, Shelden et al - first attempt with
    cutting trocar into the trachea.
  • 1985, Ciaglia et al -percutaneous dilational
    tracheostomy (PDT)
  • 1989, Schachner et al - Rapitrach
  • 1990, Griggs et al - the guidewire dilating
    forceps (GWDF)

22
Surgical techniquespercutaneous procedure
23
Surgical techniques percutaneous procedure
24
Surgical techniques percutaneous procedure
25
Surgical techniques percutaneous procedure
  • Should be done in carefully selected patients
  • Under fiber optic control
  • To be ready to switch to open procedure

26
Risk factors for complications
  • Age infants and adults over 75
  • Obesity
  • Smoking
  • Poor nutrition
  • Recent illness, especially an upper-respiratory
    infection
  • Alcoholism
  • Chronic illness
  • Diabetes

27
Complications - general
  • Rate in children - up to 70
  • Tracheotomy related death - 2-3(overall)
  • Rate in adults up to 66

28
Complicationsimmediate
  • Apnea due to loss of hypoxic respiratory drive.
    This is mainly important in the awake patient.
    Ventilatory support must be available.
  • False root
  • Bleeding
  • Pneumothorax or pneumomediastinum

29
Complicationsimmediate
  • Damage to the vocal cords (direct)
  • Injury to adjacent structures recurrent
    laryngeal nerves, the great vessels, and the
    esophagus.
  • Post-obstructive pulmonary edema
  • Hypotension
  • Arrhythmia

30
Complicationsearly
  • Early bleeding This is usually the result of
    increased blood pressure as the patient emerges
    from anesthesia and begins to cough.
  • Plugging with mucus
  • Tracheitis
  • Cellulitis
  • Tube displacement
  • Subcutaneous emphysema
  • Atelectasis

31
Complicationslate
  • Bleeding - tracheoinnominate fistula
  • Tracheo- and laryngomalatia
  • Stenosis
  • Tracheoesophageal fistula
  • Tracheocutaneous fistula
  • Granulation
  • Scarring
  • Failure to decannulate

32
Complicationslate
33
Tracheotomy care
  • Not aggressive and not too much deep
  • To prevent irritation and secondary inflammation
    due to discharge
  • Once or more daily remove and clean. Attention on
    crusts
  • Suctioning
  • Skin care
  • Inner tube care

34
Tracheotomy care

35
Tracheotomy care
  • Humidification
  • Tube position
  • Tube position
  • Artificial nose
  • To prevent decubitus of trachea
  • Not to cover with blanket!
  • Pay attention on patients beard and chin
    position!

36
Tube exchange
  • After the tract is exist 4-5 days after the
    operation
  • Rate of exchange depends on clinical situation of
    the specific patient type of discharge, type of
    tube, medical status, age..
  • Should be done by experienced staff

37
Tube exchange-difficult situations
  • When the stoma is scarred, calcified, distorted
    or obscured by granulation tissue
  • When the trachea is deviated or rotated
  • When the trachea is narrowed or smaller than
    normal
  • When the patient is a child

38
Tube exchange-difficult situations
  • When the patient is obese
  • If the tube must be placed quickly in an
    emergency
  • If it is a new or recent tracheotomy
  • If the person performing the change is not
    well-trained

39
TYPES OF TRACHEOSTOMY TUBES
  • CUFLESS TUBES
  • CUFFED TUBES

40
Speech with tracheotomy
  • Its possible to speak with tracheotomy, also for
    mechanically ventilated patients and for
    spontaneous breathers.

41
Speech with tracheotomy
  • Spontaneous breathers
  • Tolerate cuffless mech. ventilation
  • Conscious patient

42
Speech with tracheotomy (Passy-Muir valves)
  • For mechanically dependent patients that may
    tolerate cuff deflation
  • For unable to close the tube outlet with finger
    (quadriplegia)

43
Speech with tracheotomy
  • Mechanically ventilated patient that can not
    tolerate balloon deflection (sever COPD)
  • The air comes from additional external source via
    small tube above the balloon

44
Eating with tracheotomy
45
Points for discussionTiming of Tracheotomy?
  • There is no clear-cut guidelines when elective
    Tracheotomy should be done.
  • Important for decision expectations for
    extubation, general medical status, indications
    for mech. ventilation (cervical spine cut off
    do as soon as possible).
  • Consilium decision internist, intensivist, ENT,
    pulmonologist

46
Points for discussionwhere? Op. room vs bed site
  • Bed site is less expensive
  • The same rate of complications
  • ICU only (not general departments)
  • Level of equipment (light source, diathermia,
    ergonomic conditions, instruments)
  • Staff (nurse, assistant, anesthesiologist)
  • Hospital policy

47
Decanulationwhen?
  • Resolution of pathology that necessitated the
    tracheotomy (upper airway obstruction, pneumonia)
  • Normal protective laryngeal mechanisms (no
    aspirations during normal swallowing, good
    coughing)
  • No planed further interventions (radiotherapy,
    HN operations)
  • No mechanical ventilation

48
Points for discussionpost OP chest Xray?
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