Title: Tracheotomy
1Tracheotomy
2What 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
.
3Tracheotomy. 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.
4Tracheotomy. 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
5Tracheotomy. 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."
6Tracheotomy. 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
7Tracheotomy. 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.
8TracheotomyRelative anatomy
- Major blood vessels (carotis, innominate a.,
jugular veins) - Thyroid gland
- Esophagus
- Larynx
- Nerves (Rec.Laryngeal)
- Cervical spine
9TracheotomyRelative anatomy
10Tracheotomy 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
11Tracheotomy 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
12Tracheotomy 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
13Tracheotomy 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
14Tracheotomy 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.
15Preoperative workup
- Physical assessment also surgical and
anesthesiological - CBC
- PT, PTT, INR
- Patient/apotropus confirmation
16Surgical techniques
- Open procedure
- Percutaneous procedure
17Surgical techniquesopen procedure
18Surgical techniquesopen procedure
19Surgical techniquesopen procedure
20Surgical techniquesopen procedure
21Percutaneous 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)
22Surgical techniquespercutaneous procedure
23Surgical techniques percutaneous procedure
24Surgical techniques percutaneous procedure
25Surgical techniques percutaneous procedure
- Should be done in carefully selected patients
- Under fiber optic control
- To be ready to switch to open procedure
26Risk factors for complications
- Age infants and adults over 75
- Obesity
- Smoking
- Poor nutrition
- Recent illness, especially an upper-respiratory
infection - Alcoholism
- Chronic illness
- Diabetes
27Complications - general
- Rate in children - up to 70
- Tracheotomy related death - 2-3(overall)
28Complicationsimmediate
- 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
29Complicationsimmediate
- 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
30Complicationsearly
- 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
31Complicationslate
- Bleeding - tracheoinnominate fistula
- Tracheo- and laryngomalatia
- Stenosis
- Tracheoesophageal fistula
- Tracheocutaneous fistula
- Granulation
- Scarring
- Failure to decannulate
32Complicationslate
33Tracheotomy 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
34Tracheotomy care
35Tracheotomy 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!
36Tube 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
37Tube 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
38Tube 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
39TYPES OF TRACHEOSTOMY TUBES
- CUFLESS TUBES
- CUFFED TUBES
40Speech with tracheotomy
- Its possible to speak with tracheotomy, also for
mechanically ventilated patients and for
spontaneous breathers.
41Speech with tracheotomy
- Spontaneous breathers
- Tolerate cuffless mech. ventilation
- Conscious patient
42Speech with tracheotomy (Passy-Muir valves)
- For mechanically dependent patients that may
tolerate cuff deflation - For unable to close the tube outlet with finger
(quadriplegia)
43Speech 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
44Eating with tracheotomy
45Points 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
46Points 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
47Decanulationwhen?
- 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
48Points for discussionpost OP chest Xray?