TRACHEOSTOMY

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TRACHEOSTOMY

• Dr. Manorama Mittal
• Dr. Namita Arora

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
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55yr.old man with Ca. larynx
Q1 What comes to our mind first? Q2 What
are the relevant points in the history? Q3
What do you see on examination?
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Tracheostomy for Ca Lx
Q1 What are the advantages of a pre-op.
traecheostomy? Q2 What are the disadvantages
of pre-op.traecheostomy? Q3 Traecheostomy done
in ward patient suddenly dies. What is the
likely cause? How can we prevent it? Q4 What
are the problems with post-op. traecheostomy?
Q5 For how long is humidification required in
these patients?
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Heat Moisture Exchanger (artificial nose)
Q1 What is HME? Q2 How does it work?
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Tracheostomy in a patient of chronic bronchitis
with CO2 narcosis.
Q1 Take a hypothetical case of chronic
bronchitis with CO2 narcosis with
traecheostomy.He was put on ventilator following
which he became conscious then suddenly
died.Why?
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Tracheostomy vs Prolonged intubation in
paediatric patient
Q1 What are the problems of traecheostomy in
children? Q2 What should be method of
suctioning the interval in between the two
suctions? Q3 What are the methods of
humidification? Q4 What are the problems with
humidification?
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Weaning in paediatric patient with tracheostomy
Q1 Why is weaning difficult? Q2 What is ward
decannulation?
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Patient on ventilator
Q1 What are the different types of cuffs?
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Indications of Tracheostomy

• Q1 What are the indications of preoperative
  Tracheostomy?
• Q2 What are the indications of post-op
  Tracheostomy?
• Q3 What are the other indications of elective
  Tracheostomy?
• Q4 What are the indications of emergency
  Tracheostomy?

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Cricothyroidotomy

• Q1 What are the indications of
  cricothyroidotomy?
• Q2 What are the advantages of cricothyroidotomy?
• Q3 What are the disadvantages of
  cricothyroidotomy?
• Q4 What is an absolute contra-indication to jet
  ventilation through needle cricothyroidotomy?

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Percutaneus Dialational Tracheostomy (PDT)

• Q1 Enumerate the steps of PDT?
• Q2 What are the advantages of PDT?
• Q3 What are the disadvantages of PDT?
• Q4Complications of PDT?

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Complications of Tracheostomy

• Q1 What is the cause of massive hemorrhage
  following Tracheostomy?
• Q2 What is the cause of mediastinal emphysema?
• Q3 What is a persistant stoma?
• Q4 Usually how long does a stoma take to close?

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Q1 What comes to our mind first?

• This patient must have been a smoker
• Does he have an airway compromise?
• Would he need a tracheostomy to overcome the
  airway compromise prior to surgery?

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Q2 What are the relevant points in the history?
       Smoking, tobacco chewing,alcohol intake
       Dyspnoea, dysphagia, loss of weight
appetite,fever        Hoarseness of
voice        Cough dry/productive
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Q3 What do you see on examination?

• GPE
• Vitals
• Anemia ,waxy look ,toxic ,cachectic,/anxious
• Cervical lymphadenopathy.
• II. Systemic Examination
• Respiratory System

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Q1 What are the advantages of a pre-op.
traecheostomy?
For the anaesthetist the biggest advantage is
that problems of difficult airway are bypassed
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Q2 What are the disadvantages of
pre-op.traecheostomy?
Local infection inflammation that occurs does
not allow the surgeon to demarcate the clear area
for resection.
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Q3 Traecheostomy done in ward patient
suddenly dies. What is the likely cause? How can
we prevent it?
Asphyxia i.e, hypoxia with hypercarbia get
corrected when obstruction is relieved.The
stimuli for respiration are hence abolished
leading to respiratory arrest death. VVagal
stimulation due to excessive movement of trachea
may cause death during the tracheostomy. DDeath
can be prevented by monitoring the ECG having
means to ventilate the patient in the ward.
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Q4 What are the problems with post- op.
traecheostomy?
Patient is unable to communicate if any problem
arises. We need to have a bell switch /light
switch/nurse by the side of the patient.
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Q5 For how long is humidification required in
these patients?
This is especially relevant here as these
patients have a permanent traecheostomy.Humidifica
tion required for one week after which the
columnar ciliated epithelium changes into
pseudo-stratified squamous epithelium that is
resistant to drying.
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Q1 What is HME?
It is an equipment which helps in preserving the
moisture heat of the expired breath.
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Q2 How does it work?
It contains a Nylon coil. During expiration water
condenses on the coil heats it. During
inspiration the cold dry air picks up water
vapour gets heated up while passing through the
HME. Has minimal dead space (8 to 9ml.) Has
very low resistance to flow(I to2cm H2O).
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Q1 Take a hypothetical case of chronic
bronchitis with CO2 narcosis with
traecheostomy.He was put on ventilator following
which he became conscious then suddenly
died.Why?
CO2 tissue stores in such patients are very high.
Marked hypercarbia leads to high levels of
circulating catecholamines but also desensitizes
the myocardium to their action.Sudden lowering of
CO2 levels leads to regaining of sensitivity of
myocardium but since circulating catecholamine
levels are still high, there is fibrillation
followed by cardiac arrest death.
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Q1 What are the problems of tracheostomy in
children?

• Performing a tracheostomy is very
• difficult, a specialists job
• False passage is very likely
• It has to be a planned procedure under general
  anaesthesia in an intubated child
• Subglottic oedema stenosis are very common
• Weaning is difficult

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Q2 What should be method of suctioning the
interval in between the two suctions?

• The interval in adults is 10 to 15 sec.
• The duration of suctioning should also be the
  same.
• In children there should be 3 to 4 breaths in
  between the two suctions even if the child is
  drowning in secretions.

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Q3 What are the methods of humidification?
       Wet gauze /Saline drip        Droplet
delivery (mechanical/ultrasonic)        Hot
water humidification        HME
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Q4 What are the problems with humidification?

•        Over hydration especially with
  nebulization
•        Over heating -When using hot water
  humidification
• By temporary disconnection of a pressure cycled
  ventilator because flow suddenly increases.
• Thermostat failure.

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Q1 Why is weaning difficult?
As a well fitting tube is put in children, they
are unable to breathe when the tracheostomy tube
is occluded. Hence we need to use a fenestrated
tube for weaning. Suprastomal collapse
granulation are common. Psychological
attachment to the tracheostomy tube Hence more
controlled process called ward decannulation is
used.
Fenestrated tube
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Q2 What is ward decannulation?

• Child is kept in the ward for decannulation.
• Tracheostomy tube is progressively down
  sized.Usually one size smaller each day till the
  smallest size of T tube has been tolerated.
• Tracheostomy tube is then blocked for 12 hrs
  during the day then 24hrs next day night.
• The tube is now safely removed stoma covered.
  Child observed for further 5 days.

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Q1 What are the different types of cuffs?
       Low vol. high pr, cuff Introduction is
easy        High vol. cuff Difficult to
introduce.Chance of aspiration is high if tube is
big cuff not fully inflated.       
Polyurethane (foam) cuffself inflating       
Double cuffThe two cuffs are alternately
inflated deflated.        Pressure adjusting
cuffWhen N20 is used, it diffuses into the cuff
leading to increase in intra cuff pressure but in
this tube the change in volume of cuff is shifted
to the pilot balloon which in turn is big,
pliable thin walled from where N20 diffuses out
thus preventing any rise in intra cuff pressure
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Q1 What are the indications of preoperative
Tracheostomy?

• Massive cystic Hygroma

• Ludwigs Angina

• Massive Thyroid enlargement
• (with respiratory difficulty)

• Carcinoma maxilla

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Q2 What are the indications of emergency
Tracheostomy?

• Angioneurotic oedema
• Croup
• Diphtheria
• failed intubation

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Q3 What are the indications of postoperative
Tracheostomy?

• Ca.larynx following laryngectomy
• Massive thyroid enlargement if more than 3
  tracheal cartilages are eroded or calcified.

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Q4 What are the other indications of elective
Tracheostomy?
       Prolonged ventilation        Pulmonary
hygiene/toilet (as in a respiratory cripple)
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Q1 What are the indications of
cricothyroidotomy?

• Cannot intubate, cannot ventilate needle
  cricothroidotomy for ventilation
• Difficult intubation needle cricothroidotomy
  for reterograde intubation

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Q2 What are the advantages of cricothyroidotomy?

• Simple
• Takes less than 1min to perform
• Ambulance/casualty/emergency
• personnel/nurses can perform it

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Q3 What are the disadvantages of
cricothyroidotomy?
Subglotic oedema stenosis are very likely
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Q4 What is an absolute contra-indication to jet
ventilation through needle cricothyroidotomy?
Complete/near complete obstruction at
glottic/supraglottic level
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Q1 Enumerate the steps of PDT?

• Trachea punctured with needle
• Guide wire passed
• Graded dilators passed over the guide wire
• Tracheostomy tube passed
• The whole procedure can be done while visualizing
  the trachea with a fibrescope through the
  endotracheal tube.

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Q2 What are the advantages of PDT?
       Easy to learn        Shorter
procedure        Elimination of scheduling
difficulty        Precludes necessity to shift
critical patient to OT        Half as expensive
as surgical Tracheostomy
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Q3 What are the disadvantages of PDT?
       Needs special equipment        Can be
done only in intubated patients        Contra
indicated in children        Contraindicated in
cervical spine fractures as neck cannot be
hyper extended.
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Q4 Complications of PDT?
False passage P Puncture through side
B back wall of trachea
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Q1 What is the cause of massive hemorrhage
following Tracheostomy?
Tracheo-innominate artery fistula. This happens
when tubes not in line with trachea.
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Q2 What is the cause of mediastinal emphysema?

• Too small a tracheal tube
• Excessive coughing straining on the tube

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Q3 What is a persistant stoma?
Stoma that persists for more than 2
months requires surgical closure Large stoma
may require perichondral flap from thyroid
cartilage
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Q4 Usually how long does a stoma take to close?
UUsually takes few days to a week
www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om