12/05/2015 1 tracheotomy dr j a anderson md msc. frcs(c) chief department of otolaryngology hns st...
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23-04-18 1
Tracheotomy
Dr J A Anderson MD MSc. FRCS(C)Chief Department of Otolaryngology HNS
St Michael’s HospitalUniversity of TorontoPOS November 2012
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Tracheotomy
Indications Technique
Open and percutaneous Complications Physiology of a tracheotomy Troubleshooting Decannulation
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Tracheotomy
Creation of communication between the trachea and the cervical skin with insertion of a tube
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Indications
Airway obstruction Pulmonary Secretions Ventilation Prolonged mechanical ventilation
May assist in weaning from mechanical ventilation
Prevention of glottic stenosis/complication of prolonged ett
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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
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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
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Pulmonary Secretion Clearance
Aspiration / dysphagia COPD Bronchiectesis Stasis of secretions
Poor cough Poor respiratory reserve
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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
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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)
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Example 1 Subglottic Stenosis
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Example 3Combined Glottic/Tracheal Stenosis
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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
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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
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Technique
Diagrams from Lore, Surgical Atlas 1988
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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)
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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
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Technique
Diagrams from Lore, Surgical Atlas 1988
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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
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Technique 2
DO NOT use cautery on the trachea
FIRE!
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Technique 3
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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
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Final
21. Anaesthesia: Check CO2, good breath sounds
22. Sew in the trach tube shield to skin
23. Loosely approximate incision
24. Trach ties
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Contraindications
Medically well enough for GA PEEP < 20 mm Hg Uncontrolled coagulopathy Airway pathology below tracheotomy site
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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
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Selection of Patients
Must be able to palpate landmarks adequately
Cricoid above sternal notch Low larynx/cricoid
High innominate artery problematic
PEEP > 20 contraindication
AdvantagesAdvantages Smaller wound, less
dissection ICU setting Set uptime 20 minutes Procedures time less
than 10 minutes
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Percutaneous Tracheotomy
DisadvantagesDisadvantages 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
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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
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Video Percutaneous Tracheotomy
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Tracheotomy Tubes
Portex and Shiley common brands of trach tubes.
Shiley used as standard tube at St Michael’s Hospital.
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Tracheotomy Tubes
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Tracheotomy Tubes
Bivona or foam cuff Tracoe Cuffless
Speaking valve
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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
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Odd Things That Can Happen
Trach tube place upside down No CO2 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
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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)
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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
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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
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Late Complications/Stoma
Minor amount of bleeding common due to granulation tissue /dry mucosa
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Stoma and Inferior View Vocal Folds
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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
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Physiology of Tracheotomy Respiration
AdvantagesAdvantages 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
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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)
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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!Speech Therapy assessment!
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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
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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
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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
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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 If patient in distress and does not have fixed
obstruction above, pull out trach tubeobstruction above, pull out trach tube Ventilate with mask/intubate Use flex bronchoscope or replace/OR
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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
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Troubleshooting: Bleeding
Bleeding aroundaround 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
Bleeding from withinwithin lumen Often related to suctioning Broncoscopy exam Dry mucosa Granulation tissue Coagulopathy Rare innominate fistula
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Decannulation
Goal is to ensure patient can tolerate increasedincreased airway resistance/work of breathing and secretion clearance
30% increase WOB transition from trach breathing to upper airway breathing
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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)
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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 H2O
Ceriana et al 2003
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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
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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
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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)
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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
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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
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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
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Cricothyroidotomy