Components of a standard tracheostomy tube

Following Successful Liberation From Prolonged Mechanical Ventilation

Absence of distress and stable arterial blood gases on prolonged mechanical ventilation for 5 days

Stable clinical condition indicated by factors such as:1- Hemodynamic stability2- Absence of fever, sepsis, or active infection3- PaCO2 60 mm Hg4 Normal endoscopic examination or revealing stenotic

lesions occupying 30% of the airway5 Absence of delirium or psychiatric disorders6 Adequate swallowing evaluated by gag reflex, blue

dye, and video fluoroscopy7 Patient able to expectorate on request8 Maximum expiratory pressure 40 cm H2O

ComplicationsNo. ofcasesPercent ofTotal Outcome Tracheal stenosis 21

1.85 Hemorrhage 9 0.87 Tracheocutaneous fistula 6 0.53 Infection 5 0.44 Pneumothorax 3 0.26 Tube decannulation/obstruction 1 0.08 Subcutaneous emphysema 1 0.08 Tracheoesophageal fistula 1 0.08

directly proportional to length inversely proportional to the radius of

the tuberaised to the 4th power (when flow is laminar) When flow becomes turbulent, airways

resistance becomes inversely proportional to the radius of the tube raised to the 5th power.

small reductions in tube radius result in large increases in resistance.

Turbulent flow occurs when flow rates are high, when secretions adhere to the inside of the tube and because of tube curvature.

The word tracheostomy is derived from 2 Greek wordsmeaning “I cut the trachea.”

ENDOTRACHEAL TRACH

Size ID length Vd 6 6 31 11

7 7 34 15 8 8 35 18 8.5 8.5 36 24 mm cm ml

Size ID length Vd 4 5 10 3 6 7 12 5 8 8.5 12 6 10 9 12 8 mm cm ml

Tracheostomy tubes have an important effect on respiratoryphysiology. The most recent and methodologicalrobust studies indicate that these tubes reduce resistive andelastic WOB when compared to ETTs. This is a result oftracheostomy tubes lessening inspiratory and expiratoryairways resistance and intrinsic PEEP.

Before tracheostomyVt ml 329Ve l/m

9.2F b/m 28PEEPi cm/h20

2.9PTP cm/h20xs/min 236WOB J/L .97WOB J/min

8.9Exp RAW 9.4

After tracheostomy p312 0.47 8.1 0.2626 0.511.6

0.02155 0.09.81 0.096.6

0.046.3 0.07

20 surgical patients 14 men Mean age 58 Acute lung injury Ventilate mean 16

days Met extubation

criteria Failed extubation

twice before trach decision

80% had #8 ETT 20% #7 ETT Measurements: 6-8

hours before and 12 hours after surgical trach.

THE 2ND TRACHEAL RING IS DIVIDEDLATERALLY AND THE ANTERIOR PORTION REMOVED

INSTEAD OF RESECTING AND REMOVINGTHE TRACHEAL RING, IT CAN BE USED TO CREATE A FLAP, WHICH CANBE ATTACHED TO THE SKIN. THIS METHOD, DESCRIBED BY BJORK.,

FIBEROPIC BRONCHOSCOPY IS USED TO HELP PLACE THE GUIDE

WIRE CORRECTLY FOR PDT. HERE THE WIRE IS SEEN IN THE ANTERIOR PART OR

THE TRACHEA, PASSING BETWEEN THE 2ND AND 3RD TRACHEAL RINGS.

HERE IS THE BRONCHOSCOPIC VIEW OF THE TIP OF A DILATOR ENTERINGTHE TRACHEA OVER THE GUIDE WIRE DURING PLACEMENT OF A PERCUTANEOUSDILATIONAL TRACHEOSTOMY.

A SERIES OF TAPERED DILATORS ARESEQUENTIALLY INSERTED OVER THE GUIDE WIRE TO CREATE THE STOMA FORPLACEMENT OF THE TRACHEOTOMY TUBE.

THE BLUE RHINO IS A SINGLE DILATOR THAT CAN BE USED INSTEAD OF THE SEQUENTIAL DILATORS OF THE CIAGLIA METHOD

The Rig Veda, sacred book of Hindu medicine, written

between 2000 and 1000 BC.

The Ebers Papyrus, dating from about 1550

BC. The Ebers Papyrus is written in hieratic Egyptian writing and preserves for us the most voluminous record of ancient Egyptian medicine known.

The ancient Chinese text Huang Ti Nei Ching Su Wen contains no reference to any surgical procedure.

In the 8th century BC, Homer is said to have described the relief of choking persons on cutting into the trachea.

Hippocrates (4th century BC) may have referred to tracheal cannulation as a treatment for quinsy (peritonsillar abscess).

Alexander the Great, in the 4th century BC, “punctured the

trachea of a soldier with the point of his sword when he saw the man choking from a bone lodged in his throat.”

Both Aretaeus and Galen, in the 2nd Century AD, wrote that Asclepiades of Bithynia performed elective tracheostomy in around 100 BC. McClelland RM

Galen, the most eminent Greek physician after Hippocrates.

Antyllus of Rome told in AD 340 of making a transverse incision between the 3rd and 4th tracheal rings, drawing the cartilages apart with hooks, and subsequently sewing the edges of the wound together once the patient could breathe more freely. Frost EA

Antyllus', a 4th century Roman physician.

The first account of the procedure to be written by the surgeon who performed it

was by Brasavola in 1546, who used it to relieve airway obstruction from enlarged tonsils. McClelland RM

Antonio Musa Brassavola (variously spelled Brasavoli, Brasavola, or Brasavoli, born January 16, 1500 in Ferrara) was an Italian physician and one of the most famous of his time.

At about the same time , Fabricius ab Aquadependente is said to have performed a tracheostomy on a patient with a foreign body in the larynx , as well as on several other occasions. Frost EA

The first step towards percutaneous tracheotomy was made by the famous Italian anatomist and surgeon Fabricius of Aquapendente ( 1537-1619).

Sanatorius , in 1590, first used a trocar for tracheostomy, and reported leaving a cannula in place for 3 days. Frost EA

The Italian surgeon Sanctorio Sanctorius (1561-1636) was probably the first surgeon to describe

percutaneous tracheotomy (Sanctorius, 1626).

The word tracheostomy was first used by Heister in 1739 (German surgeon Laurentius Heister(1683-1758).

George Washington, who died in 1799, developed progressive upper-airway obstruction, the cause of which is thought most likely to have been acute epiglottitis. Scheidemandel HH. Did George Washington die of quinsy? Arch Otolaryngol 1976;102(9):519–521.5.

Witt CB Jr. The health and controversial death of George Washington. Ear Nose Throat J 2001;80(2):102–105.

The prominent physician Elisha C Dick, who examined the former president, recommended tracheostomy, but was overruled by the other physicians in attendance. Frost EA. Tracing the tracheostomy . Ann

OtolRhinol Laryngol 1976;85(5 Pt 1):618–624.

Witt CB Jr. The health and controversial death of George Washington Ear Nose Throat J 2001;80(2):102–105.

In the early 19th century, performance of the procedure became more widespread and there were multiple reports in the medical literature. Trousseau reported in 1869 on 215 patients in whom tracheostomy was performed in the treatment of diphtheria (with 47 survivors), his series having begun during the 1830s.

The 1860 yearbook of the New Sydenham Society contained some 38 papers devoted to

indications and techniques of tracheostomy.

In this country,the famous surgeon Chevalier Jackson refined the technical aspects of the procedure and described them in detail in 1909.

Chevalier Jackson standardized the indications for tracheostomy, the technique itself, and the instruments used, around the turn of the 20th century. He developed anatomically correct tracheostomy tubes, recommended a“high” tracheostomy location (ring 2 or 3).

1. Merriam-Webster Online Dictionary: • Tracheostomy: the surgical formation of an opening intothe trachea through the neck especially to allow the passageof air • Tracheotomy: the surgical operation of cutting into thetrachea especially through the skin2. Stedman’s Medical Dictionary: • Tracheostomy: An operation to make an opening intothe trachea. • Tracheotomy: The operation of incising the trachea, usuallyintended to be temporary3. Oxford English Dictionary:• Tracheostomy: The operation of

making an opening inthe trachea near its upper end, so that the patient canbreathe through it; also, the opening so made • Tracheotomy: = tracheostomy

administer positive-pressure ventilation

provide a patent airway provide protection from aspiration Airway protection in head injured or

comatose patient and in postoperative neurosurgical patients

provide access to the lower respiratory tract forairway clearance

ID OD Curve1. Angled2. Curved Length1. Xl proximal2. Xl distal3. normal Cuffed1. Low pressurea) Fenestratedb) Non-fenestrated1. Tight to shaft2. Foam Uncuffed

Shiley uses the Jackson scale most of the time (xl and SCT uses ISO)

w/IC #4 = ID= 5.0, #6= ID 6.4, #8= ID 7.6 , #10= ID 8.9mm.

Portex uses the International Standards Organization (ISO) scale. Median –measure at shaft.

The functional internal diameter size. Subtract 1mm for inner cannula.

w/o IC #6= ID 6mm, #7 =ID 7mm, #8= ID 8mm

the rigid cricoid cartilage encases a 1.5–2.0-cm region known as the subglottic space.

Inferior to cricoid is the trachea, a cylindrical tube that extends inferiorly and slightly posteriorly.

The trachea is made up of 18–22 C-shaped rings consisting of rigid cartilage anteriorly and laterally, and a membranous posterior portion.

In the average adult, the distance from cricoid to carina is approximately 11 cm in length, with a range of 10–13 cm.

#4 11.47 cm H2O/L/s #6 3.96 “ #8 1.75 “ #10 0.69 Mullins JB, Templer JW, Kong J, Davis WE, Hinson J.

Airwayresistance and work of breathing in tracheostomy

tubes. Laryngoscope 1993;103(12):1367–1372

SHAPE #MALE #FEMALE

C 14 U 33 D 16 E 21 T 16 O 0

38 10 6 45 0 1The tone of the trachealis

muscle that bridges the gaps posteriorly between rings is responsible for the shape differences.

1.Reduced dead space2.Less airway resistance3.Decreased work of breathing4.Better secretion removal with

suctioning5.Less likelihood of tube obstruction6.Improved patient comfort7.Less need for sedation8.Better glottic function, with less risk

of aspiration9.Ability to move patient out of the

intensive care unit10.Changes in clinician behavior

Inner Diameter Outer Diameter Length 6 9.2 64.5 7 10.5 70 7.5 11.3 73 8 11.9 75.5 8.5 12.6 78 9 13.3 81

Can be used with Perc kit. Markings line up.

Pathologic correlates for hypoxemia1. Low inspired O2: high altitude, smoke

inhalation.2. Alveolar hypoventilation: COPD acute

exacerbation, Acute asthma exacerbation, neuromuscular weakness.

3. Ventilation-perfusion mismatch: COPD exacerbation, asthma exacerbation, mild CHF, mild pna, mild atelectasis.

4. Shunt, right to left: severe exacerbation COPD/asthma, severe CHF/pneumonia/atelectasis, ARDS.

5. Diffusion defect: acts a a V/Q mismatch.

Work this table back and forth to determine FIO2 change and device change.

Low flow vs high flow; aka variable O2 devices vs fixed O2 devices.

A)The amount of oxygen (FiO2) desired (*This is the fundamental consideration.)

B) The degree of FiO2 precision required.

(*The Venturi mask is the mask of choice for “CO2 retainers”.)

C)Patient comfort and compliance. D)The need for aerosol mist.

1) Most commonly used device because of excellent patient tolerance.

2) The delivered oxygen at any flow setting depends primarily on the patient’s ventilatory pattern.

3) Can deliver from 24 – 40% oxygen and is ordered at flows of ¼ to 6 liters per minute.

4) Humidification should be used for flows greater than 4L/minute.

(*Exceptions: Humidification for flow rates <4L/min may be considered if the patient requests it, if the patient experiences epistaxis, or if the patient complains of a dry nose, dry secretions, and/or a sore throat.)

1) A reservoir bag is added to the simple mask design to deliver over 60% oxygen (from 60-80% oxygen).

2) A Non-Rebreather Mask is used and the 2 flaps are removed to create a Partial Non-Rebreather Mask.

3) The system allows the first part of the patient’s exhalation to enter the bag (anatomic dead space gas).

4) The reservoir bag should NOT deflate completely on inspiration. If this occurs, the patient may rebreathe his or her own CO2.

5) Partial rebreathers should always run at about 10 liter/minute to prevent total collapse.

1) The use of valves in the non-rebreather mask allows for one way flow of 100% oxygen into the reservoir bag and then out to the patient with no rebreathing of expired gas.

2) This delivery system is used when one needs to deliver a high percentage of oxygen quickly.

3) Flow rates of 10 – 15 liters per minute theoretically provide the patient’s entire inspired volume.

4) Increased respiratory drive along with improper seal of the mask may all for room air to be inspired.

6) The non rebreather mask contains 2 valves. Check labeling to be sure valves are latex free.