Tracheostomy Tube.

Dr. O’shea’s Tutorial.Valmiki K. Seecheran.

Surgery Senior Clerkship.

Year V MBBS| UWI Cave Hill.

Tracheostomy.

• Operative procedure that creates a surgical airway in the cervical trachea.

• Studies have supported percutaneous over open however debate remains over the surgeon’s experience and comfort in addition to the institution.

• Open.• Amongst the oldest procedures in history.

• Percutaneous technique. • Invented in 1980’s.

Indications.

• Prolonged intubation.

• Facilitation of ventilation support.

• Inability of patient to manage secretions.

• Upper airway obstruction.

• Inability to intubate.

• Adjunct to major head and neck surgery.

• Adjunct to management of major head and neck trauma.

Contraindications.

• Relative.• Laryngeal carcinoma.

• Absolute.• Nil.

Complications.

• Bleeding.

• Infection – Tracheitis.

• Pneumothorax.

• Injury.• Cricothyroid muscle, vocal muscles and vocal cords.

• Recurrent laryngeal nerves.

• Thyroid gland + Inferior thyroid veins.

Tracheostomy vs Tracheal Intubation.

• Increased patient mobility.• More secure airway.• Increased comfort.• Improved airway suctioning.• Early transfer of ventilator-dependent patients from the intensive care unit

(ICU).• Less direct endolaryngeal injury.• Enhanced oral nutrition.• Enhanced phonation and communication.• Decreased airway resistance for promoting weaning from mechanical

ventilation.• Decreased risk for nosocomial pneumonia in patient subgroups.

Tracheostomy tubes.

• Hollow tube +/- cuff.

• Arc-shaped or angled.

• Electively inserted directly into trachea via surgical incision or wire-guided progressive dilation technique.

• There are many types of tracheostomy tubes;• PVC.• Silicone.• Siliconized PVC.• Silver.• Armored tubes.

PVC Type.

• Polyvinyl chloride.

• Highly modifiable due to additives – flexibility, opacity, color, heat stability, density, chemical resistance.

• High degree of biocompatibility, flexibility under changing temperature and humidity.

• Easily sterilized but prone to retention of bacteria – single use.

• Cheap, readily available.

• Excellent water and chemical resistance.

Silicone type.

• Silicone.

• Reduces adherence of secretions and bacteria by promoting easier passage for mucus.

• Can be sterilized but confined to single patient use.

• Cost effect – long term – patient dependent.

Tube size.

• Ideal size maximizes the functional internal diameter.

• The distal end of the tube should sit comfortably in the trachea and no closer than 1-2 cm from the carina.

• Average habitus. • #6 Shiley cuffed tracheostomy tube – women.

• #8 Shiley cuffed tracheostomy tube – men.

Cannulae.

• Outer cannula is the main body of the tube that passes into trachea.

• Single lumen tubes contain only the outer cannula.

• Some tubes have single or multiple fenestrations on the superior curvature of the shaft.• Allows airflow, phonation and effective coughing.

• Fenestrated tubes are contraindicated in patients who require positive pressure ventilation.

• Some tubes allow an inner tube which is removable.• This allows maintenance of a clear airway by removing the inner tube to clear

secretions.

(A) Uncuffed single-cannula tubes.

(B) Cuffed single-cannula tubes.

Double-cannula tube shown with choice of fenestrated and non-fenestrated inner cannulae. Obturator for insertion is also included at the bottom.

Adult swivel, neonatal, and pediatric neck flanges.

The neck plate attached to the proximal end of the tube prevents the tube from descending into the trachea and allows for securing the tube with tapes, ties, or sutures.

Tracheostomy care.

• Routine changes – Tracheostomy tubes are routinely changed 7 to 14 days after initial insertion and then every 60 to 90 days.

• Patient discomfort – reduce size.

• Patient-ventilator asynchrony – Patient-ventilator asynchrony that is related to the tracheostomy tube may respond to changing the tube.

• Cuff leak – changing of tube.

• Fracture – Fracture of the tracheostomy tube or flange.

• Type change – Changing a tracheostomy tube from one type to another may be indicated by the clinical circumstances; as an example, changing from a balloon cuff to either a foam cuff or a cuffless tracheostomy tube.

• Bronchoscopy – Flexible bronchoscopy generally requires a tracheostomy tube with an inner diameter of at least 7.5 mm; thus, the tracheostomy tube may need to be changed to one with a larger inner diameter to facilitate bronchoscopy.

Decannulation.

• No upper airway obstruction.

• The ability to clear secretions that are neither too copious nor too thick.

• The presence of an effective cough.

Thank you.