Trachesotomy

Reza Furqon S

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TrachesotomyIndicationsTechniqueOpen and percutaneousComplicationsPhysiology of a tracheotomyTroubleshootingDecannulation

Tracheotomy

Creation of communication between the trachea and the cervical skin with insertion of a tube

IndicationsAirway obstructionPulmonary SecretionsVentilationProlonged mechanical ventilationMay assist in weaning from mechanical ventilationPrevention of glottic stenosis/complication of prolonged ett

Fixed Airway ObstructionTumours of upper aero digestive tractChronic airway obstruction up to 80% lumenExternal compression by tumourAnaplastic thyroid, massive lymphadenopathyForeign BodyGlottic Stenosis/tracheal stenosisTrauma upper airway

Non-Fixed Airway ObstructionTraumaExpanding neck hematomaMaxillofacial traumaLaryngeal fractureInflammatoryInhalation injuryAnaphylaxisEpiglottitisLudwigs Angina/Deep Neck space infectionBilateral vocal cord paralysis

Fiberoptic Intubation can be successful

Pulmonary Secretion ClearanceAspiration / dysphagiaCOPDBronchiectesisStasis of secretionsPoor coughPoor respiratory reserve

VentilationNeuromuscular disorder affecting respiratory musclesReduced respiratory effortLimited pulmonary reserveCOPD, Scoliosis, bronchiectesisCentral respiratory depression Reduced LOCSevere obstructive sleep apneaCor pulmonale, failure CPAP

Prolonged Intubation7-10 days ettRisk Factors for Glottic StenosisDiabetesFemaleSize ETT and # ettHemodynamic instabilityIncidence glottic stenosis: 5% over 10 days (Whited 1984)

Example 1 Subglottic Stenosis

Example 3Combined Glottic/Tracheal Stenosis

Prolonged IntubationWeaning from ventilatorRelative indication for tracheotomyModest gains in respiratory function after tracheotomy may be enough to increase chance of successful weaning from ventilatorTrend of patients ventilator requirements5 day reversibility of common ICU admitting diagnoses

TracheotomyDecision made patient requires tracheotomyOpen or percutaneous technique75% of tracheotomies done at SMH are done percutaneously in ICU at bedsideVariations of open tracheotomy technique General principles are the sameExternal approach through neck soft tissueCreation of opening in tracheaPlacement of tube to maintain airway

TechniqueDiagrams from Lore, Surgical Atlas 1988

EquipmentTracheotomy setRight angles, cricoid hook, trach spreaderTracheotomy tubeShiley most commonSelect size (6, 8 most common)Cuffed non-fenestrated for most ICU patientsFenestrated if voicing expected (use non-fen inner cannula during procedure)

Open TracheotomyPosition the patientNeck extendedRoll under shouldersArms tuckedOn OR bedPalpate landmarks

Transverse incision half way between cricoid and sternal notchRetraction Divide strap muscles in midline

TechniqueDiagrams from Lore, Surgical Atlas 1988

Technique contThyroid isthmusDivide or retract Identify cricoid and upper tracheal rings using blunt dissectionBlunt cricoid hook helpfulRetract cricoid in superior direction

Tracheotomy tube cuff checked and obturator inDeflate cuff of endotracheal tubeHorizontal incision between tracheal rings (below the second ring)Suction lumen if necessarySpread rings apart with spreader or scissors

Technique 2DO NOT use cautery on the tracheaFIRE!

Technique 3

Technique Endotracheal tube withdrawn until just above the open tracheal siteTracheotomy tube with obturator, pushed into mid lumen of trachea, then directed inferiorlyObturator withdrawn and inner cannula placedAnaesthetic connector tubing passed over and connectedCuff inflatedDO NOT LET GO OF THE TUBE

Final

Anaesthesia: Check CO2, good breath soundsSew in the trach tube shield to skinLoosely approximate incisionTrach ties

ContraindicationsMedically well enough for GAPEEP < 20 mm HgUncontrolled coagulopathyAirway pathology below tracheotomy site

Tracheotomy TubesPortex and Shiley common brands of trach tubes. Shiley used as standard tube at St Michaels Hospital.

Tracheotomy Tubes

Tracheotomy TubesBivona or foam cuffTracoe CufflessSpeaking valve

Complications: IntraoperativeBleeding 2.8%*Recurrent laryngeal nerve injuryTracheoesophageal fistulaPneumothorax: rareFalse passageAnterior dissection most commonIncidence

Odd Things That Can Happen Trach tube place upside downNo CO2 tracing despite surgeon positive tube is in the airwayCut the pilot tube of the cuff while cutting the suturesTrach tube coughed across table after correct placementDifficulty with air leakCuff leak/tube too short or not large enough /position tubeBlocked tube secondary to secretions/blood

Tracheotomy: Early ComplicationsBleedingMinor commonMajor tracheoinnominate fistula (

Late ComplicationsTracheal stenosisTracheal chondritisSubglottis stenosis- high tracheotomyTracheomalaciaTracheoesophageal fistulaFailure of stoma closure when decannulated

Overall complication rate 15-30% in ICU patients largely minor with no long term morbidity

Tracheoinnominate FistulaMore than 10 days post tracheotomy (as early as 5 days)Sentinel bleedAngiogram/CTA for diagnosisSurgical explorationInterventional radiology-stent Associated with low tracheotomy placement, wound infection or aberrant artery

Late Complications/StomaMinor amount of bleeding common due to granulation tissue /dry mucosa

Stoma and Inferior View Vocal Folds

Physiology of TracheotomyNeck breathingBypass upper airway and nasal functionLoss of humidification/heat airflowDryness, thick secretionsVoicing possible with speaking valveLoss of smell /reduced tasteLoss glottic closure function for cough

Physiology of Tracheotomy Respiration

AdvantagesLower work of breathing (30%) c/w normal airwayFacilitates secretion clearanceAspiration or thick secretionsLess dead space (100 mL)Reduced airway resistanceAssists in patient independence from mechanical ventilationPatient comfort (better than ett)Epstein 2005 Respiratory Care

Physiology of Tracheotomy Respiration

DisadvantagesTube diameter and shapeincreases turbulent airflow, secretions adhere inside tubeLoss of humidification/heat function of upper airwayCiliary function affectedBiofilm colonizationDiminish cough/loss glottic closureReduce laryngeal elevation during swallowPatient comfort (better no tube at all)

DysphagiaCommon issue in neurological impaired ptTube required for secretion management particularly in patient with florid aspirateTube presence associated with limitation of the cephalad excursion of larynx during swallow and can contribute to dysphagia/aspirationEndoscopic / fluoroscopic assessmentSpeech Therapy assessment!

Postoperative Tracheotomy CareHumidification via trach mask/Instill salineClear secretions, prevent crustInner cannula cleaning tid at leastIf non-ventilated, change cuffed tube to non-cuffed at 5-7 days Ties changed 2 people if possibleMost hospital have nursing/RT protocolTeach everyone trach care including patient, family

Inner Cannula CareFrequently done tid or moreSaline and hydrogen peroxide (1:1) and trach brushRinse with sterile water/saline and reinsertSpare inner cannula and store in clean covered container Ties should be one finger tight and square knotRespiratory Therapy Protocol SMH

Troubleshooting DislodgementCausesTies too looseCoughcuff deflatedtube too short/wrong size for patientClinical signsDifficulty in ventilating patient Increased airway pressureSuction catheter obstructedNon Ventilated PatientPoor coughSudden voice changeStridor, SOBSuction catheter blocked

What to do: DislodgementExtend neckRemove inner cannulaUse obturator to redirect tracheotomy tube into lumenIf patient in distress and does not have fixed obstruction above, pull out trach tubeVentilate with mask/intubateUse flex bronchoscope or replace/OR

Troubleshooting Tube ObstructedMucous plug or blood clot most likelyGranulation tissue, particularly fenestrated tubesRemove inner cannula, suction, instill salineBronchoscopy If no other recourse, pull out trach tube and if necessary, replace new tube with obturatorIntubate/ventilate from above

Troubleshooting: BleedingBleeding around trach stomaMinor bleeding immediately post-opModerate bleeding/venous oozing often related to thyroidExamine woundPack, surgicel, if not controlled, take back to ORBleeding from within lumen Often related to suctioning Broncoscopy examDry mucosaGranulation tissueCoagulopathyRare innominate fistula

DecannulationGoal is to ensure patient can tolerate increased airway resistance/work of breathing and secretion clearance30% increase WOB transition from trach breathing to upper airway breathing

DecannulationIndication for tracheotomy has resolved/improvedPatient able to cope with secretionsUpper airway patent - examined if necessaryAppropriate vocal cord functionGood respiratory reserve/overall respiratory statusGag reflex present (5-10% no gag)

DecannulationStable clinical conditionHemodynamic stabilityAbsence of fever, sepsis infectionAdequate swallowing Gag reflex, bedside swallowing assessment, video fluoscopyMaximum expiratory pressure > 40 cm H2O

Ceriana et al 2003

Decannulation ProtocolDownsize tube to either 4 or 6 ShileyCuffless fenestrated tubeGradually increase corking/cap of trachCorked 24-48 hours before decannulationRemove tracheostomy tubeOcclusive dressing for stomaPersistent patent stomaOccasionally requires local flap to closeOutpatient procedure under local, infection common

Difficult to DecannulateGranulation tissueFenestra obstructedTracheal mucosal edema/supraglottic edemaNG, aspirationLaryngeal pathologyGlottic stenosis, cord paralysisPulmonary secretionsIncrease airway resistance not tolerated

Tracheotomy: SummarySafe method of airway managementOpen versus percutaneous technique availableComplications largely minorMortality rare from procedure directly0.3%* in last 30 years (grouped data)

SummaryAdvantages/risks of a tracheotomy for that individual patient must outweigh the disadvantages/risks without one.Indication for TracheotomyMedical comorbiditiesRespiratory /deglutition functionAbility to cope with secretionsTrial of corking/decannulation

CricothyroidotomyPrep and position as for trachIdentify landmarksLocal anaestheticIncision over cricothyroid membranePlacement of small tracheotomy tube, ETT or large bore needle with attachment for ventilation

CricothyroidotomyAdvantagesQuick c/w open trachNo laryngeal injuryFailure of intubation attempts in emergency situationDisadvantagesCan cause laryngeal injuryMust be sure of landmarksSmall tube required

Cricothyroidotomy

Terima kasih

**The outline for the talkPercutaneous may be new to some and a short video is available time permitting.The altered respiratory physiology is an important topic and it is the basis of a lot of the required tracheotomy care to prevent obstruction and other complications**Why the pt was trached in the first place is crucial if you are called to manage a complication or make a decision regarding care of a trach tube pt.**Some of these may be managed with a flexible endoscopic intubation and then a trach may be performed ie Ludwigs angina, maxillofacial trauma (need ett out of the way, expect arch bars)*Main goal is to prevent pneumonia/sepsis with better secretion clearance with suctioning/cough via trach.The medical conditions that predispose to the indication overlap considerably. For example, neurologic deficits are a common reason for significant aspiration, poor cough and inability to swallow.

Recovery from a significant head injury or stroke may take months and trach care is an important issue for this patient population. *The second historical indication for tracheotomy was for polio in 1932. Up until then, the only indication was for acute upper airways obstruction with a very high mortality rate. Neuro indications could be bilateral paralysis of diaphragm to brainstem stroke or post head injury. A common indication particularly the chronic care and rehabilitation facilities. However, at times patient require reassessment as to whether or not their original indication still necessitates a tracheotomy for their care and in most cases this is straight forward following the decannulation protocol but in others, a more formal evaluation is needed. Patients often are send to SMH from outside institutions for this assessment regarding tracheotomy.

*The video clip shows a man about 4 months post bypass who was ett for 21 days and never trached. He has significant stridor and no abduction of his cords at all. In fact, it nicely shows that as he inhales, his vocal get slightly pulled together (due to Bernoulli effect, negative pressure against the glottis as airflow if drawn in). As he exhales, his cords are alightly more open but his airway is about 3 mm wide at most. I just show the clip long enough to demonstrate this and then move on to next slide. This is a frequent reason that a patient fails decannulation. Surgical procedures can address the problem in some individuals but not all. Can be a cause of permanent tracheostomy.ie endoscopic laser arytenoidectomy or external laryngotracheoplastyLower video shows another patient who underwent open laryngoplasty with a stent in for four weeks and then was decannulated. St the start of the video, his wife say Wow Bob because she and the pt have been following his glottic stenosis prob lem with the video monitor during each examination and they both became quite good at understanding the findings on endoscopy. He has an open posterior glottic and some mobility of his folds but still not normal. ***This is an relative indication for tracheotomy. Many patients in the ICU have a tracheotomy performed because the ICU team feels that with just these modest changes, it may tip the balance in favour of the patient weaning from the ventilator. There is no exact protocol for this but a combination of factors including current ventilator settings (ie how much O2 , Peep) neurological status, other comorbidities like CAD, renal failure and how reversible their current acute condition are all factors taken into account. Often, the staff just know if they trach a patient, they will likely wean. *Cuffed tube placed during GA usually changed to a non cuffed fenestrated for voicing and /or planning for decannulationBasically, all patients are considered by the ENT service as a potential percutaneous tracheotomy. If they do meet the indications for a perc, the patient has an open trach in the OR. *Brief outline of procedure, standard approach, pt ett, under ga, next extended, between 2-3 ring etc.*****This is when it is tempting to use cautery on the trachea. There is a risk of tracheal fire if you use electrocautery on the trachea when opening the rings. The ignitor is the cautery, the accelerant is the oxygen and the ett tube burns. *****SMH uses exclusively shiley tubes in part for surgeon preference and in part to conform to a consistent protocol for nursing and respiratory care.We had problems when different tubes and inner cannulas were either not available or did not fit and made a decision to conform to one type of trach tube . Occasionally a special needs of a patient might require an alternate tube. The essential material is polyvinyl chloride or PVC with an outer cannula and in most types, also an inner cannula. Inner cannulas are designed to increase safety by allowing the inner cannula to be moved is obstructed with secretions or blood. The Fenesra is the hole in the back of the trach to faciliate airflow through the tube and not just around the tube if the patient is voicing or planning decannulation. The initial tube placed is also a cuffed one since the patient is under a GA. The sizes between these two main types is not the same. Shiley uses the diameter of the inner cannula as the size ie 6mm or 8mm. Portex uses an alternate system. Portex tubes have closer to a 90degree curvature in the tube and Shiley is less acutely angled. This may make one or the other more comfortable depending on their neck shape and thickness of soft tissue between the neck and the trachea in a patient with longterm or permanent tracheotomyA size 6 and 8 are the most common tube sizes used. *Jackson or Stainless steel: flatter shield, different material sometimes better tolerated by one patients tissues than anotherI will often try a metal or other material tube when granulation tissue is problematic but the metal tube is obviously more rigid and less conforming to the airway.Moore tubes are silicone and quite soft and flexible. They come in normal and extra long length and also conform to patient stome/trachea.Neither are fenestrated.*Two other tubes used in a different patient populations.Bivona is a foam cuff and inflates with a larger surface contact area on the tracheal mucosa. They also come in an extra long tube that can be extra long coming out of the neck or extra long at the tip of the tube for difficult to fit patients.These are for ventilator dependent patients and these do not have an inner cannula due to the silicone material- secretions are not supposed to adhere). Patients who tend to tend to have an airleak with the standard tube and low pressure, high volume air filled cuff (like Shiley) may do better with Bivona foame cuff. The fome cuff is supposed to be less traumatic for tracheal mucosa with low pressure and larger surface area contact.The trach tube on the right is a Tracoe which is a cuffless thermo adaptive tube that does conform to the patients stoma/tracheal shape over time. I have many patients who use this tube who are ambulatory and they find it more comfortable with less granulation tissue formation. It is flatter and fits under a shirt better but the speaking valve which is integrated with the inner cannula, does make a small click as it closes. Downside is that the tube breaks easier, cracks more readily and they cost a lot. Shiley cost 85$ cdn and a tracoe is $400 at least. They last about 6 months on average.

Paper by Jarrett et al 2002 on Biofilms on Tracheostomy tubesCompared PVC, silicone, stainless steel and sterling silver. A biofilm is an organized matrix of bacterial colonies. Most comon pathogens are pseudomonas and staph epidermidis which form polysaccharide matrices. Pseudomonas in particular likes to form a sessile colonies of bacteria that attaches to surfaces.They cultured the tube surfaces with the two pathogens and noted no difference on biofilm formation .

*Intraop complications are uncommon and we also have a similar experience of around a 1% complication rate. **Tube obstruction with secretions or blood is the most common problem. Next most common is a wound infection, often staph or pseudmonas and treated with local wound care and antibiotics, usually resolves. More rare is a true chondritis due to a pseudomonas infection of the tracheal cartilage. This can be a serious problem in a diabetic with loss of tracheal rings and difficulties used the stoma with poor fit and airleak. If this is extensive, the trach tube has to be removed after the pt intubated and the wound is packed with wet to dry packing until it closes. ***The risk of a massive bleed from a tracheo innominate fistula is very rare. In fifteen years at SMH there have been 2 known death associated with this complication. Both complicated with wound infection in severely ill patients. At least two weeks post op. This is usually during their inpatient stay in an acute care setting. Longterm complications from tracheotomy are usually local issues like granulation tissue, bleeding and infections. patients tend to develop granulation tissue at their stoma site in response to the presence of foreign material. This can cause localized infection, minor bleeding and at time obstruct the fenestra of their tube with the pedunculated tissue.

Video clip shows a view of a stoma with trach removed using a flexible nasendosope. At site, there is moderate granulation tissue inside the stoma and the tracheal wall is moderately dry with some mild crusting and flecks of blood. The patient coughs and clears mildly sticky secretions.Humidification must be provided since the usual method of nasal humidification and heating of air is bypassed with a tracheotomy. This is beneficial to the mucosa but the skin around the stoma does not tolerate being constantly wet. I often recommend that patients use saline drops placed into the trach tube several times a day to add extra mucosal humidification (assuming the patient has a decent cough) . *Video shows much cleaner stoma, healthy mucosa and minimal granulation tissue. Inferior view of vocal folds is not done on every patient but we do examine the airway with a flexible endosocpe prior to decannulation if there has been any difficulties with decannulation protocol or if there has been an airway obstruction. *Cough function Normally glottic closure permits a blast of increased intrathorcic pressure to bolster cough and assist in secretion clearance.

Hassle factor: pts and caregivers would all prefer not to look after a trach. High on the inconvenient level and requires training and a certain comfort level with cleaning and cannula care. Nonetheless, tracheotomy is often a necessary part of complex patient.*Chadda et al 2002 Measured WOB on 10 pts while trached, then after decannulation and WOB increased by up to 30% when trach removed Obvious access for secretion clearance particularly important in patients who have florid aspiration and or significant pulmonary secretions with a reduced cough.Often a multifactorial problems with respiratory function ie brainstem stroke with reduced respiratory and/or laryngeal function on a neuromuscular level with aspiration causing recurrent pneumonia and thick secretions. Lowered airway resistant has not been proven to be significant at times due to; 1) tube lumen smaller than normal glottic aperture and 2) turbulent airflow due to increased flow rate and shape of the tube Many patients who fail extubation are successfully weaned once tracheotomy is performed. Literature is mixed but support appears to support tracheotomy in ett patients who have been difficult to wean that there is reduced work of breathing (elastic and resistive)

Patient comfort should not be underestimated when compared with endotracheal intubation. However, many patients not on mech ventilation would be more comfortable without a tracheotomy tube.*Lowered airway resistant has not been proven to be significant at times due t 1) tube lumen smaller than normal glottic aperture and 2) turbulent airflow due to increased flow rate and shape of the tube However, many patients not on mech ventilation would be more comfortable without a tracheotomy tube.

Physiology of tracheotomy and its effects are contradictory. On one hand, a trach facilitates pulmonary secretion clearance and at the same time, the loss of humidification/heat transfer by bypassing upper airway thickens secretions and can cause mucosa dessication. The resulting loss of ciliary function and thickened secretions can predispose to mucous stasis subsequent respiratory infections.*This problem comes up in the head injury and neurologically affected population quite often. On one hand, the trach is indicated to deal with aspiration and on the other hand, it contributes to it.Wide variation in patient swallowing function and neurological status. Floridly aspirating patient are staying trached to clear secretion and helpfully prevent pneumonia.Microaspiratoin patients with minimal aspiration on deglutition study with good cough and clearance of the aspirate and no other indication ,I would try decannulating.In the middle, I often want information from the nursing unit where the patient has been about the quantity and thickness of secretions. If suction is rare, pt able to clear secretion well through tube, swallowing their saliva, will trial corking / decannulation. Worse come to worse, trach has to get put back in. Upper airway examination for vocal fold function, clearing secretions and an assessment by speech language pathology is indicated.A bedside swallow assessment can be very helpful and a formal deglutition study if possible. I frequently assess patient because the SLP involved needs more information about laryngeal function either regarding airway, voice or swallowing. *The altered physiology is reflected in the required tracheotomy care. Combination of nursing and respiratory care. Many patients/family members can be taught some portions or all of trach care. This increases comfort level and safety. In my opinion, the more individuals who are able to change and clean an inner cannula around a trach dependent patient, the better. *

Ambulatory and independent living trach patients end up always doing their own trach care or with family member to help. The nursing guidance and home care at the beginning is crucial but their knowledge base increases quickly and they do not need nursing care long term.Keep the ties snug around the neck. A trach tube that can wiggle too much ends up causing more discomfort, coughing and granulation tissue.

*Causestrach ties too looseCoughing tube outCuff deflatedtube too short for that patients anatomy

*Extending the neck to to place tube is important since this is the position that it was put in and it makes the easiest alignment to replace tube. Try to remove inner cannula is pt in distress since secretions are the most common cause of obstruction and replacing the inner cannula is often effective.The obturator is used to replace the outer cannula if it is dislodged.

Important to know why the patient is trached. If there is no airway obstruction, the track is blocked and none of the above has worked, rempoving the trach may be the best way to temporarily relieve the obstruction. Most patients who are not ventilated with a trach can be intubated if needed or breath with an oxygen mask or oral airway in place. **Around stoma bleeding can also be from granulation tissue which can be excised and cauterized usually at bedside. or in clinic setting. Post op minor stoma bleeding often treated with local packing and silver nitrate or surgicel packing.

Increase saline instillation /humidification to reduce mucosal bleeding.

*When to take a trach tube out. Pt must be able to tolerate increased work of breathing to remove trach, and cope with their secretions, Micro aspiration can at times be tolerated if the patient has a sensate trachea and can clear the secretion well. This is an area where sometimes a trial of decannulation may be the only way to test if the patient can cope with minor aspiration without pneumonia developing.*Micro aspiration can at times be tolerated if the patient has a sensate trachea and can clear the secretion well. This is an area where sometimes a trial of decannulation may be the only way to test if the patient can cope with minor aspiration without pneumonia developing.No gag present in 5-10% of normals. *Micro aspiration can at times be tolerated if the patient has a sensate trachea and can clear well. This is an area where sometimes a trial of decannulation may be the only way to test if the patient can cppe with minor aspiration without pneumonia developing.Max expiratory pressure RT can measure.

*Can decannulate with downsizing but easier to breath around tube is fenestra is not ideally positioned within trachea and stoma does close around smaller tube.Usually a 6 Shiley in most patient, occasioally a 4 in a smaller woman. I will wait 2 3 months before closing with a flap.Almost always they get infected and I want the stoma as small as possible.

*Presence of NG can increase supraglottic edema, reflux, stasis of secretion in hypopharynx. If likely to have prolonged inability to swallow and pt may be able to be decannulated with a good cough and secretion clearance, suggest g-tube placement. *Mortality rate for this procedure was close to 100%in the late 1800s and 40% in 1930s. ****