TRACHEOSTOMY & CRICOTHYROIDOTOMY

INTRODUCTION

• Tracheostomy is an operative procedure that creates a surgical airway in the cervical trachea

• It is considered synonymous with tracheotomy

LARYNX & TRACHEA

ANATOMY I

ANATOMY II

ANATOMY III

ANATOMY IV

UPPER AIRWAY OBSTRUCTION -RECOGNITION

• Dyspnea • Stridor • Voice change • Decreased or absent breath sounds • Restlessness • Hemodynamic instability (late) • Loss of consciousness (very late)

INDICATIONS FOR TRACHEOSTOMY

• To bypass obstruction • Long-term Mechanical ventilation• Neck trauma • Tumour • Bilateral vocal cord paralysis • Laryngeal Edema• Respiratory failure

FORMS OF TRACHEOSTOMY

• Emergency tracheostomy

• Urgent tracheostomy

• Elective tracheostomy

INTRAOPERATIVE DETAILS:TRACHEOSTOMY

TRACHY TUBES

TUBE PARTS

METALIC TUBES

PLASTIC TUBES

• Chest X-ray after trachy

POSTOPERATIVE DETAILS

• Postoperative care is critical.

• Copious secretions is the normal

• Suctioning every 15 minutes may be required

• Suctioning should be shallow initially

• Suctioning should be limited to no more than 15 seconds

POSTOPERATIVE DETAILS 2

• Humidified oxygen helps prevent inspissation of the secretions.

• Mucolytic agents may be employed. • If uncorrected, mucus plugging of the inner cannula

can cause a life-threatening obstruction.

POSTOPERATIVE DETAILS 3

• The original tube is left sutured in place for 5-7 days to allow the tract to heal.

• Then the sutures are removed, and the tube is replaced.

• The site should be kept clean and dry to minimize infection

• Patient and family education should begin

FOLLOW-UP CARE• Speaking: should be encouraged when cuff is

deflated

• Swallowing: Swallowing is more difficult

• Evaluate risk of aspiration before feeding

• Educate: both patient and family

• Equipment: for discharge

SUCTIONING• "STERILE TECHNIQUE" - the use of a sterile catheter

and sterile gloves for each suctioning procedure.

• "CLEAN TECHNIQUE" - the use of a clean catheter and nonsterile, disposable gloves or freshly washed, clean hands for the procedure.

• “MODIFIED CLEAN TECHNIQUE" - nonsterile gloves and sterile catheters).

SUCTIONING DEPTH

• SHALLOW SUCTIONING – suctioning at the hub of the tracheostomy tube to remove secretions coughed up to the opening of the tracheostomy tube.

• The PRE-MEASURED TECHNIQUE - the catheter is inserted to a pre-measured depth, with the most distal side holes just exiting the tip of the tracheostomy tube.

• DEEP SUCTIONING - the insertion of the catheter until resistance is met, withdrawing the catheter slightly before suction is applied.

WHEN IS SUCTIONING REQUIRED?

• Whenever patient is unable to clear secretions by coughing

• Bleeding down the airway

WHEN TO SUCTION 1

• Mucus bubbling in trachyostomy tube • Audible gargling sounds• Difficult breathing• Restlessness• Gurgles heard on auscultation • Low SpO2

WHEN T SUCTION 2• Stridor or changes in breathing

• Cyanosis

• Increased ventilator inspiratory pressure (for patient on ventilator, a high pressure alarm may sound)

• Patient request

INSTILLING• Introduction of normal saline into the airway to aid

removal of thick, tenacious secretions. • TENACIOUS SECRETIONS– Systemic hydration

– Humidification

– Chest physiotherapy

– Suctioning, coughs and assisted coughs

– Mucolytic agents

COMPLICATIONS

• IMMEDIATE

• EARLY

• LATE

COMPLICATIONS 1

• IMMEDIATE

–Bleeding

–Pneumothorax/Pneumomediastinum

– Injury to adjacent structures

COMPLICATIONS 2

• EARLY

–Bleeding

– Tube obstruction

– Tube displacement/dislodgement

– Subcutaneous Emphysema

–Atelectasis

COMPLICATIONS 3• LATE–Bleeding

– Tracheal stenosis

– Tracheomalacia

– Tracheo-esophageal fistula

– Failure to de-cannulate