TRACHEOSTOMY

Dr. Amit KochetaDr. Amit Kocheta DNB TraineeDNB Trainee

Dept. of Anesthesia & Intensive Care UnitDept. of Anesthesia & Intensive Care Unit

BMHRC, BhopalBMHRC, Bhopal

What is a Tracheostomy??

A tracheostomy is a artificial (usually) surgically created airway fashioned by making a hole in the anterior wall of the trachea and the insertion of a tracheostomy tube, which may or may not be permanent

History Tracheostomy is one of the oldest surgical

procedures. A tracheotomy was portrayed on Egyptian

tablets dated back to 3600 BC. Asclepiades of Persia is credited as the first

person to perform a tracheotomy in 100 BC. The first successful tracheostomy was

performed by Brasovala in the 15th century. 

Modern Percutaneous Tracheostomy (PCT) device was developed by Toye and Weinstein in 1969,

The Wire guided technique for percutaneous tracheostomy was developed and reported in the same year by the American surgeon, Ciaglia.

Ever since the PCT has evolved, the resources required for a surgical tracheostomy (ST), the need of operating room, and personnel have been eliminated

Indications Upper Airway obstruction secondary to –

trauma, burns corrosive poisoning, laryngeal dysfunction, foreign body, infections, inflammatory conditions, neoplasms, Postoperatively, Obstructive sleep apnea

Access for pulmonary toilet Prolonged ventilatory support Airway protection in head injured or comatose patient

and in postoperative neurosurgical patients

Contraindications Absolute1. Need for an emergency airway2. Performance of the procedure in children as cartilages is soft. Relative1. High degree of ventilatory support– PEEP >8cm H2O, FiO2 >

50%2. Unstable cervical spine3. Uncorrected Coagulopathy4. Presence of neck mass or pervious neck surgery5. History of mediastinal irradiation due to intrathoracic fibrosis6. Previous history of surgical tracheostomy7. Increased intracranial pressure

Advantages of Tracheotomy Increased patient mobility More secure airway Increased comfort Improved airway suctioning Early transfer of ventilator-dependent patients

from the intensive care unit (ICU) Less Endo-laryngeal injury Enhanced oral nutrition Enhanced phonation and communication Decreased airway resistance for promoting

weaning from mechanical ventilation Decreased risk for nosocomial pneumonia

How To Create a Tracheostomy Cricothyroidotomy

For Urgent Procedures

Percutaneous Tracheostomy Can be done in the ICU at the bedside

Surgical Tracheostomy

Anatomy

•The trachea is a fibromuscular tube supported by 20 hyaline cartilages which are opened posteriorly.

•The soft tissue posterior wall is in contact with the oesophagus.

•Trachea lies in midline of the neck extending from Cricoid cartilage (C6) superiorly to the tracheal bifurcation at the level of sternal angle (T5).

Anatomy•In adults it is 12-16 cm long and 13-16 mm wide in women and 16-20 mm wide in men

•The blood supply is primarily supported by the bracheocephalic artery and through the inferior thyroid and bronchial arteries.

•The nerve supply is by parasympathetic and sympathetic fibres.

•The parasympathetic supply to the trachea is by the recurrent laryngeal nerve – a branch of the vagus nerve

Landmarks for Tracheostomy

Tracheostomy Tubes Tracheostomy tubes are available in a variety of sizes and

styles, from several manufacturers. Dimensions of tracheostomy tubes are given by their

inner diameter (ID), outer diameter (OD), length, and curvature.

Tracheostomy tubes can be angled or curved, a feature that can be used to improve the fit of the tube in the trachea.

Cuffs on tracheostomy tubes include high-volume low-pressure cuffs, tight-to shaft cuffs, and foam cuffs.

Tracheostomy tubes which have an inner cannula are called dual cannula tracheostomy tubes.

Metal versus Plastic tracheostomy tubes

Tracheostomy tubes can be of either metal or plastic.

Metal tubes are constructed of silver or stainless steel.

Metal tubes are not used commonly because they are

→ expensive,

→ rigid construction,

→ uncuffed

→lack a 15 mm connector for attachment

to a ventilator

Plastic tubes are most commonly used and are made from polyvinyl chloride or silicone.

Polyvinyl chloride softens at body temperature (thermo labile), conforming to patient’s tracheal anatomy and centering the distal tip in the trachea

Tracheostomy tube selection

Tracheostomy tube selectionion While selecting a tracheostomy tube, the ID and OD, its

curvature and proximal and distal length must be considered. If the ID is too small, it will →increase the resistance through the tube, →make airway clearance difficult, → increase the cuff pressure required to create seal If the OD is too large, → Difficulty in speech →difficult to pass through the stoma. →may not conform to the shape of the trachea, →compression of the membranous trachea.

Tracheostomy tubes are available in standard length or extra length.

Extra length tubes are constructed with either extra proximal length (horizontal extra length) or with extra distal length (vertical extra length)

Extra proximal length facilitates tracheostomy tube placement in patients with a large neck (e.g. obese patients).

Extra distal length facilitates placement in patients with tracheaomalacia or tracheal anomalies.

Care must be taken to avoid inappropriate use of these tubes, which may induce distal obstruction of the tube

Cuffed Tracheostomy tube Cuffed tracheostomy tubes

allow airway clearance, protection from aspiration positive pressure ventilation

It is recommended that cuff pressure be maintained at 20–25 mmHg (25–35 cm H2O) to

minimize the risks for both

tracheal wall injury and aspiration.

Fenestrated tracheostomy tubes The fenestrated tracheostomy

tube is similar in construction to standard tracheostomy tubes, with the addition of an opening in the posterior portion of the tube above the cuff.

With the inner cannula removed, the cuff deflated, and the tracheostomy air passage occluded, the patient can inhale and exhale through the fenestration and around the tube.

This allows for assessment of the patient’s ability:- to breathe through the normal oral/nasal route preparing the patient for decannulation allowing phonation

Supplemental oxygen administration to the upper airway (e.g. nasal cannula) may be necessary if the tube is capped.

Percutaneous Tracheostomy 1955, Shelden et al - first attempted PCT with cutting trocar into

the trachea. The wire-guided technique for percutaneous tracheostomy was

developed and reported in 1986 by the American surgeon, Ciaglia. 1990, Griggs et al - the guide wire dilating forceps (GWDF) Several variants of the percutaneous tracheostomy technique have been developed. Using a wire guided sharp forceps (Griggs technique) Using a single tapered dilator (Blue Rhino) Passing the dilator from inside the trachea to the outside (Fantoni’s technique); Using a screw like device to open the trachea wall (PercTwist).

Technique As an alterative to ST , percutaneous dilational

tracheostomy (PDT) has become a very common method of placing a tracheostomy in critically ill patients in the intensive care unit.

It is rapid, simple, easy to learn, and cost effective. The procedure should be deferred in patients having an

INR>1.5, Activated partial thromboplastin time >45 seconds Platelet count of < 50,000⁄ ml.

To prevent inadvertent injury of the membranous posterior tracheal wall or too lateral a location of the tracheostomy, a technique of observing and directing the needle and wire placement, using fiberoptic bronchoscopy is recommended

In order to visualize the upper rings of the trachea with the bronchoscope, the endotracheal tube (ET) must be withdrawn until the its tip is just in the larynx.

Patients requiring a tracheostomy only for airway access or protection often can have a laryngeal mask airway replace the endotracheal tube to provide the route for bronchoscopic visualization.

PDT is usually performed in an anesthetized patient, and can be done in the intensive care unit or operating room.

The patient should be monitored by SpO2, EtCO2 and ECG.

The patient is positioned as for the surgical tracheostomy. A pillow is placed under the shoulders, the neck is moderately extended, and the first three tracheal rings are identified

The anterior neck is prepared with povidine iodine and draped with sterile sheets.

The skin overlying first and second tracheal rings is infiltrated subcutaneously with 3-5 ml of 1% Xylocaine with Epinephrine (1:200,000), and a 1.5 cm vertical incision is made and blunt dissection is performed to expose the Pretracheal fascia.

The anterior trachea is palpated and the intended site is punctured with a 14G intravenous cannula in a postero-caudal direction.

The entry of the IV cannula in trachea is confirmed by aspiration of air into a saline filled syringe.

A guide wire is inserted through the cannula, and the cannula is withdrawn. The tracheal opening is dilated over the guide wire until a stoma of sufficient size to accommodate the desired tracheostomy tube is created.

The method of dilating the tracheal opening over the guide wire varies with various methods

Ciaglia technique

With Ciaglia technique, the tracheal opening is dilated by using a series of plastic dilators inserted over the guide wire

Griggs Technique Using a tracheal spreader

modified to thread over the wire; this technique involves forceps dilation to create the skin path and tracheal stoma.

The trachea is entered between the appropriate tracheal rings with an intravenous catheter.

The guide wire is threaded through the catheter.

The sharp-tipped dilating forceps are passed over the wire, spread in the skin and soft tissues of the neck and into the trachea, and spread again

A tracheostomy tube is placed over the guide wire and through the passage created.

Tracheal injury may be higher with this technique (especially if performed without bronchoscopy) than the other PDT techniques.

Blue Rhino dilator Blue Rhino dilator is a single,

tapered dilator that is used instead of the sequential dilators of Ciaglia.

It has a slippery coating that makes insertion very easy.

It is softer and therefore (probably) less likely to damage the membranous tracheal wall.

Since there is only a single dilator to pass, insertion is more rapid.

A substantial amount of force is needed to insert the dilators and tracheostomy tube, which often collapses the trachea and fractures a tracheal ring

Fantoni's technique

In an attempt to prevent membranous tracheal (posterior) wall injury and protect the anterior rings from fracture, Fantoni devised a special dilating tube that is placed translaryngeally through the trachea and pulled out rather than forced in.

After the guide wire is placed, a fiberoptic scope is used to direct the retrieval of the wire and bring it out of the endotracheal tube in Fantoni’s technique.

The special tube is pulled from the inside through the trachea and dilates its own path

After placement, the dilating tip is removed, the upper part of the tube reversed in the trachea and the cuff inflated.

During placement, a small-diameter cuffed endotracheal tube can be used to support gas exchange while dilation is being performed

Percu Twist technique

Percu Twist , a screw action dilator that was designed to allow dilation with twisting while lifting the trachea rather than pushing down.

Ciaglia Blue Dolphin technique

Ciaglia Blue Dolphin (CBD) is a new technique for PDT using radial balloon dilation, thereby eliminating downward pressure during insertion and dilation.

Choosing a Technique ST vs. PCT Coagulation abnormalities favor ST over PDT, since

bleeding vessels are more easily controlled under direct vision.

High levels of need for oxygenation would favor ST over PDT (i.e. FiO2> 0.7 and positive end-expiratory pressure > 10 mm Hg)

Patients with unstable or fragile cervical spines would favor ST over PDT.

Patients having recent surgical repair of neck injuries may benefit from PDT because of its lower wound-infection rate.

Patients with “unfavorable” neck anatomy would favor ST over PDT (i.e. previous surgery, neck masses, poor neck mobility, or obesity)

Early Complications Early bleeding: This is usually the result of

increased blood pressure as the patient emerges from anesthesia and begins to cough.

Plugging with mucus Tracheitis Cellulitis Tube displacement Subcutaneous emphysema Atelectasis Pneumothorax

Late Complications Bleeding - Due to tracheoinnominate fistula

→ 0.4% with mortality rate of 85% to 90%.

→Major airway hemorrhage may occur within first several days or as long as 7 months after performance of a tracheostomy.

→Risk factors : excessive tube movement, low placement of the tracheostomy, sepsis, poor nutritional status, and corticosteroid therapy

Tracheo and laryngomalatia Stenosis- It can develop from 1 to 6 months after

decannulation risk for tracheal stenosis ranges between 0% and 16%

Tracheoesophageal fistula fewer than 1% of patients as a result of pressure

necrosis of the tracheal and esophageal mucosa from the tube cuff Risk factors : high cuff pressures, presence of a nasogastric tube, excessive tube movement, and underlying diabetes mellitus

Tracheocutaneous fistula Granulation

Scarring

Failure to decannulate

Tracheotomy care Humidification Tube position To prevent decubitus of trachea Suctioning Skin care To prevent irritation and

secondary inflammation due to discharge

Inner tube care Daily to remove and clean crusts

Tracheostomy and weaning A lot of research is being done on the optimal timing A lot of research is being done on the optimal timing

of performing a tracheostomy.of performing a tracheostomy. For patients requiring prolonged mechanical For patients requiring prolonged mechanical

ventilation, performing an early tracheostomy (within ventilation, performing an early tracheostomy (within 2 days) is considered to facilitate early weaning.2 days) is considered to facilitate early weaning.

Advantages of early tracheostomyAdvantages of early tracheostomy reduced dead space decreased airway resistance, decreased work of breathing, better secretion clearance by suctioning, reduced requirements of sedatives and MR better glottic function with reduced risk of aspiration,

atelectasis, pneumonia , shortened ICU stay

Surgical Tracheostomy Surgical tracheostomy (ST) is usually performed

in the operating room on a patient under general anesthesia, but it may be performed at the bedside in the intensive care unit.

The patient’s shoulders are elevated with head extension (unless cervical disease or injury is present), elevating the larynx and exposing more of the upper trachea.

Local anesthesia with a vasoconstrictor is usually infiltrated into the skin and deeper tissues

The skin of the neck over the 2nd tracheal ring is identified, and a vertical incision about 2–3 cm in length is created.

Sharp dissection following the skin incision is used to cut across the platysma muscle, and bleeding controlled by hemostats and ties or electocautery.

Blunt dissection parallel to the long axis of the trachea is then used to spread the submuscular tissues until the thyroid isthmus is identified

If the gland lies superior to the 3rd tracheal ring, it can be bluntly undermined and retracted superiorly to gain access to the trachea

There are 2 basic approaches to tracheal entry.

the 2nd tracheal ring is divided laterally and the anterior portion removed.

Lateral sutures are used to provide counter traction during tracheostomy-tube insertion.

These are left uncut to provide assistance if the tube is accidentally dislodged later.

Speech with tracheotomy Spontaneous

breathers Tolerate cuffless

mech. ventilation Conscious patient For mechanically

dependent patients that may tolerate cuff deflation

For unable to close the tube outlet with finger (quadriplegia) (Passy-Muir

valves)

A tracheostomy speaking valve is a one-way valve, allows air in, but not out

This forces air around the tracheostomy tube, through the vocal cords and the mouth upon expiration, enabling the patient to vocalize

Decannulation

Make sure… Ready to be decannulated

No further need for tracheostomy

Maintaining own airway

Not aspirating

Steps to decannulation

1. Involve physiotherapist

2. Change to fenestrated uncuffed tube

3. Start capping off tracheostomy (NOT with a cuffed unfenestrated tube!)

4. When 24 hrs of uninterrupted capping at normal saturation, decannulation is possible

Decannulation itself

1. Prepare equipment (Same as for tube change, including fresh tube)

2. Take a deep breath

3. Remove tube and suction stoma

4. Close with steristrips and sleek

5. Daily dressing and steristrip change

6. Patient to cover wound when talking

What if things go wrong??

• Always follow ABC

• A blocked tube is invariably the problem

• Remove tube if rapid suctioning fails or is even slightly delayed

• Direct ventilation over stoma may be effective

• An ET tube works well through a tracheal stoma