TRACHEOSTOMY

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TRACHEOSTOMY CRICOTHYROIDOTOMY
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INTRODUCTION

• Tracheostomy is an operative procedure that
  creates a surgical airway in the cervical trachea
  
• It is considered synonymous with tracheotomy

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LARYNX TRACHEA
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ANATOMY I
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ANATOMY II
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ANATOMY III
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ANATOMY IV
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UPPER AIRWAY OBSTRUCTION -RECOGNITION

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

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INDICATIONS FOR TRACHEOSTOMY

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

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FORMS OF TRACHEOSTOMY

• Emergency tracheostomy
• Urgent tracheostomy
• Elective tracheostomy

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INTRAOPERATIVE DETAILSTRACHEOSTOMY
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TRACHY TUBES
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TUBE PARTS
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METALIC TUBES
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PLASTIC TUBES
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• Chest X-ray after trachy

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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

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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.
  

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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

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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

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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).

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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.

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WHEN IS SUCTIONING REQUIRED?

• Whenever patient is unable to clear secretions by
  coughing
• Bleeding down the airway

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WHEN TO SUCTION 1

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

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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

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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

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COMPLICATIONS

• IMMEDIATE
• EARLY
• LATE

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COMPLICATIONS 1

• IMMEDIATE
• Bleeding
• Pneumothorax/Pneumomediastinum
• Injury to adjacent structures

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COMPLICATIONS 2

• EARLY
• Bleeding
• Tube obstruction
• Tube displacement/dislodgement
• Subcutaneous Emphysema
• Atelectasis

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COMPLICATIONS 3

• LATE
• Bleeding
• Tracheal stenosis
• Tracheomalacia
• Tracheo-esophageal fistula
• Failure to de-cannulate

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