Tracheotomy

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Tracheotomy
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What isTracheotomy

• The word tracheotomy is derived from the Latin
  trachea and tomein (to make an opening).
• Tracheostomy is an operative procedure that
  creates a surgical airway in the cervical trachea
  .

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Tracheotomy. History.

• Ttracheotomy is one of the oldest surgical
  procedures. it was even pictured on Egyptian
  tablets in 3600 BC !
• 2000 BC The Rgveda described a healed
  tracheostomy incision.
• 100 BC Asclepiades described a tracheostomy
  incision for improving the airway.
• Ca 400 BC Hippocrates condemned tracheostomy,
  citing threat to carotid arteries.
• Ca 50 AD Aretaeus of Cappadocia warned against
  performing tracheostomy because of the risk of
  secondary wound infections.

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Tracheotomy. History.

• Ca 100 AD Antyllus described the first familiar
  tracheotomy a horizontal incision between 2
  tracheal rings to bypass upper airway
  obstruction. He also pointed out that tracheotomy
  would not ameliorate distal airway disease (eg,
  bronchitis).
• 131 AD Galen elucidated laryngeal and tracheal
  anatomy. He was the first to localize voice
  production to the larynx and to define laryngeal
  innervation. Additionally, he described the
  supralaryngeal contribution to respiration (eg,
  warming, humidifying, filtering).
• 400 AD The Talmud advocated longitudinal
  incision

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Tracheotomy. History.

• Ca 400 AD Caelius Aurelianus derided
  tracheostomy as a "senseless, frivolous, and even
  criminal invention of Asclepiades."
• 600 AD The Susruta Samhita contained routine
  acknowledgment of tracheotomy as accepted therapy
  in India.
• Ca 600 AD Dante pronounced it "a suitable
  punishment for a sinner in the depths of the
  Inferno."

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Tracheotomy. History.

• 1546 Brasavola published account of tracheotomy
  for tonsillar obstruction. He was the first
  person known to have actually performed the
  successful operation.
• 1561-1636 Sanctorius was the first to use a
  trocar and cannula. He left the cannula in place
  for 3 days.
• 1550-1624 Habicot performed a series of 4
  tracheotomies for obstructing foreign bodies.
• 1702-1743 George Martine developed inner
  cannula.
• 1718 Lorenz Heister coined the term
  "tracheotomy," which was previously known as
  "laryngotomy" or "bronchotomy

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Tracheotomy. History

• 1805 Viq d'Azur described cricothyrotomy.
• 1833 Trousseau reported 200 cases of diphtheria
  treated with tracheotomy.
• 1909 Chevalier Jackson codified indications and
  techniques for modern tracheotomy and warned of
  complications of high tracheotomy
  (cricothyrotomy).
• 1932 Wilson advocated prophylactic tracheotomy
  in cases of poliomyelitis.

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TracheotomyRelative anatomy

• Major blood vessels (carotis, innominate a.,
  jugular veins)
• Thyroid gland
• Esophagus
• Larynx
• Nerves (Rec.Laryngeal)
• Cervical spine

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TracheotomyRelative anatomy
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Tracheotomy Indications To bypass obstruction

• - Tumors (of oropharynx, larynx, upper trachea)
• Infections (epiglottitis, severe
• tracheobronchitis)
• - Bilateral Vocal Cord Paralysis
• Trauma (laryngeal, maxillofacial fractures)
• Edema (tongue, laryngopharynx)
• Intubation failure
• Foreign body obstruction
• Subglottic or tracheal stenosis

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Tracheotomy IndicationsProlonged intubation

• Need for prolonged respiratory support, such as
  in Bronchopulmonary Dysplasia
• To reduce anatomic dead space and increase the
  chance for mechanical ventilation withdrawal
• To prevent decubitus and secondary infections in
  oropharynx (and trachea and tracheal perforations
  ?!)
• To improve the patients quality of life (easier
  toilet, ability to speak and eat (not in comatose
  patient), increase the mobility)
• Neuromuscular diseases paralyzing or weakening
  chest muscles and diaphragm

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Tracheotomy Indicationsmiscellaneous

• Congenital abnormalities (tracheomalatia,
  subglottic or glottic stenosis, craniofacial
  abnormalities (Pierre Robin, Triecher Collins
  syndromes)
• Obstructive Sleep Apnea Syndrome
• Aspirations related to muscle or sensory problems
• Prophylaxis (as preparation for extensive HN
  procedures, before radiotherapy for HN CA)
• Cervical spinal cord injuries with respiratory
  muscles paralysis

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Tracheotomy advantages

• Less irritation of nose, mouth and throat mucous
  membranes
• A nasal tube carries a higher risk of incurring
  sinusitis
• Cleansing the mouth is much easier to perform
  thus preventing oral cavity infections
• The patient is more able to cough up mucus as the
  airway distance is shorter
• Ability to speak
• When awake and if the patient can swallow and his
  condition allows it, he may eat and drink

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Tracheotomy disadvantages

• Some irritation or pain in the neck region in the
  first days after placing the canula.
• A scar will remain visible on the neck (after
  removal of the tranchea canula).
• Possible complications.

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Preoperative workup

• Physical assessment also surgical and
  anesthesiological
• CBC
• PT, PTT, INR
• Patient/apotropus confirmation

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Surgical techniques

• Open procedure
• Percutaneous procedure

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Surgical techniquesopen procedure
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Surgical techniquesopen procedure
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Surgical techniquesopen procedure
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Surgical techniquesopen procedure
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Percutaneous tracheotomy(history)

• 1955, Shelden et al - first attempt with
  cutting trocar into the trachea.
• 1985, Ciaglia et al -percutaneous dilational
  tracheostomy (PDT)

• 1989, Schachner et al - Rapitrach
• 1990, Griggs et al - the guidewire dilating
  forceps (GWDF)

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Surgical techniquespercutaneous procedure
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Surgical techniques percutaneous procedure
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Surgical techniques percutaneous procedure
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Surgical techniques percutaneous procedure

• Should be done in carefully selected patients
• Under fiber optic control
• To be ready to switch to open procedure

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Risk factors for complications

• Age infants and adults over 75
• Obesity
• Smoking
• Poor nutrition
• Recent illness, especially an upper-respiratory
  infection
• Alcoholism
• Chronic illness
• Diabetes

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Complications - general

• Rate in children - up to 70
• Tracheotomy related death - 2-3(overall)

• Rate in adults up to 66

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Complicationsimmediate

• Apnea due to loss of hypoxic respiratory drive.
  This is mainly important in the awake patient.
  Ventilatory support must be available.
• False root
• Bleeding
• Pneumothorax or pneumomediastinum

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Complicationsimmediate

• Damage to the vocal cords (direct)
• Injury to adjacent structures recurrent
  laryngeal nerves, the great vessels, and the
  esophagus.
• Post-obstructive pulmonary edema
• Hypotension
• Arrhythmia

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Complicationsearly

• 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

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Complicationslate

• Bleeding - tracheoinnominate fistula
• Tracheo- and laryngomalatia
• Stenosis
• Tracheoesophageal fistula
• Tracheocutaneous fistula
• Granulation
• Scarring
• Failure to decannulate

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Complicationslate
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Tracheotomy care

• Not aggressive and not too much deep
• To prevent irritation and secondary inflammation
  due to discharge
• Once or more daily remove and clean. Attention on
  crusts

• Suctioning
• Skin care
• Inner tube care

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Tracheotomy care

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Tracheotomy care

• Humidification
• Tube position
• Tube position

• Artificial nose
• To prevent decubitus of trachea
• Not to cover with blanket!
• Pay attention on patients beard and chin
  position!

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Tube exchange

• After the tract is exist 4-5 days after the
  operation
• Rate of exchange depends on clinical situation of
  the specific patient type of discharge, type of
  tube, medical status, age..
• Should be done by experienced staff

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Tube exchange-difficult situations

• When the stoma is scarred, calcified, distorted
  or obscured by granulation tissue
• When the trachea is deviated or rotated
• When the trachea is narrowed or smaller than
  normal
• When the patient is a child

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Tube exchange-difficult situations

• When the patient is obese
• If the tube must be placed quickly in an
  emergency
• If it is a new or recent tracheotomy
• If the person performing the change is not
  well-trained

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TYPES OF TRACHEOSTOMY TUBES

• CUFLESS TUBES
• CUFFED TUBES

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Speech with tracheotomy

• Its possible to speak with tracheotomy, also for
  mechanically ventilated patients and for
  spontaneous breathers.

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Speech with tracheotomy

• Spontaneous breathers
• Tolerate cuffless mech. ventilation
• Conscious patient

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Speech with tracheotomy (Passy-Muir valves)

• For mechanically dependent patients that may
  tolerate cuff deflation
• For unable to close the tube outlet with finger
  (quadriplegia)

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Speech with tracheotomy

• Mechanically ventilated patient that can not
  tolerate balloon deflection (sever COPD)
• The air comes from additional external source via
  small tube above the balloon

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Eating with tracheotomy
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Points for discussionTiming of Tracheotomy?

• There is no clear-cut guidelines when elective
  Tracheotomy should be done.
• Important for decision expectations for
  extubation, general medical status, indications
  for mech. ventilation (cervical spine cut off
  do as soon as possible).
• Consilium decision internist, intensivist, ENT,
  pulmonologist

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Points for discussionwhere? Op. room vs bed site

• Bed site is less expensive
• The same rate of complications
• ICU only (not general departments)
• Level of equipment (light source, diathermia,
  ergonomic conditions, instruments)
• Staff (nurse, assistant, anesthesiologist)
• Hospital policy

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Decanulationwhen?

• Resolution of pathology that necessitated the
  tracheotomy (upper airway obstruction, pneumonia)
• Normal protective laryngeal mechanisms (no
  aspirations during normal swallowing, good
  coughing)
• No planed further interventions (radiotherapy,
  HN operations)
• No mechanical ventilation

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Points for discussionpost OP chest Xray?