73 Tracheotomy

Tracheotomy

What is“Tracheotomy”

• 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 .

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.


• 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


• 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."


• 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”

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.

Tracheotomy

Relative anatomy

• Major blood vessels (carotis, innominate a., jugular veins)

• Thyroid gland• Esophagus• Larynx• Nerves (Rec.Laryngeal) • Cervical spine

Tracheotomy

Relative anatomy

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

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 patient`s 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

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 H&N

procedures, before radiotherapy for H&N CA)• Cervical spinal cord injuries with respiratory muscles

paralysis

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

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.

Preoperative workup

• Physical assessment also surgical and anesthesiological

• CBC

• PT, PTT, INR

• Patient/apotropus confirmation

Surgical techniques

•Open procedure

•Percutaneous procedure

Surgical techniquesopen procedure




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)

Surgical techniquespercutaneous procedure

Surgical techniques percutaneous procedure



• Should be done in carefully selected patients

• Under fiber optic control

• To be ready to switch to open procedure

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

Complications - general

• Rate in children - up to 70%

• Tracheotomy related death - 2-3%(overall)

• Rate in adults – up to 66%

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

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

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

Complicationslate

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

Complicationslate

Tracheotomy care

• Suctioning

• Skin care

• Inner tube 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

Tracheotomy care

•

Tracheotomy care

• Humidification

• Tube position

• Tube position

• “Artificial nose”

• To prevent decubitus of trachea

• Not to cover with blanket!

• Pay attention on patient’s beard and chin position!

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

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

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

TYPES OF TRACHEOSTOMY TUBES

• CUFLESS TUBES

• CUFFED TUBES

Speech with tracheotomy

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


• Spontaneous breathers

• Tolerate cuffless mech. ventilation

• Conscious patient

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)


• Mechanically ventilated patient that can not tolerate balloon deflection (sever COPD)

• The air comes from additional external source via small tube above the balloon

Eating with tracheotomy

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

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

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, H&N operations)

• No mechanical ventilation

Points for discussionpost OP chest Xray?

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73 Tracheotomy