Upload
gamal-agmy
View
1.695
Download
4
Embed Size (px)
Citation preview
Tracheostomy; When to Perform and How to
Manage
Gamal Rabie Agmy, MD,FCCP
Professor of Chest Diseases
,Assiut University
Tracheostomy History
The Tracheostomy is
one of the oldest
surgical procedures.
It can be traced back
to Egyptian tablets
from 3600 B.C.
Who famous person died of
an upper airway obstruction
because their M.D. was
unwilling to perform his 1st
tracheostomy on a person
of such stature??
*George Washington
toured his estate on
horseback one cold
and rainy day in 1799.
*The next day he had
severe upper airway
swelling.
Antonio Musa Brasavola, an Italian
physician, performed the first
documented case of a successful
tracheotomy. He published his account
in 1546. The patient, who suffered from
a laryngeal abscess and recovered from
the procedure
26% 25%
20%
27%
Rate of Tracheostomy 11% vs 12.5%
1998 vs 2004
Evolution of Mechanical Ventilation in
Response to Clinical Research Esteban A et al. Am J Respir Crit Care Med 2008; 177: 170–177
WHY ?
WHEN ?
WHICH ?
WHO and HOW?
• Prolonged intubation
• Facilitation of ventilation support
• Inability of patient to manage secretions
• Upper airway obstruction
• Inability to intubate
• Adjunct to major head and neck surgery
• Adjunct to management of major head
and neck trauma
INDICATIONS FOR TRACHEOSTOMY
Facilitate prolonged assisted ventilation
- Coma
• Major Head injury
• Cerebral bleed/infarct/lesion
• Encephalitis
- High spinal cord injury
- Neuromuscular disorder
• Guillain-Barre syndrome
• Critical Care Polyneuropathy
- COPD
Why Tracheostomy
Pelosi P et al Crit Care 2004; 8:322-324
Inability to prevent pulmonary
aspiration
- Posterior fossa/infratentorial lesions
• Cerebellum/brain stem
• Basilar/posterior cerebral artery
• Encephalitis
- Cranial nerve dysfunction
Why Tracheostomy Pelosi P et al Crit Care 2004; 8:322-324
Upper airway obstruction
- Maxillofacial surgery or trauma
- Congenital malformation
- Facilitate upper cervical surgery
- Vocal cord paralysis
Why Tracheostomy Pelosi P et al Crit Care 2004; 8:322-324
Predictors of Outcome for Patients With COPD
Requiring Invasive Mechanical Ventilation Nevins ML et al Chest 2001;119;1840-1849
- Previous Mechanical Ventilation
- FEV1/FVC < 30% predicted
- COPD Exacerbation
- Low Ht (< 35%) and Albumin (< 2.5 g/dL)
- APACHE (> 15, 6 hrs after MV)
- Active Malignacy
TRACHEOSTOMY VS
TRANSLARYNGEAL INTUBATION
– Increased patient mobility
– More secure airway
– Increased comfort
– Improved airway suctioning
– Early transfer of ventilator-dependent patients from the intensive care unit (ICU)
– Less direct endolaryngeal injury
– Enhanced oral nutrition
– Enhanced phonation and communication
– Decreased airway resistance for promoting weaning from mechanical ventilation
– Decreased risk for nosocomial pneumonia in patient subgroups
Heffner, Hess.Clinics in Chest Medicine 22 , 2001.
- Tracheal complications
- Aggressive procedure
- Risk of stomal infection
- Esthetic sequelae
- Bleeding
- Psychological trauma
- Delayed ICU discharge
- Organizational difficulties
- Increased risk in ward
Disadvantages of Tracheostomy
Pelosi P et al Crit Care 2004; 8:322-324
Blot F et al. Chest 2005; 127:1347–1352
Absolute contraindications (rare):
- Soft tissue infections of the neck
- Anatomic aberrations
Relative controindications:
- Severe respiratory distress with
refractory hypoxemia and hypercapnia
- Hematologic and coagulation disorders
Contraindications for tracheostomy (?) Groves DS et al Curr Opin Crit Care 2007, 13:90–97
Reduction of dead space
Reduction of airway resistance and dead space Reduced rate of VAP
Less need for sedation
Shortened weaning period
Shortened ICU stay
Lower mortality
Direct effects Indirect effects
Postulated
Diehl JL et al.Am J Respir Crit Care Med 1999, 159:383-388
Tracheostomy: WOB and PEEPi
Is tracheostomy associated with better
outcomes for patients requiring long-term
MV ? Combes A et al. Crit Care Med 2007; 35:802–807
Tracheostomy does not improve the outcome of
patients requiring prolonged MV: A propensity
analysis Clec’h C et al Crit Care Med 2007; 35:132–138
Odds ratios for post-intensive care unit mortality
associated with tracheostomy in patients matched on
propensity scores
- All patients 2.57 1.20-5.48 0.01
- Patients decannulated
before discharge 1.43 0.42-4.90 0.56
- Patients not decannulated
before discharge 3.73 1.41-9.83 0.008
OR 95% CI p Value
- If the need for an artificial airway
is anticipated to be greater than 21
days
Plummer AL, Gracey DR. Consensus conference on artificial
airways in patients receiving mechanical ventilation. Chest
1989; 96:178–180
Indications for tracheostomy
Chastre J, Bedock B, Clair B, et al. Which tracheal route
should be used for mechanical ventilation in the critically ill?
Thirteenth consensus conference on resuscitation and
emergency medicine. Rean Urg 1998; 7:435–442
Indications for tracheostomy
- Mechanical ventilation anticipated to
last between 10 and 21 days
- The decision left to the attending MD
- Daily assessment was recommended
as to the need for continued intubation
MacIntyre NR, Cook DJ, Ely EW Jr, et al. Evidence-based guidelines for
weaning and discontinuing ventilatory support: a collective task force
facilitatedby the American College of Chest Physicians; the American
Association for Respiratory Care; and the American College of Critical
Care Medicine. Chest 2001; 120 (6 Suppl):375S–395S.
Indications for tracheostomy
- After an initial period of stabilization
on the ventilator (generally, within 3–7
days)
- When apparent that the patient will
require prolonged ventilator
assistance
Tracheostomy in the critically ill:
indications, timing and techniques
Groves DS et al Curr Opin Crit Care 2007, 13:90–97
Prolonged
Mechanical
Ventilation
How Is Mechanical Ventilation Employed
in the Intensive Care Unit ?
Esteban A et al Am J Respir Crit Care Med 2000; 161; 1450–1458
Percentage of pts with tracheostomy
Outcome of mechanically ventilated
patients who require a tracheostomy Frutos-Vivar F et al. Crit Care Med 2005;
33:290 –298
Tracheostomy performed
at a median
time of 12 days (7–17) from
beginning mechanical
ventilation.
Incision 1 cm below the cricoid or halfway between the cricoid and the sternal notch.
Retractors are placed, the skin is retracted, and the strap muscles are visualized in the midline. The muscles are divided along the raphe, then retracted laterally
The thyroid isthmus lies in the field of the dissection. Typically, the isthmus is 5 to 10 mm in its vertical dimension, mobilize it away from the trachea and retract it, then place the tracheal incision in the second or third tracheal interspace
• Shiley
tracheostomy tube:
#6
• Shiley
tracheostomy tube:
#8 for
bronchoscopy.
Guidewire and catheter are advanced
together into the trachea as far as the
skin positioning marks on the guide
catheter to the skin.[
Guidewire introduction, with removal
of sheath
PERCUTANEOUS DILATIONAL TRACHEOTOMY
PERCUTANEOUS DILATIONAL TRACHEOTOMY
Guidewire and catheter are advanced together into the trachea as far as the skin positioning marks on the guide catheter to the skin
Guidewire, guide catheter, and dilator unit are advanced together into the trachea to the skin positioning mark
PERCUTANEOUS DILATIONAL TRACHEOTOMY
The tracheotomy tube is loaded onto a dilator and advanced into the trachea over the guidewire and catheter. The guidewire and catheter are removed, leaving only the tracheostomy tube in the trachea
PERCUTANEOUS DILATIONAL
TRACHEOTOMY
Cook Ciaglia percutaneous dilatational tracheostomy kit
Percutaneous trachesotomy techniques "classical" Ciaglia technique
Ciaglia P, Firsching R, Syniec C.
Elective percutaneous dilatational tracheostomy a new simple bedside
procedure: preliminary report.
Chest 1985; 87:715-719
Griggs forceps technique
Griggs WM, Gilligan JE, Myburg JA.
A simple percutaneous tracheostomy technique
Surgery 1990; 170:543-544
PercuTwist
Frova G, Quintel M.
A new simple method for percutaneous tracheostomy: controlled
rotating dilation
Intensive Care Med 2002; 28:299-303
Fantoni - translaryngeal technique
Fantoni A, Ripamonti D.
A non-derivative, non surgical tracheostomy: the translaryngeal method.
Intensive Care Med 1997; 27:386-392
Criggs
Ciaglia
Frova
Blue Rhino
T-Dagger
Blue Dolphin
Seldinger guide wire Carina
Technical approach
Management
LONG-TERM MANAGEMENT
• CHOICE OF CANNULA
• CUFF MANAGEMENT
• MALPOSITION
• REPLACEMENT
• HUMIDIFICATION
• DYSPHAGIA
• PHONATION
• WEANING
LONG-TERM MANAGEMENT
• CHOICE OF CANNULA
• CUFF MANAGEMENT
• MALPOSITION
• REPLACEMENT
• HUMIDIFICATION
• DYSPHAGIA
• PHONATION
• WEANING
ANGLED
CURVE
Specific case of thorax deformity
INNER CANNULA
Jackson
size
ID with inner
cannula
ID without
inner cannula
ED
4 5.0 mm 6.7 mm 9.4 mm
6 6.4 mm 8.1 mm 10.8
mm
8 7.6 mm 9.1 mm 12.2
mm
10 8.9 mm 10.7 mm 13.8
mm
LONG-TERM MANAGEMENT
• CHOICE OF CANNULA
• CUFF MANAGEMENT
• MALPOSITION
• REPLACEMENT
• HUMIDIFICATION
• DYSPHAGIA
• PHONATION
• WEANING
20-30 cmH20
DEFLATED CUFF INFLATED CUFF
INFLATED DEFLATED
DEFLATED CUFF INFLATED CUFF
LONG-TERM MANAGEMENT
• CHOICE OF CANNULA
• CUFF MANAGEMENT
• MALPOSITION
• REPLACEMENT
• HUMIDIFICATION
• DYSPHAGIA
• PHONATION
• WEANING
LONG-TERM MANAGEMENT
• CHOICE OF CANNULA
• CUFF MANAGEMENT
• MALPOSITION
• REPLACEMENT
• HUMIDIFICATION
• DYSPHAGIA
• PHONATION
• WEANING
TUBE REPLACEMENT
• FIRST CHANGE ADVISABLE > 10-15
DAYS AFTER TRACHEOSTOMY
• NO FIXED SCHEDULE FOR
REPLACEMENT BUT HIGHLY
DEPENDENT ON LOCAL POLICY
• CLOSELY LINKED TO THE TYPE OF
CANNULA (INNER CANNULA etc) AND
TO THE QUALITY OF DOMICILIARY
MANAGEMENT
LONG-TERM MANAGEMENT
• CHOICE OF CANNULA
• CUFF MANAGEMENT
• MALPOSITION
• REPLACEMENT
• HUMIDIFICATION
• DYSPHAGIA
• PHONATION
• WEANING
PHYSIOLOGIC CHANGES
AFTER TRACHEOTOMY
LONG-TERM MANAGEMENT
• CHOICE OF CANNULA
• CUFF MANAGEMENT
• MALPOSITION
• REPLACEMENT
• HUMIDIFICATION
• DYSPHAGIA
• PHONATION
• WEANING
Tracheotomy and dysphagia
58%26%
16%
OF
NGP
PEG
RESPIRATORY INTENSIVE CARE UNIT
PAVIA 2000-2008 (710 patients)
TRACHEOSTOMY AND
DYSPHAGIA
• EPIGL. BACKWARD FOLDING 80%
• RETENTION IN VALLECULAE 70%
• LARYNX ELEVATION 40%
• GAG REFLEX 30%
• VOCAL CORDS ADDUCTION 30%
• ORAL TRANSPORT PHASE 20%
• COUGH REFLEX 20%
LONG-TERM MANAGEMENT
• CHOICE OF CANNULA
• CUFF MANAGEMENT
• MALPOSITION
• REPLACEMENT
• HUMIDIFICATION
• DYSPHAGIA
• PHONATION
• WEANING
PHONATION
• REQUIRED A SUBGLOTTIS
PRESSURE OF AT LEAST 2-3
cmH2O
• REQUIRED A FLOW THROUGH THE
UPPER AIRWAY > 3 L/min
Speaking during spontaneous breathing
One way Passy Muir
Valve to speak under
mechanical ventilation
INSPIRATION ESPIRATION - ZEEP
ESPIRATION
+ PEEP
LONG-TERM MANAGEMENT
• CHOICE OF CANNULA
• CUFF MANAGEMENT
• MALPOSITION
• REPLACEMENT
• HUMIDIFICATION
• DYSPHAGIA
• PHONATION
• WEANING
Tracheotomy at discharge
57%
43%
NO
YES
RESPIRATORY INTENSIVE CARE UNIT
PAVIA 2000-2008 (618 patients)
Patients weaned from tracheotomy
5%
34%
32%
29%
NM
PA
PC
PO
RESPIRATORY INTENSIVE CARE UNIT
PAVIA 2000-2008 (352 patients)
CONCLUSIONS
Complications of
Tracheostomy
• Complications 5-40%
• Mortality <2%
• Complications are more frequent in
emergency situations, severely ill
patients and small children.
Complications of
Tracheostomy
– Stoma
• Stoma site infection
• Stomal hemorrhage
• Poor stoma healing after decannulation with scar, keloid, or tracheocutaneous fistula
Complications of
Tracheostomy
–Trachea
• Granuloma
• Tracheoesophageal fistula fewer than 1% of patients as a result of
pressure necrosis of the tracheal and
esophageal mucosa from the tube cuff
risks: high cuff pressures, presence of a
nasogastric tube, excessive tube movement,
and underlying diabetes mellitus
Complications of
Tracheostomy
• Tracheoinnominate fistula: 0.4% with mortality rate of 85% to 90%.
Major airway hemorrhage may occur first within 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
• Tracheal stenosis: can develop from 1 to 6 months after decannulation
risk for tracheal stenosis ranges between 0% and 16%
• Tracheomalacia