Percutaneous tracheostomy

Dr Nor Hidayah Zainool Abidin

Supervisor: Dr Noryani

Percutaneous Tracheostomy

11/3/2015prepared by Anor Hidayah

OUTLINES• History of Tracheostomy

• Definitions

• Indications

• Complications

• Tracheostomy Tubes & Components

• procedure

• Inner Cannula & Stoma Site Care

• Flange and Stay Suture Care

• Suctioning

• Cuffed Tracheostomy Care

• Changing a Tracheostomy Tube

• Tracheostomy weaning and removal


History of tracheostomy

• Tracheotomy was first depicted

on Egyptian artifacts in 3600 BC

• It was described in the Rigveda,

a Sanskrit text, circa 2000 BC


http://en.wikipedia.org/wiki/Egypt

http://en.wikipedia.org/wiki/Rigveda

http://en.wikipedia.org/wiki/Sanskrit

Ibnu Sina (980-1037)

• Described tracheal intubation in The Canon of

Medicine in order to facilitate breathing.

Ibn Zuhr (1091–1161) in the 12th century

• The first correct description of the tracheotomy

operation for treatment of asphyxiation


• Tracheotomies were used in the early 1800's for

airway inflammation in children due to Diphtheria.

The first documented successful tracheotomy

performed on a child was reported in 1808.


• In 1965, McDonald and Stocks describe the use of

intubation and respiratory support in neonate.

• Many more children surviving with tracheostomies

due to subglottic stenosis


• The percutaneous dilatational tracheostomy (PDT)

introduced by Ciaglia et al. in 1985, which involves

progressive dilatation with blunt-tipped dilators, is

the most frequently used and evaluated in the

literature.

• In 1989, Schachner et al. introduced a rapid PT

technique, Rapitrac, which did not get

considerable acceptance because of

complications associated with, and reservations

towards, the sharp edges of the dilating forceps.


Basic tracheal anatomy• Trachea lies midline of the

neck

• Extending from cricoid cartilage (C6) superiorly

• To the tracheal bifurcation (level of sternal angle T5)

• Comprises of 16 – 20 C shaped cartilage ring

• Length about 10 -12cm


Definitions

Word tracheostomy is derived from two words meaning “I cut trachea” in Greek

Tracheotomy

• Incision made below the cricoid cartilage through the 2nd – 4th tracheal ring

Tracheostomy

•The opening or stoma made by this incision.

Tracheostomy Tube

• Artificial airway inserted into the trachea during tracheotomy.


Tracheostomy Tube Components


Indications of Tracheostomy

• Acute upper airway obstruction

• Chronic upper airway obstruction

• Injury or post head and neck surgery To obtain and maintain a patent airway when compromised

• To facilitate weaning from mechanical ventilation

• To prevent and /or treat retained tracheobronchial secretions

• To reduce the risk of pulmonary aspiration


Timing of Tracheostomy

<3weeks

Early

> 3 weeks

Late

• Early tracheostomy was associated :o Similar survival at one month

o Improve short term clinical outcome

o early tracheostomy did not change any outcomes at one year


Adverse events occurred in 39%

hypoxemiastoma

inflammation

stoma

infectionbleeding

•A higher likelihood of weaning from the ventilator77 vs 68 %

• A higher likelihood of being discharged from the ICU within 28 days48 vs 39%

• A trend towards a lower rate of pneumonia14 vs 21%

Multicenter trial (419 patients) that randomly early (mean 7 days) VS late tracheostomy (mean 14 days)


observational series

randomized trials

meta-analyses

terms of

mortality

mechanical

ventilation days

length of

stay

The timing of tracheostomy did not appear to impact 30 day or 2 year mortality or ICU length of stay

Does not appear to impact the rate of nosocomial pneumonia following tracheostomy


Decision for tracheostomy• Mechanical ventilation anticipated to last between 10 and 21 days

• After an initial period of stabilization on the ventilator (generally, within 3–7 days)

• Daily assessment for ventilatory weaning

o need for continued intubation

o readiness to wean

o When apparent that the patient will require prolonged ventilator assistance

• Individualized according to the clinical circumstances and the patient's preference

• The decision left to the attending Specialist/Intensivist


Advantages of tracheostomy

1. Reduced laryngeal damageReduced laryngeal stenosis

Less voice damage

2. Better secretion removal with suctioning

3. Lower incidence of tube obstruction

4. Less oral injury (tongue, teeth, palate)

5. Improved patient comfortLess sedation/analgesia required

6. Better oral hygiene

7. Enhance nursing care



1. Improved ability to communicate lip reading

2. Preservation of glottic competence1. Less aspiration risk

3. Better preserved swallowing, earlier oral feeding

4. Lower resistance to gas flow

5. Less tube dead space better weaning from mechanical ventilation

6. Ease of reinsertion if displaced

7. Allows less skilled care

Advantages of tracheostomy


Disadvantages of Tracheostomy

• Tracheal complications

• Aggressive procedure

• Risk of stomal infection

• Esthetic sequelae

• Bleeding

• Psychological trauma

• Organizational difficulties

• Increased risk in ward


Nosocomial pneumonia• A retrospective study of 137 patients who underwent

tracheostomy

• significant bacterial colonization (>100,000 cfu/mL)

• fever on the day of tracheostomy• the need for sedation beyond 24

hours after tracheostomy

There was a 26% incidence of pneumonia in the study population, occurring at a mean of 9 days after the tracheostomy.

Nosocomial pneumonia


Study reports – Nosocomial infection

Lower rate

six-fold increase

Prospective cohort study of over 800 mechanically ventilated

Case-control study of 354 patients who were mechanically ventilated for more than seven days

The timing of tracheostomy (early versus late) does not appear to impact the rate of nosocomial pneumonia following tracheostomy 11/3/2015prepared by Anor Hidayah

Associated Clinical Complications

Immediate:

• Haemorrhage

• Pneumothorax

• Accidental displacement of the tube

Intermediate:

• Tube occlusion by secretions and/or blood

• Infection

• Cuff over/under inflation

Late:

Tracheal ulceration• Tracheo-cutaneous

fistula

• Granulation tissue (skin/tracheal)

• Tracheal stenosis

• Scar formation


Advantages of Percutaneous

Dilatation Technique

• Simple technique

• Can be done at the bedside in ICU

• Reduces the risks associated with the possible need to transfer a critically ill patient out of the ICU

• Does not require operating theatre less expensive in terms of human and material resources

• Possibly less waiting time for patient

• Early tracheostomy

• Associated with less peristomal bleeding


Contraindications

• Age < 15 yrs

• Gross distortion of the neck due to haematoma, tumor, thyromegaly or scarring from previous neck surgery

• Un-correctable bleeding diathesis

• Obese, short or bull neck that obscures the anatomical landmarks in the neck

• Inability to extend the neck because of cervical fusion, rheumatoid arthritis, or other cervical spine instability


Percutaneous Insertion• Procedure to be done in ICU

LandmarkNeedle

injectionGuidewireinsertion

Introducer DilatationTrachy tube

insertion


Patient preparation

• Take GSH, Latest FBC, BUSE and Coagulation profile• Withhold anticoagulants • Draw bedside curtains• The procedure is explained in full to the patient and/or

significant others.• Consent obtained. Record in the medical notes.• Fast patient for 6 hours• Discontinue deeding 6 hours prior to the procedure • Aspirate the nasogastric tube again immediately prior to the

procedure.• Prepare all required equipment• Proper position the patient supine• Ensure the head of the bed area is free from obstruction


Patient preparation

• To facilitate the procedure the patient is administered a combination of Propofol and +/- an opioid via an IV infusion.

• Full monitoring is instituted, and ventilatory parameters altered

• Fio2 increased to 100%

• Tidal volume increased to compensate for airleakaround deflated ETT cuff

• Adjust peak airway pressure alarm to allow for the raised pressures during ETT manipulation.

• The patient’s eyes are taped closed





Inner Cannula & Stoma Site

Care

• To help maintain a patent airway

To prevent infection

To maintain skin integrity

To help prevent tube displacement

Objective

• Inner cannula must be checked at least every 4hrs

•Stoma site must be checked at least daily or when attending cannula. Site must be kept clean and dry

•Ties: ensure they are clean and dry

Frequency


Securing Tracheostomy Ties

Velcro Ties

• Bring longer piece o (B) around neck and underneath section

o (A) Leave 1 finger space between ties and patients neck.


Securing Tracheostomy Ties

Cotton Ties

• Bring one long end around the neck and tie to short end in single knot.

• Repeat on the other side ensuring that 1 finger space is remaining between the ties and the patient’s neck

• Tracheostomy ties changed when wet or soiled and routinely at least once a week.

• 2 person involve


Flange and Stay Suture Care

• Most surgically inserted tracheostomy tubes and occasionally percutaneous tubes are secured in position with silk sutures

• Removal time:

o at the time of the first tube change

o i.e. approximately 5 - 7 days post insertion

Observe suture sites for signs of infection and treat accordingly


Suctioning• to remove endotracheal secretions maintain patent

airway

• as needed pulmonary secretions

• Selecting appropriate catheter size.o ensure the suction catheter is < /= 1/2 the internal diameter of

tracheostomy tube.

Tube size

4

8 + 4 =12

(Tube size x 3) / 2

8 x 3 /2 = 12


Suctioning Procedure

1. vacuum pressure is > 20Kpa’s / 100- 150mmHg2. Ventilated patient hyper-oxygenated (i.e. increase FiO2 to

100%) for > 30 seconds prior to suctioning, to minimise hypoxia during and after the suctioning event.

3. Maintaining sterility4. Insert the suction catheter to approximately 15cm without

applying suctioning5. Smoothly withdraw catheter from the airway applying

continuous suction. 6. = / < 15secs.7. 3 times per-session.

The Nurse must undertake the following:Explain the procedure to the patientPerform hand hygiene and apply sterile glovesApply apron and fluid shield mask


Cuffed Tracheostomy Care• Indications for Cuffed Tube Use:

o The patient required mechanically ventilation

o Less than 24/48hours post insertion.

o high risk aspiration from gastric or oral secretions

o Unstable condition

• Stabilises the tracheostomy tube in the trachea.

Indications for cuff re-inflation: 1. Desaturation (must check inner cannula first)2. Respiratory or cardiovascular distress3. Constant oral drooling4. No swallows observed


Cuff Pressure Measurement• An underinflated cuff i.e. pressure too low, can lead

to

o inadequate seal around the cuff

o increasing risk of aspiration

o causing loss of positive pressure where the patient is ventilated

• The recommended cuff pressure 25cmH2O

• Cuff pressures should not exceed 32cmH20.

• If leak present increase tube size

• Palpation of the external balloon is not an adequate method of pressure estimation


• Cuff deflation procedure:

o Explain procedure to the patients.

o Suction oropharynx to remove any secretions

o With the assistance of a 2nd nurse, suction via tracheostomy tube while the second nurse slowly aspirates air from air inlet port.

o Once deflated, expiratory noises may be heard as air passes up around the tracheostomy tube reassure the patient that this is normal and will settle


Stoma Care• At least once a day or more frequently reduce the risk

of skin irritation and peri-stomal infection.

Stoma Cleaning Procedure

• Remove and dispose of any soiled dressings

• Using aseptic technique, clean the stoma site using gauze and normal saline

• apply a skin barrier cream on patient’s skin is excoriated i.e. soft paraffin


Changing a Tracheostomy

Tube• The recommended minimum time before the first tube

change or decannulation iso 5-7days following surgical tracheostomy

o 7- 10days following percutaneous tracheostomy.

Rationale: To enable the tract to become established and minimise risk of occlusion.

• Changed every 28-30 days

• For weaning purposes i.e. downsizing, change to cuffless or fenestrated.

Elective

Indications

• Tube dislodgement or accidental removal

• Tube obstruction (decreased risk when using double lumen tubes).

Emergency

Elective11/3/2015prepared by Anor Hidayah

• Document the type of tube, size, the date it was performed and last changed

• Ventilated patient fast patient for 4 hours before tube changed.

• Emergency equipment

1st Tube change

•must always be carried out by a doctor •The track from the skin to the trachea may not be well formed

Subsequent tube changes

• Registered competent nurse







Tracheostomy weaning and

removalo Medically stable

o The primary indication for tracheostomy has been resolved.

o Spontaneously breathing off the ventilator for 24-48 hours.

o Effective cough reflex

o Free from serious bronchopulmonary infection

o Minimal pulmonary secretions (suctioning < 4-6 hourly)

o O2 Therapy is less that 40% (FiO2 < .4)

o Successfully tolerating cuff deflation.

o Adequate nutritional intake


Weaning Procedure

Stage 4

Patient tolerance to Decannulation cap (not routine)

Stage 3

Patient tolerance to use of Passy Muir Speaking Valve

Stage 2

Patient tolerance to Downsizing the Tracheostomy tube (not routine at present)

Stage 1

Patient tolerance for Cuff deflation


Stage 1- Cuff Deflation• This is usually carried out 24 – 48 hrs after tube insertion

Why?

• To assess if patient can manage their own airway and manage their own oral secretions despite alteration in tracheal airflow.


Stage 2- Downsizing• Usually undertaken 5-7 days after the original tube

insertion

• Rationale: Airflow is increased either around or through the tracheostomy tube and this reduces the work of breathing for the patient.


Stage 3- Speaking valve

• at least 48-72 hours post tracheostomy, prior to the initial placement

• allowing air in through the valve on inspiration, but closing on expiration

• Where speaking valve is tolerated the patient and valve:o Ensure Cuff is deflated prior to applying / using

the speaking valve

o Do Not Leave the Speaking Valve on overnight unless specifically ordered


Stage 4 - Decannulation

• Decannulation Cap

• blocks the tracheostomy tube

• patient breathe through nose and mouth

Rationale

• The use of a decannulation cap increases patient confidence and gradually increases respiratory muscle strength and avoids over exertion.

• Capping is tolerated for at least 24 consecutive hours


Stage 5• Decannulation

(Removal of the Tracheostomy Tube)

INDICATION

• The decision to decannulation / remove tube is based on the ability of the patient to maintain their own airway without the tracheostomy tube insitu.


Stage 5• Decannulation Predictors

o Patient has successfully completed the latter 4 stages of weaning. (not all patients will go through each stage of the process)

o Patient is able to expectorate pulmonary secretions effectively

o Patient is not myopathic


Summaries• 2 methods of Tracheostomy – surgical open

tracheostomy and percutaneous tracheostomy

• Percutaneous tracheostomy offer many benefits and a good alternative

• Timing of tracheostomy does not have clear association with better outcome but its clearly have many benefit in term of patient comfort and nursing care

• Percutaneous tracheostomy does not have clear association with nosocomial pneumonia

• Tracheostomy care knowledge and skills is important for both doctors and nurses

• 4 stages of weaning and decanulation of tracheostomy


References• St. James’s Hospital : Nursing Tracheostomy Care

Guidelines - Guidelines Number: SJH:N(G):009

• Uptodate - Overview of tracheostomy


Healthcare

Percutaneous tracheostomy