2. LERNING OBJCTIVES
To know about surgical anatomy of trachea
To know about various techniques of tracheostomy
To know about various tubes used
To know about things to look for during tracheostomy
To know about complications occurring during the
procedure and their management
3. What is a Tracheostomy?
A tracheostomy is a artificial (usually) surgically
created airway fashioned by making a hole in the
anterior wall of the trachea and the insertion of a
tracheostomy tube, which may or may not be
permanent
4.
5. Why Perform a Tracheostomy 1
Upper airway obstruction
urgent (cricothyroidotomy)
non-urgent (conventional tracheostomy)
Facilitation of airway toilet
Long term ventilation
Difficulty in weaning the ventilator
Decreases airway resistance (tube size)
Paralysis of respiratory muscles (e.g. disease)
Eliminates dead space
6. Why Perform a Tracheostomy 2
Surgical reasons
Including head and neck surgery
Trauma
Including burns
7. How To Create a Tracheostomy
Cricothyroidotomy
For Urgent Procedures
Percutaneous Tracheostomy
Can be done in the ICU at the bedside
Surgical Tracheostomy
Subthyroid incision to trachea between 2nd and 3rd
tracheal rings
8. When to Create a Tracheostomy
Controversial
ETT can be in situ for over 4 weeks in some studies!!!
Generally, consider a tracheostomy if patient
intubated for 7 days with no foreseeable extubation in
the next few days
9. Procedure
Skin
Dissection
Separate straps
Divide thyroid isthmus
Window in trachea
Below 1st ring
Stitch in place
Incision=ba
d
Hole=good
12. Types of Tracheostomy Tubes 2
“Button”
A plug
Useful when there is a possibility of requiring the
tracheostomy tube again
Percutaneous Tracheostomy
20. Long Term Problems 1
Subglottic stenosis
Incidence decreased by low pressure cuffs
Incidence increased by cricothyroidotomy over surgical
tracheostomy
Tracheal stenosis
Oesophago-tracheal fistula
Increased bacterial colonisation of the airways
21. Long Term Problems 2
Vocal cord dysfunction
Chronic
Recurrent laryngeal nerve injury
Temporary
Stomal granulations and scarring
Non healing of wound
Erosion into the innominate artery (<1%)
Occurs in 1st and 2nd week
Swallowing Problems
22. Benefits of a Tracheostomy
More comfortable and more stable
Tube size can be larger (less resistance)
Allows tubes to be changed more easily
Better quality suctioning
Depending on indication for tube and the type of tube,
patients can eat and talk
Can promote oral nutrition
23. Post-op care
Nursing job with medical responsibility
Regular gentle suctioning
Meticulous wound and stoma care
Primary goal is to keep tube in stoma
Tube change after 5 days if required – earlier can be
risky
ENT do not normally need to be involved in all
aspects of trache care!!
24. General Care of a Tracheostomy
Sterile suctioning (as prone to infections)
Gases given should be humidified
Emergency equipment should be immediately present
(at bedside)
26. Equipment of tube change
Nurse or assistant
Oxygen mask
Tracheal dilators
Suction
New tube (tested)
Good light source
Bougie
Intubation equipment available
27. Decannulation
When ventilation or suctioning no longer needed, and
patient can control their own airway and not be at risk
for aspiration
Can occur when patient has
Good cough
Good ABGs (relative, for the patient)
Clear lungs
No pathogens in sputum
28. Make sure…
Ready to be decannulated
No further need for tracheostomy
Maintaining own airway
Not aspirating
29. Steps to decannulation
1. Involve physio
2. Change to fenestrated uncuffed tube
3. Start capping off tracheostomy (NOT with a cuffed
unfenestrated tube!)
4. When 24 hrs of uninterrupted capping at normal
sats, decannulation is possible
30. Decannulation itself
1. Prepare equipment (Same as for tube change,
including fresh tube)
2. Take a deep breath
3. Remove tube and suction stoma
4. Close with steristrips and sleek
5. Daily dressing and steristrip change
6. Patient to cover wound when talking
31. • Always follow ABC
• A blocked tube is invariably the problem
• Remove tube if rapid suctioning fails or is
even slightly delayed
• Direct ventilation over stoma may be
effective
• An ET tube works well through a tracheal
stoma
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36. In Summary
Most traches are elective for a specific cause (or
perhaps multiple causes)
Not free of complications which can be early
(immediate) or late
Have many benefits over a conventional ETT
May be permanent or temporary
Cuffed or uncuffed, fenestrated or unfenestrated