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Patient with tracheostomy
Presentor: Abraham SonnyModerator: Dr. Rani Sunder
www.anaesthesia.co.in
Age : 40 years
Gender : male
Presenting complaint : hoarseness of voice for 8 months.
status tracheostomy since 3 months
History of present illness :
patient noticed hoarseness in his voice 8 months back .
increased progressively
not associated with stridor
No history of dyspnoea dysphagia No history of cough or expectoration.
No history of bleeding from tracheostomy site accidental decannulations tube obstruction infection at the stoma site difficulty in replacement/ change of
tracheostomy tube
Patient was posted for direct laryngoscopic examination and VC biopsy.
Past history:
Surgical:• patient underwent microlaryngeal surgery 6 months back under
GA, u/e.• Was diagnosed as vocal cord papilloma• Symptoms subsided subsequently.• Patient had a recurrence of symptoms 3 months back for which he
underwent repeat resection of the lesion. • Towards end of the surgery there was bleeding from operative site
which was controlled with adrenaline soaked gauge.• At the end of surgery elective tracheostomy was done for airway
protection. Histopathological examination revealed sqamous cell carcinoma and
patient was referred to AIIMS.
Medical:not a known case of DM. HTN, asthma, TB
Personal history : non smoker, non alcoholic
Family history : non contributory
General physical examination: NO pallor/ icterus/ cyanosis/ edemaPatient conscious oriented in time , place and person Sitting comfortably on bed .
vitals :
PR – 80/min
BP- 130/80 mmHg
RR – 20/ min
afebrile
Systemic examination:
tracheostomy :
5.0 mm portex uncuffed tracheostomy tube in situ
stoma site looks healthy to inspection
No evidence of bleeding, local infection
respiratory system :
Inspection :
bilateral air entry equal and adequate.
no abnormal pulsations
Auscultation :
Bilateral air entry equal
Normal vesicular breath sounds
No crepitations, rhonchi.
lab investigations:
Hb – 12.3 gm%TLC – 7,500 Platelet count – 249 X 103
BU – 30mg/dlNa – 142 , K – 4.1 (Meq/dl) LFT – within normal limits
Chest X ray – normal
DIAGNOSIS :
recurrent vocal cord papillomatosis (?Squamous cell carcinoma) with status tracheostomy for direct laryngoscopic examination and biopsy of the lesion.
TYPES OF TRACHEOSTOMY TUBES
metal :
stainless steel / silver
parts : inner tube, outer tube, obturator.
disadvantages :
no standard 15mm connector
rigid ( can cause injury)
no cuff
expensive
synthetic : PVC / silicone
cuffed or uncuffed , with or without inner tube, with or without fenestrations
Great Ormond street, Portex, Shiley
Advantages : 15 mm connector
thermolabile
cheaper
Other modifications : extra proximal length
extra distal length
Silver tube
Synthetic cuffed tube
Synthetic uncuffed tube
Fenestrated tube
Passy Muir speaking valve
Tape eyelet
Neck flangeNeck flangeNeck flangeNeck flange
Indications for tracheostomy
1. Upper airway obstruction – secondary to trauma, burns, corrosive poisoning, laryngeal dysfunction, foreign body, infections, inflamatory conditions, neoplasms, postoperative, OSA
2. Access to pulmonary toilet
3. Prolonged ventilatory support
4. Airway protection in head injuried/ comatose patients and in patient who cannot protect their airway.
Advantages of tracheostomy over ETT in prolonged mechanical ventillation
• decrease in airway resistance and dead space
• prolonged intubation promotes formation of laryngeal and subglottic stenoses
• Eases airway care and suctioning
• Reduces risk of tracheal extubation
• Eases tube reinsertion
• Facilitates oral communication and speech
• Improves oral, nasal, and facial hygiene
• Raises patient comfort level
Complications of tracheostomy
Immediate :1. Hemorrhage 2. Apnea : due to CO washout. Treaed with
5%co or by increasing the dead space.3. Pneumothorax4. Injury to recurrent laryngeal nerve5. Aspiration of blood : prevented by use of
cuffed tracheostomy tube.6. Injury to esophagus
Intermediate :1. Bleeding2. Accidental decannulation : a serious
complication in first week. Reinsertion can lead to formation of blind passage.
3. Obstruction of tube : crusts, mucus plug4. Subcutaneous emphysema : due to tight
suturing of wound/ stoma. Treated by releasing sutures.
5. Local wound infection6. Pulmonary infection
Late :
1. Hemorrhage : erosion of major vessel, tracheoarterial fistula (80-90% mortality).
2. Obstruction : granulations, mucus plug
3. Tracheal stenosis
4. Tracheo esophageal fistula
5. Corrosion of tracheal tube and aspiration of fragments
CRUSTINGInspired air filtered, warm and humidified.Become dry and coldDries tracheal and pulmonary secretionsInterferes with ciliary capacity to move mucus
blanketThick tenacious mucus scabs can lead to
infection, obstruction, atelectasis and pneumonia.
Prevented by proper humidification and hydration
GRANULATIONS
Appear near the stoma, in the lumen just above the stoma.
• Obstruct following decannulation (elective/ accidental)
• Blocks the tube
• Bleeding during decannulation
• Failed decannulation
CARE OF TRACHEOSTOMYSuctioning :Glottis is bypassed : so cough reflex lost.Increased mucus secretionTo prevent obstruction of tube
Size of catheter < half the ID of TT to prevent hypoxia and atelectasis.
Time < 15secNot more than 3 passes Sterile precautions
HUMIDIFICATION
• To prevent drying of pulmonary secretions• To preserve mucociliary function
METHODS1. Heated humidifiers : new tracheostomy, dehydrated patients, immobile patients, patient with tenacious secretions
2. Heat moisture exchanger filters:
adequately hydrated patients
mobile patients not suitable for patients with
copious secretions
3. Nebulizers : with normal saline
(ultrasonic nebulizer)
4. Steam tent
Tube change: Stoma and tract is well formed with in 7- 10
days . After that changing outer tube is safe In an observational study, Yaremchuk et al
reported fewer complications due to granulation tissue after implementation of a policy in which tubes were changed every 2 wks.
laryngoscope 2003;113(1):1-10
Percutaneous tracheostomy : different methods
• In 1985, Ciaglia et al described the percutaneous dilational tracheostomy (PDT). The method is based on needle guidewire airway access followed by serial dilations with sequentially larger dilators.
• Schachner et al reported the Rapitrach method in 1989. This method consists of using a dilating forceps device with a beveled metal conus that is designed to advance forcibly over a wire into the airway.
• In 1990, Griggs et al reported the guidewire dilating forceps (GWDF) method. This method is based on a forceps similar to that of the Rapitrach method, except without a cutting edge on the tip of the instrument.
Other methods• Modified Ciaglia technique (ie, Ciaglia Blue Rhino)
have been reported by Byhahn et al. The technique represents a major modification of PDT. Dilation of the stoma is formed in a single step by means of a hydrophilically coated, curved dilator—the Blue Rhino.
• In 1993, Fantoni et al presented a new translaryngeal airway access method. This technique passes the dilator between the vocal cords and pushes out through the neck tissues to obtain stoma. It decreases probability of posterior tracheal wall injury.
Contraindications for PDT• Absolute :1. Need for emergency airway2. In children (cartilages soft)
• Relative :1. High degree of ventillatory support (PEEP>8cm water,
FiO2 > 50%)2. Unstable cervical spine3. Uncorrected coagulopathy4. Presence of neck mass or previous neck surgery5. History of mediastinal irradiation6. Previous history of surgical tracheostomy
Cricothyroidotomy
• In emergency when obstructed airway cannot be secured through the laryngeal route.
technique :
1. Intravenous catheter
2. Cricothyroidotomy set
3. Surgical
Mini tracheostomy
• Small bore tube (4.0 mm, uncuffed) inserted through the cricothyroid membrane or tracheal stome after decannulation.
• Used primarily for tracheal toileting
• Can be used for administration of oxygen
Comparison of types of tracheostomy
Surgical tracheostomy
Percutaneous dilation
Crico
thyroidotomy
Mini
tracheostomy
SITE 2nd – 3rd or
3rd – 4th
1st and 2nd or
2nd – 3rd
Cricothyroid membrane
Cricothyroid membrane
method
•Surgical dissection
•Cut the trachea
Puncture and dilatation under FOB guidance
Puncture with needle
Cut the membrane
Elective or emergency
Always elective (in OT or ICU setting)
For emergency access to airway
•Tracheal toileting
•Oxygen delivery
Decannulation • Reduce the size of the tube at each tube change .• Assess the airway above the stoma with a fibreoptic
endoscope .• Use a fenestrated tube, allowing the patient to breath
through the larynx (using a speaking valve or decannulation plug).
• Or block the smaller sized plastic tube with a cork or decannulation plug for increasing lengths of time.
• The patient should be able to tolerate the blocked tube for at least 24 hours continuously (under strict monitoring in the hospital).
• After decannulation, firm and air-tight dressing is applied to allow the tract to close and heal.
Vocal cord papilloma
• caused by the human papilloma virus• bimodal age distribution• Hoarseness is the most common presenting
symptom• papillomas have a high rate of recurrence• Treatment involves repeated debulking of the
warty growths• In 3-5% of patients, respiratory papillomas may
undergo malignant degeneration to squamous cell carcinoma
When to do tracheostomy in prolonged mechanical ventillation ?
• Sugerman et al found no difference in duration of mechanical ventillation, ICU stay, mortality, incidence of pneumonia between early(3-5days), late (10-14 days) tracheostomy and orotracheal intubation.
J Trauma 1997
• Rumbak et al compared same parameters and concluded that early tracheostomy had significantly better outcome than late.
Critical care medicine 2004
