Upper air way obstruction

&Tracheotomy

Dr. Lamia AlMaghrabiConsultant ENT

King Saud Medical City

Congenital1 Subglottic or upper tracheal stenosis.2 Laryngeal web.3 Laryngeal and vallecular cysts.4 Tracheo-oesophageal anomalies.5 Haemangioma of larynx.

Trauma1 Prolonged endotracheal intubation.2 Gunshot wounds and cut throat, laryngeal fracture.3 Inhalation of steam or hot vapour.4 Swallowing of corrosive fluids.5 Radiotherapy

Infections1 Acute epiglottitis2 Laryngotracheobronchitis.3 Diphtheria.4 Ludwig’s angina.

Malignant tumours1 Advanced malignant disease of the tongue, larynx, pharynx or upper trachea.2 As part of a surgical procedure for the treatment of laryngeal cancer.3 Carcinoma of thyroid.

Bilateral laryngeal paralysis1 Following thyroidectomy.2 Bulbar palsy.3 Following oesophageal or heart surgery.

Foreign body

LIFE THREATENING AIRWAY OBSTRUCTION

Cricothyroidotomy. Indication:

Failure of endotracheal intubation, and no time for tracheostomy.

Tracheotomy

Indications Technique

Open and percutaneous Complications Physiology of a tracheotomy Decannulation

Tracheotomy

Creation of communication between the trachea and the cervical skin with insertion of a tube.

Indications

Upper Airway obstruction. Pulmonary Secretions. Ventilation. Prolonged mechanical ventilation.

May assist in weaning from mechanical ventilation.

Prevention of glottic stenosis/complication of prolonged endotracheal tube.

Pulmonary Secretion Clearance

Aspiration / dysphagia COPD Bronchiectesis Stasis of secretions

Poor cough Poor respiratory reserve

Ventilation Neuromuscular disorder affecting respiratory

muscles Reduced respiratory effort

Limited pulmonary reserve COPD, Scoliosis, bronchiectesis

Central respiratory depression Reduced level of consciousness

Severe obstructive sleep apnea Cor pulmonale, failure CPAP

Prolonged Intubation

7-10 days ett Risk Factors for Glottic

Stenosis Diabetes Female Size ETT and # ett

Incidence glottic stenosis: 5% over 10 days (Whited 1984)

Tracheotomy

Decision made patient requires tracheotomy.

Open or percutaneous technique.

75% of tracheotomies done are done percutaneously in ICU at bedside.

General principles: External approach through neck soft tissue. Creation of opening in trachea. Placement of tube to maintain airway.

Types of tubes

Cuffed and uncuffed

Fenestrated and unfenestrated

Single and double lumen

Various diameters

Cuffs

To protect airway To allow ventilation

Uncuffed Cuffed

fenestrations

Allow patient to ventilate past tube via upper airway

Allow speech

Single/Double lumen

Double lumen allows easy cleaning

Single lumen has a greater internal diameter

Procedure

Skin Dissection Separate straps Divide thyroid isthmus Window in trachea Below 1st ring Stitch in place

Incision=bad

Hole=good

Contraindications

Medically well enough for GA Uncontrolled coagulopathy Airway pathology below tracheotomy site

Tracheotomy Tubes

Portex and Shiley common brands of trach tubes.

Shiley used as standard tube at St Michael’s Hospital.

Tracheotomy Tubes

Tracheotomy Tubes

Bivona or foam cuff Tracoe Cuffless

Speaking valve

Complications: Intraoperative

Bleeding 2.8%* Recurrent laryngeal nerve injury Tracheoesophageal fistula Pneumothorax: rare False passage

Anterior dissection most common Incidence <1%

*Kost et al 1994

Tracheotomy: Early Complications

Bleeding Minor common Major tracheoinnominate fistula (<0.2%)*

Obstruction of tube (2.5%)* Dislodgement (1.4%)* Pneumothorax (1 - 2.5%)* Wound Infection

Local care, antibiotics (staph/pseudomonas)

Late Complications

Tracheal stenosis Tracheal chondritis Subglottis stenosis- high tracheotomy Tracheomalacia Tracheoesophageal fistula Failure of stoma closure when decannulated

Overall complication rate 15-30% in ICU patients largely minor with no long term morbidity

Physiology of Tracheotomy

Neck breathing Bypass upper airway and nasal function Loss of humidification/heat airflow Dryness, thick secretions Voicing possible with speaking valve Loss of smell /reduced taste Loss glottic closure function for cough

Physiology of Tracheotomy Respiration

AdvantagesAdvantages Lower work of breathing (30%) c/w normal airway Facilitates secretion clearance

Aspiration or thick secretions Less dead space (100 mL) Reduced airway resistance Assists in patient independence from mechanical

ventilation Patient comfort (better than ett)

Epstein 2005 Respiratory Care

Physiology of Tracheotomy Respiration

Disadvantages Tube diameter and shape

increases turbulent airflow, secretions adhere inside tube Loss of humidification/heat function of upper airway

Ciliary function affected Biofilm colonization

Diminish cough/loss glottic closure Reduce laryngeal elevation during swallow Patient comfort (better no tube at all)

Postoperative Tracheotomy Care

Humidification via trach mask/Instill saline Clear secretions, prevent crust Inner cannula cleaning tid at least If non-ventilated, change cuffed tube to non-

cuffed at 5-7 days Ties changed 2 people if possible Most hospital have nursing/RT protocol Teach everyone trach care including patient,

family

Decannulation

Decannulation

Goal is to ensure patient can tolerate increasedincreased airway resistance/work of breathing and secretion clearance

30% increase WOB transition from trach breathing to upper airway breathing

Decannulation

Indication for tracheotomy has resolved/improved

Patient able to cope with secretions Upper airway patent - examined if necessary Appropriate vocal cord function Good respiratory reserve/overall respiratory

status Gag reflex present (5-10% no gag)

Decannulation

Stable clinical condition Hemodynamic stability Absence of fever, sepsis infection

Adequate swallowing Gag reflex, bedside swallowing assessment,

video fluoscopy

Maximum expiratory pressure > 40 cm H2O

Ceriana et al 2003