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TRACHEOSTOMY AND ITS CAREDR. ASHWIN MENON

ANATOMY

SURFACE ANATOMY

JACKSONS SAFETY TRIANGLE

TRACHEA

RELATIONS OF THE TRACHEA

Cervical part of trachea

Thoracic part of trachea

CERVICAL PART OF THE TRACHEAAnterior Relation:The skin and the superf. & deep fascia.Jugular arch & overlapped by the sternohyoid and sternothyroid muscles.Tracheal cartilage 2-4 isthmus of the thyroid gland Above which an anastomotic artery connect the b/l sup. Thyroid ABelow and in front are the pre tracheal fascia, inf. Thyroid V communicative band between Ant jugular V, thymic remnants & thyroidea ima A.In Children the brachio cephalic A crosses, obliquely in front of the trachea at or a little above the upper border of the manubrium; Left BCV also rise a little above this level

Lateral Relation: Paired lobes of the thyroid gland descending to the 5th or 6th tracheal cartilageasThe carotid sheath enclosing the common carotid A, IJV & vagus nerve. The inferior thyroid A lies laterally.

Posterior Relation:

Oesophagus- running between the trachea & the vertebral column.The recurrent laryngeal nerves ascend on either side.

THORACIC PART OF TRACHEAAnterior Relation:Manubrium sterniOrigin of sternohyoid & sternothyroid MusclesThymic remnants.Inferior Thyroid & Left brachiocephalic VAortic archBrachio cephalic A (R)Left CCADeep cardiac plexusLymph nodes.

Posterior Relation:OesophagusVertebral columnThoracic duct (left & posterior to the oesophagus)

Lateral Relation:Right - Right lung upper lobe & pleuraRight BCV, Sup. Venacava,Rt Vagus Nerve & Azygous V.Left- Left CCA & Left subclavian A, Arch of Aorta, Left Vagus Nerve, Left recurrent laryngeal nerve

BLOOD SUPPLY OF THE TRACHEA

Mainly by the Inferior Thyroid Artery

Thoracic end Bronchial arteries which anastomose with the Inferior Thyroid A and also supply the Oesophagus

VEINS: to Inferior Thyroid venous plexus

LYMPHATICS: Pretracheal & (R & L) Paratracheal LN Inferior tracheobronchial sub- carinalnodes

NERVE SUPPLY

Tracheal branches of the vagi.Recurrent laryngeal nerves.The sympathetic trunks.

RLN motor fibers to the muscles of the trachea an trachealis muscle, also carry sensory fibers from the mucous membrane.

Sympathetic nerve fibers derived mainly from middle cervical ganglion.

LAYERS OF DISSECTION

TRACHEOSTOMY SURGICAL STEPS

Pre-Operative Check listIndicationClotting Profile of PatientScreeningGood assistantCorrect size tubeInstruments This applies to Elective cases only

Position of Patient

Position (contd)

Marking the Incision

Infiltration

The patient should be draped using three small and one large sticky drape.

A head drape should not be used, as it needs to be unwrapped in order to gain access to the ET tube and this cannot be done in a hurry, as it is cumbersome.

Place one small sticky drape on either side of the neck, up to the angle of the jaw making sure that the anaesthetic tube is not stuck to the drape. The third drape is applied horizontally just under the chin.

Incision

DISSECTION

Thyroid Isthmus

Dealing with Thyroid Isthmus

Tracheal OpeningThe tracheostomy should be sited over the 2nd and 3rd or 3rd and 4th tracheal cartilages. It is always better to identify Cricoid cartilage by palpation and count the rings downwards.

The tracheostomy must not involve the first tracheal ring because of the high incidence of post-op, subglottic stenosis if it is divided.

The trachea should be incised longitudinally in the midline through these cartilages or if the cartilages are heavily calcified, a window, big enough to take an appropriate sized tube, should be cut in the anterior aspect of the tracheal cartilages.

Care must be taken not to dissect laterally as the recurrent laryngeal nerves may be damaged.

A pair of heavy scissors may be necessary to cut through heavily calcified cartilages.

When one is ready to make the incision in the trachea, the anaesthetist should be alerted so that he/she can be ready to withdraw the tube.

Check that all the equipment is available and working before making your incision. Make especially sure that the right size tube has been selected.

If the trachea is relatively deep to the skin edge, an adjustable flange tube is recommended as there is less likelihood of the tube being displaced in the early post-operative period.

Make every effort not to puncture the cuff of the tube. The easiest way to do this is to ask the anaesthetist to push the tube further down the trachea towards the carina before making the hole.

Once the trachea is incised the tube is withdrawn under direct vision until the tip is just above the incision.

It should not be removed as it can be rapidly advanced to secure the airway in the event of a problem.

Tracheostomy Tube InsertionTracheal dilators will be needed to enable the tube to be inserted into the tracheal lumen.

The assistant should now hold the tube in situ until it is secured. Use a flexible suction catheter down the tube to suction any blood or mucus out of the trachea and connect the catheter mount to the tracheostomy tube and the anaesthetic tubing.

Securing the TubeThe tube itself should be secured with both tracheostomy ties and sutures.

This will prevent the tube from falling out if someone is offended by blood on the ties and decides to change them in the immediate post-operative period!

The tube is sutured in place using a thick silk stitch. The stitch is placed through the loop provided for the ties and not through the plastic of the flange itself.

The sutures are tied with just enough slack to allow the gauze soaked in betadine (or Lyofoam) dressing to be inserted between the skin and the tracheostomy tube

The tracheostomy tapes are tied around the neck only once the sand bag has been removed from behind the patients shoulders and the neck has been flexed.

Emergency TracheostomyVertical Incision between Cricoid and Suprasternal notch.

Straight incision up to or including trachea in one incision.

Insert the tube as soon as possible

Once tube is in place and patient is ventilated, then hemostasis.

Indications

Upper Airway Obstruction.

Pulmonary Ventilation.

3. Pulmonary Toilet.

4. Elective Procedure.

UPPER AIRWAY OBSTRUCTION

TraumaForeign bodyInfectionsMalignant lesions

Pulmonary Ventilation

Tracheostomy should be performed in a patient still requiring ventilation through an endotracheal tube for more than a one week.

Pulmonary Toilet

Those who cannot cough and clear their chest.

Prevent aspiration by low pressure high volume cuff tracheostomy tube.

Elective Procedures

For major head and neck operations.

PEDIATRIC TRACHEOSTOMY

INDICATIONSIn Infants:Subglottic haemangiomaSubglottic stenosisLaryngeal cystGlottic webB/L VC paralysis

INDICATIONSIn Children:Acute laryngotracheo bronchitisEpiglottitisDiphtheriaLaryngeal oedemaExt. Laryngeal traumaProlonged intubationJuvenile laryngeal papillomatosis

PERCUTANEUS DILATIONAL TRACHEOSTOMYICU Bed Side Tracheostomy

Use of guide wire and Dilators

Under the vision of Bronchoscope through endo tracheal tube

Less time.

Not suitable for thick neck and in emergency

COMPLICATIONS OF TRACHEOSTOMYIntraoperative Complications.Bleeding and injury to big vesselsInjury to tracheoesophageal wallPneumothoraxEarly ComplicationsBleedingTracheostomy tube obstructionTracheostomy tube displacementInfection

COMPLICATIONS OF TRACHEOSTOMYLate ComplicationsTracheal StenosisGranulation tissueTracheocutaneus fistulaTracheo - inominate fistula

PROBLEMS DURING TRACHEOSTOMY CARE

TRACHEOSTOMY CARE

AIMSPrevent complications associated with tracheostomy.Help in the full recovery of the patient.Give the patients and attendants an understanding of the problem.

Can be considered under two periods:1)Care when the patient needs the tracheostomy.2)Care when the patient needs to be weaned off the tracheostomy.

While doing tracheostomy care what to document in the file?

After doing a tracheostomy, you have put somebody into danger by preventing him from shouting for help if he needs any.

The best way to prevent this is by giving a hand bell to the patient which he can ring whenever he needs help.

However if the patient is on ventilator, we have electronic alarms-right.

Care when the patient needs the tracheostomy?Care of the wound/stomaCare of the tubeCare of the lungs and trachea

First and foremost thing to do after a tracheostomy is done: Do a chest X ray.This helps in knowing the position of the tube, how far is it from the carina and if any problems have occurred during tracheostomy. Also the condition of the lung is documented.

Care of the wound/stomaWe have opened the skin into the lung by doing a tracheostomy.Infection can enter from the surface into the lung or vice versa.Also the incision site can get infected.Hence a barrier is to be maintained between the lung and the skin.Simple sterile dressing with an antibiotic soaked guaze is all that is needed.

Take a simple 2 by 2 square gauze.Clean the operative site with betadine.Cut the gauze half in the midline.Soak it with antibiotic solution or ointment.Place the gauze in such a way that the cut part accomodates the tube and the remaining stays on the wound.Inspect the wound daily for any granulations or infection.

If there are granulations, antibiotic steroid is applied.If there is infection, take a swab for c/s and treat accordingly.Make sure the tube retainers are secure.Change dressing once daily.During the process of decannulation, just apply a tight bandage to the wound. It just heals without issues.

Care of the tube

Partial block can be cleared by suctioning.Near complete block requires a tube change immediately, or else patient will land up in negative pressure pulmonary edema.

What to do?Do not panic.Deflate the cuff in case of cuffed tube.Remove the inner cannula if it is there, there ends the matter.Get a tube same size or smaller.Change the tube. Law states that two medical personnel should be there while changing the tube.If the tracheostomy is less than 48 hours old, have a tracheostomy set with you.Alternatively use the rail road technique of changing the tube.

Changing the inner cannula

Railroading technique of changing tubeInsert suction catheter and remove the tube, keep catheter in place without displacingThread a new tube over the suction catheter and secure it in place,then remove the catheter.

Standard technique: give extension, remove the old tube, introduce the new tube as if introducing a suction catheter for suctioning. Do not force push the tube. It might form a false track.

Care of the lungs and tracheaCare of the cuff.Suctioning.Humidification and oxygenation.Expulsion of secretions

Cuff pressureUsing a cuff pressure manometer, check the pressure of the tracheostomy cuff. Should be less than 25 cm of H2O. If more chances of tracheal injury. If more pressure is needed, then change the tube. As a simple rule, air in cc about half the size of tracheostomy tube is sufficient for adequate volume and pressure of the cuff.

Check if the cuff is functioning daily by pressing the pilot and waiting for it to slowing fill up.

Also patient will elicit a cough reflex when the pilot is pressed if cuff is intact.

Deflate cuff hourly for five minutes-not really needed if pressure and volume are correct.

OVERINFLATION CUFF MANOMETER

SUCTIONING Most of the problems related to tracheostomy happen due to the technique of wrong suctioning.Vigorous suctioning can cause both barotrauma as well as physical trauma, leading to bleeding and lung collapse. Unsterile technique can cause lung infection.Timid technique can cause retention of secretions and tube block.Suction sos if there is gurgling/rattling. No need for hourly suction.

Tips for suctioning:Use a suction catheter whose size is less than or equal to half of the ID of the tracheostomy tube to be suctioned.Set the suction pressure to 60-150 mm of Hg by adjusting the knob on the machine.Do not introduce the suction catheter too much inside else it will injure the carina. See the chest x ray to find out how much away from the carina is the tube tip. Measure the length of the tube from the obturator. Mark on the suction catheter how much to introduce.Alternatively use a flexible bronchoscope to measure the length. Use sterile universal precautions.

Catheter sizesColour of catheterNumber in FGSize of catheter in mmCan be used with tracheostomy No.GREY51.703.0, 3.5LIGHT GREEN62.004.0, 4.5, 5.0BLUE82.705.5, 6.0BLACK103.306.5,7.0,7.5WHITE124.008.0, 8.5, 9.0DARK GREEN144.709.0ORANGE165.30WE DO NOT HAVE TRACHEOSTOMY TUBES FOR THIS ONESRED186.00

Instill few drops of saline into the tracheostomy opening. Followed by few drops of sodium bicarbonate solution. Helps in softening the secretions and easy expulsion.

Wait for cough reflex. Hold your breath. Introduce the suction catheter sterile in closed position and take it out slowly in revolving motion after opening the suction. Catheter should be out before you feel like re-breathing again. Can be repeated.

In case of ventilated patients, increase the PEEP, disconnect the tube, suction.

Closed suction systemAlternatively a novel method of suctioning called the closed suction system can be used wherein 1)there is no need to disconnect the patient from the ventilator while suctioning.2)sterile technique3)no need to change catheters4)no need for sterile precautions5)cost effective in the long runThe set up is connected to the tracheostomy tube and kept. Suction can be done any time without disturbing the ventilation.

CLOSED SUCTION SYSTEM

Care when the patient needs to be weaned off the tracheostomy1)humidification, temperature regulation and oxygenation.2)expulsions of secretions and swallowing3)speech4)home care5)decannulation

Humidification, temperature regulation and oxygenationUsually achieved while on oxygen because it is humidified. A HME(heat and moisture exchanger) is fixed to the circuit which does the job of conserving heat.Oxygen can be given by mask or by T-piece recovery kit(if not on ventilator).If patient not needing oxygen a Thermovent T can be connected to the tracheostomy.Alternatively , the stoma/tube can be kept covered with a wet gauze.

THERMOVENT -T

Expulsion of secretionsPhysical therapy in the form of chest physiotherapy.

Pharmocological agents like terbutaline, bromhexine.

Swallowing therapy is started to help in handling the secretions and meet the nutritional needs.

Speech while on tracheostomyIf using an metal tube, patient can simply occlude the opening of the tube with thumb during expiration to phonate.If using cuffed tubes, special tubes designed for the same to be used.If using uncuffed portex or tracoe tubes, other than digital occlusion, specially designed speaking valves as attachments for the tubes are available.Advantage being the hands are free, if needed, oxygen also can be delivered simultaneously which does not happen with digital occlusion.

SPEAKING VALVES

CARE AT HOMEPatient and attendants are educated while in the hospital regarding self tracheostomy care.Strictly no water sports.Commercially available kits for dressing and tube cleaning can be purchased.To buy a suction machine.Tracheostomy shower cap to be used while taking a shower.Always to carry a smaller size tube in case there is accidental decannulation.

SHOWER SHIELD

DECANNULATION Tracheostomy is not needed if:Indication for the procedure is tided over.Patient is breathing without ventilator; maintaining saturation on room air.Able to handle his secretions without aspiration .Excellent cough reflex and healthy lung.Once a decision has been made that the patient does not need a tracheostomy any more, the procedure of decannulation is started.IDL to look at condition of vocal cords.X ray neck lateral view, to look at the airway above the tracheostomy.Alternatively a flexible nasopharyngolaryngoscopy will evaluate everything.

If the condition is feasible, first down size the tube to the smallest size through which only inspiration happens fully, but expiration happens through both glottis and the tube. Patient should be able to produce a faint voice without the tube being occluded, good voice with the tube occluded.In adults about a size 6 Romson tube Gradually block the tube for 48 hours and allow for normal activities.If no distress, remove the tube and plaster it.Observe for 24 hours and discharge.

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