Tracheostomy – Indications and Complications Dr Gary Kroukamp Ear,Nose and Throat Specialist Tygerberg and Kingsbury Hospitals

History Rigveda - 2000 BC Alexander the Great - 4th Century BC Ancient Greeks - Asclepiades 124 BC Diptheria - early 1800s - 32% survival Intubation prior to ET tube - mid 1800s Polio - 1930s Chevalier Jackson - 1932

Respiratory Functional Why a trachy ? Airway patency for ventilation where intubation via the upper airway is not appropriate. Upper airway Obstruction Respiratory Functional

Indications for tracheostomy Obstructive Congenital subglottic stenosis, Traumatic tracheal, laryngeal injuries, facial fractures Neoplastic laryngeal, thyroid, oesophageal Infective epiglottitis, oropharyngeal abscess Inflammatory angioedema, corrosives,burns Neurological vocal cord palsy, MND, MS, MG Postoperative tracheal/laryngeal/oral surgery Difficult airway emergency trachy

Indications tracheostomy - combined (head, facial and chest injuries)

Functional indications Ventilation/ Weaning Predicted ventilation > 10 days Flail chest, polytrauma, head injuries, severe burns Narcotic overdoses, Tetanus, Pneumonias, Muscle weakness, Postop elective ventilation in resp failure Sputum production

Advantages over ET Tubes Comfort Easier to nurse  Dead space (70-100ml / 10-50%) Better oral hygiene No sinusitis, nasal or oral ulceration, subglottic stenosis Less nosocomial pneumonia Better airway toilet Weaning easier Awake patient

Causes of ET tube trauma Duration of laryngeal intubation >48 h: significant laryngeal ulceration >96 h: severe damage, possible permanent damage Inadequate fixation of tube Wrong size tube Overinflated cuff (Gastro-oesophageal reflux)

“Gold Standard” Technique Open procedure Vertical midline incision Blunt dissection Thyroid isthmus displaced or divided and tied off Tracheal vertical slit – Paediatric or round/oval window – Adult Appropriate sized tube – adjustable length if obese or severe soft tissue swelling Single suture through flange superiorly, midline Tapes around neck in neutral position – not tied with bow Post-op CXR

Post-operative Dislodgement of tube Surgical emphysema Pneumothorax/Pneumomediastinum Obstruction of tube – crusting Infection(perichondritis,wound infection,secondary haemorrhage) Tracheal necrosis - leading to tracheal stenosis or tracheo-oesophageal fistula Post obstructive pulmonary oedema

Prevention Routine CXR post op Humidification Regular suctioning with saline Treat infection Removal as soon as is safe

Late Subglottic and tracheal stenosis Granulation tissue Tracheo-arterial fistula Tracheocutaneous fistula Decannulation difficulty Scar hypertrophy or keloid

Prevention Large volume, low pressure cuff Slight air leak in children Properly positioned and fixed Restless patient Gentle suctioning

Paediatric complications More common esp < 1 year 38% late complications Granulation and tracheal stenosis Duration the most important factor Preterm

Complications – wound Closed suction system Velcro skin protection less movement Alewyn clean and dry avoid bulk Traction Support piping Evac system

Normal larynx

Intubation trauma

Interaritenoid adhesion

Vocal granuloma/nodule

Subglottic trauma

What’s new? – tracheal stenosis Cuff design High volume/low pressure Less traumatic More flexible softer materials

Pooling above the cuff – aspiration pneumonia Aspiration port cuff shlop

Suction above the cuff

Extended length trachy Securing Bolt Variable length adjustor

Percutaneous technology

Percutaneous trachy

Percutaneous trachy

Percutaneous trachy

Tracheo-Innominate fistula 1%, mortality, week old, site, sentinel bleed, management

The Happy Trachy Team work and Attention to Detail Most problems are preventable Operative technique Movement Strapping, dressings Patency Humidification Patient teaching Team work and Attention to Detail