Upper air way obstruction & Tracheotomy Dr. Lamia AlMaghrabi Consultant ENT King Saud Medical City

Congenital 1 Subglottic or upper tracheal stenosis. 2 Laryngeal web. 3 Laryngeal and vallecular cysts. 4 Tracheo-oesophageal anomalies. 5 Haemangioma of larynx. Trauma 1 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 Infections 1 Acute epiglottitis 2 Laryngotracheobronchitis. 3 Diphtheria. 4 Ludwig’s angina. Malignant tumours 1 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 paralysis 1 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.

TRACHEOSTOMY EMERGENCYELECTIVE TRACHEOSTOMY OPENPERCUTANOUS

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 UncuffedCuffed

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 1 st 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

Bivona or foam cuffTracoe 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 ( %)* 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 Advantages 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

increased Goal is to ensure patient can tolerate increased 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 H 2 O Ceriana et al 2003