TRACHEOSTOMY & CRICOTHYROIDOTOMY DR FRANK EDWIN

INTRODUCTION Tracheostomy is an operative procedure that creates a surgical airway in the cervical trachea It is considered synonymous with tracheotomy

LARYNX & TRACHEA

ANATOMY I

ANATOMY II

ANATOMY III

ANATOMY IV

UPPER AIRWAY OBSTRUCTION -RECOGNITION Dyspnea Stridor Voice change Decreased or absent breath sounds Restlessness Hemodynamic instability (late) Loss of consciousness (very late)

INDICATIONS FOR TRACHEOSTOMY To bypass obstruction Long-term Mechanical ventilation Pulmonary toiletting Neck trauma Tumor Bilateral vocal cord paralysis Laryngeal Edema Respiratory failure

FORMS OF TRACHEOSTOMY Emergency tracheostomy Urgent tracheostomy Elective tracheostomy

INTRAOPERATIVE DETAILS: TRACHEOSTOMY

TRACHEOSTOMY

TRACHY TUBES

TUBE PARTS

METALIC TUBES

PLASTIC TUBES

USE OF FENESTRATED TUBE

Chest X-ray after trachy

POSTOPERATIVE DETAILS Postoperative care is critical. Copious secretions is the norm Suctioning every 15 minutes may be required Suctioning should be shallow initially Suctioning should be limited to no more than 15 seconds

POSTOPERATIVE DETAILS 2 Humidified oxygen helps prevent inspissation of the secretions. Mucolytic agents may be employed. If uncorrected, mucus plugging of the inner cannula can cause a life-threatening obstruction.

POSTOPERATIVE DETAILS 3 The original tube is left sutured in place for 5-7 days to allow the tract to heal. Then the sutures are removed, and the tube is replaced. The site should be kept clean and dry to minimize infection Patient and family education should begin ASAP

FOLLOW-UP CARE Speaking: should be encouraged when cuff is deflated Swallowing: Swallowing is more difficult Evaluate risk of aspiration before feeding Educate: both patient and family Equipment: for discharge

SUCTIONING "STERILE TECHNIQUE" - the use of a sterile catheter and sterile gloves for each suctioning procedure. "CLEAN TECHNIQUE" - the use of a clean catheter and nonsterile, disposable gloves or freshly washed, clean hands for the procedure. “MODIFIED CLEAN TECHNIQUE" - nonsterile gloves and sterile catheters).

SUCTIONING DEPTH SHALLOW SUCTIONING – suctioning at the hub of the tracheostomy tube to remove secretions coughed up to the opening of the tracheostomy tube. The PRE-MEASURED TECHNIQUE - the catheter is inserted to a pre-measured depth, with the most distal side holes just exiting the tip of the tracheostomy tube. DEEP SUCTIONING - the insertion of the catheter until resistance is met, withdrawing the catheter slightly before suction is applied.

WHEN IS SUCTIONING REQUIRED? Whenever patient is unable to clear secretions by coughing Bleeding down the airway

WHEN TO SUCTION 1 Mucus bubbling in trachy tube Audible gargling sounds Laboured breathing Restlessness Gurgles heard on auscultation Low SpO2

WHEN T SUCTION 2 Stridor or changes in breathing Cyanosis Increased ventilator inspiratory pressure (for patient on ventilator, a high pressure alarm may sound) Patient request

INSTILLING Introduction of normal saline into the airway to aid removal of thick, tenacious secretions. TENACIOUS SECRETIONS Systemic hydration Humidification Chest physiotherapy Suctioning, coughs and assisted coughs Mucolytic agents

COMPLICATIONS IMMEDIATE EARLY LATE

COMPLICATIONS 1 IMMEDIATE Bleeding Pneumothorax/Pneumomediastinum Injury to adjacent structures

COMPLICATIONS 2 EARLY Bleeding Tube obstruction Tube displacement/dislodgement Subcutaneous Emphysema Atelectasis

COMPLICATIONS 3 LATE Bleeding Tracheal stenosis Tracheomalacia Tracheo-esophageal fistula Failure to de-cannulate