1. Tracheotomy Dr J A Anderson MD MSc. FRCS(C)
Chief Department of Otolaryngology HNS
St Michael’s Hospital
University of Toronto
POS November 2012
15/04/2017

2. Tracheotomy Indications Technique Complications
Open and percutaneous
Complications
Physiology of a tracheotomy
Troubleshooting
Decannulation
The outline for the talk
Percutaneous may be new to some and a short video is available time permitting.
The altered respiratory physiology is an important topic and it is the basis of a lot of the required tracheotomy care to prevent obstruction and other complications

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

4. Indications Airway obstruction Pulmonary Secretions Ventilation
Prolonged mechanical ventilation
May assist in weaning from mechanical ventilation
Prevention of glottic stenosis/complication of prolonged ett
Why the pt was trached in the first place is crucial if you are called to manage a complication or make a decision regarding care of a trach tube pt.

5. Fixed Airway Obstruction
Tumours of upper aero digestive tract
Chronic airway obstruction up to 80% lumen
External compression by tumour
Anaplastic thyroid, massive lymphadenopathy
Foreign Body
Glottic Stenosis/tracheal stenosis
Trauma upper airway

6. Non-Fixed Airway Obstruction
Trauma
Expanding neck hematoma
Maxillofacial trauma
Laryngeal fracture
Inflammatory
Inhalation injury
Anaphylaxis
Epiglottitis
Ludwig’s Angina/Deep Neck space infection
Bilateral vocal cord paralysis
Fiberoptic Intubation can be successful
Some of these may be managed with a flexible endoscopic intubation and then a trach may be performed ie Ludwigs angina, maxillofacial trauma (need ett out of the way, expect arch bars)

7. Pulmonary Secretion Clearance
Aspiration / dysphagia
COPD
Bronchiectesis
Stasis of secretions
Poor cough
Poor respiratory reserve
Main goal is to prevent pneumonia/sepsis with better secretion clearance with suctioning/cough via trach.
The medical conditions that predispose to the indication overlap considerably. For example, neurologic deficits are a common reason for significant aspiration, poor cough and inability to swallow.
Recovery from a significant head injury or stroke may take months and trach care is an important issue for this patient population.

8. Ventilation Neuromuscular disorder affecting respiratory muscles
Reduced respiratory effort
Limited pulmonary reserve
COPD, Scoliosis, bronchiectesis
Central respiratory depression
Reduced LOC
Severe obstructive sleep apnea
Cor pulmonale, failure CPAP
The second historical indication for tracheotomy was for polio in Up until then, the only indication was for acute upper airways obstruction with a very high mortality rate.
Neuro indications could be bilateral paralysis of diaphragm to brainstem stroke or post head injury.
A common indication particularly the chronic care and rehabilitation facilities. However, at times patient require reassessment as to whether or not their original indication still necessitates a tracheotomy for their care and in most cases this is straight forward following the decannulation protocol but in others, a more formal evaluation is needed.
Patients often are send to SMH from outside institutions for this assessment regarding tracheotomy.

9. Prolonged Intubation 7-10 days ett Risk Factors for Glottic Stenosis
Diabetes
Female
Size ETT and # ett
Hemodynamic instability
Incidence glottic stenosis: 5% over 10 days (Whited 1984)
The video clip shows a man about 4 months post bypass who was ett for 21 days and never trached. He has significant stridor and no abduction of his cords at all. In fact, it nicely shows that as he inhales, his vocal get slightly pulled together (due to Bernoulli effect, negative pressure against the glottis as airflow if drawn in). As he exhales, his cords are alightly more open but his airway is about 3 mm wide at most.
I just show the clip long enough to demonstrate this and then move on to next slide.
This is a frequent reason that a patient fails decannulation. Surgical procedures can address the problem in some individuals but not all. Can be a cause of permanent tracheostomy.ie endoscopic laser arytenoidectomy or external laryngotracheoplasty
Lower video shows another patient who underwent open laryngoplasty with a stent in for four weeks and then was decannulated. St the start of the video, his wife say Wow Bob because she and the pt have been following his glottic stenosis prob lem with the video monitor during each examination and they both became quite good at understanding the findings on endoscopy. He has an open posterior glottic and some mobility of his folds but still not normal.

10. Example 1 Subglottic Stenosis

11. Example 3 Combined Glottic/Tracheal Stenosis

12. Prolonged Intubation Weaning from ventilator
Relative indication for tracheotomy
Modest gains in respiratory function after tracheotomy may be enough to increase chance of successful weaning from ventilator
Trend of patients ventilator requirements
5 day reversibility of common ICU admitting diagnoses
This is an relative indication for tracheotomy. Many patients in the ICU have a tracheotomy performed because the ICU team feels that with just these modest changes, it may tip the balance in favour of the patient weaning from the ventilator. There is no exact protocol for this but a combination of factors including current ventilator settings (ie how much O2 , Peep) neurological status, other comorbidities like CAD, renal failure and how reversible their current acute condition are all factors taken into account. Often, the staff just ‘know’ if they trach a patient, they will likely wean.

13. Tracheotomy Decision made patient requires tracheotomy
Open or percutaneous technique
75% of tracheotomies done at SMH are done percutaneously in ICU at bedside
Variations of open tracheotomy technique
General principles are the same
External approach through neck soft tissue
Creation of opening in trachea
Placement of tube to maintain airway
Cuffed tube placed during GA usually changed to a non cuffed fenestrated for voicing and /or planning for decannulation
Basically, all patients are considered by the ENT service as a potential percutaneous tracheotomy. If they do meet the indications for a perc, the patient has an open trach in the OR.

14. Technique Diagrams from Lore, Surgical Atlas 1988
Brief outline of procedure, standard approach, pt ett, under ga, next extended, between 2-3 ring etc.
Diagrams from Lore, Surgical Atlas 1988

15. Equipment Tracheotomy set Tracheotomy tube
Right angles, cricoid hook, trach spreader
Tracheotomy tube
Shiley most common
Select size (6, 8 most common)
Cuffed non-fenestrated for most ICU patients
Fenestrated if voicing expected (use non-fen inner cannula during procedure)

16. Open Tracheotomy
Transverse incision half way between cricoid and sternal notch
Retraction
Divide strap muscles in midline
Position the patient
Neck extended
Roll under shoulders
Arms tucked
On OR bed
Palpate landmarks

17. Technique
Diagrams from Lore, Surgical Atlas 1988

18. Technique cont’d Thyroid isthmus Divide or retract
Identify cricoid and upper tracheal rings using blunt dissection
Blunt cricoid hook helpful
Retract cricoid in superior direction
Tracheotomy tube cuff checked and obturator in
Deflate cuff of endotracheal tube
Horizontal incision between tracheal rings (below the second ring)
Suction lumen if necessary
Spread rings apart with spreader or scissors

19. Technique 2 DO NOT use cautery on the trachea FIRE!
This is when it is tempting to use cautery on the trachea. There is a risk of tracheal fire if you use electrocautery on the trachea when opening the rings. The ignitor is the cautery, the accelerant is the oxygen and the ett tube burns.
DO NOT use cautery on the trachea
FIRE!

20. Technique 3

21. Technique
Endotracheal tube withdrawn until just above the open tracheal site
Tracheotomy tube with obturator, pushed into mid lumen of trachea, then directed inferiorly
Obturator withdrawn and inner cannula placed
Anaesthetic connector tubing passed over and connected
Cuff inflated
DO NOT LET GO OF THE TUBE

22. Final Anaesthesia: Check CO2, good breath sounds
Sew in the trach tube shield to skin
Loosely approximate incision
Trach ties

23. Contraindications Medically well enough for GA PEEP < 20 mm Hg
Uncontrolled coagulopathy
Airway pathology below tracheotomy site

24. Percutaneous Tracheotomy
Bedside tracheotomy in ICU patients
An alternative not replacement for open trach
General anaesthesia and paralysis for procedure
Fiberoptic broncoscopic guidance
Ciaglia ‘Blue Rhino” by Cooke $200
Bronchoscopic guidance
Experienced personnel
Anaesthesia
Respiratory therapist
Surgeon

25. Selection of Patients Must be able to palpate landmarks adequately
Cricoid above sternal notch
Low larynx/cricoid
High innominate artery problematic
PEEP > 20 contraindication
Advantages
Smaller wound, less dissection
ICU setting
Set uptime 20 minutes
Procedures time less than 10 minutes
Anatomy is main limiting factor once pt is medically well enough to consider a tracheotomy.
OR costs at least 1000 an hour/ Trach tube cost is the same for either, Shiley etc
Getting access to do a trach in the OR can be difficult since they are elective procedures and can delay timing of tracheotomy which may mean the pt stay in the ICu longer

26. Percutaneous Tracheotomy
Disadvantages
Not for everyone
Must ventilate with ETT in high position
Maybe an air leak during procedure
Must use Shiley tube
Experienced personnel
Contraindications same as open and
Anatomic limitations
Not for everyone means the patient, the setting and the surgeon. The necessary ICU setting, appropriate staff for anaesthesia, bronchoscopic guidance and surgical experience important to successfully performing this procedure with very low complication rate (<1%).

27. Technique Identify landmarks Local anaesthetic Small incision midline
ETT moved superiorly until cuff at cords
Bronchoscope with connector in ETT
Needle in midline into trachea
Guide wire passed inferiorly
Small calibre dilator
Wire sheath and ‘blue rhino’ dilator pushed along wire into trachea
Trach tube with fitted introducer passed over wire into trachea
May delete slide and just talk over video.

28. Video Percutaneous Tracheotomy
Video is 2 minutes of perc procedure and I orient the audience to the anatomy, indicate that the bronchoscopic view can be on a video monitor so everyone involved can visualize the procedure. Anaesthesia runs the bronch and d\anaethesia and paralysis.
The technique itself takes less than ten minutes but the ICU takes 20 minutes for set up. Patient position, drugs, find all personnel required etc.
The blue rhino dilator is the large curved blue dilator and it is a single dilator kit. SHiley tubes 4 6 or 8 can be used.

29. Tracheotomy Tubes Portex and Shiley common brands of trach tubes.
SMH uses exclusively shiley tubes in part for surgeon preference and in part to conform to a consistent protocol for nursing and respiratory care.We had problems when different tubes and inner cannulas were either not available or did not fit and made a decision to conform to one type of trach tube . Occasionally a special needs of a patient might require an alternate tube.
The essential material is polyvinyl chloride or PVC with an outer cannula and in most types, also an inner cannula. Inner cannulas are designed to increase safety by allowing the inner cannula to be moved is obstructed with secretions or blood.
The Fenesra is the hole in the back of the trach to faciliate airflow through the tube and not just around the tube if the patient is voicing or planning decannulation. The initial tube placed is also a cuffed one since the patient is under a GA.
The sizes between these two main types is not the same. Shiley uses the diameter of the inner cannula as the size ie 6mm or 8mm. Portex uses an alternate system. Portex tubes have closer to a 90degree curvature in the tube and Shiley is less acutely angled. This may make one or the other more comfortable depending on their neck shape and thickness of soft tissue between the neck and the trachea in a patient with longterm or permanent tracheotomy
A size 6 and 8 are the most common tube sizes used.
Portex and Shiley common brands of trach tubes.
Shiley used as standard tube at St Michael’s Hospital.

30. Tracheotomy Tubes
Jackson or Stainless steel: flatter shield, different material sometimes better tolerated by one patients’ tissues than another
I will often try a metal or other material tube when granulation tissue is problematic but the metal tube is obviously more rigid and less conforming to the airway.
Moore tubes are silicone and quite soft and flexible. They come in normal and extra long length and also conform to patient stome/trachea.
Neither are fenestrated.

31. Tracheotomy Tubes Bivona or foam cuff Tracoe Cuffless Speaking valve
Two other tubes used in a different patient populations.
Bivona is a foam cuff and inflates with a larger surface contact area on the tracheal mucosa. They also come in an extra long tube that can be extra long coming out of the neck or extra long at the tip of the tube for difficult to fit patients.
These are for ventilator dependent patients and these do not have an inner cannula due to the silicone material- secretions are not supposed to adhere).
Patients who tend to tend to have an airleak with the standard tube and low pressure, high volume air filled cuff (like Shiley) may do better with Bivona foame cuff. The fome cuff is supposed to be less traumatic for tracheal mucosa with low pressure and larger surface area contact.
The trach tube on the right is a Tracoe which is a cuffless thermo adaptive tube that does conform to the patients stoma/tracheal shape over time. I have many patients who use this tube who are ambulatory and they find it more comfortable with less granulation tissue formation. It is flatter and fits under a shirt better but the speaking valve which is integrated with the inner cannula, does make a small click as it closes. Downside is that the tube breaks easier, cracks more readily and they cost a lot. Shiley cost 85$ cdn and a tracoe is $400 at least. They last about 6 months on average.
Paper by Jarrett et al 2002 on Biofilms on Tracheostomy tubes
Compared PVC, silicone, stainless steel and sterling silver.
A biofilm is an organized matrix of bacterial colonies. Most comon pathogens are pseudomonas and staph epidermidis which form polysaccharide matrices. Pseudomonas in particular likes to form a sessile colonies of bacteria that attaches to surfaces.
They cultured the tube surfaces with the two pathogens and noted no difference on biofilm formation .
Bivona or foam cuff
Tracoe Cuffless
Speaking valve

32. 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
Intraop complications are uncommon and we also have a similar experience of around a 1% complication rate.

33. Odd Things That Can Happen
Trach tube place upside down
No CO2 tracing despite surgeon positive tube is in the airway
Cut the pilot tube of the cuff while cutting the sutures
Trach tube coughed across table after correct placement
Difficulty with air leak
Cuff leak/tube too short or not large enough /position tube
Blocked tube secondary to secretions/blood

34. 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)
Tube obstruction with secretions or blood is the most common problem.
Next most common is a wound infection, often staph or pseudmonas and treated with local wound care and antibiotics, usually resolves.
More rare is a true chondritis due to a pseudomonas infection of the tracheal cartilage. This can be a serious problem in a diabetic with loss of tracheal rings and difficulties used the stoma with poor fit and airleak. If this is extensive, the trach tube has to be removed after the pt intubated and the wound is packed with wet to dry packing until it closes.

35. 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

36. Tracheoinnominate Fistula
More than 10 days post tracheotomy (as early as 5 days)
Sentinel bleed
Angiogram/CTA for diagnosis
Surgical exploration
Interventional radiology-stent
Associated with low tracheotomy placement, wound infection or aberrant artery

37. Late Complications/Stoma
The risk of a massive bleed from a tracheo innominate fistula is very rare. In fifteen years at SMH there have been 2 known death associated with this complication. Both complicated with wound infection in severely ill patients. At least two weeks post op. This is usually during their inpatient stay in an acute care setting.
Longterm complications from tracheotomy are usually local issues like granulation tissue, bleeding and infections. patients tend to develop granulation tissue at their stoma site in response to the presence of foreign material. This can cause localized infection, minor bleeding and at time obstruct the fenestra of their tube with the pedunculated tissue.
Video clip shows a view of a stoma with trach removed using a flexible nasendosope. At site, there is moderate granulation tissue inside the stoma and the tracheal wall is moderately dry with some mild crusting and flecks of blood. The patient coughs and clears mildly sticky secretions.
Humidification must be provided since the usual method of nasal humidification and heating of air is bypassed with a tracheotomy. This is beneficial to the mucosa but the skin around the stoma does not tolerate being constantly wet. I often recommend that patients use saline drops placed into the trach tube several times a day to add extra mucosal humidification (assuming the patient has a decent cough) .
Minor amount of bleeding common due to granulation tissue /dry mucosa

38. Stoma and Inferior View Vocal Folds
Video shows much cleaner stoma, healthy mucosa and minimal granulation tissue. Inferior view of vocal folds is not done on every patient but we do examine the airway with a flexible endosocpe prior to decannulation if there has been any difficulties with decannulation protocol or if there has been an airway obstruction.

39. 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
Cough function Normally glottic closure permits a blast of increased intrathorcic pressure to bolster cough and assist in secretion clearance.
Hassle factor: pts and caregivers would all prefer not to look after a trach. High on the inconvenient level and requires training and a certain comfort level with cleaning and cannula care. Nonetheless, tracheotomy is often a necessary part of complex patient.

40. 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
Chadda et al Measured WOB on 10 pts while trached, then after decannulation and WOB increased by up to 30% when trach removed
Obvious access for secretion clearance particularly important in patients who have florid aspiration and or significant pulmonary secretions with a reduced cough.
Often a multifactorial problems with respiratory function ie brainstem stroke with reduced respiratory and/or laryngeal function on a neuromuscular level with aspiration causing recurrent pneumonia and thick secretions.
Lowered airway resistant has not been proven to be significant at times due to; 1) tube lumen smaller than normal glottic aperture and 2) turbulent airflow due to increased flow rate and shape of the tube
Many patients who fail extubation are successfully weaned once tracheotomy is performed. Literature is mixed but support appears to support tracheotomy in ett patients who have been difficult to wean that there is reduced work of breathing (elastic and resistive)
Patient comfort should not be underestimated when compared with endotracheal intubation. However, many patients not on mech ventilation would be more comfortable without a tracheotomy tube.

41. 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)
Lowered airway resistant has not been proven to be significant at times due t 1) tube lumen smaller than normal glottic aperture and 2) turbulent airflow due to increased flow rate and shape of the tube
However, many patients not on mech ventilation would be more comfortable without a tracheotomy tube.
Physiology of tracheotomy and its effects are contradictory. On one hand, a trach facilitates pulmonary secretion clearance and at the same time, the loss of humidification/heat transfer by bypassing upper airway thickens secretions and can cause mucosa dessication. The resulting loss of ciliary function and thickened secretions can predispose to mucous stasis subsequent respiratory infections.

42. Dysphagia Common issue in neurological impaired pt
Tube required for secretion management particularly in patient with florid aspirate
Tube presence associated with limitation of the cephalad excursion of larynx during swallow and can contribute to dysphagia/aspiration
Endoscopic / fluoroscopic assessment
This problem comes up in the head injury and neurologically affected population quite often. On one hand, the trach is indicated to deal with aspiration and on the other hand, it contributes to it.
Wide variation in patient swallowing function and neurological status.
Floridly aspirating patient are staying trached to clear secretion and helpfully prevent pneumonia.
Microaspiratoin patients with minimal aspiration on deglutition study with good cough and clearance of the aspirate and no other indication ,I would try decannulating.
In the middle, I often want information from the nursing unit where the patient has been about the quantity and thickness of secretions. If suction is rare, pt able to clear secretion well through tube, swallowing their saliva, will trial corking / decannulation. Worse come to worse, trach has to get put back in.
Upper airway examination for vocal fold function, clearing secretions and an assessment by speech language pathology is indicated.
A bedside swallow assessment can be very helpful and a formal deglutition study if possible.
I frequently assess patient because the SLP involved needs more information about laryngeal function either regarding airway, voice or swallowing.
Speech Therapy assessment!

43. 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
The altered physiology is reflected in the required tracheotomy care. Combination of nursing and respiratory care. Many patients/family members can be taught some portions or all of trach care. This increases comfort level and safety. In my opinion, the more individuals who are able to change and clean an inner cannula around a trach dependent patient, the better.

44. Inner Cannula Care Frequently done tid or more
Saline and hydrogen peroxide (1:1) and trach brush
Rinse with sterile water/saline and reinsert
Spare inner cannula and store in clean covered container
Ties should be one finger tight and square knot
Ambulatory and independent living trach patients end up always doing their own trach care or with family member to help. The nursing guidance and home care at the beginning is crucial but their knowledge base increases quickly and they do not need nursing care long term.
Keep the ties snug around the neck. A trach tube that can wiggle too much ends up causing more discomfort, coughing and granulation tissue.
Respiratory Therapy Protocol SMH

45. Troubleshooting Dislodgement
Causes
Ties too loose
Cough
cuff deflated
tube too short/wrong size for patient
Clinical signs
Difficulty in ventilating patient
Increased airway pressure
Suction catheter obstructed
Non Ventilated Patient
Poor cough
Sudden voice change
Stridor, SOB
Suction catheter blocked
Causes
trach ties too loose
Coughing tube out
Cuff deflated
tube too short for that patient’s anatomy

46. What to do: Dislodgement
Extend neck
Remove inner cannula
Use obturator to redirect tracheotomy tube into lumen
If patient in distress and does not have fixed obstruction above, pull out trach tube
Ventilate with mask/intubate
Use flex bronchoscope or replace/OR
Extending the neck to to place tube is important since this is the position that it was put in and it makes the easiest alignment to replace tube.
Try to remove inner cannula is pt in distress since secretions are the most common cause of obstruction and replacing the inner cannula is often effective.
The obturator is used to replace the outer cannula if it is dislodged.
Important to know why the patient is trached. If there is no airway obstruction, the track is blocked and none of the above has worked, rempoving the trach may be the best way to temporarily relieve the obstruction. Most patients who are not ventilated with a trach can be intubated if needed or breath with an oxygen mask or oral airway in place.

47. Troubleshooting Tube Obstructed
Mucous plug or blood clot most likely
Granulation tissue, particularly fenestrated tubes
Remove inner cannula, suction, instill saline
Bronchoscopy
If no other recourse, pull out trach tube and if necessary, replace new tube with obturator
Intubate/ventilate from above

48. Troubleshooting: Bleeding
Bleeding around trach stoma
Minor bleeding immediately post-op
Moderate bleeding/venous oozing often related to thyroid
Examine wound
Pack, surgicel, if not controlled, take back to OR
Bleeding from within lumen
Often related to suctioning
Broncoscopy exam
Dry mucosa
Granulation tissue
Coagulopathy
Rare innominate fistula
Around stoma bleeding can also be from granulation tissue which can be excised and cauterized usually at bedside.
or in clinic setting. Post op minor stoma bleeding often treated with local packing and silver nitrate or surgicel packing.
Increase saline instillation /humidification to reduce mucosal bleeding.

49. Decannulation
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
When to take a trach tube out. Pt must be able to tolerate increased work of breathing to remove trach, and cope with their secretions,
Micro aspiration can at times be tolerated if the patient has a sensate trachea and can clear the secretion well. This is an area where sometimes a trial of decannulation may be the only way to ‘test’ if the patient can cope with minor aspiration without pneumonia developing.

50. 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)
Micro aspiration can at times be tolerated if the patient has a sensate trachea and can clear the secretion well. This is an area where sometimes a trial of decannulation may be the only way to ‘test’ if the patient can cope with minor aspiration without pneumonia developing.
No gag present in 5-10% of normals.

51. Decannulation Stable clinical condition Adequate swallowing
Hemodynamic stability
Absence of fever, sepsis infection
Adequate swallowing
Gag reflex, bedside swallowing assessment, video fluoscopy
Maximum expiratory pressure > 40 cm H2O
Micro aspiration can at times be tolerated if the patient has a sensate trachea and can clear well. This is an area where sometimes a trial of decannulation may be the only way to ‘test’ if the patient can cppe with minor aspiration without pneumonia developing.
Max expiratory pressure RT can measure.
Ceriana et al 2003

52. Decannulation Protocol
Downsize tube to either 4 or 6 Shiley
Cuffless fenestrated tube
Gradually increase corking/cap of trach
Corked hours before decannulation
Remove tracheostomy tube
Occlusive dressing for stoma
Persistent patent stoma
Occasionally requires local flap to close
Outpatient procedure under local, infection common
Can decannulate with downsizing but easier to breath around tube is fenestra is not ideally positioned within trachea and stoma does close around smaller tube.
Usually a 6 Shiley in most patient, occasioally a 4 in a smaller woman.
I will wait 2 – 3 months before closing with a flap.Almost always they get infected and I want the stoma as small as possible.

53. Difficult to Decannulate
Granulation tissue
Fenestra obstructed
Tracheal mucosal edema/supraglottic edema
NG, aspiration
Laryngeal pathology
Glottic stenosis, cord paralysis
Pulmonary secretions
Increase airway resistance not tolerated
Presence of NG can increase supraglottic edema, reflux, stasis of secretion in hypopharynx. If likely to have prolonged inability to swallow and pt may be able to be decannulated with a good cough and secretion clearance, suggest g-tube placement.

54. Tracheotomy: Summary Safe method of airway management
Open versus percutaneous technique available
Complications largely minor
Mortality rare from procedure directly
0.3%* in last 30 years (grouped data)
Mortality rate for this procedure was close to 100%in the late 1800s and 40% in 1930s.

55. Summary
Advantages/risks of a tracheotomy for that individual patient must outweigh the disadvantages/risks without one.
Indication for Tracheotomy
Medical comorbidities
Respiratory /deglutition function
Ability to cope with secretions
Trial of corking/decannulation

56. Cricothyroidotomy Open versus percutaneous technique
Prep and position as for trach
Identify landmarks
Local anaesthetic
Incision over cricothyroid membrane
Placement of small tracheotomy tube, ETT or large bore needle with attachment for ventilation

57. Cricothyroidotomy Advantages Quick c/w open trach No laryngeal injury
Failure of intubation attempts in emergency situation
Disadvantages
Can cause laryngeal injury
Must be sure of landmarks
Small tube required

58. Cricothyroidotomy