1. Tracheostomy May 4th /05

2. History Greek tracheo plus stoma (mouth)
 creation of a opening in the trachea by suturing the skin of the neck to the tracheal mucosa
 the placement of a tube through the anterior neck into a tracheotomy
Asclepiades in the first century BC described their use for of upper airway obstruction relief
Clin Chest Med 2003

3. History 18th & 19th centuries Trousseau diphtheria epidemic
 surge in the tracheostomy performance
& technique improvements but Still mortality 73%
1909 Jackson modern tracheostomy description
1969 Toy & Weinstein the percutaneous tracheostomy
1985 Ciaglia percutaneous dilatational tracheostomy
Clin Chest Med 2003

4. Indications Permanent tracheostomy post laryngectomy
Relief of upper airway obstruction
Rx uncontrolled tracheobronchial secretions
Prolonged mechanical ventilation
Clin Chest Med 2003

5. Advantage of Trach over ETT
Stable airway
Minimize laryngeal injury
Improved pulmonary toilet and oral hygiene
improved patient comfort
potential for speech and oral feeding
Decreased requirement for sedation or restraints
Facilitated ventilator weaning
Shorter intensive care unit stay
Clin Chest Med 2003

6. Physiological changes
Loss of warming ,humidifying & filtering function of upper airway  thick secretions
Defective cough & ciliary function
Tube induced mucus production
 increased risk of atelectasis
Loss of smelling decreased appetite

7. Anatomy Adult trachea 10 -13 cm larynx to carina
trachea slides easily in the cephalo-caudal direction tremendous variability
With neck extension half the length is above the thoracic inlet

8. Anatomy Incomplete rings with post membrane At thoracic inlet
trachea dives from anterior to posterior
behind the thymus, innominate vein & artery
In the elderly this angle can approach 90 degrees

9. Anatomy Approaching the trachea anteriorly in the midline encounters :
superficial cervical fascia,
crossing branches of the ant. jugular veins
sternohyoid and sternothyroid muscles
thyroid isthmus 2nd ring level
pretracheal fat pad
inferior thyroid veins &
occasionally a thyroid ima artery

15. Percutaneous Dilatational Tarch
Selection Criteria
Uncomplicated translaryngeal intubation
Palpable cricoid cartilage at least 3 cm above
the sternal angle
Appropriate neck extension
Hemodynamically stable
FIO2 < below 60%
PEEP < 10 cm H2O
Clin Chest Med 2003

16. Percutaneous Dilatational Tarch
Exclusion criteria
Distorted neck anatomy
 head and neck tumors, thyromegaly or scarring Refractory coagulopathy
Tracheomalacia
Neck soft tissues infection
Inability to extend the neck
 cervical fusion, fracture, or arthritis
Clin Chest Med 2003

17. Cricothyroidotomy Emergency situation
Most reliable landmark  laryngeal prominence
Palpation along the midline inferiorly toward the sternal notch
the cricothyroid membrane
immediately above the cricoid cartilage.
Clin Chest Med 2003

18. Cricothyroidotomy
The cricothyroid membrane is identified and incised along its inferior border transversely
Tracheal hook is inserted under the thyroid cartilage.
Gentle vertical dilation is to allow passage
of a 6 mm or 7 mm tube
Clin Chest Med 2003

19. Tube-free tracheostomy
Alternative to tracheostomy tube when it is expected to remain for months to years
To avoid the morbidity associated with an indwelling tube
horizontal omega-shaped skin incision extending beyond the margins of the sternocleidomastoid & arching to the level of the cricoidcartilage
Creation of a muscle & tracheal flap
Clin Chest Med 2003

20. Tube-free tracheostomy
Subplatysmal flaps
inferiorly  manubrium
laterally  beyond the sternocleidomastoid
superiorly  hyoid bone.
Thyroid isthmus is divided
the two lobes mobilized to be sutured gathering the accompanying strap muscles & tendons
Clin Chest Med 2003

21. Tube-free tracheostomy
Anterior tracheal flap
elevating the 2nd & 3rd tracheal rings
The stoma is intubated until the patient is
stable and breathing spontaneously
 decannulated.
Clin Chest Med 2003

22. Minitarcheostomy Matthews and Hopkinson in 1984
novel, minimally invasive method to facilitate endotracheal suctioning and clear secretions
4 mm cannula through cricothyroid membrane
trachea can be stimulated by a catheter to produce a cough to clear secretions.
Clin Chest Med 2003

23. Minitarcheostomy
preservation of glottic function, secretions can be coughed up via the normal route
Speech and swallowing are unaffected.
The cannula is capped when not in use
Clin Chest Med 2003

24. Minitarcheostomy Indications
Prophylactic
Postop major thoracic or upper abdom Sx
Extubated pts with expected poor cough
Therapeutic
sputum retention pneumonia, COPD exacerbations
major atelectasis (usually postoperative),
depressed LOC
thoracic trauma
Respiratory muscle weakness.
Clin Chest Med 2003

25. Minitarcheostomy The success rate 96% to 100%
The average duration of use 1 week
There were no late complication 1-4 y
2 small RCT post pulmonary Sx 30 & 25 Pts
Decrease in post op atelectasis & pneumonia
& need of bronch
J Thorac Cardiovasc Surg 1991
Eur J Surg 1991

26. Trach Tube selection Diameter The smallest outer diameter tube
will minimize the risk of tracheal stenosis
The widest inner diameter
 decrease airflow resistance
Size 8 men & 6 women.
Inner cannula
 safe & simple cleaning
Clin Chest Med 2003

27. Trach Tube selection Cuffed tube  mechanical ventilation
Uncuffed tube
 off ventilator to decrease work of breathing
Wire-reinforced tube
 enforced security & position tube
Clin Chest Med 2003

28. Trach Tube selection The fenestrated tube  spontaneously breathing pt
for easy phonation with the tube capped
can be blocked with cannula for ventilation
High chance to be blocked by secretion
, blood or granulation tissue
 needs changing frequently
Clin Chest Med 2003

29. Trach Tube selection Tight-to-shaft Bivona tube
 intermittent ventilation
high pressure, saline filled balloon
when deflated is flush with the tube
without inner cannula
One way speaking valve
 Allow phonation
exhalation through vocal cord
Clin Chest Med 2003

31. Decanulation Fenestrated tube  cuff deflated  cuffless tube
Downsizing progressively smaller size tubes
Allows the stoma to gradually fill in around the tube.
Decannulation plug
Tube removal dry, sterile dressing

32. Complications Early Late Bleeding , pneumothorax,
SC emphysema pneumonia ,
Injury to recurrent laryngeal nerve
Trachoesophageal fistula
Accidental extubation
Late
Tracheal stenosis , Tracheomalacia
Skin breakdown
Cuff rupture or herniation

33. Should we trach more Pts ?
A lot of studies still no solid answer
Different patient populations
Different timing of tracheostomy
Different surgical techniques & experience

34. Early Vs late Trach in Burn Pt
Prospective Randomized controlled 19962000
21 pt early Trach ET Vs 23 trach D 14
Predicted probability of prolonged ventilation formula
1ry outcome  hospital stay & mortality
2ry outcome extubation rate , oxygenation
& pneumonia rate
Jr of Burn Care & Rehab 2002

38. Early Vs late Trach in SICU Pt
Retrospective 2000 2002
Early trach < 7 Vs late > 7 days
Outcomes mechanical ventilation ,VAP ,
ICU & hospital stay
Am Jr of Surgery 2005

42. Early Vs Late Trach in Head Injury Pts
2 y prospective randomized study
Early 5th or 6th day Vs late
Isolated severe head injury
Admission GCS < 8
Cerebral contusion on CT scan
GCS score 8 on the fifth day without any sedation
Outcomes : ventilation , VAP ,
ICU & hospital stay
Trauma 2004

46. Surgical Vs Percutaneous Trach
Few RCT
No mortality difference
Time advantage for PT  less prep time
Shorter time from required to be done
PT may have lower bleeding rate
Anaesth Intensive Care 1999
Chest 2000

48. LMA instead of ETT in Trach
Randomized prospective 60 pts
Bedside trach with brocoscopic aid
Outcomes : procedure time
oxygenation & ventilation
complications
Intensive care med 2002

51. Thanks