1. By Ussana Promyothin MD.
Tracheostomy
By Ussana Promyothin MD.

3. Tracheostomy Indication
Surgical opening in the trachea for ventilation
Indication
Bypass upper airway obstruction
Clearance secretion at lower respiratory
Prevent aspiration gastric content in absent of laryngeal reflex

4. Other indication
Prolong intubation(1-3wks) children more prolong
Laryngeal injury
Fracture face neck area

5. Also
Improved oral hygiene
Oral movement for communication
Reduction damage larynx,nose ,mouth

6. Contraindication Prolong bleeding
On anti-coag, anti-pletlet medication

7. Elective tracheostomy
Emergency tracheostomy: should avoid, expertised surgeon,team
In children: perform only with a secured airway either from ET tube or bronchoscope in OR
Emergent tracheostomy should be avoided if possible
Risk to vascular,lung and uncontrolled airway

8. Hyperextend the neck,

9. 2 FB above thyroid notch ring 2,3

10. Skin incision,horizontal /vertical

11. Find white line,Test tracheostomy cuff

12. Clean trachea,aspirate air then push xylocaine

13. Stay suture,open trachea by inverted U flap,cross,vertical (in children stay suture on both sides of incision)

14. Standby tracheal dilator,suction,

17. Post operation care Irrigation with saline and suction q 15 mins
Suction not exceed 15 seconds (block airway and suck Oxygen out)
Humidification Oxygen (decrease thick mucus)

18. Observe bleeding and subcutaneous emphysema
Off packing 24-48hrs
Left tube in place 5-7 days
Stitch off and off stay suture 7th day

19. Blow Cuff when on ventilation or prevent aspiration
Not exceed 25 cm H2O
Clean inner tube
analgesic

20. Complication Immediate Apnea :loss hypoxic drive,COPD  ventilator
Post obstructive pulmonary edemaPEEP
Pneumothorax chest x-ray post op
Injury to adjacent organ:thyroid ,vessel, esophagus,recurrent laryngeal nerve

22. Pneumothorax

24. Early Bleeding HT, skin,thyroid,soft tissue Mucus inner tube
Tracheitis humidification, minimize FiO2, Stabilize tracheostomy
Cellulitis: wound care,antibiotic
Displacement: pass E-T tube, NG tube

25. Late
Bleeding
-innominate vessel:usually in 2wks,high mortality (low tracheostomy,mobilized tracheostomy tube,high pressure cuff,local infection)
-granulation( stroma, tip of tube)
Tracheoesophageal fistula:risk in retain NG tube

27. Type of Tracheostomy Type/description permanent ventilator Inner tube
size
jackson
yes no
4-5
shiley
4-6-8
portex
no(7-14days)
7-8
blueline
no(1month)

30. Cricothyrodotomy:maneuver to buy time

33. Advantage
Near skin and less dissection
Disadvatage
Trauma to subglottic area
Contraindication:children<12 yrs,infection at larynx,laryngeal trauma and risk transecting tumor

34. Tracheostomy care Clean skin around stroma Change gauze
Clean inner tube
Aware obstruction or slip out of tube

35. Weaning tracheostomy tube
Reason for tracheostomy has resolved
Stable lung status(O2<40%)
Effective swallow,gag,and cough reflex
Adequate nutrition, sleep, psychososial suppor
Cuff deflate trial

36. Method Flexible bronchoscope or IDL
Assess cord movement,granulation,stenosis area
Admit,size tube down
Plug tube day,all day night
Off tube,observe before discharge

38. Epistaxis

39. Abnormal bleeding per nose
Cause
Trauma ,nose picking ,nose blowing
URI, allergic rhinitis
Septum deviation
Decongestant ,nasal spray
Foreign body
Tumor
Post surgery

40. Hypertension, artherosclerosis
Anticoagulation drug,ASA,NSAID
Decrease plt
Liver function disease

41. Site of bleeding

42. MANAGEMENT Immediate evaluation :vital sign,airway Stop bleeding
Compress nose,cold pack

44. Anterior epistaxis Little’s area region
Ephridine or adrenaline pack (vasoconstrict agent)
Beware in HT
CAUTERIZATION
30%TCA,silver nitrate, electrical cautery
Gel foam

45. Anterior nasal packing

46. Nasal speculum

47. Headlight

48. Suction

49. Anterior nasal packing

50. Vasaline gauze or coated with antibiotic ointment
Apneanaso-vagal reflex bradycardia,hypotension
Remove packing 2-4 days later
Antibiotic and decongestant

51. Posterior nasal packing

52. Foley catheter

53. Posterior nasal packing

54. Anterior and posterior nasal packing

55. Posterior packing :oxygen face mask
Elevate head 30 degree
Antibiotic cover Staph aureus
Liquid diet
Remove packing 3-5 day later
If high fever ,hypotension, remind toxic shock syndrome

56. Angiogram and embolization
Surgery
Ligation artery
Endoscopy

57. Sinusitis

60. Anatomy and function Resonance to voice Humidify and warm air
Increase the area of olfactory
Absorb shock to head
Keep nasal chamber moist
Protect thermal to brain
Contribute facial growth
Lighten bone of skull

61. Acute bacterial sinusitis
Cause
URI,AR
Dental infection
Obtruction ostium: structure,tumor
Immotile cilia
Foreign body: NG tube

62. Symptom Fever Maxillofacial pain Dental pain Otalgia
Posterior nasal drip
Nasal congestion

65. Causative agent
viral
S.pneumoniae
H.influenzae
M.catarrhalis
Other bacteria
Fungus

66. FILM SINUS

67. Management Proper antibiotic Systemic decongestant:maxiphed
Beware: HT, Heart disease, urinary retention
Topical decongestant: not exceed 3 days
Mucolytic agent
Antihistamine if suspected allergy
Normal saline irrigation

68. If failure medication
Antral puncture
For drainage and C/S
CHRONIC BACTERIAL SINUSITIS
Greater than 12 wks duration symptom
Treatment: antibiotic 4-6 wks
CT scan
Surgery : ESS (endoscopic sinus surgery)

70. ESS

71. Complication sinusitis
Mucocele
Orbital complication: cellulitis abscess
Intracranial complication: meningitis brain abscess