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By Ussana Promyothin MD.
Tracheostomy By Ussana Promyothin MD.
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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
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Other indication Prolong intubation(1-3wks) children more prolong Laryngeal injury Fracture face neck area
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Also Improved oral hygiene Oral movement for communication Reduction damage larynx,nose ,mouth
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Contraindication Prolong bleeding
On anti-coag, anti-pletlet medication
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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
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Hyperextend the neck,
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2 FB above thyroid notch ring 2,3
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Skin incision,horizontal /vertical
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Find white line,Test tracheostomy cuff
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Clean trachea,aspirate air then push xylocaine
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Stay suture,open trachea by inverted U flap,cross,vertical (in children stay suture on both sides of incision)
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Standby tracheal dilator,suction,
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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)
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Observe bleeding and subcutaneous emphysema
Off packing 24-48hrs Left tube in place 5-7 days Stitch off and off stay suture 7th day
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Blow Cuff when on ventilation or prevent aspiration
Not exceed 25 cm H2O Clean inner tube analgesic
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Complication Immediate Apnea :loss hypoxic drive,COPD ventilator
Post obstructive pulmonary edemaPEEP Pneumothorax chest x-ray post op Injury to adjacent organ:thyroid ,vessel, esophagus,recurrent laryngeal nerve
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Pneumothorax
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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
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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
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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)
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Cricothyrodotomy:maneuver to buy time
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Advantage Near skin and less dissection Disadvatage Trauma to subglottic area Contraindication:children<12 yrs,infection at larynx,laryngeal trauma and risk transecting tumor
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Tracheostomy care Clean skin around stroma Change gauze
Clean inner tube Aware obstruction or slip out of tube
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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
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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
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Epistaxis
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Abnormal bleeding per nose
Cause Trauma ,nose picking ,nose blowing URI, allergic rhinitis Septum deviation Decongestant ,nasal spray Foreign body Tumor Post surgery
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Hypertension, artherosclerosis
Anticoagulation drug,ASA,NSAID Decrease plt Liver function disease
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Site of bleeding
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MANAGEMENT Immediate evaluation :vital sign,airway Stop bleeding
Compress nose,cold pack
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Anterior epistaxis Little’s area region
Ephridine or adrenaline pack (vasoconstrict agent) Beware in HT CAUTERIZATION 30%TCA,silver nitrate, electrical cautery Gel foam
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Anterior nasal packing
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Nasal speculum
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Headlight
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Suction
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Anterior nasal packing
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Vasaline gauze or coated with antibiotic ointment
Apneanaso-vagal reflex bradycardia,hypotension Remove packing 2-4 days later Antibiotic and decongestant
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Posterior nasal packing
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Foley catheter
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Posterior nasal packing
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Anterior and posterior nasal packing
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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
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Angiogram and embolization
Surgery Ligation artery Endoscopy
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Sinusitis
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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
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Acute bacterial sinusitis
Cause URI,AR Dental infection Obtruction ostium: structure,tumor Immotile cilia Foreign body: NG tube
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Symptom Fever Maxillofacial pain Dental pain Otalgia
Posterior nasal drip Nasal congestion
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Causative agent viral S.pneumoniae H.influenzae M.catarrhalis Other bacteria Fungus
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FILM SINUS
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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
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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)
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ESS
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Complication sinusitis
Mucocele Orbital complication: cellulitis abscess Intracranial complication: meningitis brain abscess
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