4. INDICATIONS FOR TRACHEOSTOMY Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.2005. Goldenberg D, et al Tracheotomy: changing indications and a review of 1,130 cases, J Otolaryngol 31:211–215, 2002 Adjunct to management of major head and neck trauma Adjunct to major head and neck surgery Inability to intubate Upper airway obstruction Inability of patient to manage secretions Facilitation of ventilation support Prolonged intubation
5. INDICATIONS FOR TRACHEOSTOMY The Lindholm Scale of Laryngotracheal Damage Grade I erythema and edema without ulceration Grade II superficial ulceration of the mucosa <1/3 airway circumference Grade III continuous deep ulceration <1/3 airway circumference or superficial ulceration >1/3 airway circumference Grade IV deep ulceration with exposed cartilage.
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7. Incision 1 cm below the cricoid or halfway between the cricoid and the sternal notch. Retractors are placed, the skin is retracted, and the strap muscles are visualized in the midline. The muscles are divided along the raphe, then retracted laterally
8. The thyroid isthmus lies in the field of the dissection. Typically, the isthmus is 5 to 10 mm in its vertical dimension, mobilize it away from the trachea and retract it, then place the tracheal incision in the second or third tracheal interspace
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15. • Secretions in the trach • Suspected aspiration of gastric or upper airway secretions • Increase in peak airway pressures when on ventilator • Increase in respirations or sustained cough or both • Gradual or sudden decrease in ABG • Sudden onset of respiratory distress when airway patency is questioned Indications For Suctioning
16. Tracheostomies should be suctioned whenever physical examination reveals the presence of secretions CLEARANCE OF SECRETIONS
18. SPEECH Tracheostomy Speaking Valve Passy-Muir A tracheostomy speaking valve is a one-way valve, allows air in, but not out forces air around the tracheostomy tube, through the vocal cords and out the mouth upon expiration, enabling the patient to vocalize
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28. Guidewire and catheter are advanced together into the trachea as far as the skin positioning marks on the guide catheter to the skin.[ Guidewire introduction, with removal of sheath PERCUTANEOUS DILATIONAL TRACHEOTOMY
29. PERCUTANEOUS DILATIONAL TRACHEOTOMY Guidewire and catheter are advanced together into the trachea as far as the skin positioning marks on the guide catheter to the skin Guidewire, guide catheter, and dilator unit are advanced together into the trachea to the skin positioning mark
30. PERCUTANEOUS DILATIONAL TRACHEOTOMY The tracheotomy tube is loaded onto a dilator and advanced into the trachea over the guidewire and catheter. The guidewire and catheter are removed, leaving only the tracheostomy tube in the trachea
Antonio Musa Brasavola, an Italian physician, performed the first documented case of a successful tracheotomy. He published his account in 1546. The patient, who suffered from a laryngeal abscess and recovered from the procedure
INDICATIONS FOR TRACHEOTOMY Current indications for tracheotomy are: prolonged intubation and mechanical ventilation, bypass of an upper airway obstruction, easier management of secretions, as an adjunct to chest or head and neck surgery in which ventilation problems or prolonged intubation are anticipated ( Table 106-2 ). The earliest indication for the procedure was upper airway obstruction resulting from trauma or infection. As late as the 1950s, the major indication for 2444 Other causes of upper airway obstruction necessitating tracheotomy include obstruction due to neoplastic processes, or functional obstruction such as bilateral vocal cord paralysis or edema secondary to smoke inhalation or caustic agent ingestion. In such cases, patients are usually stabilized by tracheal intubation or with a cricothyrotomy and tracheotomy later. Although facial fractures in and of them selves are not an indication for tracheotomy, in cases of severe maxillo-facial trauma, tracheotomy is sometimes used to secure an airway where intubation would be difficult or damaging. Today, the most common indication for tracheotomy is prolonged tracheal intubation, usually with mechanical ventilation. A recent review of more than 1000 consecutive tracheotomies found that 76% were performed to facilitate mechanical ventilation.[ 21
Mentally alert patients tolerate a tracheostomy better than an endotracheal tube and experience less facial and oral discomfort.[ 6 ] Enhanced comfort may decrease the need for sedation that has been associated with an increased risk for nosocomial pneumonia.[ 80 ] Tracheostomy also allows greater mobility, including moving to a chair. Early transfer from the ICU is facilitated with performance of a tracheotomy for patients who are not ready for weaning from mechanical ventilation Ventilator-dependent patients have opportunities for articulated speech after placement of a tracheostomy . Speech and an ability to communicate spontaneously enhance patients' well-being and sense of control.[ 47 ] [ 61 ] [ 86 ] The inability to communicate has been identified by patients as one of their most significant sources of psychologic stress during ventilator dependency Recent studies suggest that mechanically ventilated patients who receive a tracheostomy have a lower risk for nosocomial pneumonia Lower airway resistance with a tracheostomy decreases ventilatory load and provides an opportunity for accelerating weaning from mechanical ventilation in patients with borderline lung function. Lower airway resistance may explain why trauma patients who undergo early tracheotomy have a shorter period of mechanical ventilation and ICU stay than patients managed with prolonged translaryngeal intubation and delayed tracheotomy . Endotracheal tubes have a higher resistance in vivo than predicted by their manufactured caliber because inspissated secretions decrease the luminal diameter and promote turbulent airflow .
There is no evidence to guide the frequency of tracheostomy tube changes. It is a common practice to change the tracheostomy tube when it is grossly soiled, if it malfunctions (e.g., cuff rupture), or if a tube of another design is needed (e.g., fenestrated tube). Changing the tracheostomy tube is not a benign procedure. Complications include inability to insert the replacement tube, insertion of the replacement tube into a false passage[ 74 ] (soft tissue of the neck or mediastinum), bleeding, and patient discomfort. The risk for these complications decreases with the age of the tracheal stoma. For this reason, it is recommended that changing the tracheostomy tube be avoided for at least 1 week after surgical creation of the stoma and that the first tube change is performed by the surgeon who performed the tracheotomy. If a difficult tracheostomy tube change is anticipated (e.g., obese patient, airway anomaly, short and thick neck), a clinician experienced in endotracheal intubation should be present.
There is no evidence to guide the frequency of tracheostomy tube changes. It is a common practice to change the tracheostomy tube when it is grossly soiled, if it malfunctions (e.g., cuff rupture), or if a tube of another design is needed (e.g., fenestrated tube). Changing the tracheostomy tube is not a benign procedure. Complications include inability to insert the replacement tube, insertion of the replacement tube into a false passage[ 74 ] (soft tissue of the neck or mediastinum), bleeding, and patient discomfort. The risk for these complications decreases with the age of the tracheal stoma. For this reason, it is recommended that changing the tracheostomy tube be avoided for at least 1 week after surgical creation of the stoma and that the first tube change is performed by the surgeon who performed the tracheotomy. If a difficult tracheostomy tube change is anticipated (e.g., obese patient, airway anomaly, short and thick neck), a clinician experienced in endotracheal intubation should be present.
Cuff pressures also can increase when patients undergo anesthesia with volatile gases. Diffusion of volatile gases into a cuff inflated with air increases cuff pressures to critical levels above mucosal capillary perfusion pressure within 2 hours of a surgical procedure.[ 112 ] Anesthesiologists should monitor cuff pressures during prolonged procedures or inflate cuffs with the anesthetic gas mixture at the start of surgery. The latter approach requires reinflation of the cuff with air at the end of the procedure
Because suctioning is uncomfortable, it should be performed only when indicated and not at a fixed frequency.[130] The upper airway also should be suctioned periodically to remove oral secretions. Hyperinflation and hyperoxygenation generally are recommended before suctioning to prevent suction-related hypoxemia The effectiveness of secretion clearance is similar for closed-system catheters and that of the conventional suction technique.[140]
Patients who can breathe spontaneously during intervals of weaning from mechanical ventilation may speak spontaneously with the use of a fenestrated tracheostomy tube.[59] After removal from mechanical ventilation, the inner cannula of the fenestrated tube is removed, allowing expiratory airflow through the larynx when the external end of the tracheostomy tube is occluded transiently. Deflation of the tracheostomy tube cuff during periods of spontaneous breathing can enhance expiratory airflow further across the vocal cords. Application of a one-way valve (e.g., Passy-Muir valve, Passy and Passy, Irvine, CA; Phonate Speaking Valve, Mallinckrodt Medical, St Louis, MO) (Fig. 4) (Figure Not Available) permits inspiratory airflow through the tracheostomy tube during inspiration but closes during expiration promoting airflow through the tube fenestrations and around a deflated cuff.[75] [96] [106] [107] Patients managed with a Passy-Muir valve require careful evaluation to be certain that the airway resistance during exhalation with breathing through a fenestrated tube does not interfere with weaning.[34]
Normally speech is obtained by a steady stream of air that comes from the lungs and passes by the vocal cords as we exhale. This air is modified by the vocal cords which vibrate as the air passes through to produce sound A tracheostomy speaking valve is a one-way valve that allows air in, but not out. This forces air around the tracheostomy tube, through the vocal cords and out the mouth upon expiration, enabling the patient to vocalize
tracheostomy tube provides opportunities for oral nutrition but also complicates alimentation because of tube interference with normal swallowing and airway control A.[ 18 ] An inflated tracheostomy cuff does not protect patients from aspirating into the lower airway oral contents that pass through an incompetent glottis. Tracheostomy tube prevents normal upward movement of the larynx during swallowing and hinder glottic closure. Speech therapists should evaluate oral motor strength, swallowing, and the adequacy of volitional and reflex coughing and the gag reflex. The presence of a gag reflex, however, does not ensure that pharyngeal contents will not be aspirated during refeeding The first feeding attempts should begin with ice chips to accustom patients to swallowing, followed by soft foods, such as gelatins, that would not have important consequences if aspirated into the airway
Patients can be evaluated for decannulation after they demonstrate stability for 24 to 48 hours after discontinuation of mechanical ventilation. The patient's ability to protect the airway should be assessed for 24 hours by deflating the tracheostomy cuff and observing for signs of aspiration.[ 48 ] Evidence of moderate to severe aspiration warrants laryngoscopic inspection of the glottis before further weaning efforts.
Patients can be evaluated for decannulation after they demonstrate stability for 24 to 48 hours after discontinuation of mechanical ventilation. The patient's ability to protect the airway should be assessed for 24 hours by deflating the tracheostomy cuff and observing for signs of aspiration.[ 48 ] Evidence of moderate to severe aspiration warrants laryngoscopic inspection of the glottis before further weaning efforts.
Tracheostomy can cause tracheal stenosis adjacent to the tube cuff or at the level of the tracheostomy stoma site.[ 4 ] [ 5 ] [ 51 ] [ 52 ] High-volume, low-pressure cuffs have decreased markedly the incidence of stenosis at the cuff site.[ 24 ] Tracheal stenosis at the stoma site, however, continues to be an important clinical problem that can develop from 1 to 6 months after decannulation .[ 60 ] The incidence of tracheal stenosis after tracheotomy in patients who require long-term ventilation is unknown because of the absence of longitudinal studies with adequate follow-up. Published studies of patients in a critical care managed setting with a tracheostomy suggest that the risk for tracheal stenosis ranges between 0% and 16% (Table 1). [ 25 ] [ 29 ] [ 85 ] [ 116 ] [ 135 ] [ 136 ] Most patients, however, lose only 10% to 40% of their tracheal caliber, which usually does not compromise ventilatory function. Tracheomalacia with dynamic airway narrowing during spontaneous expiration also occurs. Randomized studies comparing the long-term outcome of patients managed with standard surgical tracheotomy compared with percutaneous dilational tracheostomy have not been performed. Synonyms and related keywords: tracheomalacia, flaccidity of supporting tracheal cartilage, widening of the posterior membranous wall, reduced anterior-posterior airway caliber, tracheal collapse, structural abnormality of the tracheal cartilage, airway obstruction, abnormally increased compliance of the trachea, percutaneous tracheostomy, aortopexy
There is no evidence to guide the frequency of tracheostomy tube changes. It is a common practice to change the tracheostomy tube when it is grossly soiled, if it malfunctions (e.g., cuff rupture), or if a tube of another design is needed (e.g., fenestrated tube). Changing the tracheostomy tube is not a benign procedure. Complications include inability to insert the replacement tube, insertion of the replacement tube into a false passage[ 74 ] (soft tissue of the neck or mediastinum), bleeding, and patient discomfort. The risk for these complications decreases with the age of the tracheal stoma. For this reason, it is recommended that changing the tracheostomy tube be avoided for at least 1 week after surgical creation of the stoma and that the first tube change is performed by the surgeon who performed the tracheotomy. If a difficult tracheostomy tube change is anticipated (e.g., obese patient, airway anomaly, short and thick neck), a clinician experienced in endotracheal intubation should be present.