Tracheostomy

1. Tracheostomy By Ussana Promyothin MD.

3. Tracheostomy 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,highmortality (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

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. Tracheostomycare • 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