U pper air way obstruction & Tracheotomy

1. Upper air way obstruction &Tracheotomy Dr. Lamia AlMaghrabi Consultant ENT King Saud Medical City

2. Malignant tumours 1 Advanced malignant disease of the tongue, larynx, pharynx or upper trachea. 2 As part of a surgical procedure for the treatment of laryngeal cancer. 3 Carcinoma of thyroid. Congenital 1 Subglottic or upper tracheal stenosis. 2 Laryngeal web. 3 Laryngeal and vallecular cysts. 4 Tracheo-oesophageal anomalies. 5 Haemangioma of larynx. Trauma 1 Prolonged endotracheal intubation. 2 Gunshot wounds and cut throat, laryngeal fracture. 3 Inhalation of steam or hot vapour. 4 Swallowing of corrosive fluids. 5 Radiotherapy Bilateral laryngeal paralysis 1 Following thyroidectomy. 2 Bulbar palsy. 3 Following oesophageal or heart surgery. Infections 1 Acute epiglottitis 2 Laryngotracheobronchitis. 3 Diphtheria. 4 Ludwig’s angina. Foreign body

3. LIFE THREATENING AIRWAY OBSTRUCTION • Cricothyroidotomy. • Indication: • Failure of endotracheal intubation, and no time for tracheostomy.

5. Tracheotomy • Indications • Technique • Open and percutaneous • Complications • Physiology of a tracheotomy • Decannulation

6. Tracheotomy • Creation of communication between the trachea and the cervical skin with insertion of a tube.

8. Indications • Upper Airway obstruction. • Pulmonary Secretions. • Ventilation. • Prolonged mechanical ventilation. • May assist in weaning from mechanical ventilation. • Prevention of glottic stenosis/complication of prolonged endotracheal tube.

9. Pulmonary Secretion Clearance • Aspiration / dysphagia • COPD • Bronchiectesis • Stasis of secretions • Poor cough • Poor respiratory reserve

11. Ventilation • Neuromuscular disorder affecting respiratory muscles • Reduced respiratory effort • Limited pulmonary reserve • COPD, Scoliosis, bronchiectesis • Central respiratory depression • Reduced level of consciousness • Severe obstructive sleep apnea • Cor pulmonale, failure CPAP

12. Prolonged Intubation • 7-10 days ett • Risk Factors for Glottic Stenosis • Diabetes • Female • Size ETT and # ett • Incidence glottic stenosis: 5% over 10 days (Whited 1984)

15. Tracheotomy • Decision made patient requires tracheotomy. • Open or percutaneous technique. • 75% of tracheotomies done are done percutaneously in ICU at bedside. • General principles: • External approach through neck soft tissue. • Creation of opening in trachea. • Placement of tube to maintain airway.

16. Types of tubes • Cuffed and uncuffed • Fenestrated and unfenestrated • Single and double lumen • Various diameters

17. Cuffs • To protect airway • To allow ventilation Uncuffed Cuffed

18. fenestrations • Allow patient to ventilate past tube via upper airway • Allow speech

19. Single/Double lumen • Double lumen allows easy cleaning • Single lumen has a greater internal diameter

20. Procedure • Skin • Dissection • Separate straps • Divide thyroid isthmus • Window in trachea • Below 1st ring • Stitch in place Incision=bad Hole=good

21. Contraindications • Medically well enough for GA • Uncontrolled coagulopathy • Airway pathology below tracheotomy site

22. Tracheotomy Tubes Portex and Shiley common brands of trach tubes. Shiley used as standard tube at St Michael’s Hospital.

23. Tracheotomy Tubes

24. Tracheotomy Tubes Bivona or foam cuff Tracoe Cuffless Speaking valve

25. Complications: Intraoperative • Bleeding 2.8%* • Recurrent laryngeal nerve injury • Tracheoesophageal fistula • Pneumothorax: rare • False passage • Anterior dissection most common • Incidence <1% *Kost et al 1994

26. Tracheotomy: Early Complications • Bleeding • Minor common • Major tracheoinnominate fistula (<0.2%)* • Obstruction of tube (2.5%)* • Dislodgement (1.4%)* • Pneumothorax (1 - 2.5%)* • Wound Infection • Local care, antibiotics (staph/pseudomonas)

27. Late Complications • Tracheal stenosis • Tracheal chondritis • Subglottis stenosis- high tracheotomy • Tracheomalacia • Tracheoesophageal fistula • Failure of stoma closure when decannulated • Overall complication rate 15-30% in ICU patients • largely minor with no long term morbidity

28. Physiology of Tracheotomy • Neck breathing • Bypass upper airway and nasal function • Loss of humidification/heat airflow • Dryness, thick secretions • Voicing possible with speaking valve • Loss of smell /reduced taste • Loss glottic closure function for cough

29. Physiology of Tracheotomy Respiration Advantages • Lower work of breathing (30%) c/w normal airway • Facilitates secretion clearance • Aspiration or thick secretions • Less dead space (100 mL) • Reduced airway resistance • Assists in patient independence from mechanical ventilation • Patient comfort (better than ett) • Epstein 2005 Respiratory Care

30. Physiology of Tracheotomy Respiration Disadvantages • Tube diameter and shape • increases turbulent airflow, secretions adhere inside tube • Loss of humidification/heat function of upper airway • Ciliary function affected • Biofilm colonization • Diminish cough/loss glottic closure • Reduce laryngeal elevation during swallow • Patient comfort (better no tube at all)

31. Postoperative Tracheotomy Care • Humidification via trach mask/Instill saline • Clear secretions, prevent crust • Inner cannula cleaning tid at least • If non-ventilated, change cuffed tube to non-cuffed at 5-7 days • Ties changed 2 people if possible • Most hospital have nursing/RT protocol • Teach everyone trach care including patient, family

32. Decannulation

33. Decannulation Goal is to ensure patient can tolerate increasedairway resistance/work of breathing and secretion clearance • 30% increase WOB transition from trach breathing to upper airway breathing

34. Decannulation • Indication for tracheotomy has resolved/improved • Patient able to cope with secretions • Upper airway patent - examined if necessary • Appropriate vocal cord function • Good respiratory reserve/overall respiratory status • Gag reflex present (5-10% no gag)

35. Decannulation • Stable clinical condition • Hemodynamic stability • Absence of fever, sepsis infection • Adequate swallowing • Gag reflex, bedside swallowing assessment, video fluoscopy • Maximum expiratory pressure > 40 cm H2O Ceriana et al 2003