Patient with Tracheostomy case presentation

1. Patient with Tracheostomycase presentation Presentor :Dr.Praveen Moderator:Dr.G.Prasad www.anaesthesia.co.inanaesthesia.co.in@gmail.com

2. Case presentation Name- Mr. Sudhakar, Age -18 years Sex- male, Place – U.P Occupation-student, Informant-Mother Chief complaints • Bleeding from the nose– since 1 year • Nasal obstruction –since 6 months

3. History of present illness 1.Bleeding from the nose – since 1 year • insidious in onset • Episodic ,gradually progressive-started with once in a month to once in a week • Beginned with bleeding from right nostril , later developed bleeding from the left nostril too • The amount ranged from 10ml to 50ml

4. Later developed blood coming from mouth during episodes of nasal bleeding, • Initially bleeding episodes subsided on their own, later twice required nasal packing to control the bleeding from local doctor • Never required any iv fluids or any blood transfusions after bleeding episodes

5. History of present illness 2. Nasal obstruction – since 6 months • Insidious in onset • Gradually progressive, • Initially started with obstruction of right nostril, later progressed to involve the left nostril also • H/O mouth breathing & snoring +

6. H/O respiratory distress 4 months back (April-07), during an episode of nasal bleeding • Required an emergency operation to relieve obstruction by making tracheostomy in the neck

7. H/O decreased hearing from the right ear + • H/O swelling of right cheek +  • No H/O Hoarseness of voice • No H/O cough with expectoration or blood streaked sputum

8. No H/O vomiting of blood • No H/O passing blood in the urine/ stool • No H/O protrusion of eyeball • No H/O, any focal neurological deficit • No H/O, Headache/ Vomiting/Blurring of vision/ Convulsions

9. Treatment history • Required twice nasal packing to control bleeding ( by local doctors) • Required tracheostomy to relieve respiratory distress (in AIIMS-casualty)

10. Past medical history No H/S/O tuberculosis / jaundice/HTN • Family history No H/O bleeding tendency in the family

11. Personal history • Vegetarian • Non smoker/ non alcoholic • Bowel & bladder habits- regular • Sleep –sound • Appetite- good

12. Clinical examination Patient is a adolescent male, moderately built& nourished, conscious, oriented to time, place & person • pallor + , no icterus/ cyanosis/cervical lymphadenopathy/ oedema • No clubbing • PR-88/min, • BP- 140/90mmHg • RR-24/min • Afebrile

13. Local examination • External appearance- broad nasal bridge + • Fullness of the right side of nose + • Swelling of the right cheek + • Decreased fogging at the right nostril + • Oral cavity- NAD

14. Systemic examination Respiratory system • Trachea was in midline • B/L chest movements were equal • B/L air entry +,NVBS & equal in corresponding areas B/L conducted sounds +

15. Cardiovascular system • Apex beat- left-5th intercostal space in mid clavicular line • S1, S2 heard, in mitral & aortic areas, NO murmurs

16. Per abdominal examination • Soft • No organomegaly

17. Central nervous system • Conscious, oriented • Cranial nerves –Normal • No focal neurological deficit

18. Airway examination • Tracheostomy tube (7.5mm,PVC, uncuffed) in situ Stoma site looks healthy No evidence of infection or bleeding

19. Provisional diagnosis • JUVENILE NASOPHARYNGEAL ANGIOFIBROMA WITH STATUS TRACHEOSTOMY D/D – Infected polyps Carcinoma nasopharynx Rhabdomyosarcoma

20. Laboratory investigations • Hb- 9.1 gm % • Platelets-2,40,000/ mm3 • Blood urea-22mg % • Serum creatinine- 1.1mg % • Na -144meq/L, K- 4.4meq/L • Sr.bilirubin -0.9mg % • Proteins – total- 8.9gm%, albumin-4.7gm %, • SGOT- 203 IU/L, SGPT-306 IU/L, ALP-295 IU/L

21. USG-Abdomen- normal study, • Viral markers- anti HAV-IgM –Negative HBsAg – Negative, anti HEV IgM- Negative HIV (1+2)-Negetive X ray Chest – normal

22. CECT- coronal & axial • Large soft mass centered in the region of pterygopalatine fossa with extension into the infratemporal fossa, nasal cavity, sphenoid, ethmoid sinuses, right orbit, vidian canal, foramen rotundum & right middle cranial fossa

23. MRI- PNS • Findings consistent with juvenile nasopharyngeal angiofibroma with extension into right orbit, middle cranial fossa, infratemporal fossa, sphenoid sinuses, oropharynx & nasal cavity

24. Final diagnosis • JUVENILE NASOPHARYNGEAL ANGIOFIBROMA WITH INTRA CRANIAL EXTENSION WITH STATUS TRACHEOSTOMY

25. What is a Tracheostomy?-definition • A tracheostomy is a artificial (usually) surgically created airway fashioned by making a hole in the anterior wall of the trachea and the insertion of a tracheostomy tube, which may or may not be permanent

26. Tracheostomy – historyEuropian J of cardio-thoracic sx..2007 • The oldest known reference identifying a procedure akin to a tracheostomy is found in a sacredHindu book from the 2nd millennium before Christ • The first successful tracheostomy was recorded in 1546 by Italian physician ( Antonio Moussa Brasavola) for a patient suffering from laryngeal abscess

27. Tracheostomy - history • In mid 1800s, this procedure was performed on children with diphtheria • Dr. Chevalier Jackson Established safe guidelines Basics still used today, Described: • Long incision • Avoidance of the cricoid • Division of the isthmus • Slow, careful surgery • Post-op care

28. Why Perform a Tracheostomy? - indications • Upper airway obstruction • Retained secretions • Respiratory insufficiency

29. Indications- contd Upper airway obstruction • Infections – Acute laryngotracheo bronhitis, Acute epiglottitis Ludwigs angina, Peritonsillar, retropharyngeal abscess • Trauma – External injury to larynx & trachea Fracture mandible, or maxillofacial trauma

30. Indications-Upper airway obstruction • Neoplasms –Benign or malignant neoplasms of larynx , pharynx,, upper trachea, thyroid • Foreign body larynx • Oedema of larynx –steam, irritant, fumes or gases, allergy, radiation • Congenital anomalies-laryngeal web.cysts,

31. Indications…contd Retained secretions • Inability to cough – coma due to any cause • Paralysis of respiratory muscles • Spasm of respiratory muscles • Painful cough – chest injuries • Aspiration of pharyngeal secretions

32. Tracheostomy -contra indications • Skin infection • Prior major neck surgery which completely obscures the anatomy

33. Anatomy of the neck with thyroid, the cricoid, & the isthmus of thyroid gland The tracheostomy is carried out at least one to two rings beyond the cricoid Anatomy of the neck

34. Tracheo bronchial tree

35. How To Create a Tracheostomy ?Methods • Cricothyroidotomy • For Urgent Procedures • Percutaneous Tracheostomy • Can be done in the ICU at the bedside • Surgical Tracheostomy • Subthyroid incision to trachea between 2nd and 3rd tracheal rings

36. Timing of tracheostomy • Timing of tracheostomy is influenced by the indication for the procedure • Early tracheostomy significantly reduced duration of artificial ventilation & length of stay in in ICU systemic review & metaanalysis of studies of the timings oftracheostomy… Br Med J 2005

37. Timing of tracheostomy • In RCT comparing early (<48hrs) Vs Late (14-16days) tracheostomy in patients with respiratory failure the early group had a significantly decreased mortality, pneumonia & time of mechanical ventilation Crit Care Med 2004

38. Timing of tracheostomy • A systemic review & meta-analysis comparing early Vs late tracheostomy in trauma patients found no difference in days on mechanical ventilation , length of ICU stay, frequency of pneumonia A systemic review & meta-analysis.. Am Surg 2006 • Recommendation in critically ill adult patients requiring prolonged mechanical ventilation, tracheostomy performed at an early stage (within 1 week ) may shorten the duration of artificial ventilation & length of ICU stay European J of Cardio-thoracic surgery…2007

39. Types of tracheostomy 1. Emergency tracheostomy 2. Elective tracheostomy  therapeutic  prophylactic

40. Types of tracheostomy…….contd • Emergency tracheostomy  when airway obstruction is complete or almost complete  there is an urgent need to establish the airway  intubation or laryngotomy are either not possible or feasible

41. Elective tracheostomy • Therapeutic – to relieve obstruction -- to remove tracheobronchial secretions • Prophylactic- To guard against  anticipated respiratory obstruction or  Aspiration of blood or pharyngeal secretions such as extensive Sx of tongue, floor of mouth, mandibular resection

42. Permanent tracheostomy • B/L abductor paralysis • Laryngeal stenosis • COPD patients • Obstructive sleep apnea

43. High tracheostomy Above the level of thyroid isthmus It violates the 1st tracheal ring of trachea Tracheostomy at this site can cause perichondritis of the cricoid cartilage & subglottic stenosis Indication- carcinoma of the larynx Tracheostomy ..high..mid..low.

44. Tracheostomy • Mid tracheostomy • Preferred • Done through the 2nd & 3rd rings, • Needs division of thyroid isthmus or its retraction to expose trachea • Low tracheostomy • Done below the level of isthmus • Trachea is deep at this level & close to several large vessels • Tracheostomy tube may impinge on suprasternal notch

45. Functions of tracheostomy • Alternate pathway for breathing • Improves the alveolar ventilation • Protects the airway • Permits the removal of tracheobronchial secretions • For IPPV beyond 72hrs- tracheostomy is superior to intubation • Definitive airway –in difficult airway situations

46. Advantages over ETT • Improvement of respiratory mechanics facilitates weaning by reduced work of breathing ( decrease in flow resistance), intrinsic PEEP is also reduced Am J Respir Crit Care Med 1999 • Reduced laryngeal ulceration Endotracheal intubation can result in severe injury of the upper airway • Improved nutrition, enhanced mobility & speech

47. Advantages over ETT….. • Improved patient comfort less sedation is required in patients mechanically ventilated • Patient can be nursed outside ICU • Clearance of secretion.

48. Disadvantages of tracheostomy over ETT intubation • Surgical procedure with its procedure related complications • Stomal complications • Tracheo- innominate artery fistula formation • Tracheoesophageal fistula formation

49. Surgical tracheostomy

50. Surgical tracheostomy • Underlying medical conditions should be stabilized prior to the procedure to allow for safe transport to & from the OT • Routine monitoring as well as invasive monitoring already in place should be maintained during the procedure & transport