صفحه 1:
Tracheostomy
صفحه 2:
Why, when, and how?
- There is evidence that tracheostomy was first performed as long ago as
2000 BC, although the first clearly documented tracheostomy was in the
15th century.
= In the last 60 yr, percutaneous tracheostomy methods have been developed
- In the case of an elective tracheostomy procedure performed in the intensive
care unit, there remains debate about the timing of insertion
- Current evidence suggests that there are no significant differences in critical
care or hospital length of stay associated with an early (<10 days) vs a late
(>10 days) tracheostomy procedure, although the number of sedation days
is reduced inpatients in whom an early tracheostomy is performed.
صفحه 3:
Why, when, and how?
- For patients who are unable to wean from invasive ventilation
within one to three weeks of intubation, tracheostomy and
transfer to a long-term assisted care (LTAC) facility is often
considered. There is no optimal time for this transition with
practice-pattern variation among physicians. The decision
should be individualized according to the clinical circumstances
and the patient's preference such that daily assessment of a
patient's progress, readiness to wean, and need for
tracheostomy is warranted.
صفحه 4:
Advantages and disadvantages of tracheostomy versus tracheal intubation
r 0 ae
Advantages | Ease of replacement (once tract has formed) Rapid insertion by skilled consultant in most settings
Speech, mobility, and swallowing enhanced Lack of need for surgical procedure (risk, expense)
Patient can be aursed outside of ICU Lack of stomal complications
Ease of suctioning
Patient comfort
Complications at cuff site Complications at cuff site
Stomal complications Laryngeal complications
Possible contribution to ultimate laryngeal injury Replacement requires skill at all mes
‘Tracheo-innominate artery fistula formation Generally requires ICU level supervision
Possible increase in pulmonary infections Injuries at nose of mouth
Access to mediastinum by infections agents after local surgery
High mortality for inadvertent decannulation before tract formation
Graphic 76699 Version 2.0
صفحه 5:
Indications for tracheostomy
Laryngeal web/cysts, B/L choanal atresia, Tracheo-
esophageal fistula, Craniofacial anomalies,
Subglottic/tracheal stenosis
Acute epiglottitis, Diphtheria, Acute
layngotracheobronchitis, Ludwig's angina
External injury to larynx/trachea, maxillofacial
injury, corrosive injury, inhalational injury
Tumours of larynx, pharynx, tongue, upper trachea
Foreign body lodged in larynx
B/L abductor paralysis, Bulbar palsy
Congenital
Infective
Trauma
Neoplasm
Foreign Body
| Vocal cords
صفحه 6:
Types of tracheostomy tube
Cuffed and uncuffed
Fenestrated and unfenestrated
Single and double lumen
Various diameters
صفحه 7:
cuffs
~ To protect airway
- To allow ventilation
|
صفحه 8:
fenestrations
- Allow patient to
ventilate past tube via
upper airway
- Allow speech
صفحه 9:
Single/Double lumen
- Double lumen allows
easy cleaning
- Single lumen has a
greater internal
diameter
صفحه 10:
Occlude port
for talking زر
02 or
compressed air
Cuff pressure
manometer
صفحه 11:
+ If conscious ,1-2% lidocaine
+epinephrine is infiltrated in
the
line of incision and area of
dissection
* Sometime general
anesthesia
with intubation is used
Tanique:
1.Airway control
2.Patient position: supine
neck extended
pillow under the shoulder
3. Anesthesia
* Not necessary if pt is
unconscious or n emergency
situations
صفحه 12:
Identify the landmarks
IMPORTANT ANATOMY
Tracheostomy placement between tracheal rings, typically between
109 2۳0 8 30 tracheal rings
صفحه 13:
Preoperative Assessment
- Informed consent
- Coagulation profile adequate, platelet count >50000
- Neck examination- to anticipate difficulties in procedure as in
enlarged thyroid, limited neck extension.
صفحه 14:
Tanique
صفحه 15:
a transverse Incision 1 cm below the
cricoid
or two finger above the sternal notch
صفحه 16:
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
صفحه 17:
‘The thyroid tsthmus lies In the 1۱6۱0۵ ۲
the dissection. Typically, the isthmus is 5 to 10 mm
in its
vertical dimension.
Retract it up
صفحه 18:
Identify trachea. Anesthetist should remove any tapes used to
secure the endotracheal tube and prepare to withdraw the tube
slowly under direct vision by the surgeon. Then place the
tracheal incision in the second or third tracheal interspace.
صفحه 19:
Tube is inserted and secured
صفحه 20:
Complications
* Immediate:
- Hemorrhage
- Local injury-cricoid cartilage,
- 1st tracheal ring, carotid artery
- recurrent laryngeal nerve
- Air embolism
- Apnea
- Cardiac arrest
صفحه 21:
Complications
* Intermediate(few hours or days):
- Secondary hemorrhage
- Tube displacement
- Tube blockage
- Subcutaneous emphysema
- Pneumothorax
- Infection
- Tracheal necrosis
صفحه 22:
Complications
- Hemorrhage
- Granuloma formation
> Tracheo-oesophageal fistula
- Tracheo-cutaneous fistula
- Laryngotracheal stenosis
- Difficult decannulation
- Tracheostomy scar
صفحه 23:
Reference:
Uptodate Jan 21 2019
BJA education