12-13 Tracheostomy and trach care-updated 1444 (2).pdf

Respiratory Care Therapeutics Course (RT 264) Tracheostomy (Surgical Airway) 1444 (2023) Tracheostomy Learning Objectives & Outcomes The Student will be able to: Provide a definition of a tracheostomy State the indications for a person requiring a trac...

Respiratory Care Therapeutics Course (RT 264) Tracheostomy (Surgical Airway) 1444 (2023) Tracheostomy Learning Objectives & Outcomes The Student will be able to: Provide a definition of a tracheostomy State the indications for a person requiring a tracheostomy State the different techniques used to form a tracheostomy Recognise the various types and parts of standard tracheostomy tubes. Identify the complications of a tracheostomy Identify purpose and steps of care of trachesotomy Tracheostomy What is Tracheostomy? Tracheostomy is a surgical opening in the anterior wall of the trachea just below the larynx., bypassing the upper passages (pharynx and larynx). What are the Types of Tracheostomy? Temporary or Permanent Tracheostomy Emergency or ElectiveTracheostomy Surgical (open) Tracheostomy; incision to trachea between 2nd and 3rd tracheal rings Percutaneous Tracheostomy (Can be done in the ICU at the bedside) Mini-tracheostomy and Cricothyroidotomy : can be done in emergency Tracheostomy aiming to: To provide and maintain a patent airway To enable the removal of tracheobronchial secretions To permit long term positive pressure ventilation To improve patient comfort To decrease the work of breathing and increase volume of air entering the lungs Tracheostomy Indications of Tracheostomy I - Upper airway obstruction due to: Infections, Acute epiglottitis, retropharyngeal abscess Trauma – External injury to larynx & trachea Neoplasms –Benign or malignant neoplasms of larynx , pharynx,, upper trachea, thyroid Oedema of larynx – steam, irritant, fumes or gases, allergy, radiation 2- Obstructive Sleep Apnea (OSA) and Obesity Hypoventilation Syndrome (OHS): failure of CPAP and other medical therapies 3- Ventilator Dependence - Prolonged Intubation: patients requiring ventilator support for longer than 7 days. - Inability to protect airway :diaphragm paralysis from neuromuscular disorders such as Guillan Barre syndrome 4- Retained secretions Tracheostomy Contra indications of Tracheostomy Skin infection Prior major neck surgery which completely obscures the anatomy Uncorrected coagulopathies (bleeding tendency) What is the role of RT in Tracheostomy? The role of RT in tracheostomy may include: Managing the trach tube Making ventilator changes as needed. Assisting with bronchoscopist. Monitoring the patient Tracheostomy Tracheostomy (Trach.) Tubes Types Tracheostomy Tubes:- Single lumen or double lumen tube Cuffed tubes or Un-cuffed tube Fenestrated ( either cuffed or un-cuffed) or un-fenestrated tube The tube may be plastic or metal tube. Metal tubes (silver or stainlsteel) Un-cuffed Cuffed un-fenestrated Fenestrated Tracheostomy Parts of Trach Tube Sizes ranges from 2.5mm to 11mm - Parts:- - Outer cannula: a curved tube keeps tracheostomy stented open - Inner cannula: can be removed for cleaning and replaced - Obturator: to introduce trach in a non-traumatic fashion - Face plate (flanges): sits flush against neck, is often sutured initially -Inflatable cuff: can be inflated or deflated depending on need for ventilation (in case of cuffed tube only) & pilot balloon Tracheostomy Single Lumen Vs Double Lumen Tubes Single Lumen tubes: Tube requires replacement every 5-7 days Disadvantages: Short term use, can easily become blocked Indications: - A single lumen tube maximizes the inner lumen of the tracheostomy tube decreasing airway resistance. Double Lumen Tubes: The inner lumen in double lumen tracheostomy tubes reduces the internal diameter by 1-1.5 mm. This may increase the patient’s effort of breathing. A double lumen tracheostomy tube can remain in place for a maximum of 30 days. The inner lumen can be changed/cleaned frequently reducing the risk of occlusion A double lumen tracheostomy tube has a removable inner lumen. Secretions can adhere to the internal lumen of a tracheostomy tube and severely reduce the inner lumen diameter increasing the work of breathing and/or obstructing the patient’s airway. Tracheostomy Cuffed Tubes with inflatable cuff The cuff allows ventilation and prevents aspiration Inflatable cuffs are used when an air-tight seal is required around the tube. The cuff is not to hold the tube in position – it is usually required when: 1) when the patient is unable to breathe on their own and requires artificial respiration. or 2) when an air-tight seal is necessary to prevent blood and other secretions from running down the sides of the tracheostomy tube into the lungs. During and following surgery to the head and neck, such complications are a real danger and it is for this reason that a cuffed polythene tube is used for the first couple of days post-operatively. Disadvantages of Cuffed Tubes The cuff exerts a pressure on the surrounding tissues when it is inflated. In time, this pressure can cause damage to the tissues, resulting in necrosis, a fistula or stenosis in the trachea The patient cannot speak when the cuff is inflated as no air can go past the vocal cords – this has a massive psychological impact on the patient. If a patient with a cuffed tube can speak it could be a sign that the tube is displaced, or the cuff inadequately inflated. Tracheostomy Un-cuffed Tubes Maintains airway once aspiration risk has passed Increase airflow to the larynx Which patients: Long term tracheostomy pts Patients who do not require a seal Paediatrics Disadvantages :Unable to maintain seal in an emergency situation Fenestrated Tube Increases airflow to larynx/ vocalisation and it may be Cuffed or un-cuffed These are used for weaning and enables phonation (speaking) The fenestrated tube can be used as such if the patient is tolerating the cuff down To suction always use the non fenestrated inner tube for suctioning Fenestrated are the only tubes that can be intentionally occluded Tracheostomy Inner Cannula an inner cannula: An inner cannula allows maintenance of tube patency aids tube hygiene The inner cannula provides a vital safeguard against life-threatening complications of tube obstruction in a cuffed tube and must be present at all times. Changing the Inner Cannula If copious secretions- check every 4 hours (more if indicated) Remove and clean using sterile water and replace as soon as possible If tube is kinked or damaged replace with new sterile inner tube Other issues- brushes, cleaning fluids, infection and storage of inner cannula Tracheostomy Advantages of Trach Tube over ETT Intubation Improvement of respiratory mechanics Reduced laryngeal ulceration Endotracheal intubation can result in severe injury of the upper airway Improved nutrition, enhanced mobility & speech Improved patient comfort: less sedation is required in patients mechanically ventilated Patient can be nursed outside ICU Clearance of secretion. Disadvantages of tracheostomy in contrast to ETT intubation Surgical procedure with its procedure related complications Stoma-related complications More incidence of Tracheo- innominate artery fistula formation More incidence of Tracheoesophageal fistula formation Tracheostomy Tracheostomy procedure (Surgical tracheostomy ) Site of Tracheostomy (..High..Mid..Low.) 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 Mid tracheostomy  Is the Preferred site  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 Tracheostomy Surgical tracheostomy (cont.,) Positioning-supine with pillow under the shoulder& roll under the neck 3-5cm transvers skin incision – 1cm below the cricoid cartilage Strap muscles – retracted laterally The thyroid isthmus – retracted superiorly/ inferiorly/ divided Percutaneous dilation tracheostomy (PDT), also referred to as bedside tracheostomy, is the placement of a tracheostomy tube without direct surgical visualization of the trachea. Tracheostomy PDT Procedure Operator enters the tracheal lumen below the second tracheal ring with an introducer needle. The tract between the skin and the tracheal lumen is then serially dilated over a guidewire and stylet. A tracheostomy tube is placed under direct bronchoscopic vision over a dilator. Placement of the tube is confirmed again by visualizing the tracheobroncial tree through the tube. Tube is secured to the skin with sutures and the tracheostomy tape. PDT versus Surgical tracheostomy (ST) When elective tracheostomy is indicated in critically ill patients, the technique of PDT offers important advantages over ST, With PDT – less clinically significant wound infection is observed compared with ST, probably related to less tissue trauma & tighter fit between cannula & skin PDT Needs special equipment PDT Contra indicated in children Tracheostomy Perioperative Complications of Tracheostomy Immediate problems Long Term Problems Pneumothorax Subglottic stenosis Incidence decreased by low pressure cuffs Wound infection (reasonable common) Incidence increased by cricothyroidotomy Bleeding or high surgical tracheostomy Usually only in coagulopathic patients Tracheal stenosis Difficult insertion Oesophago-tracheal fistula Accidental decannulation Increased bacterial colonisation of the airways Occlusion due to secretions Vocal cord dysfunction Air embolism Chronic: Recurrent laryngeal nerve injury Temporary Aspiration Stomal granulations and scarring Surgical emphysema Non healing of wound Tracheo-innominate fistula Swallowing Problems