- Prevention
of complications of prolonged endotracheal intubation
- May
facilitate airway suctioning and improve patient comfort during
weaning
- Consent
Prepare tubes - men us. take size 8; women size 6-7; cuffed with
an inner tube that can be removed for cleaning.
- General
anaesthesia
- Local
anaesthesia
- Position
carefully. Supine
- Head
ring
- ECG,
blood pressure and pulse oximetry monitoring
- Horizontal
skin crease incision placed halfway between the cricoid and
suprasternal notch (aiming 3-4th tracheal rings)
Through skin and subcut fat and platysma with diathermy.
Keep in midline,
Then blunt dissection; relatively avascular; split strap muscles
in midline and retract sideways.
- Separate
the pretracheal muscles and divide the thyroid isthmus between
clamps (usually can be lifted or pushed out way instead of
dividing though; bleeds)
- Pretracheal
vessels just below the cricoid may need diathermy
- Clean
/ skeletonize the anterior tracheal wall
Feel cricoid and count down to 3-4 ring. Now check tube, check
lumen, check inflates.
- When
the trachea is palpated, the ETT is withdrawn to the sub-glottic
region
- 1-2
cm incision centred on the third or fourth ring/2nd
– 3rd ring; will hear air escaping. No diathermy here
as oxygen in airway. No 11 blade then enlarged with Mayo scissors.
For a temporary trache, make a horizontal incision.
Emergency - make a longitudinal incision. If long term
trachy, cut a small ring of cartilage out of the trachea (heals
ok).
- Do
not excise segments or cut flaps (complications include subsequent
stenosis
- Insert
tracheal dilators, or 2-0 silk stitch through the cut tracheal
edge on each border and leave the ends long
Pass tube (upwards to start with then turn it around).
Inflate cuff. Then connect ventilator and look for CO2
trace.
- Secure
tube to skin; don't close the wound else may get surgical
emphysema.
- Bleeding
o From
thyroid isthmus or inferior thyroid vein
o In
young children the brachiocephalic vein may rise above the
suprasternal notch.
- Perforating posterior tracheal wall can result in
tracheoesophageal fistula or mediastinitis
- Post-op bleeding from skin edge of isthmus; pack; if copious
then tube may be eroding through tracheal wall or innominate
vessel (disaster; 90% mortality).
- Obstruction; mucus or clots; remove, suction, humidify, clean.
- CXR
Tracheostomy
· Supine, neck
extended, shoulder support, headring, reverse trendelenberg
· Head drape
· Check tracheostomy
tube & cuff
· Incision 2cm above
notch, skin crease, measure length, mark prior to incising
· Incision through
platysma
· Subplatysmal flaps
to thyroid prominence & jugular notch
· Joll’s retractor
· Open deep fascia in
midline
· Expose 3rd
– 6th
tracheal
rings
— Divide isthmus if
necessary between Criles
· Suture in trachea
· Warn anaesthetist
· Incise trachea with
inferiorly based U-shaped flap
— Replace suture if
necessary with prolene, long loop
· Draw back ET tube
· Insert tracheostomy
tube
· Inflate cuff &
connect to ventilator
· Close platysma
· Close skin with
interrupted sutures
· Secure tracheostomy
tapes
Tracheostomy
What are the indications for tracheostomy?
—
Relief
of airways obstruction
Congenital
Subglottic
stenosis, laryngeal cyst, tracheo-esophageal abnormalities
Aquired
Trauma to larynx
Infection – epiglotitis,
laryngotracheobronchitis
Burns to larynx
Oedema from anaphylaxis
Tumour
– carcinoma of larynx, tongue, pharynx, thyroid
Bilateral vocal cord palsy
Foreign body
Sleep apnea syndrome
—
Temporary
and permanent protection of tracheo-bronchial tree
Neurological
disease – MS, myasthenia gravis
Trauma
– burns to face and neck
Head
and neck surgery – oropharynx resection or supraglottic
laryngectomy
Coma-
from trauma or drug overdose
—
Respiratory
insufficiency
Tracheostomy
has advantages in reducing
upper airways
dead space by 70% and reducing work of breathing.
Tracheostomy
allows easier swallowing mobility and speech compared with ET
tube, allows patient
to be nursed outside of ICU, allows easier suctioning
For all
above reasons it is better when weaning a patient from
ventilatory support.
Generally
early tracheostomy (7-10 days of mechanical ventilation) is
appropriate in
patients for whom weaning is not likely before 14 days.
What is the role of early tracheostomy
(<1 week)
Randomized studies suggest a benefit in
terms of infection, hospital and
ventilator days. There may also be a mortality benefit.
What different ways are there to perform
tracheostomy?
Percutaneous or
open.
Percutaneous
dilatational Tracheostomy
decreases the risk of wound infection and bleeding.
Complications in
percutaneous
tracheostomy are reduced if bronchoscopic guidance is used.
Relative
contra-indications to
percutaneous tracheostomy include: Age <15years,
uncorrectable bleeding
diasthesis, gross distortion of neck (haematoma, thyromegaly,
scarring from
previous neck surgery, short fat neck which obscures land marks.
How do you perform an open tracheostomy?
· Pre-operative:
obtain consent from patient. If patient is ventilated discuss
with family and
treating team the risks and benefits of procedure
· Check
coagulation and platelets pre-opertively.
· Blood for
group and hold
· Withhold
heparin if used
· Perform only
in operating room with anaesthetist
· Perform under
GA with ET tube in situ
· If patient is
not intubated and procedure is emergent for airways obstruction
perform
cricothyroidotomy instead.
· Make sure that
appropriate size tubes are available in theatre (sizes 6-9 for
adult). Size 7
is appropriate for most adults.
· Supine, neck
extended, folded sheet between shoulders, headring, reverse
trendelenberg
· Head drape
· Check
tracheostomy tube & cuff
· I make a
vertical incision starting at the cricoid and continuing down
for 4-5cm
· Incision
through skin, fat and platysma and continue down directly over
midline.
· Subplatysmal
flaps to thyroid prominence & jugular notch
· Joll’s
retractor
· Open deep
fascia in midline and
separate the
sternohyoid muscles
· Expose 3rd
– 6th
tracheal
rings using scissor dissection
—
Expose
the capsule of the thyroid gland
—
Clamp,
ligated and divide all thyroid veins in the region with 2/0
Vicryl ties
—
Identify
the thyroid isthmus
—
Slide
Metz scissors under the thyroid isthmus and elevate it.
—
Clamp
the isthmus with Criles and divide.
—
Suture-ligate
the isthmus with 2/0 Vicryl suture ties
· Identify the
second and third tracheal rings.
· Ensure
complete haemostasis
You cannot get complete haemostasis. There
is constant oozing which
cannot be located despite optimizing light, retraction,
extending the incision
and getting an extra-assistant. What do you do?
Pack the wound and
return in 48
hours after rechecking coags. I don’t opne the trachea until it
is completely
dry.
· Warn
anaesthetist that air leak will soon occur
· Have sucker
set up
· Suture in
trachea
· Warn
anaesthetist of an air leak and ask for a few minutes of
pre-oxygenation with
100% O2.
· I make a
vertical incision in the anterior tracheal wall of the second
and third
tracheal rings with a 15 blade.
· I suction the
trachea and gently the spread the edges of the tracheotomy with
curved
haemostat. If the hole does not allow easy entrance of the tube
I excise a 1cm
segment of the third tracheal ring.
· I insert 2/0
prolene sutures in the 3rd tracheal rings either side
of the
tracheotomy and leave these long in haemostats
· I lubricate
the trachesotomy tube and ask my assistant to gentle hold the
prolene sutures
whilst I slip the tube into the trachea whilst the ET tube is
withdrawn to the
supraglottic larynx.
· The tracheostomy
tube cuff is inflated and a soft sucker introduced into the
trachea.
·I connect to
ventilator and confirm placement with end-tidal CO2 and chest
movement.
· Close I
approximate the sternohyoid above and below with 2/0 Vicryl
I loosly
approximate platysma as
above
· Close skin
with interrupted 2/0 Nylon sutures
I suture the
tracheostomy flanges to
the skin using 0 Nylon
· Secure
tracheostomy tapes round the neck
Post-op
· Humidified
oxygen with 7% CO2 and regular suctioning
You are taking
the patient back to ICU and tube
dislodges
· Have the patient re-intubated and return to
theatre. I would not attempt
to blindly re-introduce the tube in ICU or the corridor even
using the stay
sutures.
What are the
complications of tracheostomy?
Immediate:
· Tube dislodgement and asphyxia, aspiration,
Bleeding with soiling of
airway and aspiration, pneumothorax.
· The best way to deal with heavy bleeding is
to re-intubate and return
the patient to theatre for formal exploration
Early: infection in
wound or trachea.
· Infection can usually be managed with IV
Abx. Uncontrolled infection can
lead to tracheal erosion.
· Atelectasis and pulmonary infection
Late: Fistulation into
the inominate artery and
exsanguination.
· Tracheal stenosis, vocal cord palsy,
tracheo-esophageal fistula
What are the
indications for cricothyroidotomy
· For an emergency airway when intubation is
impossible
· Anasthesia: Local infiltration of lignocaine
with adrenaline or none.
This provides anesthesia and reduces bleeding.
· Preparation: Place a rolled sheet between
the shoulders. Head ring.
Sterile prep and drape.
· I grasp the thyroid cartilage between thumb
and middle finger of left
hand and use index finder to palpate the space between the
thyroid and cricoid
cartilages and infiltrate more local anesthetic.
· I make a transverse incision with a number
15 scalpel through the skin.
· I achieve haemostasis with pressure and
diathermy.
· I make a stab incision in the membrane and
then use a curved artery to
dilate the tract.
· I insert a 7F cuffed tracheostomy tube. And
suture it to the skin and
secure with tracheosomy tape.